Medical Clearance for Psychiatric Unit

[smcRN2592, ADN]

Topic: Medical Clearance

In your experience, what have you seen that constitutes “med clearance” for a psych unit?

Particularly, at a free-standing psychiatric facility. Geriatric patients. I’m trying to brainstorm to present some type of policy that constitutes med clearance and can give our staff some back-up in the future if an appropriate admit presents itself.

Backstory: I work on a geriatric psych unit that could once handle some level of patients being medically “unstable” due to the unit being part of a medical hospital. Last year, all of the inpatient medical units closed. More recently, the emergency room closed. We are now the only unit in a building that is essentially empty aside from some outpatient offices. We now have to call 911 if a patient is appearing to be medically unstable or suffers an unwitnessed fall/fall with head strike (which can be common given the population). It is understandable for this population to not but 100% healthy (obviously) but we have an extensive history of having to transfer patients to a higher level of care within 24 hours of admission, even when our ER was open. I think this could be avoided with policy that requires medical intervention for abnormalities before transfer.

Example: Report from a medical hospital’s psych holding in their ER for a new admission. The intake paperwork said the BP was 157/101. In report, I got that the BP was now 167/122 and they had not given any BP meds or other intervention since the patient arrived (day before). They did give patient tylenol for a headache. Patient has a history of stroke/TIA, 60s year old M, full code, schizophrenia dx. Would this be acceptable in your experience? Or would you require some type of intervention first?

[hppygr8ful, ASN, RN, EMT-I]

40 minutes ago, smcRN2592 said:

Example: Report from a medical hospital’s psych holding in their ER for a new admission. The intake paperwork said the BP was 157/101. In report, I got that the BP was now 167/122 and they had not given any BP meds or other intervention since the patient arrived (day before). They did give patient tylenol for a headache. Patient has a history of stroke/TIA, 60s year old M, full code, schizophrenia dx. Would this be acceptable in your experience? Or would you require some type of intervention first?

At our free standing psych we would not take this patient until the ER had at least stabilized the blood pressure. We would require medication to be given and also a cardiology clearance and we do not have a cardiologist on staff or call.

Of course our Supes have a conniption fit over a bp at 145/90 ?

Hppy

[smcRN2592, ADN]

6 minutes ago, hppygr8ful said:

At our free standing psych we would not take this patient until the ER had at least stabilized the blood pressure. We would require medication to be given and also a cardiology clearance and we do not have a cardiologist on staff or call.

Of course our Supes have a conniption fit over a bp at 145/90 ?

Hppy

Haha I figured at the very least a medication could've been given and the BP could've been reassessed before transfer but apparently, that was too much to ask for since the physician in psych triage determined the patient was medically cleared for us! That is one of the more minor occurrences I've encountered with this issue, too.. which is why I'm trying to present a policy that can be implemented and give us a leg to stand on when accepting/declining a transfer ?

[Here.I.Stand, BSN, RN]

3 hours ago, smcRN2592 said:

Example: Report from a medical hospital’s psych holding in their ER for a new admission. The intake paperwork said the BP was 157/101. In report, I got that the BP was now 167/122 and they had not given any BP meds or other intervention since the patient arrived (day before). They did give patient tylenol for a headache. Patient has a history of stroke/TIA, 60s year old M, full code, schizophrenia dx. Would this be acceptable in your experience? Or would you require some type of intervention first?

I’ve never worked psych.... but DANG. That would make me more than a little uncomfortable!

[hppygr8ful, ASN, RN, EMT-I]

2 hours ago, smcRN2592 said:

Haha I figured at the very least a medication could've been given and the BP could've been reassessed before transfer but apparently, that was too much to ask for since the physician in psych triage determined the patient was medically cleared for us! That is one of the more minor occurrences I've encountered with this issue, too.. which is why I'm trying to present a policy that can be implemented and give us a leg to stand on when accepting/declining a transfer ?

We do have set parameter's which I will try to look up and send you. But I am off tomorrow and taking my son to see Pet Cemetery - so won't be able to do that until Friday. We have a psych RN do a nurse to nurse which list several criteria that must be met for transfer to us. I'll see if I can get this for you.

[TriciaJ, RN]

Psych is often a dumping ground for the people that no one else wants to deal with. I remember receiving an elderly lady from a medical unit due to "psychosis". They kept giving her perphenazine and she kept getting worse. Our psych resident assessed and cleared her medically to be transferred to psych.

When she arrived, she had echolalia and grossly elevated vital signs. She wasn't psychotic; she was delirious. We had to ask the resident to please work her up for neuroleptic malignant syndrome and she did end up with that diagnosis.

[Davey Do]

Recently, we were getting an admission from a northern Illinois hospital for an overdose attempt on benzos. Reporting ER RN said VS were fine, labs were fine, (UDS+ for benzos, surprise surprise), patient fine, everything fine, but I didn't feel like they had been observing her long enough. We had had a benzo overdose attempt sometime back who fell out and went medical over 24 hours after being admitted to geriatric psych.

I asked if Poison Control had been contacted, received a "no" and requested they do so. Long story short, she had an elevated CK, required more fluids and the patient stayed at the referring hospital for another day.

I felt really good about that situation.

I didn't have to do the admission.