medically cleared?

[betterliving]

What do psych nurses consider the words "medically cleared" mean if that is a requirement prior to admission/transfer to an in-patient psych (in this case gero-psych) unit? We are currently in the "if the doctor says so" phase and wonder if that's where we'll end up. We don't accept patients with IV's onto the unit but much else is OK.

Opinions are welcome as are guidelines used effectively in general hospitals with psych units in same building.

Anyone with any experience in ERs would be especially helpful.

Thanks!

[lucianne]

We generally take it to mean no IV lines and stable vital signs, but there are always those that end up being shipped back off our unit again.

[Nurse Ratched, RN]

I would take it to mean, "If the person didn't have the psych problem, they wouldn't be hospital material." I.E. medical issues and VS are stable and some basic common-sense workup has been done to rule out other problems causing the agitation or whatever is wrong (UA, CBC, CMP, med levels where appropriate.)

My issue with having geriatric folks transferred to psych units is that most of the time, it IS a medical problem causing the "psych" issue (UTI, pain, hyponatremia, toxic med levels, etc.) Not saying that there aren't strictly psych problems present in some geriatric folks, but we are not always attuned to the subtle messages our geri patients give us as to their physical condition.

[maureeno]

we have become a de-facto

med-psych unit

so 'medically cleared'

now means

not currently coding.....

we have IVs, O2, etc.

no respirators yet!

[Nurse Ratched, RN]

And they wonder why nurses leave. I'm guessing, maureeno, that no one there signed up to work on a med-psych or gero-psych unit? I imagine the turnover is increasing. Very sad.

Are there formal written admission criteria which patients must meet prior to being admitted? There should be. I feel for you - we also get non-responsive elderly in whose admitting reason is "aggressive behavior." While we are a med-psych unit, many times we find that the problem is ALL med and NO psych. Not knocking ECF nurses, just wondering if the mgt there has any sort of algorithm used to start ruling out problems before just automatically ejecting the resident.

If not, the psych docs that take call all need to be on the same page about what must be done prior to receiving admitting orders to a non-medical psychiatric unit (either at the ECF or if the pt is dumped in the ED.)

Then, education needs to be provided to ECF staff who are actually in positions of authority as well as floor staff. "X is the information we expect when receiving a pt before they will be directly admitted from your unit."

Sadly, too often failure to do these basic things has often led to a turf to the ICU after arriving on the psych unit.

As far as receiving patients from in-house, if the predominant problem is med (i.e. workup has been done, pt is suffering from nasty UTI and is confused and wil likely clear with IV atbx but requires full-time supervision and is unable to care for self at this moment) then alternatives to placing pt in a less appropriate unit need to be attempted first. One-on-one sitters, encouraging family assistance if available, and last-choice, medical restraints where indicated, (if pt is pulling out IV, etc.) There are very few circumstances where the only option remaining is to put the patient on a locked unit.

Since psych is so often the red-headed stepchild of a hospital, I encourage you and your co-workers to take your concerns to you immediate supervisor and keep on barking up the food chain until someone in command has enough sense to realize that this is a patient safety (read: LIABILITY) issue.

[ethurman]

I have had pts transferred to our psych unit from another hosp.

where the physician medically cleared the patient (pt with history

of COPD) said the pt was hallucinating. Asked for ABGs this

MD was offended asked about labs he said, "pt needs psych

she'll be there in 30min"

This hospital and the hospital I worked at r in the same corp.

The pt arrived to the hosp. When EMS was bringing pt

off the elevator the pt went into resp arrest we had to code

the pt--was successful and transfer to ICU. Pts ABGs were

out of whack. After pt was stable med. confusion and hall

miracleously vanished. This same doc sent us another pt

he said was medically clear and went straight into ICU

due to ABGs out of whack again.

We also established a policy that any pt we were going to

admit either brought with them a statement from their family

doc of med. clearance with routine set of labs: cbc, thyroid prof,

EKG, bmp, ua any abn doc was to address if not referred by

family doc they were seen by our ER and medically cleared

with the above labs done also. When we received a call

for referral we informed the referral source that we would

consider them for admission but they have to be medically

cleared prior to arriving on our unit that meant statement

and results of labs.

[Nurse Ratched, RN]

Ethurman, that's fantastic - actual criteria supported by and adhered to by the powers that be :). Sounds like a lot of facilities could learn from yours!

[betterliving]

Any requirements do need to be supported by administration, and understood by administration, otherwise the education needed to maintain basic legalities and safety falls on the charge nurse. This is an exhausting proposition in many ways: sometimes the charge nurse is the everything (ie. only) nurse on a smaller unit, and the "teaching" involved is time and labor intensive.

There's also the stress involved in what seems to de-evolve into arguments. Example, I was recently given report on a "drunk old woman" that involved NO labs, not even an etoh level. My question about the level of intoxication (blood alcohol), was met with irritation and ER doc complaints about the demanding nurse, along with a tangential "the pulse ox is OK". The psychiatrist whom I notified advocated the path of least resistance, basically to let the ER doc take responsibility for declaring medical clearance and accept the lab-less patient. Certainly one way to reduce stress.

Anyway, one of many examples, where you just have to hope, it seems, that the patient will be OK on the non-medical psych unit and that on the issue of accountability, the RN will be able to place the budren of responsibility where it really is. Of course, I have taken to being very thorough in my documentation (on the nurse-to-nurse report sheet), jotting down what I ask about and the responses given. I consider this part of the admission paperwork if patient arrives to unit. I don't seek to make trouble for the fallible organization I'm employed by, but clearly, there is a need to protect one's professionalism and livelihood, along with patient safety.

I am a very experienced and capable psych nurse, have never been nor will ever be a critical care RN, and last worked on med-surg about 15 years ago. I make no bones about my strengths and non-strengths and refuse to be unreasonably exploited (just reasonably so? ;-) The guidelines and awareness shared by other posters on this thread are appreciated.

[maureeno]

Dear Nurse Ratched

thanks for your support!

our unit has to take involuntarily detained patients

and over the years the interpretation and use of the law has widened.

I have had experience on this same unit for 21 years and 'mental disorder' now includes patients it did not in the past.

we are a dumping ground for nursing homes and DD residences

also, in this last year we cared for a full torso burn pt. and for pts. with broken bones [HIP, pre and post surgery] Many pts are detained for diabetic or renal non-compliance.

I'll say it is interesting, but the challenge of maintaining a theraputic environment is tricky!

yes, you've got it, there has been tremendous staff turnover

and psychiatry is a stepchild

But I am in it for the long haul

and am fortunate to be a part of a large group of mental health workers

[husband, friends] who have all been 'called' to the work.

[Will Benson]

Unfortunately, in the nursing "world" of blond-haired, blue eyed perfect specimens, we psych nurses have been the red-haired, bastard step-children. In the unit where I work, we receive ER patients for psych who have "medically cleared", but will code once they arrive to our unit. I think the docs don't give the psych patients any creedance because 1). they are afraid of the psych patients or 2) the patients have difficulty explaining what is wrong. We have had a number of elderly arrive to our floor, diagnosed as dementia, when they really have a delirium because they have a UTI ( or low potassium, or anemia, etc) and had the doc even done the minimum "medical clearance" (such as order a CBC, for God's sake) he would have found this.

I think that it's unfortunate, but we are going to see more medically compromised psych patients. Managed care has made it significantly more difficult to be admitted to a hospital. This will translate into a high incidence of medical co-morbidity for the psych patients that ARE admitted. Our unit not only takes IVs, we also are doing NG tubes, PEG tubes,TPN, tube feeds, PICC lines and Central Lines. Sometimes I think there's no such thing as "pure" psychiatry anymore. When I get a report from the ER stating that the patient has been "medically cleared" for admission to the unit, I ask for the name of the doctor who medically cleared him.

[craftirn]

Our medically cleared get UDS and BAL prior to coming to the unit from the ER. Suffice it to say that does not medically CLEAR anyone and there are many problems with getting medical doctors down to our unit in a timely manner. Unless it is an obvious medical problem, it is missed until we pick it up on teh nursing assessment.

[betterliving]

sorry, but what is BAL? basic....?