Harbor:Psych patients

• ED Policy #6: Psych Patients potentially needing monitoring for OSA
  • Patients in the Psychiatric ED who may require treatment with sedating medications and are deemed to be at risk for significant oxygen desaturation when sedated, based on clinical evidence, should be transferred to a monitored bed in the ED.
    • Examples of clinical evidence include
      • A credible history of significant obstructive sleep apnea (OSA) or witnessed apnea
      • Hypoxia, or
      • Desaturation when sleeping after treatment with sedating medications.
    • Transfers to the ED from the Psychiatric ED for concerns about OSA should be based on physician clinical judgment, and not solely on body mass index. These patients are co-managed by physicians from both areas.
    • For psych admissions to psych inpatient unit, must be cleared by Pulmonology or admitted to medicine

• COVID negative patients
  • ED maintains primary management of the patient until physically transferred to psych

• COVID positive patients
  • Once medically cleared, to psych if an isolation room is available
  • In no isolation room available, then the patients will be kept in the AED (preferable G24/25) and care of patient will be transferred to the psych team
    • If the psych team is concerned about a patient’s medical condition, med ED can be consulted for evaluation at any time.
      • Specific to COVID, we would generally consider the following vitals to be concerning if there is not an alternate reason (such as meth-induced tachycardia):
        • Fever >100.4 should be treated with Tylenol 15mg/kg (max 1000mg, consider hx of liver issues) and/or Motrin 10mg/kg (max 400mg, consider elderly age, GI, and renal hx)
          • Should re-assess 1 hour after medication as this will likely improve HR & RR
        • HR>110
        • SBP<100
        • RR>24
        • O2 sat <93%

Dr. Chappell & Dr. Makhinson 6/30/22

• Exodus Psychiatric Urgent Care
  • Acute side is open 24/7
  • Outpt side (for med refills, etc) is open 24/7

• Initiating the transfer from Exodus to the AED or PED for clearance of an emergent medical condition:
  • Exodus Charge RN calls the ED to initiate transfer (call both ED physician and ED nurse).
    • Adult Attending x66902 (or x66906 as backup) or PED attending x66910 (or PED Sr. Resident x66911 as backup)
      • Attending places a pre-arrival note (include the reason for medical evaluation, presence of 5150, and any safety concerns).
    • RME Charge for adults x66950 or PED Charge for pediatric patients x66960 (Overall Charge x66930 as backup for all patients)
      • Notify RN if the patient is on a hold so a sitter can be identified.
      • Note any patients that are safety risks (high flight likelihood or history of aggressive/violent behavior) so Golden Hand can be placed.

• • Exodus will transfer the patient to the ambulance entrance of the ED via wheelchair or van with both a nurse and security officer
    • Exodus staff will then take the patient directly to triage (to the adult ED for 21 and older and to the Pediatric ED for 20 and under).
    • In the AED, the patient will be seen by the first available triage team.
    • If applicable, the original hold (5150 or 5585) documentation will accompany the patient.
    • After handoff to the triage RN, Exodus staff will be released.

• • • The patient will be evaluated by the triage team with pertinent orders placed or by the senior resident in the PED then taken directly to a room with a sitter. Any necessary tasking will occur in the ED room.
      • If there are no available rooms in the AED, tasking can occur in RME and the patient will stay in RME 12 with a sitter until a private room is available.
      • If there are no rooms available in the PED, the patient will remain in triage until a room with a sitter is made available.
    • During the process of medical evaluation, the ED provider may consult Psych for any reason (medication recommendations, concern due to a change in behavior, etc.).

• Discharging patients back to Exodus
  • After the medical evaluation is completed and the patient sent from Exodus is medically cleared and deemed stable for psychiatric assessment and not a flight or safety risk, the patients will be discharged back to Exodus.
    • The treating nurse will call the Exodus Charge RN (424.405.5888)
    • The clerk will print a “transfer packet” (do not need the EMTALA form)
      • Providers: try to complete the physician documentation so the Exodus staff can see what was medically addressed and view your MDM
  • Exodus staff (RN + security) will transport the patient back to Exodus.
  • If there is any safety or elopement concern, or there is no longer space at Exodus, the patient will be transferred to the Psych ED.
    • At their discretion, Psych may initiate a Sheriff-accompanied transfer to Exodus.
  • Any patients INITIALLY presenting to the Adult ED needing psychiatric evaluation should be sent to the Psych ED where they may then be triaged to Exodus.

• If there is even an issue with the transfer back process, please call Dr. Chappell in real time.

Dr. Chappell & Melissa Trejo (Exodus Director) 9-12-2022