Harbor:Psych patients
Code Gold Process
- Prior to calling the code gold:
- The primary nurse should escalate to the resident/attending prior to calling a Code Gold unless there is an immediate safety concern.
- The primary team should make attempts to de-escalate the patient.
- Patients must be on a legal psychiatric hold, have documented lack of capacity by a provider (should be reassessed every 24 hours), or be actively trying to hurt themselves or others. In the absence of this criteria, patients have the right to disagree with our plan of care (AMA).
- The ED attending responsible for a given patient should respond to all Code Golds.
- When the code team arrives:
- The Code Gold team leader will huddle with the primary RN and provider – why was the code called and what is the plan? This needs to be a conversation taking into account the safety and concerns of everyone.
- There may be a last opportunity for the physician and Code Gold leader to jointly attempt de-escalation
- Once the plan has been discussed with the team, the code gold team leader then assumes charge of the situation.
- The goal of the code gold team is to use the least restrictive measures to safely work with the patients.
- However, if attempts to de-escalate the patient do not prove successful they will place the patient in restraints to maintain patient and staff safety while allowing time for medications to have an effect.
- In the event there is no provider at the bedside, the primary nurse can ask that the patient be placed in restraints but has the responsibility of obtaining a provider order within 1 hour. It is the primary RN's and provider's responsibility to document the behavior/justification and place the order. The code team only provides documentation of the code times and outcome.
- In the event the provider or primary RN does not want the patient placed in restraints:
- Note: the code team cannot stand-by while care is being provided as they all have their own patient care assignments to return to. It will then be the primary team's responsibility to manage the patients behavior.
- A code gold can be reactivated as needed.
- If the patient is going to be placed in restraints:
- The team leader will direct his/her team and give specific assignments.
- The ED physicians and nurses should not get involved in the code gold process unless you are requested by the Code Gold leader. For safety purposes the code team should not move forward until all 5 members of the team have arrived with exception of immediate intervention to prevent harm. This is less of a problem in the ED as most staff have completed the AVADE III/CPI training and can assist as directed by the team leader. The team members come from our various psychiatric units and may take 2-7 minutes to respond. There is only one code gold team each day so more than one code gold call at a time will delay response further.
- Do not ask that the patient be medicated prior to being restrained (not just held down). This is for the patient and staff safety. If the patient is restrained to the paramedic gurney, the code gold team leader will make the decision on how secure and safe he/she feels the situation is. The primary nurse will be responsible for medicating the patient.
- The Code Gold team leader will huddle with the primary RN and provider – why was the code called and what is the plan? This needs to be a conversation taking into account the safety and concerns of everyone.
- It is a regulatory requirement that a debriefing occur immediately after the code situation has concluded. The primary RN and provider should be available to participate in the post debriefing.
- If you are concerned that an agitated patient may become violent and feel you need support while determining capacity or hold criteria, you may call the Sheriffs at x64450 to briefly standby during your initial assessment (they are unable to stay for a prolonged time period).
- Always utilize de-escalation tactics such as active listening, a calm but firm voice, being down at eye level, providing personal space, offering choices, and providing food.
- At the same time, it is imperative you keep your distance and maintain situational awareness, preserving unimpeded access to the doorway for rapid escape.
- Recognize that the presence of law enforcement may escalate or de-escalate the situation and adjust accordingly.
- Be aware that the Sheriffs are not legally allowed to touch or physically restrain a patient unless a crime has occurred (eg, someone has already been assaulted).
- If the patient’s behavior escalates, please call a Code Gold and document/timestamp the rationale and restraint orders as soon as possible.
ED Policy #6 (OSA)
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
- Examples of clinical evidence include
- 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.
Covid Psych Patients
- 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%
- 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)
- 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):
- If the psych team is concerned about a patient’s medical condition, med ED can be consulted for evaluation at any time.
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.
- Adult Attending x66902 (or x66906 as backup) or PED attending x66910 (or PED Sr. Resident x66911 as backup)
- Exodus Charge RN calls the ED to initiate transfer (call both ED physician and ED nurse).
- 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.
- Exodus will transfer the patient to the ambulance entrance of the ED via wheelchair or van with both a nurse and security officer
- 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.).
- 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.
- 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.
- 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.
- 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