- Review patient chart:
- To find a patient record in CareConnect, go to the “System lists / Units – RR / ED”. You can also access the ED trackboard by switching the Care Connect context to “RR- ED”. You can also go to “Pt Station” and search by MRN. Remember to use the “MD Psy Consult Liaison” context for orders and documentation.
- It is helpful to review ED notes from this visit, the outside 5150 if applicable (Chart Review activity, Media tab, scanned in as “legal”), vitals and labs from this visit, any prior psych notes (Chart Review activity, Notes tab, click “Filters” and try filtering by document type (H&P, DC summary, consults, etc.) or by author specialty – Child Psychiatry, Psychology, etc.)
- We no longer have to determine insurance status as we now accept Medi-Cal!
2) Evaluate the patient: SAFETY FIRST! #
- As you prepare to see the patient, introduce yourself to Security or the Constant Observation Aid (COA) and ask about any safety concerns (ask: is the patient calm? any behavioral problems, any agitation?) Only proceed with evaluation when safe. For advice on managing an agitated patient, refer to Purple Book -> Inpatient – > Floor Issues
-> Psychiatric -> Acute Agitation/Violence.
- Evaluation should focus on the history of present illness, safety, acute management, and disposition:
- Why has the patient come to the ED now?
- What acute management does the patient need now (meds, restraints, labs or medical workup, medical hospitalization, etc…)?
- Does the patient need a hold for DTS, DTO or GD?
- What is the lowest level of care at which the patient can be safely managed?
- Please complete and document a medication reconciliation for all patients who are boarding or admitting to psychiatry.
- As safety allows (e.g. not in acutely agitated patients), please complete a review of systems and physical exam (including full cranial nerve exam) for all patients who are being admitted to psychiatry. This can often be done after staffing, when you go back to advise the patient of the plan.
3) Collateral information and exceptions to confidentiality: #
- You must always attempt to contact a minor’s legal guardians. You do not need consent to contact a minor’s legal guardians or treatment providers (HIPAA and California law). Always make an attempt to contact the patient’s outpatient provider(s), no matter what time it is. Their patient is having a psychiatric emergency, and they should be made aware. They may have valuable history and can participate in disposition options. It is OK to leave a voice message and the ED office as the call back # (310-267-9071).
- Pt consent is generally needed to contact other family members, friends, or any other
person. Please try to obtain consent to contact at least one family member or friend for additional collateral information.
- There are 3 exceptions to the rule of patient confidentiality (always discuss with your attending and document when you break confidentiality):
- Situations that you judge to be a medical or psychiatric emergency and you need collateral information to provide emergency care
- Tarasoff Principle: Physician must warn the authorities and targeted individual about a direct threat to harm; see Blue Book -> Outpatient -> Logistics -> Legal Issues/Paperwork for details and discuss with your attending.
- Mandated Reporting: Suspected child (DCFS) (see Purple Book: Section 1 Policies and Procedures>Neglect and Abuse Reporting) or elder/dependent adult abuse (APS) (see Blue Book: ED/CL > UCLA > Legal > DCFS/APS Reporting) and discuss with your attending.
- Other helpful sources of collateral:
- Care Connect historical records: an easy way to locate records is to use the “filter” function in chart review. In Chart Review activity, Notes tab, click “Filters” and try filtering by document type (H&P, DC summary, consults, etc.) or by author specialty – Psychiatry, Psychology, etc.
- Care Everywhere: a function in Care Connect that can query other medical centers and providers who use EPIC. Must be actively queried using “request outside records” – see Blue Book -> ED/CL -> UCLA -> Collateral/Outside Records
- CURES: California (and other states) controlled substance database. Highly useful for investigating possible substance misuse / abuse, and malingering for narcotics. Must have a login/password granted by the State. All Attendings have access (psychiatry, emergency physician, etc…), and most R3’s should have access.
- EDIE: “Emergency Department Information Exchange” (EDIE) is a record that will be automatically populated as a new note in the chart when a patient arrives to the ED, if he or she has been a frequent visitor to other ED’s. You will find information in the EDIE note that may include the patient’s frequency of visits, diagnoses, cautions/warnings, and care plans.
- Pharmacy records: if you need to know the patients current prescriptions or fill patterns, you can access this if you know the patient’s pharmacy phone. Simply call and state your role as Other Sources of Collateral Information: the patient’s current provider in the emergency or inpatient setting. You can also ask the pharmacist who the last prescriber was and that person’s phone number (refer to #1 above)
- MIS records: Department of Mental Health County database that has some limited information about a patient’s encounters and diagnoses in the County system. May also list a next of kin. Can be accessed only through the daytime ED/CL social workers.
4) Staffing with the attending: #
- If you have trouble reaching the on-call attending refer to the Blue Book section: ED/CL
-> UCLA-> Contacting UCLA Attendings. This can also be found online at: https://www.uclabluebook.com/ed-cl/ucla-call/attendings/ (pw: uclanpi)
- Tips for presenting to the attending:
- State your disposition plan upfront (i.e.,”I believe this patient requires admission” or “I believe this patient can be discharged w a good outpatient plan.”). Rely on a standard presentation of information (e.g. one liner, HPI, psychiatric hx, social/fam hx, medical hx, meds, vitals & labs, MSE, suicide risk assessment, assessment and plan). Provide a brief summary of HPI and the most relevant historical information. Note any positive exam, lab, or vital signs findings (You don’t need to “nail the diagnosis” or elicit an entire life history).
- Think about the reasons why the person should be admitted or discharged. Think about alternate disposition options (see Blue Book -> ED/CL -> UCLA -> Disposition Options) including referral for deferred elective admission, referral for partial hospitalization.
- Discuss the management of the pt’s acute needs:
- Are they medically stable for admission or do they need additional workup?
- Continuing home medications? Starting any new medications (especially for withdrawal and/or agitation, psychosis, mania, or anxiety)? What PRNs?
- For admits, you can defer most treatment decisions to the primary team, your goal is to get the patient safely through the night.
- If admitting to RNPH, what level of observation (routine – every 15 minutes? 1:1 for risk of SIB or suicide on the unit, severe agitation, etc.?) is required?
- If discharging, what referrals or resources should we provide? Your attending can likely help with this.
5) Contacting the referring ED physician: #
- If you cannot reach the ED physician immediately, you may leave a message with the central work area (CWA) staff at x78407 to have the ED MD call you back or to communicate non- urgent messages. However, ultimately it is your responsibility as the consultant to contact the ED physician.
- Verify medical clearance: Communicate any concerns about pt’s medical stability to ER physician. Request labs as indicated (for B&T, typically need CBC, BMP, LFTs, utox, upt). If appropriate, discuss additional w/u needed prior to psych admission (e.g. TSH, UA, CXR, EKG, CT head, ASA/APAP levels). For pts with eating disorders, obtain BMP, Mag, Phos, TSH, and EKG.
- If there is a disagreement regarding medical appropriateness for admission to RNPH, please refer to flow chart on page 130 for escalating decision making
- Provide your recommendations: Communicate your plan (addtl labs, meds, consultation with peds/neuro, transfer, admit to RNPH, discharge with resources, etc.).
6) Co-Management orders: #
- When you are placing orders or doing your consult documentation, be sure to switch from the “RR-ED” context in Epic to the “MD Psy Consult Liaison” context. Failing to do so will make it more difficult to write your notes or place orders. If you notice that you can no longer “pend” a note but must sign it, you are probably in the wrong context. You can change context by clicking the red “EPIC” button and finding it in the drop down.
- In CareConnect, once you are in the “MD Psy Consult Liaison” context, find the orders tab and the order set: “Psy Emergency Department Co-management Orders.” You should complete co-management orders on all ED patients whom you plan to admit to NPH or transfer, since waiting time for admission to a psychiatric bed (even NPH), is highly variable, and subject to unexpected delays. Delays and prolonged wait times contribute to patient anxiety, agitation, elopement, self-directed violence, acting-out behaviors, and negative outcomes.
- All patients should have oral and IM PRN’s for agitation, at the minimum. See bottom right corner of flowchart for standard child/adolescent PRN’s. For child PRNs: While in the ER and a child is acutely agitated, remember that benzodiazepines will often disinhibit a young child. Children with autism and developmental delay are often very sensitive to medications as well. It is helpful to use diphenhydramine 25 mg po q6h PRN anxiety, and chlorpromazine 25 or 50 mg po q1h PRN agitation (NTE 200 mg from all sources in 24 hours). For severe agitation, chlorpromazine may also be written to be given IM at same doses (i.e. 25 or 50 mg q1h) “if needed in event of emergent agitation to prevent imminent harm to self or others in event pt refuses PO meds”. Higher doses can be used for bigger, older children; can discuss with attending while staffing.
- If a patient is boarding (i.e. not being admitted to RNPH right away), discuss with ED resident whether home meds (inhalers, etc) should be continued in ED, as the patient may board for days.
- Consider additional baseline labs beyond what is needed for medical clearance (e.g. if admitting to RNPH and starting an antipsychotic, consider A1c and lipid panel; if starting lithium, BMP, calcium, TSH; if starting VPA, CBC and LFTs, etc.).
7) Legal Holds: #
- Minors can be signed in “voluntarily” by their guardians and, in this case, should not be placed on a hold, even if they meet criteria. Have parents fill out voluntary admission papers. If parents are not at bedside but can be reached by phone, telephonic consent can be obtained for a voluntary admission (and for medications; see section 8 below).
- Minors should be placed on a 5585 when clinically necessary due to agitated behavior, concern for elopement, or because their parent/guardian is not reachable, refuses to sign them in voluntarily, if there is concern about the guardians’ judgment, or if they will need to transfer to an OSH.
- Wards of the court can be admitted either on a 5585 or by court order (“minute order,” usually brought by agency workers to the ER with the patient).
- Whether initiating a new hold or accepting an outside hold, there are 3 steps to complete through CareConnect. You can find handwritten 5585s in Chart Review activity, Media tab. All hand- written 5585 applications (e.g. Law Enforcement holds) should be re-written as an e5585 in Care Connect (if you are continuing the hold). Please note the hold time always starts at the time of the initial law enforcement hold. See Blue Book -> ED/CL -> UCLA -> LPS Legal Documents for details. 5585 Child Holds are written as e5150s in Care Connect:
- Write note (type “legal”) for the “Psych 5150 Application”
- Write note (type “legal”) for the “Psych 5150 Advisement”
- Place the order for the 72-hour Hold
- To enter the e5150 hold and advisement:
- Select “New Note” in CareConnect.
- For the note “Type,” select “Legal.”
- In “Insert Smartype” box enter “5150” and press enter.
- First select, “Psych 5150 Application,” which will pre-populate the note.
- Use F2 to navigate through the form addressing all required components, items highlighted in red will not be accessed by F2 but must be addressed.
- Sign the note and repeat the initial steps to select and complete the “Psych 5150 Advisement.”
- Print a copy of the advisement for the patient (go to “Chart Review” to print).
8) Child & Adolescent Med Consents: #
- Med consents are required for all psychotropic medications. Guardians can sign medication consent forms for their children. If they are not physically present, they can offer telephonic consent; this can be done digitally or with a physical print out. For a physical version, print a Telephonic Consent form from the Forms Portal (Mednet website) and have a second staff member (resident, nurse, social worker, etc.) hear the verbalized consent and sign the form.
- For the digital version, make a new note, select “Legal” for note type and in the “Insert smart text” box (with the red and blue boxes), type “Psy tele” to find the digital telephonic consent form. On this form you will also need to have a second staff member witness and electronically co-sign it by adding them as a co-signer. This form can simultaneously be used to consent for both medications and for voluntary admission.
- If the child is a ward of the court, there is a special packet called the JV-220 available on the child unit, that needs to be filled out and faxed to the court for approval.
- All attempts should be made to obtain consent for psychotropic medications prior to admission. If guardians are unreachable or JV-220 is pending, you may order benadryl oral PRN and thorazine emergency IM x 1 “if needed in event of emergent agitation to prevent imminent harm to self or others in event pt refuses PO meds.”
9) Page ED Central Work Area (CWA): #
- Once the patient is medically cleared, and when you have received a unit and bed assignment for the patient and the estimated time (ETA) that the patient can be admitted, page (p93957) or call x78407 this information to the ED CWA. The CWA will disseminate the message to the ER nurse, SW, and MD. This can also take some time if a COVID test has not been completed and therefore, can be communicated as a TO-DO in the signout in the next section.
10) Signout: #
- You must complete signout for any patient seen overnight or on a weekend who was not discharged, which includes all patients in the ED awaiting psychiatric hospitalization (both RNPH and transfer), and cases admitted to RRUCLA-MC or transferred to RRUCLA-MC from NPH (CL cases).
- Email the CL listerv with signout. Note that the ED/CL listserv is set up at 5pm by the psychiatry social worker, and you simply have to “reply all” to that list. Otherwise, the
- Status: Admitting Service (NPH or other), Board & Transfer, RRMC Transfer
- Patient name
- Legal Status: Vol, 5150, Medical Incapacity
- “1 liner”
- Important information and To Do’s (i.e. “call CWA, pending COVID/labs”)
- In the “Care Teams” activity, add the “Psychiatry-Child-ED consult” team; for cases admitting to medicine/surgery who will be followed by CL, add both the
- Status: Admitting Service (NPH or other), Board & Transfer, RRMC Transfer
“Psychiatry-Child-ED consult” team and the “Psychiatry-Child-Consult Liaison” team.
- You may add brief signout notes (SnapShot activity, “Signout Notes” tab) into CareConnect as well, keeping in mind that it is visible to the primary team.
11) Dictate or type ED Psychiatric Consultation note: #
- The universal template for ED/CL consult notes is “.PsyEDCLNote,” then use F2 to select “Psy ED Consult.” Where you see two faint blue lines, please don’t delete them, and please make sure all data entry occurs between the lines (this allows the data you enter to
pre-populate into future notes).
- Keep the HPI BRIEF (1-2 paragraphs max), and focus on the following:
- Why was the patient seen in the ER?
- What is the presenting problem(s), including description of current episode, precipitating events, relevant psychological and social stressors etc… Quantify or qualify the problems by commenting on functional decline, and trajectory of symptoms (onset, duration, context and severity).
- What is the plan (psychiatric, medical, legal, disposition)?
- Collateral contact data (family, friends, outpatient providers)
- ROS and Physical Exam including full cranial nerve exam and required for all psychiatric admissions (but are not required for patients who are discharged, or admissions to a Non- Psychiatry service)
- Caution: Please be very careful with copying and pasting information from old records: be sure that the information is relevant, accurate, and up to date. Likewise, be very careful with “Auto- filled” problem lists, medications, and elements of the history. Please complete and document a careful medication reconciliation for all patients who are boarding or admitting.
- Dictation shortcut: Location #1 Westwood; Worktype #44 Outpatient Psychiatric Evaluation). You can find the patient’s “CSN” number in CareConnect patient header.
12) Transfers: #
- ED-Social workers are available 24/7 at pager 97777. To initiate the transfer process, enter into care connect the order called “Consult to social work – Transfer to psychiatric facility”, then page the ER SW p97777 to notify them of the patient requiring transfer.
Remember to complete co- management orders and appropriate signout.
- Families frequently attempt to refuse transfer to an outside hospital. If a patient is on a hold and is determined to need psychiatric hospitalization, they may be hospitalized (and therefore transferred) against their will or preference. In contrast, a patient who is “voluntary” cannot be transferred against their will. It is preferable that we do our best to accommodate patient/family requests. However, if a patient is on a hold and requires hospitalization, guardians cannot refuse hospitalization/transfer. It can be helpful to tell the patient/family that we understand their preferences but, in a psychiatric emergency, we are ethically and legally obligated to get the patient the appropriate level of care (e.g. inpatient psychiatric services) in a timely manner. Any significant conflicts with patients or their families over such transfers should be discussed in the moment with the on-call child attending as well as the ED attending to jointly weigh the risks and benefits of transferring vs. making an exception to board for NPH specifically vs. discharge home with deferred elective admission or other resources. The clinical decision-making should be documented. The flowchart for escalating decision making can be found on page 128.
13) Resources/Referrals: #
- We can and should attempt to refer patients to appropriate follow up care when they are discharged from the ER. When necessary, we should also provide referrals for appropriate community resources. Please see concise list of discharge resources for children and adolescents that is kept in the ED social work room (x79071). This list is also available on bluebook and below on page 116 which can be printed and handed to families.
- Please consider using the crisis f/u phone call service described below for patients 13+ with suicidal ideation who are discharged.
- Crisis Follow up services (provided by Didi Hirsch): the Didi Hirsch Suicide prevention center will make outreach follow up calls to any patient age 13+ who was evaluated for suicidal ideation or behavior in the ED. They will assist with linkage to outpatient care and programs, safety planning, emotional support and coping.
- The patient only needs to verbally consent to being contacted. Leave a very brief message at
(424-362-2930) with your name, your callback number, patient’s full name, age, gender, patient’s best contact number, and the reason for referral. The patient can expect a call within 48 hours.
- Ask minors if we can give their guardian’s contact info to Didi Hirsch.