Evening Call ER Coverage

Evening Call (on pager 5PM – 9PM):

• First year fellows from UCLA, UCLA-Harbor, and UCLA-Kern all share evening call assignments. To check the call schedule, visit www.amion.com, Login: uclapsy

–       You are capped at 3 consults per evening call shift. #

• At 5PM, check the ER psychiatry SW sign out email to see if there are any pending ER child consults (children 17 and younger), any direct admissions to 4W, or any urgent child CL consults (e.g., emergent transplant clearance).
• For any of the above cases, you should receive a page from the R3 on-call, confirming that the case is ready to be seen. In the case of direct admissions, you may also be paged directly by the unit when the patient arrives on the floor.
• The R3 on-call will receive all ER consults directly until 10PM, and will page you (text or e-mails do not count as pages) with consult information when a case is called anytime before 9PM (see NOTE below). The bare minimum consult information includes patient name, MRN, and consulting physician name and callback number. If the R3 receives a page AFTER 9PM (i.e. 9PM and on), you are NOT responsible for this consult. If an ER resident pages you directly, refer them to the adult psychiatry resident for proper triage.
  • If you’d like to work in the same call room as the residents, here are the details: the CL room Reagan 4521 near the 4N unit. This is totally encouraged if you want to use it!
  • Residents now have all your contact information (cells, emails). When residents get a new consult, the R3 will return the page. They will then notify you – we emphasized that the paging is still the expected method of being informed of a consult. This page should also include the original time stamp from the ED in case there are any concerns about the timing. We ask that you confirm that you received the page so the resident knows you’re on it and they know their page went through.
• Do NOT see: 4W patients with overnight issues (that’s the psych resident’s job),

non-urgent child CL consults (sign out to the next day), and consults from UCLA Santa Monica (if urgent, may curbside with guidance from on-call attending; if non-urgent, forward consult to UCLA SM CL (Dr. Natalie Ramos at nramos@mednet.ucla.edu and Natacha Emerson at nemerson@mednet.ucla.edu)

• Staff each case with the child psychiatry on-call attending listed on Amion. Page them through the UCLA system.
• It’s 8:59PM and you get…paged. Argh. It’s happened to us all. Even 2 consults at 8:59. Technically, we are responsible for these consults. However, we are also responsible for taking off 8 hours between shifts per ACGME, and we recognize that calling in late for work the next day can be a real pain. If you DO get 1 consult at 8:59PM and have not reached a total of 3 consults and have not had a prior consult within the last hour, it’s yours. However if you get 2 consults within the period of 8:30 – 9PM, talk to the R3 on call and refer to the resident policy below, which was collaboratively developed, in order to request additional support:

Child Fellows are responsible for child psych ER consults, floor consults, and direct admissions of patients 17 and under from 5-9PM. Child fellows will be up first for child consults until 9:00 PM but caps at three consults total, and should not be asked to see more than two consults after 8 PM; additional child consults are seen by backup, the adult residents, or the moonlighter. At the discretion of #

the on-call R3 (depending on adult consult volume), moonlighters may also be asked to see child consults if the child fellow cannot start the consult within 90 minutes or if the child fellow has received more than one consult between 8:30 and 9:00.

• NOTE: As above, all child consult pages received by the R3 prior to 9PM are the responsibility of the fellow, provided you have not capped at 3 total. For example, you may be paged AFTER 9PM (i.e. 903PM) and be responsible for the consult if the R3 received the page at 859PM. They will e-mail you the page timestamp to ensure full transparency about the timing of the page. The new policy is outlined here:

ED Consults with initial page timestamp before cut off time, and paged to the resident/fellow within 10 minutes of the cut off time (e.g. 9:10), are the responsibility of the resident/fellow. #

• Besides the adult residents and the moonlighter, if volume is high, “backup” may be utilized. This is a voluntary system initiated by the on-call R3 by email, soliciting psychiatry residents and child fellows to take overflow cases. If you respond and take a case, each adult consult will yield $200 and each child case will yield $250 which will be added to your next paycheck. Taxes will be deducted.
• Really do take the 8 hours off between shifts. It will be tempting not to sometimes, but it is better for you and your patient care. When you are in the ER late, email your service attending, co-fellows and chiefs to let them know you will be late the next day.
• At the end of each shift, make sure 1) all relevant documentation is complete (admission consent, medication consent, orders, note) and 2) everyone who needs to be contacted has been updated (attending, ER resident, 4W staff, SW), and 3) send “reply all” email with dispo information for the consults you have seen to the sign-out thread.
  • Use Reply All. Do not change the subject heading. Include:
    • Status: Admitting Service (NPH or other), Board & Transfer
    • Patient name
    • MRN
    • Legal Status: Vol, 5585
    • “1 liner”
    • Important information and any To Do’s
  • When you have a dispo plan secured and are letting the ED physician know, please page or email the resident (R3, or R2 if after 10pm) with a FYI of the dispo plan as this helps them with their workflow especially if there is any delay in the signout email being sent out.
  • IF it is late and you are exhausted and want to postpone finishing your full consult note until the morning, enter in a brief progress note stating the plan. This will help eliminate any confusion if issues post-discharge emerge. As an example: “Pt seen, chart reviewed, case discussed with attending and ER resident. Dispo plan for discharge. Safety planning reviewed with parents, f/u plan for aftercare with psychiatrist within 1 week and therapist within 72 hours. Full note pending.”

Note: For all shifts, if you discharge a patient who arrived on a 5585, discontinue the order manually on EPIC. ER residents will not discontinue this order themselves and will request psychiatry to discontinue, for legal purposes. #

What to do when…

• You need to staff a patient and the attending is MIA
  • Wait 10 minutes after initial page
  • Page a second time, wait 10 minutes
  • Reference childwiki to find a list of alternative numbers to contact attending (cell phone/house phone) or call page operator at 66766 to try and reach attending by cell-phone on file.
  • Hit up your fellow fellows to see if they have any additional contact information.
  • Still no luck…look on amion and page the on-call attending for the following day (if it is Friday look for the next new attending on call either for Sunday or Monday). Wait 10 minutes for them to respond.
  • Finally, if NO ONE has called you back, page Dr. Richards. If she is not available or on vacation the next in line is Dr. McCracken.
  • Let your chiefs know of any instances where you have difficulty reaching an attending. We are keeping track!

• There are no beds on 4W and patient requires admission:
  • Board and transfer the patient. They MUST be on a 5585 hold to be transferred.

This feels unnecessary when a family is willing to sign in voluntarily, but unfortunately outside facilities will not accept a voluntary transfer due to liability risk of elopement, refusal, etc.

• Parents will frequently ask which hospital the patient will be transferred to or request a specific hospital, including UCLA. Let them know that we have no control over that process and are obligated by EMTALA to transfer the patient to the first accepting hospital and provide them the urgent psychiatric care that they need. There are no exceptions to this process.
  • If a parent continues to relent about wanting a UCLA bed as opposed to outside facility, see below.
  • Fill out 5585 hold on Careconnect (see instructions below)
  • Overnight, the assigned SW will be consulted through the B&T order set and will attempt to transfer the patient. If you need to speak to the overnight SW directly, page them at p97777 with the patient’s name, MRN, and category of hold (DTS/DTO/GD).
  • Complete “co-management order set” including labs (CBC, BMP, UA, Utox, pregnancy test) needed for transfer (see below for instructions)

• There are no beds on 4W and family wants a UCLA bed:
  • Beds can never be guaranteed. If the patient is an imminent risk and in your judgment they require hospitalization, they need to be placed on a hold and boarded and transferred. Parents cannot refuse transfer if you and the attending

believe they need admission and no 4W bed is available. Please refer to the flow chart at the end of the purple book for further information. This flow chart and language have been formulated with input of multiple entities (including risk management, hospital administration, 4W, etc.)

• If, however, the patient is NOT at imminent risk and family is able to appropriately safety plan, you can direct them to Admissions (310-267-8009) to find out when a bed is available, with the expectation that it may take 1-2 weeks for availability. This is especially appropriate for youth with eating disorders.

Those patients can be directed to Leah Parrent at 310-948-8170 for coordinating a 4W admission.

• You are admitting a ward of the court or foster youth:
  • This is a VOLUNTARY admission even though it’s arranged by the court. A minute order by the court acts as the admission paperwork.
  • Even with the minute order, if the child is older than 12, he/she MUST AGREE to admission and sign the Terms and Conditions Consent Form
  • JV-220 forms must be filled out to start any psychiatric medications (even Benadryl for sleep!). Give the completed form to 4W nursing staff so it can be faxed to the court. You will generally be completing Form JV-220A. It is available at: https://www.courts.ca.gov/documents/jv220a.pdf

• Your patient is violent or agitated:
  • ER resident will put patient on a “medical detainment” which allows security to monitor them closely in psych rooms. This is not the same as a 72-hour hold.
  • Patients on a 72-hour hold must be monitored at all times. Communicate with ER resident and nursing staff/security regarding offering/administrating PRNs.
  • If you are seeing escalating behavior or psychotic agitation, let ER security and RN know to watch the patient closely to avoid acts of self-harm or violence.
  • If the patient has ASD and is agitated, try to reduce stimulation and control the environment. Turn off bright lights, have as few people in the room as is safe, consider closing the door to reduce outside noise and try to have a parent present if that is helpful. These minor changes can often reduce the likelihood of the patient needing restraints or an IM. Avoid Benzos in this population as they can often be disinhibiting and worsen agitation.

• You got a C/L consult at night?!
  • Gather info and discuss urgency of consult with on-call child psych attending.

Most can be deferred to AM and included in email sign-out.

• If truly urgent and it comes before 9pm, see consult and staff with on-call attending. It will count towards your cap of 3 consults each night.
  • Whether you defer or staff overnight, email the daytime child psychiatry and psychology attendings with relevant information to ensure follow-up.

Helpful Tips! #

• For any questions about workflow – please direct them to your chiefs, Ashley and Rahael! Residents are a bit busy to talk through this stuff and that’s what we are here for. Don’t be

shy about reaching out! Also, the social group WhatsApp thread can also be a helpful resource for questions as some of us are night owls.

• Please put PRNs in for your patients when possible for sleep, anxiety, pain, agitation. All patients should have a PRN agitation.
• Fellows do not use the Epic signout tool for inpatient and CL. Weekday signout: If there are any signouts for the weekdays, then that should go in an email to the UCLA R3, R2 Float, R1 Float.
  • Weekend signout: Fellows on inpatient and CL sometimes send signout to the weekend attendings about contingencies when necessary. Please add weekend PGY1s, 2s, and 3s to be to these emails. Those on inpatient, please include contingencies in your Friday notes.
  • The people to cc on any weekend signout are:
    • Friday UCLA R3, R2 Overnight, R1 Overnight
    • Saturday: UCLA R3, R2 Overnight, R1 Overnight
    • Sunday: UCLA R3, R2 Float, R1 Float
  • The biggest takeaway is closed loop communication which we think may alleviate some of the anxiety that naturally happens on call. We also want to build up a sense of camaraderie with the residents, so our working relationship is built on a solid foundation.