LSU Health Care Services Division Managing The Behavioral Health Patient in LSU-HCSD Presentation To...

LSULSU Health Care Services DivisionHealth Care Services Division

Managing The Behavioral Health Managing The Behavioral Health Patient in LSU-HCSDPatient in LSU-HCSD

Presentation To The Mental Health Improvement Presentation To The Mental Health Improvement Task ForceTask Force

By By Michael K. Butler, MD, MHA, CPEMichael K. Butler, MD, MHA, CPE

October 24, 2006October 24, 2006


Behavioral HealthBehavioral Health Medical Screening Exam Medical Screening Exam

The process of determining whether a The process of determining whether a serious medical illness exists that serious medical illness exists that makes admission to a psychiatric makes admission to a psychiatric facility unsafe or inappropriate.facility unsafe or inappropriate.


GoalsGoals

Standardized Medical Screening For Standardized Medical Screening For the Behavioral Health Patientthe Behavioral Health Patient

Appropriate Laboratory TestingAppropriate Laboratory Testing Understanding EMTALA RulesUnderstanding EMTALA Rules Standard Transfer ProtocolsStandard Transfer Protocols


GoalsGoals

Safe and Appropriate Patient DispositionSafe and Appropriate Patient Disposition Adequate Documentation of Psychiatric Adequate Documentation of Psychiatric

and Co-existent Medical Diagnosesand Co-existent Medical Diagnoses Accurate Communication of Findings To Accurate Communication of Findings To

Psychiatric Unit and FacilityPsychiatric Unit and Facility Minimize the time to disposition of patientMinimize the time to disposition of patient Minimize the cost of the screening examMinimize the cost of the screening exam


Issues for PMSEIssues for PMSE

Is the patient impaired or not?Is the patient impaired or not? Is there a medical cause for the Is there a medical cause for the

suspected behavioral health suspected behavioral health problem?problem?

Do they have an unstable medical Do they have an unstable medical condition?condition?

Is the person suicidal, homicidal, or Is the person suicidal, homicidal, or gravely impaired?gravely impaired?


Types of PatientsTypes of Patients Type 1--Behavioral Health Problems Only Type 1--Behavioral Health Problems Only

(BHO)(BHO) Type 2--Behavioral Health and Stable Type 2--Behavioral Health and Stable

Medical Condition (BH and SMC)Medical Condition (BH and SMC) Type 3--Medical Problem Masquerading Type 3--Medical Problem Masquerading

As Behavioral Health (MC Not BH)As Behavioral Health (MC Not BH) Type 4--Behavioral Health Problem with Type 4--Behavioral Health Problem with

Unstable Medical Condition (BH and Unstable Medical Condition (BH and UMC)UMC)


PitfallsPitfalls

Negative Counter TransferenceNegative Counter Transference

Intoxication and WithdrawalIntoxication and Withdrawal

Fundamental Attribution ErrorFundamental Attribution Error


Differential DiagnosesDifferential Diagnoses

DeliriumDelirium

DementiaDementia

PsychosisPsychosis


DeliriumDelirium

Intracranial DiseaseIntracranial Disease

Systemic Disease with CNS Systemic Disease with CNS

InvolvementInvolvement

Substance Abuse WithdrawalSubstance Abuse Withdrawal

Toxic ExposuresToxic Exposures


DementiaDementia

Gradual Loss of Cognitive AbilitiesGradual Loss of Cognitive Abilities Clear Level of ConsciousnessClear Level of Consciousness Non-Fluctuating over The DayNon-Fluctuating over The Day Primary Deficit—Impaired Short Primary Deficit—Impaired Short

Term MemoryTerm Memory


Psychosis—Organic CausesPsychosis—Organic Causes

Age greater than 40Age greater than 40

New Diagnosis of PsychosisNew Diagnosis of Psychosis

Abnormal Vital SignsAbnormal Vital Signs

Recent Memory LossRecent Memory Loss

Clouded ConsciousnessClouded Consciousness


Vital SignsVital Signs

Blood PressureBlood Pressure

PulsePulse

TemperatureTemperature

Oxygenation AssessmentOxygenation Assessment


Key Historical InformationKey Historical Information

Age of Onset of Behavioral SymptomsAge of Onset of Behavioral Symptoms

Past Medical HistoryPast Medical History

Past Psychiatric HistoryPast Psychiatric History

Recent Illness, Hospitalization, Surgery or TraumaRecent Illness, Hospitalization, Surgery or Trauma

Suicidal or Homicidal Ideation (Thoughts and Plans)Suicidal or Homicidal Ideation (Thoughts and Plans)

Access To FirearmsAccess To Firearms

Drug or Alcohol UseDrug or Alcohol Use

Hallucinations (Visual, Auditory, or Tactile)Hallucinations (Visual, Auditory, or Tactile)


Physical FindingsPhysical Findings

Vital SignsVital Signs

Appearance (Grooming)Appearance (Grooming)

Level of AttentionLevel of Attention

AffectAffect

Eye ContactEye Contact

SpeechSpeech

Signs of Head TraumaSigns of Head Trauma

Eye—EOM and Eye—EOM and

FundoscopicFundoscopic

Neck Exam—Nuchal Neck Exam—Nuchal

Rigidity and Thyroid Rigidity and Thyroid

EnlargementEnlargement

Chest Exam-Pneumonia, Chest Exam-Pneumonia,

CHF, or ArrhythmiasCHF, or Arrhythmias

Stigmata of CirrhosisStigmata of Cirrhosis

Skin—Cold Clammy, Hot Skin—Cold Clammy, Hot

and Stickyand Sticky


Mental Status ExamMental Status Exam

OrientationOrientation MoodMood AffectAffect MemoryMemory LanguageLanguage AttentionAttention

CalculationCalculation AbstractionAbstraction General General

InformationInformation JudgmentsJudgments ThoughtsThoughts


Brief Mental Status ExaminationBrief Mental Status Examination


Laboratory TestingLaboratory TestingCurrent RegimenCurrent Regimen

CBCCBC

Complete Metabolic Complete Metabolic

ProfileProfile

UrinalysisUrinalysis Urine or Serum B-Urine or Serum B-

HCGHCG

Urine Toxicology Urine Toxicology

ScreenScreen

TFT (TSH)TFT (TSH)

RPR or VDRLRPR or VDRL

PT/PTTPT/PTT

Chest X-RayChest X-Ray

EKGEKG

Blood Alcohol LevelBlood Alcohol Level


Criteria For Laboratory TestingCriteria For Laboratory Testing

Age Greater Than 40Age Greater Than 40

New Onset Psychiatric ComplaintNew Onset Psychiatric Complaint

Abnormal Vital SignsAbnormal Vital Signs

Abnormal Physical FindingsAbnormal Physical Findings

Abnormal Neurological or Mental Status Abnormal Neurological or Mental Status

ExamsExams


MADFOCSMADFOCSDifferentiation Between the Differentiation Between the

Organic and the Psychiatric PatientOrganic and the Psychiatric Patient MemoryMemory ActivityActivity DistortionDistortion FeelingsFeelings OrientationOrientation CognitionCognition Some Other FindingsSome Other Findings


MADFOCS MnemonicMADFOCS Mnemonic


Sensitivity of Detecting Medical Issues in Sensitivity of Detecting Medical Issues in the Behavioral Health Patientthe Behavioral Health Patient

History—94%History—94%

Physical Examination—50%Physical Examination—50%

Mental Status Examination—72%Mental Status Examination—72%

Laboratory Assessment--<50%Laboratory Assessment--<50%


Disposition of PatientsDisposition of Patients

Type 1—BHO: Referral to In-Patient or Out-Type 1—BHO: Referral to In-Patient or Out-Patient Psychiatric CarePatient Psychiatric Care

Type 2—BH and SMC: Referral to In-Patient or Type 2—BH and SMC: Referral to In-Patient or Out-Patient Psychiatric Care with medical Out-Patient Psychiatric Care with medical consultation as needed.consultation as needed.

Type 3—MC not BH: Admission to Medical Type 3—MC not BH: Admission to Medical Service for treatment of Medical conditionService for treatment of Medical condition

Type 4—BH and UMC: Admission to Medicine Type 4—BH and UMC: Admission to Medicine for Stabilization of medical condition and then for Stabilization of medical condition and then transfer to psychiatric servicetransfer to psychiatric service


Suicide Risk Factors: SAD PERSONSSuicide Risk Factors: SAD PERSONS

S Sex-Males are at greater risk for S Sex-Males are at greater risk for completion while females attempt completion while females attempt more often.more often.

A Age: Bimodal distribution with A Age: Bimodal distribution with increased incidence among increased incidence among adolescents and people older than adolescents and people older than 50 years50 years

D Depression or other psychiatric D Depression or other psychiatric illnessillness


Suicide Risk Factors—SAD PERSONSSuicide Risk Factors—SAD PERSONS P Previous AttemptsP Previous Attempts E Ethanol or Other Drug UseE Ethanol or Other Drug Use R Recent Stressor: loss of a loved one, job, or R Recent Stressor: loss of a loved one, job, or

significant life changesignificant life change S Social Support Lacking: Lack of interaction S Social Support Lacking: Lack of interaction

with friends or therapistwith friends or therapist O Organized Plan: One should inquire about the O Organized Plan: One should inquire about the

specific plan, if a patient has formulated one.specific plan, if a patient has formulated one. N No Spouse: similar to lack of social support. N No Spouse: similar to lack of social support.

Single people are at increased risk.Single people are at increased risk. S Sickness: Any chronic medical illnessS Sickness: Any chronic medical illness


ReferencesReferences

Lemonick, MD, David M., “Conducting Lemonick, MD, David M., “Conducting Medical Clearance of the Psychiatric Medical Clearance of the Psychiatric Patient”, Patient”, Emergency Medicine,Emergency Medicine, March, 2006, pp. 10-19.March, 2006, pp. 10-19.

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