Managing The Behavioral Health Patient in LSU-HCSD

1. Managing The Behavioral Health Patient in LSU-HCSD Presentation To The Mental Health Improvement Task Force By Michael K. Butler, MD, MHA, CPE October 24, 2006

2. Behavioral Health Medical Screening Exam The process of determining whether a serious medical illness exists that makes admission to a psychiatric facility unsafe or inappropriate.

3. Goals • Standardized Medical Screening For the Behavioral Health Patient • Appropriate Laboratory Testing • Understanding EMTALA Rules • Standard Transfer Protocols

4. Goals • Safe and Appropriate Patient Disposition • Adequate Documentation of Psychiatric and Co-existent Medical Diagnoses • Accurate Communication of Findings To Psychiatric Unit and Facility • Minimize the time to disposition of patient • Minimize the cost of the screening exam

5. Issues for PMSE • Is the patient impaired or not? • Is there a medical cause for the suspected behavioral health problem? • Do they have an unstable medical condition? • Is the person suicidal, homicidal, or gravely impaired?

6. Types of Patients • Type 1--Behavioral Health Problems Only (BHO) • Type 2--Behavioral Health and Stable Medical Condition (BH and SMC) • Type 3--Medical Problem Masquerading As Behavioral Health (MC Not BH) • Type 4--Behavioral Health Problem with Unstable Medical Condition (BH and UMC)

7. Pitfalls Negative Counter Transference Intoxication and Withdrawal Fundamental Attribution Error

8. Differential Diagnoses Delirium Dementia Psychosis

9. Delirium • Intracranial Disease • Systemic Disease with CNS Involvement • Substance Abuse Withdrawal • Toxic Exposures

10. Dementia • Gradual Loss of Cognitive Abilities • Clear Level of Consciousness • Non-Fluctuating over The Day • Primary Deficit—Impaired Short Term Memory

11. Psychosis—Organic Causes • Age greater than 40 • New Diagnosis of Psychosis • Abnormal Vital Signs • Recent Memory Loss • Clouded Consciousness

12. Vital Signs • Blood Pressure • Pulse • Temperature • Oxygenation Assessment

13. Key Historical Information • Age of Onset of Behavioral Symptoms • Past Medical History • Past Psychiatric History • Recent Illness, Hospitalization, Surgery or Trauma • Suicidal or Homicidal Ideation (Thoughts and Plans) • Access To Firearms • Drug or Alcohol Use • Hallucinations (Visual, Auditory, or Tactile)

14. Vital Signs Appearance (Grooming) Level of Attention Affect Eye Contact Speech Signs of Head Trauma Eye—EOM and Fundoscopic Neck Exam—Nuchal Rigidity and Thyroid Enlargement Chest Exam-Pneumonia, CHF, or Arrhythmias Stigmata of Cirrhosis Skin—Cold Clammy, Hot and Sticky Physical Findings

15. Orientation Mood Affect Memory Language Attention Calculation Abstraction General Information Judgments Thoughts Mental Status Exam

16. Brief Mental Status Examination

17. CBC Complete Metabolic Profile Urinalysis Urine or Serum B-HCG Urine Toxicology Screen TFT (TSH) RPR or VDRL PT/PTT Chest X-Ray EKG Blood Alcohol Level Laboratory TestingCurrent Regimen

18. Criteria For Laboratory Testing • Age Greater Than 40 • New Onset Psychiatric Complaint • Abnormal Vital Signs • Abnormal Physical Findings • Abnormal Neurological or Mental Status Exams

19. MADFOCSDifferentiation Between the Organic and the Psychiatric Patient • Memory • Activity • Distortion • Feelings • Orientation • Cognition • Some Other Findings

20. MADFOCS Mnemonic

21. Sensitivity of Detecting Medical Issues in the Behavioral Health Patient • History—94% • Physical Examination—50% • Mental Status Examination—72% • Laboratory Assessment--<50%

22. Disposition of Patients • Type 1—BHO: Referral to In-Patient or Out-Patient Psychiatric Care • Type 2—BH and SMC: Referral to In-Patient or Out-Patient Psychiatric Care with medical consultation as needed. • Type 3—MC not BH: Admission to Medical Service for treatment of Medical condition • Type 4—BH and UMC: Admission to Medicine for Stabilization of medical condition and then transfer to psychiatric service

23. Suicide Risk Factors: SAD PERSONS • S Sex-Males are at greater risk for completion while females attempt more often. • A Age: Bimodal distribution with increased incidence among adolescents and people older than 50 years • D Depression or other psychiatric illness

24. Suicide Risk Factors—SAD PERSONS • P Previous Attempts • E Ethanol or Other Drug Use • R Recent Stressor: loss of a loved one, job, or significant life change • S Social Support Lacking: Lack of interaction with friends or therapist • O Organized Plan: One should inquire about the specific plan, if a patient has formulated one. • N No Spouse: similar to lack of social support. Single people are at increased risk. • S Sickness: Any chronic medical illness

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