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LSU Health Care Services Division 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 LSU Health Care Services Division 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. LSU Health Care Services Division Goals Standardized Medical Screening For the Behavioral Health Patient Appropriate Laboratory Testing Understanding EMTALA Rules Standard Transfer Protocols LSU Health Care Services Division 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 LSU Health Care Services Division 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? LSU Health Care Services Division 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) LSU Health Care Services Division Pitfalls Negative Counter Transference Intoxication and Withdrawal Fundamental Attribution Error LSU Health Care Services Division Differential Diagnoses Delirium Dementia Psychosis LSU Health Care Services Division Delirium Intracranial Systemic Disease Disease with CNS Involvement Substance Toxic Abuse Withdrawal Exposures LSU Health Care Services Division Dementia Gradual Loss of Cognitive Abilities Clear Level of Consciousness Non-Fluctuating over The Day Primary Deficit—Impaired Short Term Memory LSU Health Care Services Division Psychosis—Organic Causes Age greater than 40 New Diagnosis of Psychosis Abnormal Recent Vital Signs Memory Loss Clouded Consciousness LSU Health Care Services Division Vital Signs Blood Pressure Pulse Temperature Oxygenation Assessment LSU Health Care Services Division 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) LSU Health Care Services Division Physical Findings 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 LSU Health Care Services Division Mental Status Exam Orientation Calculation Mood Abstraction Affect General Memory Information Judgments Thoughts Language Attention LSU Health Care Services Division Brief Mental Status Examination LSU Health Care Services Division Laboratory Testing Current Regimen TFT (TSH) Complete Metabolic RPR or VDRL Profile PT/PTT Urinalysis Chest X-Ray Urine or Serum BHCG EKG Urine Toxicology Blood Alcohol Level CBC Screen LSU Health Care Services Division Criteria For Laboratory Testing Age Greater Than 40 New Onset Psychiatric Complaint Abnormal Vital Signs Abnormal Physical Findings Abnormal Exams Neurological or Mental Status LSU Health Care Services Division MADFOCS Differentiation Between the Organic and the Psychiatric Patient Memory Activity Distortion Feelings Orientation Cognition Some Other Findings LSU Health Care Services Division MADFOCS Mnemonic LSU Health Care Services Division Sensitivity of Detecting Medical Issues in the Behavioral Health Patient History—94% Physical Mental Examination—50% Status Examination—72% Laboratory Assessment--<50% LSU Health Care Services Division Disposition of Patients Type 1—BHO: Referral to In-Patient or OutPatient 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 LSU Health Care Services Division 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 LSU Health Care Services Division 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 LSU Health Care Services Division References Lemonick, MD, David M., “Conducting Medical Clearance of the Psychiatric Patient”, Emergency Medicine, March, 2006, pp. 10-19.