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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
LSULSU Health Care Services DivisionHealth Care Services Division
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.
LSULSU Health Care Services DivisionHealth Care Services Division
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
LSULSU Health Care Services DivisionHealth Care Services Division
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
LSULSU Health Care Services DivisionHealth Care Services Division
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?
LSULSU Health Care Services DivisionHealth Care Services Division
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)
LSULSU Health Care Services DivisionHealth Care Services Division
PitfallsPitfalls
Negative Counter TransferenceNegative Counter Transference
Intoxication and WithdrawalIntoxication and Withdrawal
Fundamental Attribution ErrorFundamental Attribution Error
LSULSU Health Care Services DivisionHealth Care Services Division
Differential DiagnosesDifferential Diagnoses
DeliriumDelirium
DementiaDementia
PsychosisPsychosis
LSULSU Health Care Services DivisionHealth Care Services Division
DeliriumDelirium
� Intracranial DiseaseIntracranial Disease
� Systemic Disease with CNS Systemic Disease with CNS
InvolvementInvolvement
� Substance Abuse WithdrawalSubstance Abuse Withdrawal
� Toxic ExposuresToxic Exposures
LSULSU Health Care Services DivisionHealth Care Services Division
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
LSULSU Health Care Services DivisionHealth Care Services Division
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
LSULSU Health Care Services DivisionHealth Care Services Division
Vital SignsVital Signs
� Blood PressureBlood Pressure
� PulsePulse
� TemperatureTemperature
� Oxygenation AssessmentOxygenation Assessment
LSULSU Health Care Services DivisionHealth Care Services Division
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)
LSULSU Health Care Services DivisionHealth Care Services Division
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
LSULSU Health Care Services DivisionHealth Care Services Division
Mental Status ExamMental Status Exam
� OrientationOrientation� MoodMood� AffectAffect� MemoryMemory� LanguageLanguage� AttentionAttention
� CalculationCalculation� AbstractionAbstraction� General General
InformationInformation� JudgmentsJudgments� ThoughtsThoughts
LSULSU Health Care Services DivisionHealth Care Services Division
Brief Mental Status ExaminationBrief Mental Status Examination
LSULSU Health Care Services DivisionHealth Care Services Division
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
LSULSU Health Care Services DivisionHealth Care Services Division
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
LSULSU Health Care Services DivisionHealth Care Services Division
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
LSULSU Health Care Services DivisionHealth Care Services Division
MADFOCS MnemonicMADFOCS Mnemonic
LSULSU Health Care Services DivisionHealth Care Services Division
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%
LSULSU Health Care Services DivisionHealth Care Services Division
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
LSULSU Health Care Services DivisionHealth Care Services Division
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
LSULSU Health Care Services DivisionHealth Care Services Division
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
LSULSU Health Care Services DivisionHealth Care Services Division
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.