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