Acute medical issues on freestanding inpatient units

[northernpsy]

After I graduated residency, I took a job doing inpatient psych at a standalone psych hospital. When I agreed to take the job I asked about the arrangement for coverage of medical issues and was told there is an IM doc who does "medical clearance" physicals on new admits, so my impression when I signed up was that the IM doc would be managing the medical side of things while I focused on their psych issues. However, it turns out this initial exam is usually the extent of the IM doc's involvement. The IM doc is usually only on the unit for a brief time each day and not usually available after hours. The IM doc doesn't supervise for the midlevels who sometimes do medical clearance physicals (the psychiatrist is the one who cosigns the mid-level's H&P). If a potentially urgent medical issue comes up, day or night, the RN pages the psychiatrist taking care of the patient to ask for guidance and determine if the patient needs to be sent out for an ER evaluation or not.

Most of the psych units I worked at in residency were connected to a general hospital so IM was always in-house and stat labs/xrays/EKGs were easily available, so this kind of setup seems like a liability to me and provokes my anxiety. Yes, sometimes it is very obvious that someone's somatic complaint is just their anxiety acting up or it's very clear that someone is physically unstable and needs to be sent out to the ER, but quite often it is something more ambiguous (for example, I worry most about chest pain cases - since it's not like I can get a stat troponin or EKG in the middle of the night, do I just send out EVERY chest pain even if I think it most likely is just anxiety?). I don't really feel that confident that I am qualified to try to tease these situations out based on a dim memory of my internship IM rotation, so then I become very anxious about my liability if I don't send everyone out to the ER when these ambiguous situations come up. Of course, I've also had ER docs get crabby with me about wanting to transfer someone that they didn't think needed an ER evaluation.

Is this kind of setup normal for inpatient psych units ? I'm curious about what you guys do to feel confident managing these situations if, like me, you went to a psych residency that wasn't especially medicine-heavy.

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[wolfvgang22]

After I graduated residency, I took a job doing inpatient psych at a standalone psych hospital. When I agreed to take the job I asked about the arrangement for coverage of medical issues and was told there is an IM doc who does "medical clearance" physicals on new admits, so my impression when I signed up was that the IM doc would be managing the medical side of things while I focused on their psych issues. However, it turns out this initial exam is usually the extent of the IM doc's involvement. The IM doc is usually only on the unit for a brief time each day and not usually available after hours. The IM doc doesn't supervise for the midlevels who sometimes do medical clearance physicals (the psychiatrist is the one who cosigns the mid-level's H&P). If a potentially urgent medical issue comes up, day or night, the RN pages the psychiatrist taking care of the patient to ask for guidance and determine if the patient needs to be sent out for an ER evaluation or not.

Most of the psych units I worked at in residency were connected to a general hospital so IM was always in-house and stat labs/xrays/EKGs were easily available, so this kind of setup seems like a liability to me and provokes my anxiety. Yes, sometimes it is very obvious that someone's somatic complaint is just their anxiety acting up or it's very clear that someone is physically unstable and needs to be sent out to the ER, but quite often it is something more ambiguous (for example, I worry most about chest pain cases - since it's not like I can get a stat troponin or EKG in the middle of the night, do I just send out EVERY chest pain even if I think it most likely is just anxiety?). I don't really feel that confident that I am qualified to try to tease these situations out based on a dim memory of my internship IM rotation, so then I become very anxious about my liability if I don't send everyone out to the ER when these ambiguous situations come up. Of course, I've also had ER docs get crabby with me about wanting to transfer someone that they didn't think needed an ER evaluation.

Is this kind of setup normal for inpatient psych units ? I'm curious about what you guys do to feel confident managing these situations if, like me, you went to a psych residency that wasn't especially medicine-heavy.

Yes, it's normal and a very common setup for free standing psychiatric hospitals. My residency in fact had a free standing psych hospital across town where we worked a lot and did call. I hated the situation of getting paged all the time for random medical stuff at 4am, urgent and mundane. This is why I don't do inpatient psych any more. I did get very good at it, bit it wasn't fun for me most of the time.

My advice is to just keep sending patients to the ER if you are uncomfortable in any way regarding a medical issue, and ignore ER doc griping, while getting better at what is an emergency and what isn't. Or change jobs.

 

[Armadillos]

Free standing psych hospitals can't run EKG and troponins? Would really suck to have to send all those folks to ER.

 

[wolfvgang22]

Free standing psych hospitals can't run EKG and troponins? Would really suck to have to send all those folks to ER.

Nursing can often do an EKG, but don't usually a blood draw in the middle of the night unless really necessary. If it is really necessary, it is more likely the patient needs to be in the ER, anyway.
We had a phlebotomist come by every morning for routine blood draws.

 

[notdeadyet]

If I had someone complaining of bad chest pain, I'm no sure how confident I'd be in basing my decision onto refer him based on a psychiatrist's interpretation of an EKG. Is that standard of care?

 

[birchswing]

If I had someone complaining of bad chest pain, I'm no sure how confident I'd be in basing my decision onto refer him based on a psychiatrist's interpretation of an EKG. Is that standard of care?

I suppose it depends on a variety of factors, but regardless of the specialist, generally, that wouldn't be the standard of care. EKGs don't rule out heart attacks or aortic dissection, as just two examples I know of. The new sensitive troponin tests are supposed to be very good at ruling out heart attacks.

EDIT: I say generally because some you can largely rule out based on demographics and/or nature of the pain, and some you can rule out with applying pressure to cartilage to see if that is the cause of the painµ.

 

[Armadillos]

If I had someone complaining of bad chest pain, I'm no sure how confident I'd be in basing my decision onto refer him based on a psychiatrist's interpretation of an EKG. Is that standard of care?

Definitely agree, I was talking about the 90% of the time when your index of suspicion is really, really low but you want to have something more objective to put in the chart. If I thought someone was actually having a MI or the EKG wasn't stone cold normal then would definitely want some with expertise evaluating the patient

 

[splik]

A free standing psychiatric hospital is no different from an outpatient clinic when it comes to managing medical problems. If the patient had a complaint that in the course of an outpatient visit would lead you to send them to the ER then that same problem on an inpatient unit should prompt transfer to the ED. its not uncommon for these hospitals to have NPs or PAs doing the medical cover or evaluation but again this is based on the notion the medical problems are basically outpatient medical problems. Anything else goes to the ER.

 

[vistaril]

Free standing psych hospitals can't run EKG and troponins? Would really suck to have to send all those folks to ER.

is this a serious post? Im only a few years out of residency(so was doing 'medical' things a lot more recently than most practicing psychs), and there is no way in hell I'd be confident looking at an ekg and feeling good about it. The vast majority of psychs I know would feel the same way.

 

[notdeadyet]

Definitely agree, I was talking about the 90% of the time when your index of suspicion is really, really low but you want to have something more objective to put in the chart. If I thought someone was actually having a MI or the EKG wasn't stone cold normal then would definitely want some with expertise evaluating the patient

But EKGs are not the standard of care for ruling out an MI. If you have a "really, really low" index of suspicion, you either work it up or don't work it up. If you work it up, it would be hard to justify not running trops.

Running an EKG on what looks to be BS chest pain and subsequently having a patient die of an actual MI would be bad indeed. Trying to justify that you didn't think the patient was having cardiac-related chest pain but running part of a test sequence to reassure yourself wouldn't stand up well in court. Bad juju.

 

[notdeadyet]

is this a serious post? Im only a few years out of residency(so was doing 'medical' things a lot more recently than most practicing psychs), and there is no way in hell I'd be confident looking at an ekg and feeling good about it. The vast majority of psychs I know would feel the same way.

I still evaluate EKGs at a freestanding psych unit I've worked on, but it's really only helpful for me for QTc intervals and change-from-baseline. It's outside of my skill set to diagnose an MI based on an EKG. Even EM docs don't do that, and they see a lot more EKGs than I do.

 

[wolfvgang22]

If in doubt, send 'em out!

 

[vistaril]

I still evaluate EKGs at a freestanding psych unit I've worked on, but it's really only helpful for me for QTc intervals and change-from-baseline. It's outside of my skill set to diagnose an MI based on an EKG. Even EM docs don't do that, and they see a lot more EKGs than I do.

of course, but reading off what the QTc is isn't really 'looking at' an EKG.

And ER docs look at EKGs all the time as *part* of the process in evaluating chest pain. They are good at it. If, on a scale from 1 to 100 in terms of ekg reading expertise, my 4 yo cousin is a 1 and a cardiologist is a 100, I'd say most psychiatrists are in the 20s and most er doctors are in the low 90s.

 

[whopper]

I worked in 2 (well maybe 3) free-standing psych facilities.

One had an IM or FP doctor there full-time and on call 24 hours a day. As cool as that sounds one of the IM doctors was so bad that I had more trust in my own medical skills vs his. He was terrible.
So in a legal sense I was covered. If he did a bad job it was on him but I never liked it cause as you'd expect I actually want good care, I just don't want CYA-medicine. This facility was a long-term psych unit.

The other was a private hospital with top doctors. They pretty much accepted no one with anything that was complicated in terms of medical problems. Things like hypertension fine, but prior MIs, having several medical conditions even if the person was stable they never took the person in. They had an IM doctor check out everyone and he was there daily but only for a few hours a day.

Last place was a geriatric unit that used to be part of the main hospital but the university bought out a local hospital a few blocks away and transferred the psych units there. An IM doc showed up everyday but only rounded and left. The problem with that place was sometimes we needed a more specific specialist-e.g. an infectious disease doctor, a cardiologist, etc., and when a consult was ordered they refused to show up even if the patient was in serious need of that doctor. I had one patient that ended up being there for 3 months because of a pissing match where the neurologist refused to show up and we couldn't discharge her unstable. I'm not making this up. I brought this up to the heads of both departments and they just ended up wasting time in bureaucracy while her bill went up to about $300,000 and the insurance company refusing to pay for the bill cause she was there so long due to people being idiots (one of the few times I even agreed with the insurance company).
In several cases the IM doctor even agreed with me that a consult was urgently needed and begged the consultant to show up and they still refused.

 

[Armadillos]

But EKGs are not the standard of care for ruling out an MI. If you have a "really, really low" index of suspicion, you either work it up or don't work it up. If you work it up, it would be hard to justify not running trops.

Running an EKG on what looks to be BS chest pain and subsequently having a patient die of an actual MI would be bad indeed. Trying to justify that you didn't think the patient was having cardiac-related chest pain but running part of a test sequence to reassure yourself wouldn't stand up well in court. Bad juju.

Fair enough, probably more a product of being a resident than anything else. Even on medicine services you will see tons of patients get EKG/trop for vague complaints overnight and the troponins won't get trended out any further and the attendings dont seem to care. I imagine this would be a different situation if I didn't know in back of head that i can fax the EKG over to the cards team in middle of night if I needed to

 

[Armadillos]

On a related note, if you order an EKG for the indication of checking QTc are you on the hook liability wise for the full interpretation of EKG? (Assuming your not trying to bill for interpretation)

 

[vistaril]

On a related note, if you order an EKG for the indication of checking QTc are you on the hook liability wise for the full interpretation of EKG? (Assuming your not trying to bill for interpretation)

thats an excellent question....the answer is I do not think so. I never get EKGS in my outpt practice. What do you guys do? The problem is that if I wanted to order an EKG, I don't even know how that would work. First, I'd have to send the patient somewhere to get it done. Who does this? We obviously don't have someone doing ekgs here(it's a private practice outpt psych group). Second how would the patient pay for it, even if I could find a place that does it? Im guessing there would be questions with prior approval/auth and stuff. Third, what happens after the pt gets the EKG at some outside facility? Do they just fax it over here?

With the way most outpt psych practices are set up, it just doesn't seem practical at all. I'll ask the patient if they have ever had any heart problems or arrythmias or whatever, and just document that.

 

[Shikima]

thats an excellent question....the answer is I do not think so. I never get EKGS in my outpt practice. What do you guys do? The problem is that if I wanted to order an EKG, I don't even know how that would work. First, I'd have to send the patient somewhere to get it done. Who does this? We obviously don't have someone doing ekgs here(it's a private practice outpt psych group). Second how would the patient pay for it, even if I could find a place that does it? Im guessing there would be questions with prior approval/auth and stuff. Third, what happens after the pt gets the EKG at some outside facility? Do they just fax it over here?

With the way most outpt psych practices are set up, it just doesn't seem practical at all. I'll ask the patient if they have ever had any heart problems or arrythmias or whatever, and just document that.

Have you contacted their PCP and asked his nurse to do one for you and then fax the sheet back to your office? This is what I do.

 

[michaelrack]

th We obviously don't have someone doing ekgs here(it's a private practice outpt psych group). Second how would the patient pay for it, even if I could find a place that does it? Im guessing there would be questions with prior approval/auth and stuff. .

i think an ekg is about $50, no pa

 

[thoffen]

Which is worse? not evaluating chest pain or evaluating it and missing ischemia because you are not well trained in it? I guess the solution to both is sending to the ED for assessment.

RE: EKG for acute chest pain when choosing to look for cardiac cause, it's absolutely necessary immediately. Your first decision point is STEMI or not. If you, however, get the EKG and then don't pursue the rest of the workup, that's probably not going to look so good for you. If you're gonna call 911 anyway, I'd still get the EKG because things are a lot different if you call them and say you have a patient with ST elevation.

 

[nexus73]

A compulsive psychiatrist I worked with found a cardiologist that was happy to see patient's to do an EKG with interpretation. I think the difficult thing is you need a baseline QTc to compare with, and the recommendations say to check EKGs as dose is titrated up, but you might not get into the cardiologist for a few weeks, so you could push up the dose and not know the QTc is getting longer for several weeks while the patient is at risk. And usually if you're starting an antipsychotic, there's a serious reason and some urgency to get a medication started or switched, so waiting 3 weeks to get a baseline EKG isn't clinically realistic.

 

[MLT2MT2DO]

Free standing psych hospitals can't run EKG and troponins? Would really suck to have to send all those folks to ER.

I don't think most psych hospitals have lab test capability.

Drawing a send out Troponin...are you worried that your malpractice premiums are too low?

 

[Armadillos]

I don't think most psych hospitals have lab test capability.

Drawing a send out Troponin...are you worried that your malpractice premiums are too low?

Clearly wasnt referring that I would sendout out troponin, was observing how different things are at academic hospitals where a lot of us train with a full array of labs/imaging/consultants available compared to completely independent psych hospitals. Although seems likely we are admitting much medically sicker patients than a freestanding hospital would be. Instead of packing up a patient and shipping them to the ER, we can just bring the consultants to us which is kind of nice.

 

[vistaril]

Have you contacted their PCP and asked his nurse to do one for you and then fax the sheet back to your office? This is what I do.

I tried to do this, but from a practical and logistical standpoint it's often not possible. For starters, a lot of patients don't have a pcp. But even the ones who do, I found that(shockingly) pcps aren't in the business of generally asking how high when we see jump. When I sent a few pts to their pcps for this(different pcps), they just made it into a separate office visit on top of the ekg. Read the ekg and everything themselves. They did fax it over to us of course too. So it cost the pt a ton(because they hadn't met deductible).....and I understand that- I certainly wouldn't do another providers work for them with no separate billing(besides the keg which they would make very little on) of my own. It would just a cluster**** for the patient.....and in the end they saw little benefit.

If there was some way I could check QT easily for the patient where it wouldn't be a hassle or costly, I would do it. But I have no idea how to do that here.

For things like Lithium levels I can send patients to labcorp and they will fax it over to us....so that isn't too bad.

 

[Shikima]

I tried to do this, but from a practical and logistical standpoint it's often not possible. For starters, a lot of patients don't have a pcp. But even the ones who do, I found that(shockingly) pcps aren't in the business of generally asking how high when we see jump. When I sent a few pts to their pcps for this(different pcps), they just made it into a separate office visit on top of the ekg. Read the ekg and everything themselves. They did fax it over to us of course too. So it cost the pt a ton(because they hadn't met deductible).....and I understand that- I certainly wouldn't do another providers work for them with no separate billing(besides the keg which they would make very little on) of my own. It would just a cluster**** for the patient.....and in the end they saw little benefit.

If there was some way I could check QT easily for the patient where it wouldn't be a hassle or costly, I would do it. But I have no idea how to do that here.

For things like Lithium levels I can send patients to labcorp and they will fax it over to us....so that isn't too bad.

http://www.fastcodesign.com/1671371/this-200-iphone-case-is-an-fda-approved-ekg-machine

 

[birchswing]

http://www.fastcodesign.com/1671371/this-200-iphone-case-is-an-fda-approved-ekg-machine

I have had one of these for a few years. It's very easy to e-mail the readings to my cardiologist and he can interpret them. He's been impressed with the device.

You can also use the app to pay to have a board-certified cardiologist analyze it for you. It also has a built in algorithm for detecting a-fib.

The default use is to get a Lead I reading, but you can also get a precordial lead by placing it directly under your left chest muscle. Works very well.

EDIT:

This is the other device I'm really excited about:

https://www.getqardio.com/qardiocore-wearable-ecg-ekg-monitor-iphone/

Continuous monitoring, 3-lead. I've been waiting for it to come out for a while now.

 

[DD214_DOC]

On a related note, if you order an EKG for the indication of checking QTc are you on the hook liability wise for the full interpretation of EKG? (Assuming your not trying to bill for interpretation)

You're always responsible for the entire thing. It's no different than ordering a CBC as part of routine monitoring for a psychotropic. You can't ignore unrelated abnormalities. You don't necessarily have to treat it or further evaluate it, but you still have to comment on it and do something about it. You may be, "just a psychiatrist", but last I checked I was still a physician.

 

[Shikima]

That's it. I'm not ordering anything. I refuse to be responsible.

 

[notdeadyet]

You're always responsible for the entire thing. It's no different than ordering a CBC as part of routine monitoring for a psychotropic. You can't ignore unrelated abnormalities. You don't necessarily have to treat it or further evaluate it, but you still have to comment on it and do something about it. You may be, "just a psychiatrist", but last I checked I was still a physician.

Yup.

That said, you are expected to perform to community standards. If you order an EKG on a patient to look for QTc prolongation and there are obvious signs of ST elevation, you'd better refer to the ER. You are no liable for catching esoteria that a cardiologist might catch, as you are not a cardiologist.

But you're still a physician. If you order a Chem 7 to look at BUN/Cr and the patient is obviously hyponatremic, you better get the patient help for the hyponatremia. Same goes with EKG.

 

[DD214_DOC]

I will say that psychiatrists, especially child psychiatrists, should have a pretty good understanding of EKGs and how to identify certain things on them. For instance, how to spot WPW or signs of aberrant conduction pathways so that you don't kill little johnny the first month you start him on Adderall.