No, I dont mean psych patients.....I mean the psych service. As a chief resident(well at least in 2 days) in psychiatry, I see the crap you guys have to deal with from us on a regular basis. Psych pts can clog up your service, and there is nothing more frustrating than a medicine intern being "stuck" with a psych pt who is stuck on a medicine service for various reasons....A few tips on how to deal with your hospitals psych consult service(the goal is to help both of us out):
1) Delirium consults are almost never needed. As much as psych wants to believe that medicine residents don't know delirium, you *do* know delirium for the most part. And delirium recs are *not* that complicated. Hell we make the same basic recs each time. Many psych residents(and some attendings) carry around a little delirium card and just use the same med recs again and again. Hell I know 2 residents who have pre-made delirium notes!! They've used it 20 times at least by now....they'll change the pt's age and race and maybe a clinical detail or two...same med recs always.
2) Just because we say the pt is not safe for discharge as he represents an acute danger to himself doesn't mean you can't discharge them. The classic example is the borderline who swallows 20 Seroquel and goes to medicine for "24 hrs obs". Well of course they are cleared medically, and a psych consult is done, and the psych recs are to admit. But alas, there are no inpt beds available. And unfortunately, as crappy as it is, we are perfectly happy to let the pt sit on your service for a week waiting for a bed to open. We'll even copy and paste a note every other day to "reassess" the pt as we wait for a bed at our institution to open. But if you're confident the pt does not need admission(as many dont), just discharge them and document the protective factors. Or light a fire under the ass of the medical SW to transfer the pt to another psych hospital.
3) What your team was told by a psych ER resident or attending doesn't have any weight once you accept the pt on your medicine service. I can't tell you how many times the medicine resident says "so we got this psychotic women who had a uti or whatever and is now ready for transfer to inpatient psych"......whoa.....I agree it *should* be that easy. but it's not. In many cases the ER psych resident will dump an obvious psych presentation on medicine for ridiculously trivial medical reasons, saying it needs to be "monitored" for 12-24 hrs or whatever.....psych ER tells the medical ER this, and often forces the medicine dump. To get the ER to dump it on medicine, sometimes the psych er person "promises" they will take the pt on psych after 24 hrs of monitoring or whatever......the thing is, that is a promise they are not authorized to make. Medicine reisdents and attendings fly off the handle(and justifiably so) when I tell them that we'll have to do a formal psych consult and there arent any beds anyways.....so what is one to do? Well, I would again try a transfer to another psych hospital......if the pt is uninsured though, might be stuck.
1) Delirium consults are almost never needed. As much as psych wants to believe that medicine residents don't know delirium, you *do* know delirium for the most part. And delirium recs are *not* that complicated. Hell we make the same basic recs each time. Many psych residents(and some attendings) carry around a little delirium card and just use the same med recs again and again. Hell I know 2 residents who have pre-made delirium notes!! They've used it 20 times at least by now....they'll change the pt's age and race and maybe a clinical detail or two...same med recs always.
2) Just because we say the pt is not safe for discharge as he represents an acute danger to himself doesn't mean you can't discharge them. The classic example is the borderline who swallows 20 Seroquel and goes to medicine for "24 hrs obs". Well of course they are cleared medically, and a psych consult is done, and the psych recs are to admit. But alas, there are no inpt beds available. And unfortunately, as crappy as it is, we are perfectly happy to let the pt sit on your service for a week waiting for a bed to open. We'll even copy and paste a note every other day to "reassess" the pt as we wait for a bed at our institution to open. But if you're confident the pt does not need admission(as many dont), just discharge them and document the protective factors. Or light a fire under the ass of the medical SW to transfer the pt to another psych hospital.
3) What your team was told by a psych ER resident or attending doesn't have any weight once you accept the pt on your medicine service. I can't tell you how many times the medicine resident says "so we got this psychotic women who had a uti or whatever and is now ready for transfer to inpatient psych"......whoa.....I agree it *should* be that easy. but it's not. In many cases the ER psych resident will dump an obvious psych presentation on medicine for ridiculously trivial medical reasons, saying it needs to be "monitored" for 12-24 hrs or whatever.....psych ER tells the medical ER this, and often forces the medicine dump. To get the ER to dump it on medicine, sometimes the psych er person "promises" they will take the pt on psych after 24 hrs of monitoring or whatever......the thing is, that is a promise they are not authorized to make. Medicine reisdents and attendings fly off the handle(and justifiably so) when I tell them that we'll have to do a formal psych consult and there arent any beds anyways.....so what is one to do? Well, I would again try a transfer to another psych hospital......if the pt is uninsured though, might be stuck.
