Story for the Day

[F0nzie]

Patient leaves a knife as a gift for me at the front desk with a message that I would know what to do with it. The following day leaves a voicemail indicating that she plans on killing her case manager and murdering the entire clinical team. 9-11 is called. Gets picked up by police and sent to an inpatient psychiatric facility. Patient evaluated and treated by an independent psychiatric nurse practitioner. Hospital stay was several days. On the day of discharge patient presents to the outpatient clinic. Hospital discharge summary reveals that medications were kept the same and Zoloft was added 50 mg PO daily. Patient presents disorganized and psychotic with a large knife in her back pocket with no intent to harm herself or anybody...back to square 1...

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[Ceke2002]

Patient leaves a knife as a gift for me at the front desk with a message that I would know what to do with it. The following day leaves a voicemail indicating that she plans on killing her case manager and murdering the entire clinical team. 9-11 is called. Gets picked up by police and sent to an inpatient psychiatric facility. Patient evaluated and treated by an independent psychiatric nurse practitioner. Hospital stay was several days. On the day of discharge patient presents to the outpatient clinic. Hospital discharge summary reveals that medications were kept the same and Zoloft was added 50 mg PO daily. Patient presents disorganized and psychotic with a large knife in her back pocket with no intent to harm herself or anybody...back to square 1...

Ah, excuse me...????

edited to add: Why the bleepin' heck would this patient be evaluated and treated by a Nurse practitioner. Sense, this makes none.

 

[shan564]

I've had a lot of patients recently who get admitted and don't improve significantly (no big med changes) but are discharged with a statement in the d/c summary saying "patient denies suicidal/homicidal intent and is now stable for discharge." I feel like the pressure to reduce hospital length of stay is getting over the top.

 

[Shikima]

I've had a lot of patients recently who get admitted and don't improve significantly (no big med changes) but are discharged with a statement in the d/c summary saying "patient denies suicidal/homicidal intent and is now stable for discharge." I feel like the pressure to reduce hospital length of stay is getting over the top.

Blame interqual.

 

[F0nzie]

Patient denies SI/HI!!!

 

[Ceke2002]

I've had a lot of patients recently who get admitted and don't improve significantly (no big med changes) but are discharged with a statement in the d/c summary saying "patient denies suicidal/homicidal intent and is now stable for discharge." I feel like the pressure to reduce hospital length of stay is getting over the top.

Patient denies SI/HI!!!

So by that logic if a patient is showing clear signs of a myocardial infarcation, but they deny any symptoms, they can be safely released from hospital?

 

[milesed]

You should pull out your "gift" and have a knife fight to MJ's Beat it.

 

[shan564]

So by that logic if a patient is showing clear signs of a myocardial infarcation, but they deny any symptoms, they can be safely released from hospital?

Well, that sounds hyperbolic, but it's probably true that if a patient denies all symptoms and asks to leave the hospital, then you have to let them leave unless they lack mental capacity to make that decision.

But yeah, "denies SI/HI" is not a satisfactory mental status exam finding. If the extent of your risk assessment for an inpatient is to ask about SI/HI and say "the patient said 'no' to those two questions," we're no better than a layperson. We need to say "no evidence of SI/HI" and do a thorough enough evaluation to say that you actually did more than just ask the patient "are you suicidal or homicidal?"

 

[WingedOx]

Well, that sounds hyperbolic, but it's probably true that if a patient denies all symptoms and asks to leave the hospital, then you have to let them leave unless they lack mental capacity to make that decision.

well you get however long your state gives you after they request to leave. I get 5 business days where I'm at now. Pretty sure it was 72 hours where I did med school.

 

[Ceke2002]

Well, that sounds hyperbolic, but it's probably true that if a patient denies all symptoms and asks to leave the hospital, then you have to let them leave unless they lack mental capacity to make that decision.

But yeah, "denies SI/HI" is not a satisfactory mental status exam finding. If the extent of your risk assessment for an inpatient is to ask about SI/HI and say "the patient said 'no' to those two questions," we're no better than a layperson. We need to say "no evidence of SI/HI" and do a thorough enough evaluation to say that you actually did more than just ask the patient "are you suicidal or homicidal?"

Exactly.

 

[shan564]

well you get however long your state gives you after they request to leave. I get 5 business days where I'm at now. Pretty sure it was 72 hours where I did med school.

But that's the maximum. You could discharge somebody before the time expires. And you could also request a longer commitment. In my state, it's 96 hours initially, but then you can request the courts to approve a 21-day stay if you're not lazy.

 

[Psychotic]

Patient leaves a knife as a gift for me at the front desk with a message that I would know what to do with it. The following day leaves a voicemail indicating that she plans on killing her case manager and murdering the entire clinical team. 9-11 is called. Gets picked up by police and sent to an inpatient psychiatric facility. Patient evaluated and treated by an independent psychiatric nurse practitioner. Hospital stay was several days. On the day of discharge patient presents to the outpatient clinic. Hospital discharge summary reveals that medications were kept the same and Zoloft was added 50 mg PO daily. Patient presents disorganized and psychotic with a large knife in her back pocket with no intent to harm herself or anybody...back to square 1...

So this is not a private practice patient of yours, but one you see at your other gig?

Have you "fired" this patient? Or have you seen her again? Can you simply refuse to see this patient again?

How does the outpatient clinic deal with these kinds of threats?

 

[F0nzie]

So this is not a private practice patient of yours, but one you see at your other gig?

Have you "fired" this patient? Or have you seen her again? Can you simply refuse to see this patient again?

How does the outpatient clinic deal with these kinds of threats?

No

Thinking about it

Tell people not to bring weapons in the clinic. Put a sign outside the clinic that says no weapons. Call the police.

The no SI/HI thing is pretty ridiculous here. Someone can be floridly psychotic or in a neurovegetative state and will not be accepted inpatient if they don't say the magic words. So they just run around the streets putting themselves at great risk until they get picked up on a PAD and of course they are either not home or they don't answer the door.

Also ACT teams here will not offer services unless patients voluntarily accept which leaves out a large population that needs services that are too impaired to accept them... And they wonder why they get stuck with personality disorders.

 

[whopper]

Fonzie, where I used to do private practice the local hospital discharged dangerous patients the second insurance stopped paying and then dumped them back to me.

I was forced to terminate patients that had a GAF lower than 45 that I knew would be non-compliant with treatment such as really bad cluster B pts just wanting medication therapy, schizophrenics who frequently stop the meds, substance abusers who kept relapsing over and over and did something dangerous while intoxicated such as attempt suicide because I knew each time the hospital would just dump them to me again and again. One of my few suicides happened because of this. I sent the pt back to the hospital literally just days after they discharged her, they discharged her again the same day, and she killed herself just a few days later.

I told the idiot office manger in the practice to stop taking patients from that hospital before this happened and the people at that office didn't get it. I would walk into work and see my schedule lined up-with many pts from that hospital.

Private practice is not equipped to handle cases that should be in a community center. Such patients mentioned above need a case manager. I've never seen a private practice yet with a case manager. That or an intensive outpt treatment or partial-hospitalization.

A few times when I did have one of these patients being dangerous in the office, when emergency services were called they were forced to bring the pt to the piece of crap hospital because it was the default hospital of the county. A few times I told them to send the patient to the university hospital where I knew they'd get better care but the police or EMS weren't allowed to do that.

 

[Ceke2002]

No

Thinking about it

Tell people not to bring weapons in the clinic. Put a sign outside the clinic that says no weapons. Call the police.

The no SI/HI thing is pretty ridiculous here. Someone can be floridly psychotic or in a neurovegetative state and will not be accepted inpatient if they don't say the magic words. So they just run around the streets putting themselves at great risk until they get picked up on a PAD and of course they are either not home or they don't answer the door.

Also ACT teams here will not offer services unless patients voluntarily accept which leaves out a large population that needs services that are too impaired to accept them... And they wonder why they get stuck with personality disorders.

At the CMHC I used to attend there were metal detectors you had to pass through, security cameras and CCTV screens clearly visible, and all access to the actual clinical rooms was via electronically coded passes only - plus they had lock down security protocols in place in case of emergencies. I know there's the whole thing about stigmatising the mentally ill by having too much security in a clinic, but I never felt stigmatised and I don't recall anyone else at the clinic complaining about stigmatisation either - we pass through similar security at banks, in stores, at hospitals, and so on, why should we be treated any differently just because this time the location happens to be a mental health clinic? That's far more stigmatising from my point of view.

Are you able to possibly bring up the issue of beefing up security where you are? Get some metal detectors installed, put up a few more cameras, that sort of thing? How are you supposed to do your job effectively if you're worried about someone potentially threatening you with a knife, or worse?

 

[F0nzie]

At the CMHC I used to attend there were metal detectors you had to pass through, security cameras and CCTV screens clearly visible, and all access to the actual clinical rooms was via electronically coded passes only - plus they had lock down security protocols in place in case of emergencies. I know there's the whole thing about stigmatising the mentally ill by having too much security in a clinic, but I never felt stigmatised and I don't recall anyone else at the clinic complaining about stigmatisation either - we pass through similar security at banks, in stores, at hospitals, and so on, why should we be treated any differently just because this time the location happens to be a mental health clinic? That's far more stigmatising from my point of view.

Are you able to possibly bring up the issue of beefing up security where you are? Get some metal detectors installed, put up a few more cameras, that sort of thing? How are you supposed to do your job effectively if you're worried about someone potentially threatening you with a knife, or worse?

Yea I asked for all of that and they thought I was crazy. Surprisingly I was the only one that did...

We have been having so many incidents at the clinic that I've been getting startled by noises and people approaching me from behind. Never experienced this in residency where we had security and locked doors.

On the positive side it has shaped me into a more protective person and hands on when staff and other patients are in trouble.

 

[F0nzie]

Fonzie, where I used to do private practice the local hospital discharged dangerous patients the second insurance stopped paying and then dumped them back to me.

I was forced to terminate patients that had a GAF lower than 45 that I knew would be non-compliant with treatment such as really bad cluster B pts just wanting medication therapy, schizophrenics who frequently stop the meds, substance abusers who kept relapsing over and over and did something dangerous while intoxicated such as attempt suicide because I knew each time the hospital would just dump them to me again and again. One of my few suicides happened because of this. I sent the pt back to the hospital literally just days after they discharged her, they discharged her again the same day, and she killed herself just a few days later.

I told the idiot office manger in the practice to stop taking patients from that hospital before this happened and the people at that office didn't get it. I would walk into work and see my schedule lined up-with many pts from that hospital.

Private practice is not equipped to handle cases that should be in a community center. Such patients mentioned above need a case manager. I've never seen a private practice yet with a case manager. That or an intensive outpt treatment or partial-hospitalization.

A few times when I did have one of these patients being dangerous in the office, when emergency services were called they were forced to bring the pt to the piece of crap hospital because it was the default hospital of the county. A few times I told them to send the patient to the university hospital where I knew they'd get better care but the police or EMS weren't allowed to do that.

This post nails it on the head. Private practice is not the appropriate level of care for high risk patients.

 

[Ceke2002]

Yea I asked for all of that and they thought I was crazy. Surprisingly I was the only one that did...

We have been having so many incidents at the clinic that I've been getting startled by noises and people approaching me from behind. Never experienced this in residency where we had security and locked doors.

On the positive side it has shaped me into a more protective person and hands on when staff and other patients are in trouble.

You shouldn't have to work like that, it's not fair to you and it's not fair to your patients. I'm sorry you're in such a concerning situation.

 

[Shikima]

Fonzie, where I used to do private practice the local hospital discharged dangerous patients the second insurance stopped paying and then dumped them back to me.

I was forced to terminate patients that had a GAF lower than 45 that I knew would be non-compliant with treatment such as really bad cluster B pts just wanting medication therapy, schizophrenics who frequently stop the meds, substance abusers who kept relapsing over and over and did something dangerous while intoxicated such as attempt suicide because I knew each time the hospital would just dump them to me again and again. One of my few suicides happened because of this. I sent the pt back to the hospital literally just days after they discharged her, they discharged her again the same day, and she killed herself just a few days later.

I told the idiot office manger in the practice to stop taking patients from that hospital before this happened and the people at that office didn't get it. I would walk into work and see my schedule lined up-with many pts from that hospital.

Private practice is not equipped to handle cases that should be in a community center. Such patients mentioned above need a case manager. I've never seen a private practice yet with a case manager. That or an intensive outpt treatment or partial-hospitalization.

A few times when I did have one of these patients being dangerous in the office, when emergency services were called they were forced to bring the pt to the piece of crap hospital because it was the default hospital of the county. A few times I told them to send the patient to the university hospital where I knew they'd get better care but the police or EMS weren't allowed to do that.

Intensive case management is the future. No body wants long term institutions or hospitalization. With more people added to a system not equipped to handle the increase in demand through ACA, it's going to get uglier before it gets better.

 

[whopper]

I mentioned this information before in the thread concerning the Holmes-Colorado movie theater shooting. It was speculation on my part but I thought perhaps the doctor treating Holmes was in a similar situation because she was treating him in an outpatient college clinic and this setting highly mimics private practice in the sense that you don't have case managers and your ability to monitor patients is as little as private practice.

In private practice you'll likely not be able to safely handle cases where the patient's GAF is below 45 unless it's by dumb luck. You can handle cases of mild depression, anxiety, bipolar disorder, even moderate, but after that no way. As for psychosis-only if it's mild or the patient is almost always compliant and meds are working well. I used to terminate schizophrenic/schizoaffective patients that were dangerous when not compliant with meds cause I knew they would just do it again and again and again and each time their family would blame me even though it was not my fault.

Termination was not unethical IMHO cause private practice cannot provide the appropriate level of care. I referred them to a community mental health agency with a case manager.

 

[Shikima]

Problem with CMH is that they'll accept no insurance or medicaid only. Which is a crock in of itself....

 

[smalltownpsych]

Intensive case management is the future. No body wants long term institutions or hospitalization. With more people added to a system not equipped to handle the increase in demand through ACA, it's going to get uglier before it gets better.

It should be but is it really happening? In our town they are shrinking the CMH program to where they are run more like an outpatient clinic, just with less qualified people. Then the patients begin to choose to come to our office because we have a nicer office and licensed psychologists instead of poorly supervised newly minted online degree LPCs. It was different when they had case managers, activities, and a day program. Ironically one of the new LPCs was one of the last of their case managers and he was quite helpful in assisting them with getting to where they needed to go. Now he can only do billable activities so no help shopping or getting to any appointments.

 

[Shikima]

Pretty lame IMO. Particularly when you look at all that needs to be done in the context of the biosociopsycho model.

 

[clausewitz2]

The biggest problem the local CMHC is facing here is that with the Medicaid expansion, the state has just sort of assumed everyone relevant will have Medicaid and so has cut off the block grants that used to fund a lot of their services. Since the population that uses CMHCs most often is generally not so good at getting the paperwork done to get Medicaid coverage, they are now hemorrhaging money. Word is they will try and declare bankruptcy to get out of their pension obligations as a desperation move.

Somehow they do not understand why their clinicians are fleeing en masse to the local VA.

 

[Shikima]

Feds are more solvent than local.

 

[WingedOx]

Somehow they do not understand why their clinicians are fleeing en masse to the local VA.

Welcome to my life. The VA is the last place around here you can make a good salary and still work with high-acuity pathology.

 

[Doctor Bagel]

Problem with CMH is that they'll accept no insurance or medicaid only. Which is a crock in of itself....

Just what I was going to say. I've seen hospital patients with private insurance who can't get anyone to see them because they're too sick for private practice, but community MH isn't set up to bill private insurance.

 

[Doctor Bagel]

It should be but is it really happening? In our town they are shrinking the CMH program to where they are run more like an outpatient clinic, just with less qualified people. Then the patients begin to choose to come to our office because we have a nicer office and licensed psychologists instead of poorly supervised newly minted online degree LPCs. It was different when they had case managers, activities, and a day program. Ironically one of the new LPCs was one of the last of their case managers and he was quite helpful in assisting them with getting to where they needed to go. Now he can only do billable activities so no help shopping or getting to any appointments.

So my rant about community mental health in my community. Our county has set up this system to determine what level of service people should get based on a LOCUS or some other type of arbitrary screening tool. With this, it seems like you have to be right at the hospital's door in terms of symptom severity to get any meaningful type of service. I've seen super sick people on multiple medications be told that they should work with their primary care provider for their medications. Nobody gets any regular psychotherapy, and yeah, people take these jobs right out of school and stick around for a few months before moving on to better things.