How long do you wait to admit patients after an overdose?

[Ψ-117]

I know it depends on the medication and how much was taken, and how the patient appears clinically, etc., but as a general rule, what would you tell a referring hospital who wants to admit someone to your psychiatric unit after a significant overdose?

For example, I received a call today about an adolescent who overdosed on 500 mg of a stimulant (either Ritalin or Adderall), and the referring ED wanted to admit him to our standalone psychiatric hospital 4 hours after the ingestion. Reportedly they called poison control who simply said to watch out for tachycardia. EKG showed sinus tachy with a rate of 117; labs were acceptable. On the surface he seemed to be medically stable, but I was concerned about how recent the overdose was and whether enough time had gone by to safely say he would remain stable.

When I did consults in my residency program, most overdoses like this probably would have been sent to a med-psych or observation unit, watched at least overnight, and held until the hospitalist declared them to be medically clear, after which transfer to a psychiatric unit would be arranged.

Today was the first time I've been asked to admit someone who had a significant overdose within the past few hours. I recommended that they observe the patient overnight before sending him our way, but a short while later I learned that another hospital had accepted the patient anyway. I don't mind someone else being willing to assume liability should anything go wrong with that patient, but I was left wondering... How long is considered long enough after an overdose to safely admit a patient? Are there any guidelines about this, or do most psychiatrists simply trust the ED physician when they say the patient is stable?

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[PistolPete]

One of my old attendings would refuse transfers on patients that had overdosed if it had been less than 24 hours, no matter how big or small of an overdose . At my current place we accept patients after they've been observed in the emergency room for about 3 to 4 hours as long as poison control has been contacted. So I guess it varies.

 

[nexus73]

Overnight on a medical floor isn't unreasonable.

 

[Information Underload]

So we don't know exactly what this kid overdosed on. Picture a scenario where he took a bunch of Ritalin LA, Concerta, Adderall XR or Focalin, where the extended release formulation produces a higher serum concentration after the 4-hour mark. Yeah, you're less likely to have a seizure on an XR formulation, but you're not out of the woods at 4 hours because the serum levels would keep rising. I don't know about the serum levels in overdose (stimulants don't typically damage the liver, so I would guess that they are still metabolized typically), but I do know that with many of the XR formulations, serum levels keep rising until about 8-hours after you take the medication--more like 9 with Adderall and Concerta. I don't think it's beyond the pale to expect them to hold a patient for 12-hours after an OD like this where they don't know exactly what this patient took, and heaven knows if they got the right time when they actually took it.

It's not going to be fun if the kid seizes or becomes agitated, delirious and psychotic on the open psych unit.

 

[deleted314290]

You are the accepting provider and at the end of the day you can say no. You should say no if you aren't comfortable with it and you don't have support if something goes wrong. Also, ED physicians notoriously over sell you on the "they are medically cleared" part and will take advantage of that if you dont ask questions.

 

[Doctor Bagel]

24 hours as a minimum is reasonable. It also depends on where you're admitting them to -- is this a psych unit that's part of a larger hospital where a transfer to the ICU would be easy or is it a stand alone hospital? Sometimes the suspicious part of me wonders if I should trust the ED and IM docs about information they received from poison control. I also agree with the post above that you've got to be questioning what the person actually took.

 

[HarryMTieboutMD]

Medical clearance and dispo should rest on the ED doctor, not the doctor on the receiving end (who hasn't seen the patient). In my program (at huge academic teaching hospital) the ED psych resident is the gatekeeper to psych admission, and the ED attendings generally do what we say (except when the administration gets involved but that is happening less frequently). (we also don't take direct transfers to our psych floor from other hospitals- they have to go through the ED). But in most of the non academic hospitals in our city, the ED doctor (+/- toxicologist) medically clears the patient, and then they go to whatever psych unit

 

[Armadillos]

Medical clearance and dispo should rest on the ED doctor, not the doctor on the receiving end (who hasn't seen the patient).

You can never trust an ER docs impression at an outside hospital for direct admissions to your unit. You need to get as much hard data labs/vitals/EKG/imaging/MAR/etc from them as you can and attempt to make your own decision. Else they will dump complete medical train wrecks on your psych unit. They don't give a damn what happens to a patient once they get them out of their ER, its a hot potato.

 

[NickNaylor]

You are the accepting provider and at the end of the day you can say no. You should say no if you aren't comfortable with it and you don't have support if something goes wrong. Also, ED physicians notoriously over sell you on the "they are medically cleared" part and will take advantage of that if you dont ask questions.

Happened recently to me in our psych ED on a patient "medically cleared" from the main ED:

"Oh, yeah, he looks great. He does have an alcohol use history so we gave him a dose of Ativan but he's talkative, a little tired but otherwise ok. Labs and vitals look ok."

About an hour later the patient finally comes in, and he's in full blown DTs. Back to the main ED he goes... thanks bud.

My other favorite is the patient who came in with an unidentified PE and was "medically cleared." Absolutely useless.

 

[notdeadyet]

Very interesting discussion.

re: the ED docs doing medical clearance- I've worked at a good few PES and inpatient units. The policy on some was that the ED docs do the medical clearance. But on ALL the units I've worked on, it's up to the admitting MD to accept admission.

Maybe a subtle distinction, but an important one. Even at places that the ED doc was in charge of medically clearing patients, policy dictated that an MD at the accepting facility had to sign off on the transfer (EMTALA?). So the ED doc can clear the patient all s/he wants, but if I don't agree as the potentially accepting doc, they don't get transferred to my unit.

Realistically, about 95% of the time, I'd accept them and agreed with the ED docs clearance. But in the other 5% of the time, they were dodgy and I requested more testing or time. It tended to be from particular docs and you started to recognize their names.

re: minimum time for clearance post-OD- I don't personally have a yardstick. If it's a known entity (witnessed OD, etc.), I have a shorter timeframe. If I'm concerned about what it might be or if there's any instability, I hold off. Overnight is a fine general rule if you're nervous.

 

[nexus73]

Do emergency doctors think the liability ends once the person leaves the emergency room? Not sure why some are so cavalier.

 

[Ψ-117]

Thanks, everyone, for your insightful responses! It's good to know how others out there are handling similar situations. And I agree, it's difficult to trust another doctor's declaration of medical clearance when you've accepted patients in the past who arrive to your unit and surprisingly don't fit the original description!

 

[whopper]

There is no general rule of thumb because it depends on the substance except this rule of thumb.

Call poison control. They have guidelines for many substances. I've had times where the ER doc wanted to send to the psych unit-mind you a psych unit where consults didn't show up more than half the time. They told me they followed the exact poison control guidelines. I'd call up poison control to double check. So long as the guidelines were followed that was at least a start to believe the ER doctor wasn't screwing with me.

 

[whopper]

Just wanted to add here's how a conversation with the ER doctor and I would go with a poison case.

Me: What susbtance, how much, what route, and how long ago? What the physical signs?
Them: -something to the effect of everything is alright-
Me: Okay, did you call poison control and follow every single protocol?
Them: If no-then I will not accept until they've called Poison Control. If yes then I tell them I will call Poison Control and double check the protocol.
I call up Poison Control. I find out the protocol for the exact substance. I usually will let the patient on the unit if the protocol was followed. I document that the ER doctor alleged to follow Poison Control's recommendations and I tell them to document it in EPIC. If I remember correctly Poison Control even gave me a print-out of the protocol when asked to do so and we would put that into the patient's chart.

I do not specifically always accept if Poison Control protocols were followed. I still try to see if there's active signs of problems, ask for vital signs and stuff like O2 saturation, and double check all the labs myself. From there if everything is OK then I accept. If something is amiss I tell the ER doctor I will only accept the patient if they can give me a reasonable explanation despite the detail that is amiss.

 

[notdeadyet]

Great advice on poison control, Whopper.

I'd also remind folks that the problem with poison control is that their advice is valid on the assumption that we KNOW the extent of what the patient has on board. Which is pretty rare.

Poison control rocks, but like whopper says: After following their recommendations, correlate it with the clinical picture before accepting admission.

 

[WingedOx]

The ED physician may be aware of the patient's medical status, but he's not actually aware of what the ability of your unit's nursing staff to do hands-on monitoring and management of the patient. That's essentially your call for if the patient can be safely cared for on your unit.

Remember, patients don't come to the hospital for doctoring, they come for monitoring/nursing. Otherwise we'd be doing this from home.

 

[Igor4sugry]

I know it depends on the medication and how much was taken, and how the patient appears clinically, etc., but as a general rule, what would you tell a referring hospital who wants to admit someone to your psychiatric unit after a significant overdose?

For example, I received a call today about an adolescent who overdosed on 500 mg of a stimulant (either Ritalin or Adderall), and the referring ED wanted to admit him to our standalone psychiatric hospital 4 hours after the ingestion. Reportedly they called poison control who simply said to watch out for tachycardia. EKG showed sinus tachy with a rate of 117; labs were acceptable.

Took a big overdose and still tachy, doesn't seem medically stable to me. Unless you plan to hook him up to tele on the unit?
Also concern with overdoses is that the patient may have ingested additional meds. What if a seizure occurs when you get him to your unit?

I think what is "medically stable" per ED docs does not match level of stability needed for your general psychiatric unit. Patient needs to be observed, and cleared by an general medicine doc in my opinion.

 

[whopper]

I'd also remind folks that the problem with poison control is that their advice is valid on the assumption that we KNOW the extent of what the patient has on board. Which is pretty rare.

Very true! If no one knows the dosage or what was ingested, refuse to accept unless you know for a fact that consults show up quickly and efficiently on your unit. I mentioned this in another thread. While I was at U of Cincinnati (on a geriatric ward no less) consults didn't show up half the time and IM was only there about 2 hours a day. So if a code happened psych residents had to deal with it.

After months of seeing this was not going to be fixed anytime soon (if at all...by the time I left that same system was in place) and after experiencing a worse outcome every few weeks because of the above I told the psych consultant and the residents to make a big big wall between psych and the other units for accepting patients. If IM or the other departments didn't like it too bad...then make their consultants show up.

 

[PistolPete]

You can never trust an ER docs impression at an outside hospital for direct admissions to your unit. You need to get as much hard data labs/vitals/EKG/imaging/MAR/etc from them as you can and attempt to make your own decision. Else they will dump complete medical train wrecks on your psych unit. They don't give a damn what happens to a patient once they get them out of their ER, its a hot potato.

This is very true.

 

[PistolPete]

Very true! If no one knows the dosage or what was ingested, refuse to accept unless you know for a fact that consults show up quickly and efficiently on your unit. I mentioned this in another thread. While I was at U of Cincinnati (on a geriatric ward no less) consults didn't show up half the time and IM was only there about 2 hours a day. So if a code happened psych residents had to deal with it.

After months of seeing this was not going to be fixed anytime soon (if at all...by the time I left that same system was in place) and after experiencing a worse outcome every few weeks because of the above I told the psych consultant and the residents to make a big big wall between psych and the other units for accepting patients. If IM or the other departments didn't like it too bad...then make their consultants show up.

The politics of medicine is terrible. This is the exact thing that I've hated the most about residency, as well as the continued stigma of psychiatry patients (i.e. being "cleared" by the ER physician which later on is obvious that it was just done by looking at the patient from the doorway).

 

[whopper]

Well a good thing is the a-holes show themselves over time. I've had some physicians in other fields where we developed good relationships. I never had a problem with taking a patient from the ER or other units so long as if a problem happened getting the patient the appropriate help in time was not a problem.

And that's a problem cause as we know this always doesn't happen but sometimes with some docs it does.

 

[vistaril]

One thing to remember about these sorts of issues is that medicine teams and the ED has been BURNED by psych again and again and again with deception on these issues. One internist/hospitalist to this day tells me "I never trust you mother****ers because when you tell us to just take the patient for 24 hours even though everyone knows they are medically stable out of the ED they end up spending 7 days on my medicine service while you guys play the no beds card every damn day we try to transfer them".

A lot of the problem is that in many hospital systems the psychiatrist who 'promised' to take a stable patient the next day('I just want them to be observed on tele for 24 hrs first') is not the same person who the next 4 days is saying "sorry, no beds".

Hospitalists and ed physicians have grown tired of our **** in this regard, and rightfully so in many cases.

 

[whopper]

A lot of the problem is that in many hospital systems the psychiatrist who 'promised' to take a stable patient the next day('I just want them to be observed on tele for 24 hrs first') is not the same person who the next 4 days is saying "sorry, no beds".

When I did residency one of the attendings promised all the time to take someone the next day when he knew for a fact he wasn't on duty. That guy was a mother-effer. My first year of residency I couldn't tell but by second year I was getting wise to it. By my 4th year, and as a chief resident the head of the department and her secretary talked to me straight about things and told me when he was a resident he was one of the worst ones, he was never good, and now is a freaking terrible attending but she needed to hire him cause there was no one else to hire.

Was kind of weird going from resident outside the inner circle of the department to getting into the inner circle.