So I was asked to do this by our program and present it to the incoming class in a few weeks......I'm just throwing together a list now. A rough draft:
1) Don't demand the ER to get innapropriate medical workups "just because". When I started night float, apparently the residents before me would demand everything under the sun ordered for pts with clear psych histories. My first night down there I had heard about a psych pt coming in with a classic psych presentation, and before I go assess the pt I see that a boatload of stuff had been ordered by the er resident......the usual laundry list plus a couple of particular illogical labs(coags for example....wtf??). I stroll over to that area of the ER to ask if there is anything medically I should be worried about(after all they've ordered all these ridiculous and useless labs), and the resident says rolls his eyes and states "well you guys always want this before accepting the pt". I chuckled, and then informed him "well I don't believe in ordering unneccessary labs. It's a waste of time and money, and detrimental to pt care as well." I made sure to say this loud enough so his attending heard as well, and word quickly spread, which led to instant respect amongst all the er on this issue. The point is that a large number of ER presentations only require a UDS. No issue makes us look more silly amongst other specialties than when we order all this stuff in the ER unneccessarily.....
2) Don't try to dump pts on our pts on medicine for issues that don't require it. Same day, different pt on night float- this 60 year old with another known psych hx comes in. She doesn't really meet criteria for admission but I'm told by attending to admit her anyways. I go to the ER resident to tell him the pt is officially ours, and he says "you're ok with this blood pressure. Usually you guys pitch a fit when it's this and demand they be sent to medicine or held in the ER forever". I glance down at the most recent vitals......171/104. I chuckle again, and say "cool, she's well perfused". The point being that she is a 60 yo with a known hx of htn who presents with some degree of noncompliance.....if she were normotensive, I *would* be wondering what's going on. Now, you have to be reasonable about it. You can't immediately accept her when she's 228/140 for example. The inpt people would be pissed when she came up to them. In that case I'd tell the ER that we will accept the pt, but they'll need to hit her up with some meds in the ed to bring it down to a more reasonable level. And usually they are cool with this. But again, instant cred was obtained amongst the ER medical people. You're also doing what's right for the pt.
3) Work efficiently, especially when psych pts are clogging up the ER. It's another issue entirely whether most of these pts should even be going through the ER to be triaged to begin with(they shouldn't), but that's beyond our control as residents. But nothing ticks off the ER medical people more than psych pts backing up in the ER and the ER person on taking forever to work through very routine cases. I *don't* mean do hurried work and sacrifice pt care. Rather, focus on making the right decision on the big picture issue(basically their dispo). A good ER H/P *very briefly* sums up the major presentation, giving enough information to make it clear why the decision was made. It also quickly documents things like protective factors for a discharge. I've seen ER people spend 45 minutes on an ER H/P(actually writing it) waxing eloquently about the pt's MSE.....NOBODY CARES. That's not the function of the psych ER.
4) Don't start pts on meds in the ER(or their first 7 hrs on the floor or whatever until the primary team comes in) that arent needed. You're job is to do two things: Decide on admit vs discharge, and make sure the pt is stable through the night. That's pretty much it. Admitting a hypomanic suicidal pt through the ER and starting whatever mood stabilzer *YOU* would start if you were going to be the pt's doctor is not appropriate. Give the pt the meds they need acutely(prns for acute psychosis/agitation, benzos for withdrawl, etc) and then leave things to the primary team. It's not your job to try to dictate the pt's care over the next two weeks. Don't cite a frequent paper comparing Lamictal vs Tegretol in your H/P as a reason for choosing one over the other. You shouldnt be choosing period as that's not your role. It harms pt care when the primary inpatient team sees this the next day because then they switch things around, and that just confuses the pt and family more.
That's 4 big ones I can think of....any others?
1) Don't demand the ER to get innapropriate medical workups "just because". When I started night float, apparently the residents before me would demand everything under the sun ordered for pts with clear psych histories. My first night down there I had heard about a psych pt coming in with a classic psych presentation, and before I go assess the pt I see that a boatload of stuff had been ordered by the er resident......the usual laundry list plus a couple of particular illogical labs(coags for example....wtf??). I stroll over to that area of the ER to ask if there is anything medically I should be worried about(after all they've ordered all these ridiculous and useless labs), and the resident says rolls his eyes and states "well you guys always want this before accepting the pt". I chuckled, and then informed him "well I don't believe in ordering unneccessary labs. It's a waste of time and money, and detrimental to pt care as well." I made sure to say this loud enough so his attending heard as well, and word quickly spread, which led to instant respect amongst all the er on this issue. The point is that a large number of ER presentations only require a UDS. No issue makes us look more silly amongst other specialties than when we order all this stuff in the ER unneccessarily.....
2) Don't try to dump pts on our pts on medicine for issues that don't require it. Same day, different pt on night float- this 60 year old with another known psych hx comes in. She doesn't really meet criteria for admission but I'm told by attending to admit her anyways. I go to the ER resident to tell him the pt is officially ours, and he says "you're ok with this blood pressure. Usually you guys pitch a fit when it's this and demand they be sent to medicine or held in the ER forever". I glance down at the most recent vitals......171/104. I chuckle again, and say "cool, she's well perfused". The point being that she is a 60 yo with a known hx of htn who presents with some degree of noncompliance.....if she were normotensive, I *would* be wondering what's going on. Now, you have to be reasonable about it. You can't immediately accept her when she's 228/140 for example. The inpt people would be pissed when she came up to them. In that case I'd tell the ER that we will accept the pt, but they'll need to hit her up with some meds in the ed to bring it down to a more reasonable level. And usually they are cool with this. But again, instant cred was obtained amongst the ER medical people. You're also doing what's right for the pt.
3) Work efficiently, especially when psych pts are clogging up the ER. It's another issue entirely whether most of these pts should even be going through the ER to be triaged to begin with(they shouldn't), but that's beyond our control as residents. But nothing ticks off the ER medical people more than psych pts backing up in the ER and the ER person on taking forever to work through very routine cases. I *don't* mean do hurried work and sacrifice pt care. Rather, focus on making the right decision on the big picture issue(basically their dispo). A good ER H/P *very briefly* sums up the major presentation, giving enough information to make it clear why the decision was made. It also quickly documents things like protective factors for a discharge. I've seen ER people spend 45 minutes on an ER H/P(actually writing it) waxing eloquently about the pt's MSE.....NOBODY CARES. That's not the function of the psych ER.
4) Don't start pts on meds in the ER(or their first 7 hrs on the floor or whatever until the primary team comes in) that arent needed. You're job is to do two things: Decide on admit vs discharge, and make sure the pt is stable through the night. That's pretty much it. Admitting a hypomanic suicidal pt through the ER and starting whatever mood stabilzer *YOU* would start if you were going to be the pt's doctor is not appropriate. Give the pt the meds they need acutely(prns for acute psychosis/agitation, benzos for withdrawl, etc) and then leave things to the primary team. It's not your job to try to dictate the pt's care over the next two weeks. Don't cite a frequent paper comparing Lamictal vs Tegretol in your H/P as a reason for choosing one over the other. You shouldnt be choosing period as that's not your role. It harms pt care when the primary inpatient team sees this the next day because then they switch things around, and that just confuses the pt and family more.
That's 4 big ones I can think of....any others?
