Guidelines for the Emergency Psychiatry Rotation

Welcome to the Emergency Psychiatry rotation! The ED psych rotation is intended to allow the psychiatry resident to
become competent in assessing and managing patients with acute psychiatric illness, symptoms, or distress. Patient care
in the emergency psychiatry setting emphasizes the ability to appropriately triage patients, perform and document
focused psychiatric evaluations, work with a multidisciplinary team to care for acutely ill patients, co-manage acute
psychiatric issues with the General Emergency Department team (GED), and appropriately disposition patients. The ED
psych resident (EPR) will learn how to manage acute agitation, substance intoxication and withdrawal, psychosis,
suicidality, homicidality, and other acute crises. To accomplish this, the EPR should strive to increase his/her medicolegal
knowledge and knowledge of the medical system in which the ED operates. A full list of milestone-based goals and
objectives is included separately.

General overview:
 The EPR is responsible for responding to all new and existing (i.e. “follow up”) adult psychiatric evaluations
requested in the emergency department and co-managing their patients with the GED.
 Unless a patient will be leaving the ED in less than an hour, it is the responsibility of the EPR to initiate treatment
for that patient, similar to what would be offered in an inpatient psychiatric unit.
 The EPR is responsible for reevaluating patients who are still in the ED at the start of his/her shift. This will help
the EPR develop a sense of ownership of his/her patients and an understanding of the acute issues pertinent to
the patient.
o Regardless of the time of the last psychiatric note, the EPR should write a brief progress note in EPIC
documenting the 8 AM transfer of care (see page 3 for an example of a progress note).
o So long as a patient physically remains in the ED, the ED psychiatry team continues to assume the role of
consultant for that patient. This holds true even when patients have already been admitted to Rush, are
awaiting a bed or are awaiting transfer to an outside hospital, or are awaiting discharge.
 Each patient under the co-management of the ED psych team needs to be seen a minimum of twice a day for
the duration of time the patient is in the ED.
o Any time a patient is seen, there should be a brief progress note documenting the encounter.
o Any time there is a change in the treatment plan (e.g. a patient is placed in restraints, a medication is
started, or there a change in disposition), there should be a brief note documenting the change.
o Note that the myth that a patient needs to be seen every 12 hours is false. Patients should be seen
twice a day.
 At the start and end of his/her shift, the EPR should verify that all required documentation (e.g. psychiatric
evaluation notes in EPIC, voluntary or involuntary forms) has been completed in order to avoid delays in
management and disposition. The EPR should also verify that the GED has actually entered previously agreed
upon recommendations for medications, laboratory data, EKGs, assessment scales, etc, into EPIC
 Following the AM handoff (see Handoffs below), the EPR should touch base with the AM emergency psychiatry
attending to run the list and discuss a preliminary plan of action for the morning.
 The EPR should frequently check in with the Psychiatry RN, Clinical Resource Coordinator, Mental Health
Technician, and Security personnel to review any interval patient events or safety concerns, as well as to discuss
treatment and disposition plans. A sample “checklist” is located at the end of this document titled “Emergency
Psychiatry Patient Flow Checklist.”
 The EPR covers the “1’s” pager. He/she is responsible for signing into the "1s" following the AM handoff
 The EPR is responsible for updating the ED Psychiatry Daily List in EPIC each morning and periodically throughout
the work day.
 At 1 PM, the EPR should touch base with the PM emergency psychiatry attending to run the list and discuss a
preliminary plan of action for the afternoon
 If a patient is likely to be admitted to one of the inpatient psychiatric units, the EPR must order PRNs for
agitation. This will help ensure the safety of the patient and staff once the patient arrives onto the unit and
before he/she is assessed by the resident on call. Please note that psychiatry residents are NOT permitted to
place active orders while the patient is in the ED. Thus, PRNs for agitation should be ordered as “sign and held.”
Hours of ED psych rotation:
 8 AM to 5:30 PM Mon-Fri with the following exceptions
o Wednesdays: 8 AM to 11 AM (this pertains to PGY-2s only)
o Clinic days: 8 AM to 12 PM (this pertains to PGY-2s only)
o PGY-1s are excused for their daily didactic

Emergency Psychiatry Attending Supervision:

An emergency psychiatry attending will provide direct supervision in the ED between the hours of 8 AM and 5 PM.
 Hours of AM attending: Roughly 8 AM to 1 PM
 Hours of PM attending: Roughly 1 PM to 5 PM

Additionally, one attending will be assigned to provide you with one hour of supervision weekly to review challenging
cases, discuss articles, and provide an opportunity for feedback. In most cases, Dr. Kimchi will serve as your supervisor.

The contact information for the attendings is as follows:

Dr. David Banayan: (312) 709-0419 Dr. Charles Hebert: (312) 513-2092
Dr. Katrina Burns: (916) 765-7413 Dr. Eitan Kimchi: (443) 854-3106
Dr. Fernando Espi: (216) 255-7219 Dr. Kirk Harris: (716) 207-1462

Handoffs:
Handoffs with other mental health clinicians should be efficient and focused on safety concerns and the current
treatment plan (including disposition). The receiving clinician should have a good understanding of the patient’s chief
complaint, reason for psychiatric evaluation, diagnoses, major safety issues and transfer plans.

Handoffs in the ED will occur at the following times:

 Verbal handoff in the morning as a conference call between ED resident, night float, ED attending for the
morning, and CL staff member carrying the 6611 pager. The night float resident “quarterbacks” the handoff and
ensures that all parties are on the phone.
 Verbal handoff in the evening between ED resident, evening call resident and moonlighter.
 Verbal handoff when a patient is transferred from the ED to one of the inpatient psychiatric units. The EPR
should contact the resident on call to inform him/her of the incoming admission, discuss recommendations, and
review any medical/psychiatric/legal concerns.

On Wednesdays, the EPR will perform a handoff with a faculty member (typically NPs Meghan Baldwin or Katy
Perticone) at approximately 11 AM. The receiving faculty member is listed in the ED schedule as “PM attending.” Ms.
Perticone can be reached at (607) 237-7542. The receiving faculty member will carry the 1s following the handoff.

On clinic days, the EPR will perform a handoff with either a PGY-3 or -4 (1 st half of the year) or PGY-2, -3, or -4 (2 nd half of
the year) at approximately 12 PM. The receiving resident will carry the 1s following the handoff. He/she is listed in the
ED schedule as “PM resident.”

Please use the Emergency Psychiatry Handoff Checklist at all handoffs. You should have access to the EPIC Smart Phrase
“.EDPSYCHHANDOFF.” A copy of the Handoff Checklist is also located at the end of this document.

Receiving a request for a psychiatric evaluation:

The EPR may be notified of a psychiatric evaluation either through the 1111 pager, by phone, or verbally. Psychiatric
evaluations are not to be discriminated by the method they were requested. Consults must come from a physician or
advanced practice provider (e.g. physician’s assistant or nurse practitioner). Please encourage the clinician requesting
the consult to enter the order for the consult in EPIC.

Consultations should be started as soon as the request is made by the ED staff, and must begin within an hour of the
request. Exceptions are permitted when multiple psychiatric evaluations have been requested; however adequate
information must be obtained to appropriately triage and prioritize the requests. Usually this should include at least a
brief “eyes on” assessment of the patient within one hour of a request. Expected delays in starting an evaluation should
be communicated to the requesting ED staff, along with an estimate of when an evaluation will be completed.
Intoxication with alcohol or other substances of abuse is never a justified reason to delay a consult. We do not wait until
a patient is clinically or legally sober to start a consultation. We begin our evaluation and management of the patient as
soon as possible. In most cases, we will not be able to provide final recommendations regarding disposition until a
patient nears clinical sobriety. Keep in mind that intoxication is a major risk factor for suicide attempts.

Child and adolescent psychiatric evaluations:

Child and adolescent evaluations prior to 5 PM on weekdays are the responsibility of the child psychiatry fellow or
attending, and evaluation requests for patients under 18 should be directed to pager number 4141. After 5 PM, the EPR
is responsible for seeing all child and adolescent evaluations.

ED overflow (5 Kellogg) and L&D Triage psychiatric evaluations:

ED overflow evaluations prior to 5 PM on weekdays are the responsibility of the CL team, not the EPR. Please direct
requests for these consults to pager number 4141. After 5 PM, these evaluations go to the resident on call.

L&D Triage evaluations prior to 5 PM ARE the responsibility of the EPR. In nearly all circumstances, the patient should be
seen in the ED, NOT in L&D Triage itself. Provided the patient is not being admitted to L&D (at which point the patient is
considered admitted and is seen by CL rather than by the EPR), the EPR should contact the L&D representative
requesting the consult and direct them to bring the patient down to the ED. The EPR may need to guide the
representative through the process of petitioning a patient, should that be indicated.

Clarifying the question:

 Ask the person requesting the evaluation for background information and the reason for the request.
 Are there specific questions they want answered? Bear in mind that, in many cases, our job is to help the GED
reframe or revise the question they are asking.
 How have they evaluated the problem, and what do they want done?
 What interventions have been performed and what additional tests and management are planned?
 If the clinician requesting the evaluation has expectations that seem difficult to achieve in the ED, this is the time
to discuss them further.
 Provide an estimate of when the psychiatric evaluation will be completed.
 Most importantly, the person requesting the evaluation must provide information needed to properly triage
and prioritize the request. This includes a description of the patient’s current symptoms and behavior, along
with any signs of intoxication, medical instability, agitation, or distress.

Prioritizing/triaging requests:
Patents are NOT necessarily seen in the order in which they present. Rather, The EPR has the responsibility to triage
evaluation requests and to recognize patients whose needs take priority. The EPR is expected to respond to all ED
consults within one hour of request. Within that hour, the resident performs an initial evaluation of the patient to
determine the level of acuity of the patient, i.e. whether the patient must be further evaluated immediately or whether
further assessment can be safely delayed due to concurrent duties. In general, assessments for the most distressed
patients should be initiated first. Emergent needs for medication, seclusion/restraint, searches or special observation
should be explored at the time of the request and responded to promptly. Emergency room protocols will be adequate
in most cases needing seclusion, searches or observation, however the EPR should provide an immediate assessment of
any patient requiring emergent medication or restraint.

Evaluating Patients:
Guidelines for establishing safety: The psychiatry rooms in the ED are designed to enhance safety. By ED protocol, all
patients awaiting psychiatric evaluation are changed into hospital gowns, separated from their belongings, and observed
by a security officer. If asked to evaluate a patient outside of the psychiatry area the EPR will need to consider whether
safety measures are required. For requests involving violent ideation (suicidal or homicidal) or agitation, do not hesitate
to ask the ED to initiate the usual protocols above.

Attention to safety should be maintained throughout emergency evaluations. In general staff should position themselves
between the patient and the door, with no obstacles blocking exit from the room. Although it is preferable to interview
patients seated, with the door closed for confidentiality, for agitated patients it will sometimes be required to interview
standing or with the door open to maintain safety. At such times, PRN medication should be considered.

The job of the EPR is to consider what are the various factors that are coming together to bring the patient to the ED at
this moment in time. Many of the patients you will see in the ED are patients with high frequency of admissions or visits
to the ED. For many of these patients, factors contributing to their frequency of visits are often neglected. The EPR
should consider what biopsychosocial factors (e.g. unstable housing, unstable finances, insufficient family support,
subpar access to healthcare resources, and general indifference or disdain towards the patient by healthcare teams) will
need to be addressed in order to best help the patient.

Guidelines for interviewing patients:

The ED psychiatric interview is a focused assessment for the purpose of determining immediate management and
appropriate disposition. The interview will necessarily be flexible and may not cover as much detail as a typical history
and physical or outpatient intake evaluation. Despite the more limited scope, some information will be obtained in all
areas of a typical H&P. In addition to obtaining sufficient information to accurately categorize the presenting complaint,
significant psychosocial information will often be required to answer the “why now?” that motivated the ED visit.

In order to maintain confidentiality all interviews should be performed privately (door closed and family asked to wait
outside) unless the patient’s wishes or safety concerns require otherwise. If a patient who in the hallway needs to be
interviewed, the EPR can ask the ED RN or social worker to move patients around (even temporarily) in order to be able
to interview the patient in a room.

All interviews must include an assessment of risk of violence to self or others, as well as whether or not medical
problems or substance use contribute to the presentation. Because of this a brief, focused medical review of systems
must always be performed. Likewise, basic tests of cognition and neurological function (including concentration,
memory, movement and coordination) are required for nearly every patient.

Guidelines for note writing:

For your initial note, please use the EDPSYCHCONSULT template

Follow up progress notes are generally brief and follow a SOAP format. They focus on any significant acute events (e.g. a
patient goes into restraints, receives IM PRNs, or demonstrates active withdrawal symptoms, or an inpatient certificate
is renewed) and changes to the patient’s management (e.g. starting a new medication or change in disposition). The
note should include a brief mental status exam.

An example of a follow up progress note is:

 S: Case endorsed to me by [night float resident] (for the 8 AM progress notes). Reviewed interim notes. No
behavioral problems or management concerns. No PRNs given. Interviewed patient. Continues to report feeling
suicidal. Wants to be admitted (or, alternatively, patient currently asleep):
 O: Brief MSE (pertinents only)
 A: 33 y/o with recurrent MDD. Remains suicidal
 P: Continue current treatment plan (or, alternatively, recommend starting fluoxetine 10 mg daily for
depression). Awaiting inpatient financial clearance
The resident should also document any conversation he/she has had with a patient.

Guidelines for obtaining collateral information:

As with other psychiatric evaluations, collateral history is a key element of the ED psychiatric assessment and should be
obtained whenever possible. If collateral is obtained, then the EPR should document who was contacted and what was
discussed. If collateral historians are not present in the ED, the EPR should obtain consent from the patient to contact
them. Ethical and legal standards for confidentiality prohibit the disclosure of protected health care information without
the patient’s consent. In emergency situations, the need for information may require the physician to break
confidentiality and obtain collateral history without the patient’s consent. Discuss these situations with the emergency
psychiatry attending. If collateral history must be obtained without the patient’s consent, the EPR must document the
specific reasons for breaking confidentiality. At such times the EPR should disclose no more information than necessary
to appropriately manage the patient.

Absences:
All absences from the service must comply with the GME Sick and Wellness Days Policy and any psychiatry residency
program policies regarding absences, vacations, wellness days, sick days, and days off for Step 3.

Planned absences: Planned absences (e.g. vacation, wellness, and Step 3 days) during the emergency psychiatry rotation
must be approved by Dr. Kimchi and the Residency Program Director. The EPR must notify Dr. Kimchi at least 4 weeks
prior to a planned absence. Planned absences are typically permitted provided there is at least one other psychiatry
resident scheduled to cover the emergency psychiatry service on the day of the planned absence. If there is no other
resident scheduled to cover the service, then the EPR is responsible for finding another resident (“Resident 2”) to cover
him/her for this period of planned absence. Resident 2 must receive approval from his/her service chief (e.g. Dr. Hebert
for CL or Dr. Shankar for adult inpatient psychiatry) to cover the emergency psychiatry service.

Unplanned absences: If the EPR is unable to work due to illness or personal emergency, the EPR must 1) immediately
inform the ED psych attending(s) for the day by either pager or telephone AND 2) send notice by email to the ED psych
attending(s), Dr. Kimchi, and the Residency Program Director. If there is no attending assigned to a particular shift, then
the EPR must 1) immediately inform Dr. Kimchi by either pager or telephone AND 2) send notice by email to Dr. Kimchi
and the Residency Program Director.

Personal Emergencies/Sick Days:

In the event of an unexpected illness or personal emergency, the EPR must immediately notify the ED psych attending
assigned for that day. Additionally the resident must notify Dr. Kacila, Dr. Kimchi, and Hannah Gaustad-Randolph of
his/her absence in real time. Unless a different arrangement is made, the emergency psychiatry attending will assume
responsibility for covering the 1111 pager and evaluating/managing patients in the ED.

Special consideration for patients with extensive lengths of stay in the ED:
If a patient is being considered for inpatient admission and it will be challenging to transfer the patient to an outside
hospital in the next few hours, the EPR should call Dr. Robert (Bob) Shulman to see if the patient can be admitted to
Rush inpatient psychiatry instead of the outside hospital. Note that you do NOT need to wait and SHOULD NOT wait 24
or 48 hours before contacting Dr. Shulman to discuss the case for possible admission to Rush inpatient psychiatry. The
EPR should be prepared to discuss the benefits vs risks of holding the patient in the ED for possible transfer vs accepting
the patient to the inpatient psychiatric unit. To do this, the EPR should be able to discuss the psychiatric acuity of the
patient in question and the overall acuity of the ED, and have a sense of the bed status of the inpatient psychiatric units
and the overall acuity of the inpatient units.

Dress Code:
While working the emergency department or in areas where contact with patients or their families is possible, residents
are expected to dress professionally in business attire of a casual nature. Residents may wear scrubs only while rotating
in the emergency room. Bear in mind that scrubs are NOT appropriate in the outpatient clinic. Athletic shoes are only
acceptable with scrubs. Per Rush policy, scrubs should not be worn outside of the doors of RUMC. This includes the
garage and walking through the garage from one building to another.

Lounge and locker rooms:

The Emergency Department has been kind enough to permit psychiatry residents to use the ED resident call room. The
call room, which is incorrectly marked as “ED attending room,” is located outside of Pod C close to the ED lounge and
locker rooms. It is quite bare and contains a desk with a single computer. It does not contain a bed. Residents mainly use
it to store their belongings. Note that this single computer is shared by all ED residents. Like any call room, it is not
considered secure so please do not leave your valuables there. This room is not intended to be used by students. We
arranged for students to use three ED locker rooms to store their belongings during their emergency psychiatry rotation.

Supervising students:
Both physician assistant (PA) students and medical students rotate on the emergency psychiatry service. PA students are
in their second of a two and a half year program. Their exposure to psychiatry in their preclinical year is considerably
less than what medical students get in their preclinical years. On the other hand, PA students come to PA school with
thousands of hours of clinical training. Many of them have practiced as mental health workers, nurses, nurses’ aides, and
lab techs prior to PA school. ALL medical and PA students are expected to interview patients and write consultation
notes on their patients in EPIC as part of their rotation. The EPR and/or faculty member is to provide the student with
feedback on their note writing.

The hours of the student rotation are 8 AM to 5:30 PM Mondays through Fridays. Students are permitted to leave after 5
PM if excused by either the faculty member or the EPR. The student is expected to remain in the emergency department
throughout the day unless he/she is in lecture or is otherwise instructed by the resident or faculty member.

Each morning, the student should touch base with the EPR and/or faculty member to discuss a preliminary plan of
action. The EPR or faculty member will assign patients to the student to evaluate and follow through the patient’s
admission in the ED. The EPR or faculty member may assign either a new patient or a patient who was admitted on a
previous day or overnight. The student should see their patients AT LEAST twice a day.

Please review the Guidelines for students on the Emergency Psychiatry Rotation for further information about the role
and expectations of students on the emergency psychiatry service.

Student note writing:

For PA students: The EPR and non-nurse practitioner faculty members can incorporate the review of systems, past
medical history, past psychiatric history, social history, and family history from PA student notes into their own notes.
Remember to attribute the sections you are incorporating to the PA student (e.g. “Per Ms. Jones, “***”).

PA student notes should start with a disclaimer along the lines of “Please note that PA student notes are for educational
purposes only.”

For medical students: Residents and non-nurse practitioner faculty members can attest the entirety of the medical
student’s note under certain circumstances.

If you do not plan to attest the medical student note, then that note should similarly have a disclaimer along the line of
“This medical student note is for educational purposes only.”
 Emergency Psychiatry Handoff Checklist

Reason for consult: ***

Initial treatment plan: {e.g. obtain collateral, start psychotropics, CIWA, 1:1 sitter, Admit to GMF, OSH, 13K, discharge,
rehab, observation}

Have PRNs for agitation been ordered while patient is in the ED? (If so then which ones): {:60:::0}

Have other medications (e.g. Standing psychotropics, nicotine replacement) been ordered while patient is in the ED?
(If so then which ones): {:60:::0}

If the patient is being admitted to inpatient psychiatry:

1) Has all the legal paperwork been completed?: {Yes, No, or blank:14924}
2) Has the resident on call been contacted to perform a verbal handoff?: {Yes, No, or blank:14924}
3) Have admitting orders with initial medications been ordered?: (If so then which ones):  {Yes, No, or
blank:14924}
4) Recommended level of observation: {Level of observation:14926}
5) Is the patient appropriate for a roommate?: {Yes, No, or blank:14924}

If the patient is going to GMF:

1) Has the patient been added to the CL Daily List and Psych Consults list?: {Yes, No, or blank:14924}
2) Does our consult note recommend placing a psychiatry consult order for continued psychiatric care?: {Yes,
No, or blank:14924}
3) Have you recommended a sitter?: {Yes, No, or blank:14924}

When will the patient need to be evaluated in the ED (goal is twice within 24 hours): ***

To do / follow-up: {e.g. f/u labs/EKG, monitor CIWA/COWS, legal paperwork, collateral}

General overview: Add to "ED Psychiatry Daily List" --> Staff patient --> Paperwork --> SW --> ED attending/resident -->
Floor nurse --> Complete orders for admission including PRNs for agitation (signed and held)--> Contact psychiatry
resident on call to perform verbal handoff --> Update handoff in EPIC
 Emergency Psychiatry Patient Flow Checklist

Overview
☐ Reason for ED visit

Interval events
☐ Any behavioral concerns?
☐ Have PRNs/STAT meds been administered?
☐ Has patient been placed in physical restraints?

Agitation
☐ What nonpharmacological de-escalating techniques have been effective?
☐ Has staff identified any potential triggers for worsening agitation?
☐ Has psychiatry recommended PRNs for agitation?
☐ If so, have they been ordered?
☐ Does the patient have a security alert?

Other safety concerns

☐ Does patient currently have/need a safety assistant?
☐ Is patient a watch?
☐ Is a change of level of observation warranted?

Vital Signs, CIWA/COWS, labs, studies

☐ Has psychiatry recommended CIWA/COWS?
☐ If so, has it been ordered?
☐ Review pertinent CIWA/COWS, labs, studies, VS abnormalities

Standing medications
☐ Has psychiatry recommended standing meds (e.g. psychotropics, nicotine patch)?
☐ If so, have they been ordered?
☐ If so, have they been administered?

Treatment plan
☐ What are the next steps? E.g. Monitor behavior, monitor CIWA/COWS, collateral,
med changes, f/u labs/studies
☐ Reason(s) for MD/APP reassessment +/- when will it occur?

Disposition
☐ What is the patient’s disposition?
☐ Any barriers to disposition?
☐ Any paperwork that needs to be completed?