Psych Consults 101 – 2013-2014
Team:
-LaWanda Garrett, Administrative Assistant, office 9822. Duties: Receives new consults via pager (31042) or
phone (3-1573) or Carelink. Distributes consults to residents. Can help obtaining outside records for consult
patients.
-Deb Westbrook (office 9622). Valerie Annison (office on 9c). Fill in for LaWanda when she is on vacation.
-Kristine Beard MSW, pg 8582, office 9607 (MTuesThursFri) and Nancy Dodson MSW (Tues/Wed).
Duties: Help with transfers to inpatient psychiatry at UM or outside hospitals, help arrange outpatient psychiatric
follow-up, help arrange inpatient or outpatient substance rehab (in some cases). Sometimes do brief therapy and
motivational interviewing.
-CL director/primary attending: Amy Rosinski MD. Office 9810, phone 6-7820, pager 14543.
-Consult attendings: David Belmonte MD, Michael Casher MD, Lisa Seyfried MD.
-There are two teams, maize and blue, each have one attending, 1-3 residents/fellows, and 1-2 students.
Kristine/Nancy work with both teams.
Schedule:
-You can start getting paged for new consults at 8 AM. Most residents show up around 8-8:30, some arrive
earlier on core days. Efficient mornings may mean leaving earlier.
-Mornings are a good time to see follow-up patients, try to get dispo rolling on inpatient transfers, and see new
consults.
-On Tuesdays/Thursdays, core is from 12:30 to 2:15. You may still get paged and assigned new consults, but you
are expected to be at core, and attendings should cover your pager and deal with urgent issues, transfers, some
follow-ups. Med students can go see new consults, and present when you are done with core.
-Wednesdays: Grand rounds is from 10:30 to 12:00 and resident lunch from 12:00 to 1:00 pm. Same as above
with regards to new consults.
-Rounds: On Mondays/Wednesdays/Fridays: 1:00 pm room 9838. On Tuesdays/Thursdays 11:30 am in either
9838 or the resident room. Both teams meet to update social work staff on pertinent issues. Interesting cases are
also discussed, and brief teaching is done on pertinent topics.
-Consults can come in from 8 am to 5 pm. Later afternoon consults can often be deferred to the next day with the
team’s permission. Consult attendings cover the CL pager from 4:30 to 5 pm.
The Consult Process:
1) How do I get assigned consults? Consults come into LaWanda, and she keeps a rotating list of residents,
assigning the consult to the next resident on the list. Assignment is thus random. She calls the primary team back
for info if they page her, so some primary teams think she is a resident. She prints out 3 “green cards” that
contain pt info and billing information, puts them into the carousel, and pages you with the reg number and reason
for consult. She will tell you if it is a STAT consult, and if so you should immediately call the team/go see the
patient. Pick up the cards whenever convenient. Give a copy to the attending, and you can give the extra to a
student.
2) What if the consult is dumb? There are no dumb consults. Ha! Once in awhile the question could be
answered by a curbside call, or we really can’t answer it. Ask your attending in these situations. If the resident
says “My attending wants you to see this consult,” you gotta do it. Be careful with arguing, as it can stir up
trouble. If the question is just restarting Clozaril, with no other concerns, let Dr. Rosinski or Jolene Bostwick, the
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pharmacist, know. We can do it without seeing the patient. If the consult is cancelled, please tell LaWanda right
away! You don’t want your colleagues getting gipped, do you?
3) I’ve got the consult, now what? Start by “chart-mining.” Look at the admit note and the most recent progress
note. Filter careweb documents to look for psych notes, and social work notes. ER/PES notes after 6/13/12 are
under the Mi-Chart tab in Careweb documents. Before that date, they are under ER notes in regular Careweb.
Outpatient notes after 8/2012 are also in MiChart. If the pt is delirious, eyeball labs/imaging. Look at the
inpatient med profile and the MAR on Carelink to see what prns they got. Check centricity for vitals, MAWS
info is on the flowsheet too. Get the med student involved in looking up info. Some residents start filling out a
template form if dictating, or start part of the note in Create-Doc on Careweb with the preliminary info. They
then print out the skeleton note to take with them to see the patient. Some residents make their own templates.
If you don’t know a lot about delirium, capacity, cognitive screening, etc., do a 5-10 minute quick read from a
textbook to help you before the interview. For cognitively impaired patients, think about doing a MOCA exam
(can print from web). Look up DSM criteria ahead of time if you think you may forget.
Page the primary team (contact is on the green card, or on inpatient care team on Careweb). Ask them for
pertinent info, and what the pt seems like to them. If they take forever to get back to you, just go see the patient.
4) Besides seeing the patient, anything else to do? Talk to collateral informants if needed. Don’t forget about
the nurse/tech/sitter! If the patient gives permission, consider calling family or outpt psychiatrists or therapists. If
there is a safety issue, we usually will call even without permission. If the pt is from Community Mental Health
in our county, PES can look up notes from the computerized record system and fax to us at 6-6880.
5) Who staffs these things anyway? When done seeing the patient, contact your attending. Consults can be
staffed any time of day, not just after rounds. Sometimes attendings will go with you to see the case together,
especially if the interview is expected to be short, or if the consult comes in late.
6) OK I staffed it, now what? Call the primary team with your recommendations. Try to do this early, to avoid
getting the cross-cover. Be specific with doses and timing of meds, and indications. Don’t forget behavioral
recommendations. Call collateral if needed. Notify the PES resident if the case is highly acute and may act up at
night. If dictating, consider putting in alert note if patient agitated.
7) How do I document the consult? Two choices, type via Create Doc or dictate. If dictating, should be done
before leaving the hospital due to lag time. If typing, should be done before midnight. For both options, you
must use the templates. If dictating, make sure to tell the transcriptionist you are using the consult inpatient new
or follow-up templates.
8) Who helps me get stuff done? If you are getting overwhelmed, ask for help. Attendings are not “above”
doing petitions and certs, calling collateral, or seeing the occasional follow-up patient. Med students can help as
well. Update Kristine/Nancy often, not just at rounds.
9) Do I need to see this patient every day? No. Talk to your attending. Agitated/violent or actively suicidal
patients may need to be seen daily. Other patients may need to be less frequently. It is good to look at Careweb
daily on all your patients. Consider printing the to-do list via Careweb for your patients each day. If we are
recommending prns, check to see what they got on Carelink (particular pet peeve for Rosinski if you don’t know
what they got). You can also pop in to eyeball a patient without writing a note, but you CANNOT bill for that.
Attendings do not have to see every follow-up patient; sometimes the resident sees the patient alone, but still
sends the note to the attending.
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10) What do I do with this “green card”? Both attending and resident fill out for billing purposes. We can
ONLY BILL if a note is done that day. Just put the initials of the attending, your initials, date seen, and either
new or f/u under level. Keep the green cards until you sign-off or the pt is dc’d or transferred. You can write on
them all you want. When the pt is discharged or you sign-off, make sure all the visit dates are noted, and turn the
card into LaWanda (black box on her desk).
11) Stay-on or sign-off? Keep the card active if Kristine/Nancy still have work to do, or if you think you will
need to check in now or then. If you sign-off, make sure the team knows this via page or preferably via note. If
you get re-consulted on a patient previously seen by us on the same admission, can do a f/u note. If a patient was
seen by PES after hours as a consult, we can also do a follow-up note.
Med students:
-New M3s arrive every 6 weeks, and do 2 weeks on consults, 2 weeks of outpatient, and 2 weeks of inpatient.
They are gone every Friday afternoon for lectures, and another morning or afternoon in the week for their
continuity clinic. Rosinski tries to orient them on Tuesday mornings.
-We would like them to get practice presenting and doing notes, even though we cannot use most portions of their
note (Can use Past Psych, ROS, Family and Social Hx and Past Medical History). As a rough guide, try to have
them do 2 full notes per week via MedStudent Worksheet. You don’t have to submit it if you don’t have time to
electronically edit. You should try to review 1 note per week with the student, and the attending one note. You
can have them do small portions of additional note to practice (HPI, Past Psych Hx, MSE, Assessment and Plan).
-When they start, have them watch you do a few consults, then start sending them alone. Make sure to go over
the case before you have them present to the attending. Med students are helpful in getting collateral (don’t have
them call if concern is suicide), chart-mining, doing lit searches, etc.
Transfers to psych hospitals:
-If the patient needs admission, know whether the patient will be voluntary/involuntary, and talk to
Kristine/Nancy/your attending about location options. Depends on the pt’s insurance and county to some extent.
For uninsured/Medicaid patients we have to get approval from the home county for admission, and in some cases
from Wayne/Oakland county, we will need to transfer that patient back to a home county hospital. 9c is not even
an option. Good to tell the primary team up front that not all patients can go to 9c, due to insurance and legal
issues. Also remind them that it can take some time to get approval from other counties and to find a hospital.
Keep them up to date via page, as that tends to avoid angry nagging.
-We try to avoid admitting Wayne or Oakland county INVOLUNTARY patients to 9c, as the 9c attendings could
feasibly have to travel with the patient to that county for court. It is a mess, so we only do it in extreme situations.
-If the patient can feasibly come to 9c, and they are medically stable or close, fill out the 9c intake form
(Kristine/Nancy/Rosinski can e-mail to you).
-Kristine/Nancy will tell you who the 9c intake attending is, and the 9c charge RN. E-mail the intake as an
attachment to both of them, and cc Nancy/Kristine. Always good to page the 9c attending and alert them of the email, and ask if they want to meet in person to discuss. The 9c attending may accept right away, or may want to
talk to 9c nursing. 9c charge nurses often go eyeball the patient to make sure they can accommodate nursing
needs.
-When 9c attending/nurses accept the patient, they put the patient on a waiting list. Kristine/Nancy go to a daily
bed meeting at 11 am to discuss the logistics of which patients get the opening beds.
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-Some medically bedded patients (even if not 1:1 on the floor) will need to be a 1:1 on 9c. This may occur if the
pt is a fall risk, is highly agitated or impulsive, is confused, or is acutely suicidal. 9c can only accommodate a
certain number of 1:1s, so this sometimes creates a wait for consult patients. Be proactive and keep the
primary team posted about where the patient is on the list, and what the hold-up is. We can always try to find
outside hospitals for patients, but for patients with complex medical needs, this is sometimes impossible.
-Even if the primary team says the patient is stable, 9c’s idea of stable is not always the same. It’s a good idea to
see the patient yourself, look at vitals and labs. 9c nursing needs to know if the pt has needed/will need oxygen
(they generally only take stable oxygen patients). Find out if the pt is eating, toileting (incontinent, foley, BM yet
post surgery), ambulating and with what level of assistance (9c usually wants PT consult if concern for gait/fall
risk). Know the details of any wound care/ostomy needs/suctioning/contact precautions. 9c does tube feeds, but
not TPN. IV antibiotics are +/-. 9c does NOT take LVADS or pulmonary hypertension pumps.
-Once Kristine/Nancy get the a-ok that 9c accepts a patient and has an open bed, they get insurance approval (if
county patient this must be done ahead of time), and have the patient parred (registered as coming to 9c). The
consult resident writes admit orders. You can copy orders from the medicine chart, which saves tons of time! Ask
Rosinski how to do this. The consult resident must also get the voluntary or get the petition/cert. Kristine/Nancy,
primary team residents, family, or CL attendings often do the petition, and CL resident usually does the cert. Try
to time the cert as late as possible.
-PLEASE make sure the orders are accurate. If unsure about medications, labs, etc. please page the primary team
and ask. Do NOT forget about VTE assessment/prophy.
Reading Materials
-Dr. Rosinski’s filing cabinet (paper and electronic)! I have articles on most everything, just ask!
-Massachusetts General Hospital, Handbook of General Hospital Psychiatry, Stern et al., Mosby Press 2010.
-Manual of Psychiatric Care for the Medically Ill, Wyszynski and Wyszynski, American Psychiatric Publishing
2005. Great tables and practical info on capacity determination.
-American Psychiatric Textbook of Psychosomatic Medicine, Levinson et al. American Psychiatric Publishing
2010.
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