Medical Clearance – Lake County

Emergency Dept.-Algorithm for Due Process Hearings

Health and Safety Code 1317.1(2)(A):“Emergency services and care” also means an additional screening, examination, and evaluation by a physician, or other personnel to the extent permitted by applicable law and within the scope of their licensure and clinical privileges, to determine if a psychiatric emergency medical condition exists, and the care and treatment necessary to relieve or eliminate the psychiatric emergency medical condition, within the capability of the facility.

The ED staff will screen and assess the patient at the ED for care and treatment under the supervision of a licensed physician according to their standard of practice. [Reference: EMTALA]

When a patient enters the Adventist Health Clear Lake Emergency Department (ED) or the Sutter Lakeside Hospital ED, the patient is under the direct care of these aforementioned hospitals, and the ED physician holds the ultimate responsibility for successful assessment and resolution of the crisis and seeks consultation from LCBH to determine the best course to achieve that. The patient remains under the care of Adventist Health Clear Lake or Sutter Lakeside Hospital until the patient is discharged from the ED or until the patient’s care is transferred to the transport team.

The ED staff will screen and assess the patient at the ED for care and treatment under the supervision of a licensed physician according to their standard of practice. [Reference: EMTALA]

The ED staff will perform a medical screening examination to determine the medical status of the patient.

The purpose of this examination is to determine if there are any non-psychiatric medical issues requiring immediate treatment or if the patient can be medically cleared. Some out of normal limits laboratory tests (thyroid, WBC, blood sugar, etc.) can be the cause of the psychosis or other mental health condition, so these need to be treated and within normal limits in order to determine if the presentation is due to medical or mental health conditions.

If medical cause for the behavior is discovered, other than a psychiatric disorder, the ED physician and staff will proceed to treat and stabilize according to their knowledge and best practices.

1. The medical examination necessary will be determined by the ED physician which will include a face-to-face assessment by the physician, and may include: a toxicology screening, labs, and other tests as deemed necessary.
2. If the patient is determined to have a co-occurring medical condition, the ED physician should stabilize this condition to the best of his/her ability. Any unstable medical condition will limit the choices of a psychiatric hospital to those few that also have medical units.

If no emergency medical conditions are identified during the medical screening exam, aside from the behavioral health concern, the ED physician will determine that the patient is “medically cleared” and ready for a psychological evaluation.

The LCBH crisis worker will be called as a consultant to perform this evaluation.

1. A thorough verbal passdown of all pertinent information regarding the client’s presenting concerns, any concerning behaviors, and safety concerns will be conducted by either the ED nurse or physician with the LCBH crisis worker. 
2. If there are any physical factors that the medical examination has revealed, the ED staff must inform the LCBH crisis worker.

Once medically cleared, the patient stays on whatever unit they are in (Emergency Room, ICU, Med-Surg unit, etc.) for evaluation and placement.

Lake County Behavioral Health Staff are an outside consultant who comes and conducts the assessment, but then leaves and conducts placement efforts from the Behavioral Health office. (The individual is the hospital’s patient under their care).

Clarification for local hospitals on medical clearance: Medical clearance to discharge someone home is not as stringent as medical clearance to send someone to a psychiatric facility. While a hospital might send someone home with elevated laboratory test levels with appropriate treatment to bring those levels within normal limits, most psychiatric facilities want those levels in normal range before considering the individual medically cleared. 

The LCBH crisis worker will not report to the ED until the physician has determined that the client is medically stable for assessment and when the patient is determined to be at least minimally under the influence of any substances (i.e. can walk, use the restroom, and hold an ongoing conversation without falling asleep).

2 Circumstances a Crisis Worker will come before Medical Clearance

1. Patient is known to LCBH as someone who has a primary mental health diagnosis and their mental status has been decompensating in days or weeks prior to arrival at the ED. Medical clearance will still be needed from ED if hospitalization is sought.
2. When a peace officer requests mental health clearance of an individual who is currently under arrest and will be transported to the local jail if they receive mental health clearance from an LCBH crisis worker. Medical clearance may still be required if deemed necessary by the jail medical staff or if a 5150 hold is written and psychiatric placement is deemed necessary by the LCBH. Crisis worker should be contacted directly through the main office,–(707) 994-7090, during normal business hours (0800-1700 Mon-Fri, excluding Holiday’s) & through the LCBH answering service, (844) 265-7101, after hours.

One of the biggest issues facing Lake County hospitals and Behavioral Health is the lack of available inpatient psychiatric beds. With no designated Psychiatric Health Facility, designated Acute Psychiatric Hospital, or inpatient psychiatric unit in a General Acute Care Hospital, in Lake County all mental health consumers have transfer travel times from 1 to 3 hours to an available psychiatric bed.

• If an individual is medically cleared and awaiting psychiatric placement for longer than 72 hours, the 5150 hold will need to be reassessed. 
• Behavioral Health staff will re-evaluate the individual through-out an extended wait, as individuals sometimes improve with the medications administered in the Emergency Department, if they continue to meet 5150 criteria, placement continues to be sought. NOTE:Sometimes the accepting psychiatric facility requires a new 5150, then Behavioral Health staff will re-evaluate the individual to assess if they continue to meet 5150 criteria, if they do; the individual is placed on a new 5150 hold with placement and transfer continuing.
• LCBH crisis worker will update ED on placement status once every 12 hours (once between 0800-2000 & once between 2000-0800), or when placement status changes.
• The wait time when beds are not available has exceeded 70 hours on occasion, and this causes frustration on the local hospitals who have limited beds and want individuals transferred quickly.  

ORGANIC DISORDERS:

Brain injuries do not fall under “mental health”. Currently in Lake County there is no simple solution for these individuals in crisis, as long term and chronic brain issues can cause psychiatric behaviors.

• The Organic Brain Injury Committee coordinates with Orchard Park & Lake Family Resource to help deal with this subset of individuals.

Many psychiatric facilities are Not licensed to treat individuals with intellectual or other cognitive disabilities: these individuals need specialized services.

Intellectual disabilities should be referred to:
Redwood Coast Regional Center (707) 262-0470

Emergency Room physicians need to file an Adult Protective Services report for individuals with dementia, mental retardation, intellectual or other cognitive disabilities in need of placement. WIC 15700-15705

There are some instances when a patient meets 5150 criteria but because of a co-occurring medical condition (includes TBI, dementia, etc.) it is impossible to broker a bed or a 5150 hold may not be appropriate. In these situations the ED team and the LCBH crisis worker will think creatively about appropriate alternate resources (i.e. skilled nursing facilities, adult protective services, public guardian) into consideration.

BROKERING A PSYCH BED

If the LCBH crisis worker determines the patient requires a 5150 hold (i.e. psychiatric hospitalization) to resolve the psychiatric crisis, the crisis worker will return to the LCBH office to await the faxed medical lab results, toxicology screen, and physician/nurse notes and will begin to immediately contact psychiatric facilities once all hospital documentation is received.

All hospital documentation must be received  prior to brokering a psychiatric bed. A LCBH crisis worker will provide placement status updates every 12 hours at a minimum.

The ED will provide the following support in the brokering of a bed at a psychiatric facility:

• Doctor-to-doctor or nurse-to-nurse consultation, if requested by the admitting facility.
• Other medical tests (within the scope and capabilities of the ED)  if requested by the admitting facility.
• Paperwork that demonstrates the patient is medically stable and cleared for inpatient psychiatric placement.

The ED staff will provide primary treatment and monitoring for a patient placed on a 5150 hold until the patient is transferred to the transport team enroute to an accepting psychiatric facility.

When a bed is secured the LCBH crisis worker will notify the ED staff of patient acceptance so that the hospital can initiate patient transfer.

When the patient is transferred, the original 5150 application must accompany the patient to the psychiatric facility.

When a bed has been brokered, the ED physician must determine that the patient is stable for transfer and must take appropriate measures, prior to the patient exiting the ED, to ensure the safety of the patient and driver during transport.