1. Managing the perinatal Psychiatric emergency (and other useful tips for call at Women & Infants…)
Center for Women’s Behavioral Health
Women & Infants Hospital
July 11, 2017

2. Objectives Review the expectations of call at Women & Infants Hospital
Review of management of psychiatric emergencies with emphasis on the perinatal population
Review of basics in treatment in the perinatal population
Introduction of the psychiatry call team

3. When to come in within 1 hour…
Acute onset of delirium in patients who are not responsive to the initiation of the Delirium Care Plan
Acutely agitated, behaviorally dysregulated, or actively suicidal/homicidal patients on the medical or obstetrical floors
Patients where there is a high index of suspicion for post-partum psychosis. These patients must be evaluated rapidly!
Substance abuse patients in active withdrawal that cannot be managed by current protocols at Women & Infants.
Capacity assessments where there is a high degree of risk for death or injury to patient or fetus, or a significant change in care or assessment due to refusal of recommended care, or desire to leave AMA.
Patients in Triage
Any other patient in which the primary team
is requesting an urgent or emergent consult

4. Managing safety Rapid evaluation Sitter or constant observation
Notify Security x41635
Consider need for inpatient admission
Emergency certification

5. Managing Agitation Rapid efforts at de-escalation Team based:
Psychiatry
Social work
Security
Primary team
Nursing staff and management
Risk management
Consider chemical restraints
Physical restraints – Women & Infants restraint policy

6. Triage: Agitated Patient protocol
Protocol developed 2014, revised 2017
Addresses management of agitation/behavioral emergencies in patients in Triage (WIH ED)
Nursing staff trained 2-4/2015
Providers trained 9/2015, 7/2017

7. Strategies For De-escalation
Ensure staff safety at all times Maintain open clear path closest to the door Maintain a safe distance of a leg length or more from a potentially violent patient Maintain the patient’s “space” (This differs from person to person) Maintain a non-confrontational stance (Arms in front of body, not crossed) Adopt passive, non-confrontational posture and attitude, and allow patient to ventilate her feelings. Develop a therapeutic alliance with the patient Eye contact as appropriate to situation Do not face patient head-on Do not turn your back to exit room Decrease stimulation-only utilize minimum amount of people to maintain safety Provide quiet area if possible Provide for dignity and respect by removing witnesses Maintain non-threatening stance Maintain calm neutral rate and tone of voice Use eye contact as appropriate

8. Emergent Urgent Non-Urgent
Depression or Anxiety able to contract for safety
Medication management
Outpatient consultation
Urgent
(non-violent, non-deregulated with potential for decompensation)   
Suicidal gestures without plan
Alcohol or substance abuse without delirium or altered sensorium
Pregnant patient requesting detoxification
Emergent
(violent, deregulated, imminently unsafe) 
Acute suicidality – plan/intent/means, unable to contract for safety
Acute withdrawal with alteration in mental status
Homicidally or other aggressive behavior against others
Agitated/Aggressive/Non-redirectable (e.g. Manic/Psychotic/Intoxicated)
Postpartum Psychosis
Acute alteration in mental status
Non-Urgent

9. Urgent Emergent Non-Urgent Interventions: Interventions:
Interventions:
Social service consults if appropriate
Urgent
Interventions:
Place in ED Room 13 if available (refer to suicide policy for reference to room set up)
Social Work/ Psychiatric consult if appropriate
Notify Security
Consider constant observation
Emergent
Interventions:
Page psychiatry (in AMION) in house M-F 8a-5p, available 24/7 after hours
Notify ED Attending, NM/ ANM/Nursing Supervisor
Notify Security/ consult regarding intiation of “Code Grey
Notify Social Service

10. Emergency medications in pregnancy
Haloperidol PO/IM/IV: mg q1-4 hours
If IV – need telemetry monitoring and q24h ECG
Lorazepam PO/IM/IV: 1-2mg
Olanzapine PO/IM: 5-10mg q8 hours
Oral dissolving Zyprexa is not available
Benadryl PO/IM/IV: 25-50mg
Thorazine PO/IM: 25mg q4 hours
Non-preferred
Not for use in pregnant patients

11. Steps prior to transfer
Ensure patient stabilization and safety:
Medical clearance by ED attending
Medications should be administered when appropriate
If appropriate, emergency certification should be completed by psychiatry team
Emergency certified patients should be placed in room 13 with Constant Observation and security based on determination by patient care team
EMTALA forms must be completed for non-certified patients
Doc to Doc calls for non-psychiatric issues should occur via ED patient care team
Patient with emergent psychiatric condition will be transferred via private ambulance service.
Notify ambulance service of any special considerations
Restraints- both physical and chemical when indicated

12. Transfer Policy –Triage
Patient evaluated in triage by primary psych team or on call resident – decision is made for inpatient treatment
Once patient medically cleared…
Transfer Policy –Triage
Updated 6/28/2016
If patient is too agitated to be managed by WIH staff, WIH staff to transfer to a secure facility/D-POD RIH. Call D-POD Follow steps as detailed below
Call Butler to discuss bed availability & transfer
Fax clinical information, demographics, & med list to Butler
If Butler not available
Contact D-POD resident to inquire if space is available .
If no room, call other facilities & WIH to hold pt until a bed is found. Follow protocols for transfer as requested by accepting facility. Patient to be kept at WIH until bed available.
Notify WIH Staff to facilitate MD:MD & nurse:nurse
D pod able to accept patient
Call D-POD resident.
If pt accepted, call RIH to provide demographics for pre-registration.
Fax clinical information & med list to
Facilitate
Notify WIH staff to facilitate ambulance transfer
Obtain Precertification from insurance & notify PAS
Notify WIH staff to arrange ambulance transport & provide paperwork to send with patient

13. Patient cannot be transferred to a lower level of care (LOC)
Eg. RIH ER/D-POD
Pt evaluated by primary psychiatry team or on call resident – decision is made for inpatient admission
Once patient is medically cleared…
Transfer Policy—WIH Main Floors
Updated 6/28/2016
If patient is agitated
Call Butler to discuss bed availability & transfer
Fax clinical information, demographics, & med list to Butler
Manage agitation with primary providers, psychiatry C/L team, & security
Notify WIH staff to facilitate MD:MD & Nurse:Nurse
When pt stabilized
Obtain Precert & Notify PAS
Follow protocol for IP admission, if deemed necessary
Notify WIH staff to coordinate ambulance transport & provide paperwork to send with pt

14. Generic Transfer Flow (Non Butler or RIH)
Pt evaluated by primary psychiatry team or on call resident – decision is made for inpatient admission
Once patient is medically cleared…
Call facility & inquire if bed is available. Fax demographics, clinical information, & medication list/labs to facility for review.
Once bed is confirmed:
Notify WIH staff to facilitate MD to MD; Nurse to Nurse
Obtain precert from insurance company & provide info to facility
Notify floor to arrange ambulance transport & provide documents to send with pt if needed.

15. Our psychiatry CALL team!
Thamara Davis, MD
Anupriya Gogne, MD
Nina Gonzales, MD
Neha Hudepohl, MD
Tara Malekshahi, MD
Jessica Pineda, MD
Your WIH chief: Barbara Ruf, MD
WIH Psych C/L pager:
Password = wihri
Psychiatry consult Inpatient/Triage

16. Emergency slot
Mondays at 8:30AM (Or Tuesdays at 8:30AM if there is a holiday on Monday)
The patient should be directed to Women’s Behavioral Health at 2 Dudley Street, First floor and given the number (401)
Notify the following individuals about a patient booked in an emergency slot and provide the patient’s name, DOB, contact phone number and a brief description of the clinical circumstances:
Shannon Erisman
Tina Freeman
Valerie McGill
Margaret Howard
Neha Hudepohl

17. Please remember to check when you are on-call and who your backup attending is!
Check your when you are on call- signout will be sent there.

18. Call your listed backup attending I
(If unavailable after 2 tries or 30 minutes) V
Call Margaret Howard PhD, Division Director, Women’s Behavioral Health
AND/OR
Neha Hudepohl, MD, Medical Director, Women’s Behavioral Health
Call Lawrence Price MD
Medical Director, Butler Hospital
Chief of Psychiatry, Women & Infants Hospital

19. Cerner Please check to make sure your login and password are working
Ensure you know where to find a psychiatry consultation initial and follow up evaluation
Contact Barbara Ruf, MD if you do NOT have Cerner access

20. Where do you park when you come in?
100 Dudley (OB Medicine Building) has an open lot that is available to use after hours/weekends
Is located across the street from the main hospital front entrance

21. Basics in treatment: perinatal depression & anxiety
Most common complication of pregnancy
Prenatal depression:
% reported prevalence
Postpartum depression:
15% prevalence
Significant risks of untreated symptoms:
Prenatal
Postpartum
Fetal/Infant Development
Attachment

22. Perinatal Depression
Occurs in 15% of women within the first 12 months following childbirth. Symptoms frequently begin during pregnancy.
Characteristic symptoms:
Sadness
Irritability
Mood Swings
Inability to Concentrate
Sleep/Appetite Disturbances
Low Self –Esteem
Loss of Pleasure in Activities
Inability to Adjust to Role of Motherhood
Suicidal Ideation
Occurs in 15% of women, typically manifests within first 3 months following delivery, but symptom onset can frequently be in pregnancy
PP blues vs. depression

23. Medication Pregnancy Effect Breastfeeding Fluoxetine
No consistent report of congenital malformations including cardiac. May be associated with PNAS and PPHN
Colic, fussiness, drowsiness has been reported. Average RID higher (7%). May prefer alternative agent unless already exposed
Paroxetine
Some reports of cardiac malformations (AV septal defects). May be associated with PNAS and PPHN
Low RID (1.2%) make this a preferred agent in breastfeeding
Sertraline
No congenital malformations associated; lower risk of PNAS
2-3% RID make this a preferred agent in breastfeeding
Citalopram
No congenital malformations associated; consider risk of PNAS
Case reports of infant sedation
Escitalopram
May be preferred over citalopram due to lower exposure and lower risk of adverse effects
Fluvoxamine
Limited data suggest low levels in milk

24. Basics in treatment: Mood stabilizers
Lithium – often considered preferred in pregnancy, not favorable for breastfeeding
Lamotrigine – considered favorable in pregnancy and breastfeeding
Valproic acid – AVOID in pregnancy, at this time considered favorable in breastfeeding
Other anti-epileptic drugs

25. Basics in treatment: Antipsychotics
Typical antipsychotics are more studied than atypical antipsychotics
This is changing with more literature published on registries of women with perinatal exposure to atypicals
Emerging data on atypicals suggests reasonable safety profiles, though not without risk
Risperidone, quetiapine, olanzapine most commonly used
Risk often outweighs benefits in acute cases

26. Postpartum Psychosis: a psychiatric emergency!
Prevalence 1-2 per 1000 childbirths
Rate is 100 times higher in women with a history of bipolar disorder or previous history of postpartum psychosis
“Cognitive disorganization psychosis” (Wisner et al 1994)
Cognitive impairment
Bizarre behavior
Thought disorganization
Lack of insight
Delusions of reference
Delusions of persecution
Greater levels of HI and behavior
Can also present with visual, tactile, olfactory hallucinations and appear delirious
*4% of women with postpartum psychosis commit infanticide*
Typically presents rapidly after delivery – within days to weeks
Treatment- hospitalization
Spinelli MG (2009) Am J Psychiatry 166(4): )

27. Harming Infant Thoughts
Assess ego dystonic vs. syntonic
Do these thoughts appear distressing to the patient?
Dystonic – often related to depression, anxiety, OCD
Do not convey an increased risk of harm
Patients need treatment
Syntonic – consider postpartum psychosis, severe depression with psychotic features, infanticide
Consider hospitalization, separation from infant when risk is great

28. Management of Delirium
Non-pharmacologic:
Frequent reorientation
Maintain day-night cycles
Minimize nighttime interruptions
Sitter
Pharmacologic:
Correct underlying pathology
Haloperidol 0.5-2mg IV q2hours PRN agitation (NEED TELEMETRY)
Alternatives – olanzapine, quetiapine
AVOID!
Anticholinergics and antihistamines
Tricyclic antidepressants
Benzos
Dopaminergic agents
Consider AMS transfer
Continue treatment until mental status cleared
Fricchione GL et al (2008) Am J Psychiatry 165(7):

29. Perinatal Substance Abuse
4.4% of all pregnant women abuse illicit drugs 1
7.4% of pregnant women ages 18-25yo abuse illicit drugs1
Delivering mothers misusing or dependent on opiates has increased 5-fold between 2000 and 20092
1.4% of pregnant women binge drink (ave 6 drinks, 3x/mo) 3
1.) Substance Abuse and Mental Health Services Administration, Results from the 2010 National Survey on Drug Use and Health: Summary of National Findings, NSDUH Series H-41, HHS Publication No. (SMA) Rockville, MD: Substance Abuse and Mental Health Services Administration, 2011.
2.) Patrick,SW, Schumacher,RE, Benneyworth, BD, Krans, EE, McAllister, JM, Davis, MM. Neonatal Abstinence Syndrome and Associated Health Care Expenditures, United States, , JAMA. 2012; 307(18):
3.) CDC, Alcohol Use and Binge Drinking Among Women of Childbearing Age—U.S.,

30. Managing withdrawal Opiate withdrawal:
In pregnancy we typically do not let women withdraw from opiates due to risk of harm to fetus
COWS: Clinical Opiate Withdrawal Scale (based on the CIWA)
5-12 = mild
13-24 = moderate
25-35 = moderately severe
more than 36 = severe withdrawal

31. Clinical Opiate Withdrawal Scale (COWS)
For each item, write in the number that best describes the patient’s signs or symptom.
Rate on just the apparent relationship to opiate withdrawal.
Resting pulse rate
Sweating
Restlessness
Pupil size
Bone or joint aches
Runny nose or tearing
GI upset
Tremor
Yawning
Anxiety or irritability
Gooseflesh skin
Score:
5-12 = mild;
13-24 = moderate;
25-36 = moderately severe;
more than 36 = severe withdrawal

32. Perinatal OPIOIDAbuse:
ORDER SET
MEDICATIONS: methadone 15mg, tab, BID (not to be dispensed until pt accepted for outpatient treatment at CODAC), Acetaminophen 650mg PO, q6 PRN pain, Lorazepam 1mg, PO, once PRN insomnia or anxiety
FETAL EVALUATION: NST daily
LABS: urine drug screen-8 + oxycodone screen, Hepatitis C testing
CONSULTS: social service, MFM, neonatal
RELATIONSHIP WITH CODAC-PROVIDENCE FOR A SMOOTH TRANSITION TO OUTPATIENT CARE. PT MUST AGREE TO OUTPATIENT CARE BEFOREHAND AND CODAC MUST AGREE THAT PT IS APPROPRIATE
SMOOTHER TRANSITION IN CARING FOR THEIR OPIOD WITHDRAWAL AND IN SETTING THEM UP WITH OUTPATIENT CARE IDEALLY INCREASES A WOMAN’S CHANCE IN OBTAINING ABSTINENCE—AND MAKES A SMOOTHER STAY INPATIENT.

33. Managing withdrawal
Alcohol/
benzodiazepine
withdrawal
CIWA protocol

34. Delirium protocol

35. Resources for Prescribers
Reprotox through Micromedex
LACTMed
Thomas Hale’s Medications and Mother’s Milk
Massachusetts General Hospital Center for Women’s Mental Health
Motherisk
Mother to baby (OTIS)

36. Questions???