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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
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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
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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
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Managing safety Rapid evaluation Sitter or constant observation
Notify Security x41635 Consider need for inpatient admission Emergency certification
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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.
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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
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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
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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.
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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
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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
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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
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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
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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
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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
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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
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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
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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): )
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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
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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):
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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.,
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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
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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
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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.
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Managing withdrawal Alcohol/ benzodiazepine withdrawal CIWA protocol
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Delirium protocol
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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)
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Questions???
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