1. SMART Medical Clearance Training

2. Why are we doing this? For our mental health patients to… Collaborate
Standardize
Promote patient safety
Reduce unnecessary testing
Reduce cost
Reduce delays

3. How can we accomplish this?
By advancing the process of medical clearance using evidence based medicine
By using the SMART medical clearance tool

4. What is SMART Medical Clearance?
A new medical clearance tool/process developed over an 18 month period
Evidence-based & vetted by peers (SSVMS’ Emergency Care Committee and Mental Health Task Force)
Promotes standardized and expedited medical clearance, when appropriate, for mental health patients in crisis

5. SMART Medical Clearance
Was validated at Mercy San Juan Medical Center (MSJMC) & UC Davis Medical Center (UCD)
Will expedite medical clearance for some patients in a SAFE manner
Not intended for very low acuity patients that will be discharged immediately from ED

6. SMART Medical Clearance
Patient safety is priority #1
Must be filled out COMPLETELY and signed by the attending PHYSICIAN
Forces a thorough H&P and thoughtful, selective testing
If all categories marked as “No” then patient will be considered “medically cleared”

7. Page 1 Five “SMART” categories Must be “No” to pass
Any “Yes” must be evaluated and addressed by further exam, clear rationale or diagnostic evaluation
Time of resolution must be documented and initialed

8. Page 2
Abbreviations

9. Page 3
If inebriation is suspected, HII score must be completed by the provider
Must be repeated until score is less than 4
All entries must be timed and initialed

10. Page 4
Tracing curve
Entries must be timed to correlate with corresponding HII score

11. Early Lessons & Landmines (1)
The SMART Medical Clearance process is NOT:
A shortcut to more rapid medical clearance of patients
The SMART Medical Clearance process IS:
A process to consistently and efficiently guide your focused exam of mental health patients
It may take slightly more time to complete but it will benefit everyone in the end

12. Early Lessons & Landmines (2)
Be very conservative with “subjective” sections
Have a low threshold for excluding delerium
Screen ALL patients with suicidal ideation (Tylenol and ASA levels)
Comprehensively review medication lists…don’t miss necessary levels

13. Early Lessons & Landmines (3)
Best Practice: Initiate home medications immediately, especially the following categories:
Psych, anti-hypertensives, diabetic
Initiate alcohol withdrawal protocols immeditely
Urine tox screens are optional (can be helpful for risk stratification but should never exclude patients from evaluation, treatment or acceptance)

14. Early Lessons & Landmines (4)
Be a Good Partner: Work with your local accepting psychiatric facility to address their concerns
Don’t be Difficult: If they are not comfortable with a particular patient’s presentation, even if they pass the SMART clearance form, help them by obtaining the diagnostic tests that they need

15. Absolute Must Haves…
Identify champions (physicians, RNs, SWs, Psychiatrists)
In-person training for physicians to emphasize the importance and conservative approach
Training & competency for RNs on HII score
QI program oversight at your facility to interface with SSVMS’s Emergency Care Committee…to track:
Misses, bounce backs, abuse of the form

16. Launch Timeline
Validation- Mercy San Juan Medical Center & UC Davis Medical Center: February – March, 2016
March – data validation and analysis: Completed
Stage 1 Implementation (UCDMC): May 2nd
Stage 2 Implementation (Sutter Medical Center Sacramento & Mercy San Juan Med Ctr): August 1
Kaiser (Roseville, South Sac, Morse): Sepember
*Must have approval from SSVMS and facility Medical Director before implementation at your facility

17. Regional Implementation
Inpatient psychiatric facilities currently participating in pilot
Sacramento County Mental Health Treatment Center
Heritage Oaks Hospital
Sierra Vista Hospital
Sutter Center for Psychiatry
Important: establish Quality Improvement Team and Process

18. Feedback/Suggestions to: Seth Thomas, MD SethThomas@cep
Feedback/Suggestions to: Seth Thomas, MD Questions on timeline/facility engagement to: Aileen Wetzel, CEO, Sierra Sacramento Valley Medical Society (SSVMS)