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Bedside Psychiatric Evaluations

Bedside Psychiatric Evaluations

One day last winter, Pat Triplett received an urgent page: A patient who’d been on a medical unit for two weeks started lashing out at everyone in his path. By the time the Johns Hopkins psychiatrist arrived, it was too late to connect with the patient. Security staff members had already restrained him. “It exacted a huge toll on the unit,” says Triplett, “and stuck in my mind as just what we are trying to avoid.”

That incident—and others—moved Triplett to fast-track a plan to screen all newly admitted inpatients—not just those headed for psychiatric units. The idea, he says, is for a psychiatrist, nurse practitioner or psychiatric social worker to assess medical unit patients for mental health concerns early on, “before they escalate.”

The need is urgent, he adds. Roughly 38 percent of medical admissions to The Johns Hopkins Hospital have psychiatric disorders such as depression, bipolar disorder or schizophrenia. Also, up to 20 percent of the hospital’s admissions are linked to opioid addiction. These patients can demonstrate disruptive behavioral problems as well as physical symptoms.

Now, however, with the debut of the hospital’s Behavioral Intervention Team (BIT) last spring, at least one team member sees a patient, sometimes within hours of admission to a medical unit. “Not everyone will need psychiatric assessment,” Triplett says, “but some will, and the sooner they’re identified, the quicker they will be treated.”

The Johns Hopkins BIT model is still a work in progress. Currently, the team covers three medical units—about 70 beds. Triplett aims to expand coverage by introducing two more teams.

Here’s how the approach, developed by Hochang Lee, a former psychiatric fellow at the hospital, works: Every weekday morning, one BIT member meets to review patient charts that medical-surgical staff members have prepared. Afterward, all three BIT members—each trained in psychiatric evaluation—decide which patients will be seen and by whom.

Triage is tiered, says Triplett: Patients arriving after a suicide attempt, for example, are seen immediately; those who have schizophrenia as well as a medical condition with a poor prognosis, such as emphysema, are also assessed more rapidly.

BIT nurse practitioner Maureen Lewis begins each visit by scanning the electronic medical record for any history of psychiatric illness or substance abuse. When necessary, she arranges transfers to inpatient psychiatry.

Signs of depression on medical units aren’t rare, often surfacing after a major medical event, such as a heart attack. But they can be subtle, says BIT psychiatric social worker Deborah “Sunny” Mendelson. She describes an elderly patient admitted after a massive stroke.

“Everything was swirling around for him,” she recalls. Though he’d lost major abilities, “he felt especially vulnerable and sad about not seeing well enough to read the white board or adjust his bed. I told him that it takes a while for the brain to adapt, but you have the ability to communicate.” The conversation cheered the man, as did the vision consult she recommended, which led to new eyeglasses.

Often, Mendelson digs deeper. She asks how patients cope with new perceptions of themselves, particularly if they’ll need more surgery or have advanced cancer. Simply the chance to talk about their situations, she says, “can be liberating.”

But challenges abound. Triplett notes that many inpatients have a complex mix of medical and psychiatric problems, such as those who develop delirium after joint replacement surgery. New medications can also make a huge difference in mood.

The BIT program has won praise from staff members for reducing psychiatric crises and length of stay. In addition, it has raised morale, especially among nurses. Having the psych team nearby frees nurses from concerns about patients’ psychiatric needs and allows them to concentrate on their medical work.

The biggest payoff, says Triplett, is that the Behavioral Intervention Team approach improves patients’ peace of mind.

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