PMHNP: Typical Practice Day for Inpatient Psychiatric Care

00:01 Hi, I'm Jack. I'm a psychiatric mental health nurse practitioner.

00:05 And today I'm going to talk to you about typical practice day as an inpatient primary care provider of mental health care services.

00:13 Seeing patients as an inpatient provider is really different compared to outpatient care. Instead of a scheduled appointment, it's a combination of being on call and making rounds, or seeing patients who have been admitted to inpatient mental health care services. Let me walk through how being on call works. Typically, I'm on call for 24 hours at a time.

00:35 And what this means is a nurse, if she needs anything like especially like an IM shot, if we have like a psychotic patient, somebody 's going through a crisis, they'll need to call me to get approval to give those shots. Some of these shots are with Ativan, Benadryl, Haldol, Geodon, and these are all IM shots that can relax and calm the patient down.

01:01 We usually don't give these medications for behavioral problems, unless they're a danger to themselves or others.

01:09 The nurse can also call for other things like requests for pain medications, not scheduled pain medications, but like for headaches, muscle pains, stuff like that. Also, the nurse may call if the patient experienced a seizure and she needs to see if we need to send that patient out for a higher level of care.

01:32 That's usually the majority of the calls that we'll get throughout the day.

01:37 Now let's talk about when I have patients to see who are admitted to an inpatient unit.

01:42 My inpatient work is a little unusual for a nurse practitioner, because I see all of my patients via telehealth.

01:49 When I see these patients via telehealth, it's usually a patient that was admitted to our crisis unit the day before.

01:56 What will happen is I'll see these patients from 9 a.m.

01:59 to 12. The nurse will bring the patient into a private office.

02:03 I'll see the patient via video.

02:06 So we'll talk to the patient about why they're here.

02:10 The big reason I lead with that is that kind of sets the pace for me to know if they have enough insight to know actually what's going on and why they've been admitted.

02:18 Most of my patients do have an understanding of why they're there.

02:22 And I'll go through the standard questions of past medical diagnosis, past mental health diagnosis, meds they're on, meds that they think worked, meds that they think did not work for them.

02:36 A big thing for all these patients is sleep.

02:39 Sleep is so important for a lot of these inpatients.

02:42 If they're not sleeping, all these other symptoms are just going to get worse. We will go through and I'll talk to them about their goal for treatment, find out really what they want me to help them with.

02:54 At that point, I'll discuss with them my med plan.

02:57 I'll kind of give them a idea of how long I think that they'll be there without any guarantees of course, it just depends on their treatment.

03:05 We'll talk about aftercare.

03:08 I'll make sure that we have them set up for care once they leave and I'll talk a little bit more about that later on.

03:15 Because I also have an outpatient primary care practice, i'm not on call or see patients who are inpatient every day.

03:23 That way I manage my schedule in a different way.

03:27 So an example for the way my schedule works is I work inpatient telehealth on Sundays, Mondays, Tuesdays and Wednesdays. And remember when I told you I worked from 9 a.m.

03:41 to 12? Well, on Monday, Tuesday and Wednesday I'll see my inpatients that morning on telehealth, and then I'll see my outpatient clinic patients that afternoon.

03:53 It works really good for me.

03:56 My inpatient people know that I do outpatient, and my outpatient people know that I do inpatient.

04:03 So it's working really good right now.

04:06 And I really like the, it's like the best of both worlds, i get to see both patients.

04:11 Now documentation for inpatient is very similar in regards to the DSM-5 TR standards that we talked about for outpatient.

04:21 We always have to have a diagnosis and that diagnosis must match the criteria outlined in the DSM-5 TR.

04:29 We document presenting symptoms, severity and how they impact functioning just like we would for outpatient.

04:36 And then of course we do the diagnostic code which is specific to each diagnosis that you assign. And then also typically take written notes during my visit with the patients.

04:49 That way I can remain with eye contact with them.

04:52 I can be more engaged with them.

04:54 And then I'll usually type out my official note at the end of the day.

05:00 When I answer on call questions, I will always access the electronic medical record for the system to make sure I know exactly which patient I'm talking about, what their allergies are, what meds they're are taken and kind of read a quick note on what they were like when they first came in, and then what they're like today.

05:21 Because a lot of times patients come in in crisis, they're delusional, they're psychotic.

05:26 But maybe a day or two, they're a lot better.

05:28 And I like to see that progression of them getting better.

05:31 If they're not, there's something wrong and I need to intervene.

05:35 And just like outpatient services, the coding process can be completed by time or complexity. But for the inpatient services, it's a little more involved on the coding, so the facility coding team determines the level of care based on my documentation notes.

05:52 So it's really important that my notes are thorough.

05:55 I include all the stuff that the DSM documentation requires, so that those billing people can get a good picture of what's going on with the patient.

06:04 Now, for inpatients, there's more interaction with other providers around admission and discharge. When a patient first comes in for inpatient, they are evaluated by an RN, a care manager and a case manager. All of them will talk to the patient, figure out what's needed for that patient, and then just set that ball going.

06:28 Now sometimes I'll have to get involved with other providers, especially when we have a patient that's in the hospital that they're looking to place in our psych crisis center.

06:43 I'll have to look at their labs, make sure that they're appropriate for admission, because we are not a medical facility, we're a psych facility. So we want to make sure these patients are appropriate before they come to us. This can get complicated if the other provider has a different perspective on the patient situation that I do as a mental health provider.

07:04 Let me tell you about a recent situation. Just a few days ago, I had a lady that overdosed and was in the ICU at a local hospital. She had a history of seizures and was taken Depakote for her seizures.

07:21 When I looked at the labs, they called and they wanted to transfer to a psych facility. When I looked at her labs, I noticed her Depakote level was 2.1, which is super low. You want a Depakote level of 50 to 125. So this lady was way below that.

07:36 She had a seizure risk and the provider at the ICU wanted to transfer and I declined.

07:43 I told them that her medical stuff trumps her psych stuff, and that I would appreciate for them to keep her, even if they need to send her to a stepdown unit, start giving her Depakote, and when her Depakote level would reach 50, I would be happy with taking her at 50.

07:57 And in fact, two days later, her Depakote level came to 50 and we got that patient as a patient for a crisis unit.

08:05 Now screening and assessment tools are still fundamental part of my inpatient practice.

08:12 You learn about these in training.

08:13 They're very important.

08:15 These tools kind of help keep us on task and make sure we don't forget anything.

08:19 And it's a good way to document what they would score on a screening upon admission and maybe what they'd screen upon discharge.

08:26 It's a good way to compare to see how they're doing, but it's important to use current ones because they change these forms all the time.

08:34 So make sure you use the most current version of those forms.

08:38 U sing the best tools will always give you good data and can affect not only your billing, but your credibility as a quality provider.

08:46 For example, in patients with any level of cognitive impairment are typically screened with one of several mental status exams on admission and before discharge. Just like an outpatient care full medication list with the past, present medications are collected on admission and reevaluated on discharge. The emphasis on integrated treatment plan can feel bigger in an inpatient setting.

09:13 There's a lot more at stake, as the patients may be less physically and psychologically stable, and it's not unusual to be tracking blood work, ECGs more frequently when they're inpatient, as the medications quickly change.

09:31 Time management is still important in this population.

09:34 But it's different because a lot of these patients are manic or in a psychotic state. So when you're conducting an assessment, you have to really control the assessment, manage the time and be vigilant and keep these patients on task.

09:51 Sometimes they're too psychotic to assess, and you may have to medicate them and come back and look at them again the next day.

09:57 But you just have to be really careful about keeping them on task and keeping the assessment moving.

10:04 In the inpatient setting, there's an opportunity to collaborate with other disciplines like recreational therapy, case managers, therapists, and rehab centers.

10:14 It's interesting to me to provide a wraparound care for these patients.

10:18 You get to make sure they have a safe place to go.

10:22 We won't just discharge them out to the street.

10:24 We want to make sure that they're set up and they're given every chance to be successful.

10:29 Now, whether they actually go to their outpatient visits, that's a whole another story, but at least we do try.

10:36 Now, handling our urgent calls can be challenging, especially when it's in the middle of the night.

10:41 Nobody likes to be called at 2:00 in the morning, but the nurses know that they only call if it's needed, if it's the patient's in crisis or there's a situation.

10:51 And I never mind them calling me because I know they're reaching out for my help.

10:56 It's tough getting up, you gotta fire that computer up, look at that bright screen, review the chart.

11:02 And sometimes, if it's a complicated case, it's okay to tell the nurse.

11:07 Hey, give me ten minutes to review the chart, let me look at their meds, let me kind of brainstorm, and I'll call you right back.

11:15 Most people that are admitted for suicide concerns continue to have those thoughts.

11:20 They just don't go away the first day they get there.

11:23 We have to medicate them and treat those suicide ideations.

11:28 Usually with those type of patients, we won't lean on an antidepressant because, you know, some of those antidepressants can take 4 to 6 weeks to have effect, and we just don't have that much time with these patients.

11:38 We need to get them stable quickly.

11:40 We may have to consider antipsychotics in the short term.

11:44 Those medications usually work much faster within a day or two.

11:48 So depending on inpatient outpatient your medication choices are going to be different.

11:54 Some of the pros and cons of inpatient care.

11:57 Well, for a lot of the inpatient stuff, once you're done rounding on your patients and doing your chart, you're done for the day, except for any calls or messages that may come through.

12:08 And you're still going to have some of those late night urgent calls. It's just going to happen. And another con is if you have a patient come in and you are working inpatient and you're not doing telehealth like I am, you may have to go in on your day off or on the weekend to assess that patient.

12:26 There could be higher stakes regarding inpatient professional boundaries because these patients can misinterpret things more easily.

12:35 You know, a lot of these patients are delusional.

12:37 So it's really important to act as professional at as you can at all times.

12:42 Just be really clear who you are and what you're there for.

12:47 My final thoughts are that psych nurse practitioners usually don't get the opportunity to work in patient care.

12:53 It's kind of a rare thing.

12:55 So if you have the opportunity to do it, I say go for it.

12:59 You're going to learn a lot in a very short period of time.

13:03 And on top of that, it's so rewarding to see the patient come out of a crisis situation because of your quick actions.

13:12 With me working inpatient and outpatient, it's really nice for me, to me to be able to see both sides.

13:17 I mean, inpatient is challenging but rewarding, outpatient is great to kind of get to know your patients.

13:24 So if you have a chance to do inpatient and you're interested, go for it, you won't regret it.