Coronavirus — Behavioral Health Considerations in the Setting of COVID-19 — Clinical Pathway

BH Considerations in the Setting of COVID-19

Evaluation, Observation and Disposition
ED Evaluation	Location Room BH patients preferentially in ED BH Rms or EC BH 7-10 Aggression concerns, use BH 1, then other ED BH, then any ED room Overnight Hours Utilize Tele-Psychiatry for Psychiatry consultations (If families refuse Tele-Psychiatry, delayed in-person consultation is available) SW obtains, documents verbal consent SW starts Tele-Psychiatry call SW evaluates other pts Safety Observer performs visual observation outside the room If arms-length visual observation required, Safety Observer remains in the room If trouble with the call, Safety Observer presses call button or contacts SW for help SW, Tele-Psychiatrist, and ED team discuss disposition
PPE	Assume COVID-19 is possible until additional information is obtained Use Modified Expanded Precautions . Security PPE: Face Shield + Surgical Mask + Gown + Gloves Obtain from Emergency Bag outside BH 1, EDECU
Safety Observation	Ensure appropriate Safety Observer based on risk and current policies Review patient condition and PPE recommendations at each handoff
Testing for COVID-19	Test all BH patients early in the evaluation who may be considered for inpatient hospitalization Hospitalization in BH Facility or other exposure in the last 14 days, treat as exposed, quarantine for 14 days after exposure, regardless of test results
Disposition	BH patients that meet EDECU criteria, and there is no BH bed available, and patient has no history of exposure: Can evaluate/admit to EDECU with COVID pending or COVID negative test Assure modified expanded precautions (including Safety Observer) If COVID +, admit to SIU pending psych transfer If COVID negative, may stay in EDECU If ED volume, acuity is unable to accommodate this – ED Attending will talk with SIU/PSTU to admit patient Raise any concerns to ED Medical Director of the day, POL

Behavioral Health Restraint Procedure in the ED
Assume all BH patients are at high risk for COVID-19
For All BH Patients	Room and Patient safety check Safety Observation order Assure home medications are administered on schedule Identify triggers for patient escalation, ask what works or doesn’t work Environmental strategies Offer escalation medications as indicated, page Psychiatry early PPE as above
Team, Roles	Security: 2-3 guards as clinically indicated Charge RN, Bedside RN: Documentation, medication preparation PEM/Psych Attending/Fellow: Lead restraint, documentation Psych Tech Lead FLOC: Order medications, assist leadership, documentation
Process	Team Huddle early, Activate Restraint Response RN Call Button Attending, FLOC, RN, ED BH Charge, Security, Psych Tech Security dons Modified Expanded Precautions FLOC orders medications, pages Psychiatry Bedside RN obtains medications, documents Charge RN notifies hospital response team Attending/Fellows PEM, Psych Directs other team members to don precautions as needed Reviews checklist, additional medications PPE for Violent Restraint Responders
Medications	Lorazepam IM/IV: 0.05 - 0.1 mg/kg (max 4 mg) PO: 0.05 mg/kg (max 4 mg)

Bedside Checklist for Restraint of BH Patients in ED/EDECU
Team Huddle	Review the medical condition of the patient and medication plan for agitation with FLOC Identify personnel to be in the room
Charge RN	Assure BH Restraint Response RN Call Button is pushed Obtains PPE bag for Security Review orders and remind the bedside RN and FLOC/attending of documentation needs below
Bedside RN	Document on the Violent Restraint flowsheet every 15 minutes (all fields) Document the name of the Safety Observer in the room Ensure the order for Violent Restraint is entered in EPIC Remind FLOC if Violent Restraint order is about to expire, assess need for continued restraints Obtains medication
FLOC	Orders Violent Restraint Perform a face-to-face evaluation of patient within 1 hour after the restraint Document the restraint occurrence in ED note using .RESTRAINT – Documentation does not need to occur immediately, but time of restraint initiation reflected in the note needs to be within 5 minutes of time documented by RN Assess need for continued restraints Re-order restraints: Every 1 hour for patients 8 years or younger Every 2 hours for patients 9 years and older

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The clinical pathways are based upon publicly available medical evidence and/or a consensus of medical practitioners at The Children’s Hospital of Philadelphia (“CHOP”) and are current at the time of publication. These clinical pathways are intended to be a guide for practitioners and may need to be adapted for each specific patient based on the practitioner’s professional judgment, consideration of any unique circumstances, the needs of each patient and their family, and/or the availability of various resources at the health care institution where the patient is located.

Accordingly, these clinical pathways are not intended to constitute medical advice or treatment, or to create a doctor-patient relationship between/among The Children’s Hospital of Philadelphia (“CHOP”), its physicians and the individual patients in question. CHOP does not represent or warrant that the clinical pathways are in every respect accurate or complete, or that one or more of them apply to a particular patient or medical condition. CHOP is not responsible for any errors or omissions in the clinical pathways, or for any outcomes a patient might experience where a clinician consulted one or more such pathways in connection with providing care for that patient.