SMART Medical Clearance Training

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

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

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

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

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”

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

Page 2 Abbreviations

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

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

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

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

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)

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

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

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

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

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