Behavioral Health Issues Clinical Pathway — Emergency Department

EMCP Guidance: Accepting Transfers of Children with BH Concerns

As always, decision-making based on the individual child needs
Use SW and Psychiatry resources as needed to determine the best decision

Medically Cleared Children	In general, medically cleared children from OSH are not accepted Those children should be directed to local crisis centers Divert status does not affect these decisions Exceptions to Above Patient Characteristics Consider review with SW, Psych: Children currently followed by CHOP BH Team Existing neurodevelopmental issues that may benefit from pediatric subspecialty Existing medical complexity Children < 18 yrs currently on PHL campus, e.g., Buerger with BH emergency Children at CHOP Cedar Transferred due to capacity, specific behavioral and/or medical needs HUP Age < 18 yrs from HUP ED are accepted Age ≥ 18 yrs are transferred to HUP
Children Not Medically Cleared	Admit for continued medical evaluation as indicated

Medically Cleared Children

In general, medically cleared children from OSH are not accepted
Those children should be directed to local crisis centers
Divert status does not affect these decisions

Exceptions to Above
- Patient Characteristics
  - Consider review with SW, Psych:
    - Children currently followed by CHOP BH Team
    - Existing neurodevelopmental issues that may benefit from pediatric subspecialty
  - Existing medical complexity
  - Children < 18 yrs currently on PHL campus, e.g., Buerger with BH emergency
- Children at CHOP Cedar
  - Transferred due to capacity, specific behavioral and/or medical needs
- HUP
  - Age < 18 yrs from HUP ED are accepted
  - Age ≥ 18 yrs are transferred to HUP

Children Not Medically Cleared

Admit for continued medical evaluation as indicated

CHOP Cedar: Reasons for Transfer to PHL Campus and Relationship with HUP Cedar ED

Cedar and Boarding	Transfer needed when children awaiting inpatient psych placement exceeds physical capacity of CRC and CSU See Transfer Process
Crisis Resource Center (CRC)	Evaluates children ages > 5 yrs to < 18 yrs Transfer may be required if: Not eligible for Cedar care Medical clearance required Once cleared, BH evaluation is completed by CHOP ED SW, Psych team
Crisis Stabilization Unit (CSU)	Transfer may be required for medical evaluation/treatment Cedar Staff will remain with child Bed at Cedar is held (LOA-leave of absence for 24 hrs) until child's disposition in ED determined
IP Cedar	Transfer may be required for medical evaluation/treatment Bed at Cedar will be held (LOA-leave of absence for 24 hrs) until child's disposition in ED determined When inpatient admit is required, child will be discharged from Cedar Direct admit is possible via standard Transport/EMCP Process

CHOP Cedar Relationship with HUP Cedar ED for Emergent and Minor/Routine
Medical Conditions

Minor/Routine Medical Issues Requiring ED Evaluation	CHOP Cedar Psychiatrist/designee contacts EMCP to review all non-emergent transfers If EMCP agrees transfer to HUP Cedar ED is appropriate EMCP reviews with HUP Cedar ED Attending for acceptance
Unstable Patient or Non-Patient	CHOP Cedar code team will bring patients to HUP Cedar ED

Transfer Process for Children Moving from Cedar to PHL ED

Cedar psychiatrist sends chat to Transfer Center
EMCP must formally accept the patient prior to transfer, communication by phone or chat
Disposition (ED vs. EDECU) is collaborative between Cedar and EMCP depending on patient and ED factors
CHOP Transport arranges transport
If transported by a CHOP team, admit directly to ED room or EDECU
- Avoid waiting room, PHL Charge RN can identify a room
If transported by a non-CHOP team, brief screen room 4 is required prior to EDECU admit
- T7 Attending or T2 Attending ON, T4 Attending when no T7 (day,eve)
See Checklist Below

PEM/APP Process for Direct Admit to the EDECU

Process	Evaluate patient, complete ED note RN completes ED Triage note Place EDECU bed Order Complete EDECU Admit Note, EDECU Admit Orders
PEM/APP	T7 PEM, EDECU APP 7/9 a.m. to 11 p.m./1 a.m. Overnight T2 PEM and T2 HP When no T7 day, T4 PEM and EDECU APP

Psychiatrist Checklist for Patient Transfer from Cedar to CHOP PHL ED/EDECU

1. Psychiatrist Initiates Epic Chat

Chat Enterprise Medical Command
Link chat to patient chart
Note reason for transfer
- Boarding while awaiting inpatient transfer
- Medical clearance evaluation
- Acute illness, injury
- Patient does not meet Cedar criteria
Cedar psychiatrist reviews list of potential patients needing transfer to PHL, share with EMCP for staffing considerations

2. Intercampus Transfer Order Set

"Cedar LOA/Intercampus Transfer"
Obtain consent for transfer
Place order for transfer
Contact Transport Center

3. Complete the Following Documentation as Soon as Possible After Patient Accepted
to PHL ED

Patient chart
Agitation plan: 1st and 2nd line
Reconcile current psychiatric medications, specify doses and if all medications should continue
List any medical concerns, abuse
List any social concerns, legal guardian, DHS case
Complete 201 or 302

4. Hand-Off Prior to Patient Transfer

Cedar RN completes electronic hand-off to PHL ED Charge RN
Cedar psychiatrist provides hand-off to EMCP, review EDECU direct admit eligibility
Cedar therapist provides hand-off to PHL SW, including important social information
- e.g., legal guardian, DHS case, family/parent issues

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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.

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