CL Psychiatrists placing orders

[dumadr.]

Was curious what the general consensus is on this. The CL Psychiatrists at my residency program have had a policy of not placing any orders and are quite strict about it. As far as I can tell we are the only consult service in the hospital that doesn’t.

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[Bartelby]

Not placing orders is good practice. You advise the primary team about your recommendations and they choose what to implement. If you start placing the orders I think it increases the burden on your team and increases the likelihood of issues (for example, both you and the primary team unknowingly starting medications around the same time that would interact).

 

[Jules A]

I work at hospitals that do both. It is easier to only consult but unfortunately med recommendations often don’t get ordered even if discussed. I believe the patient is better served if you are able to track down attending, briefly discuss and offer to write the orders which in most cases the attendings seem to appreciate.

 

[Celexa]

Having multiple teams placing orders is a great recipe for disaster.

We never place orders and I would refuse to do so if asked on grounds it is unsafe. The entire point of having a primary team is to have a single point of contact who, in theory, knows everything going on with a patient. What if two consulting teams simultaneously place conflicting orders?

There's narrow circumstances in which it can make sense--the consulting team placing some highly specific imaging orders, for example--but as a general rule absolutely not.

 

[Stagg737]

Where I did residency and where I'm at now have options in the consult for "opinion only" vs "opinion with orders". I prefer the latter simply because my experience is that when it's opinion only recommendations often don't get implemented in an expedient manner and sometimes lead to patient events. I imagine this is largely d/t hospital culture, but I believe the "opinion only" is the typical practice and probably the better option for patient care overall (as long as actual competent physicians are running the primary team).

 

[clozareal]

I've seen it where the C-L team places orders when it's an emergency (in the ER or for restraints or for emergent medications), but otherwise the C-L team doesn't. I've also seen hospitalist consult team on the inpatient psych unit put in orders or tell the primary team what to do. It seems specific to the hospital culture.

Other than culture, I wonder if there are any other issues that come up, such as liability. For example, what if the primary team doesn't follow psychiatrist's recommendations, there's an adverse outcome as a result, and patient sues claiming that the psychiatrist neglected to put in that order despite it being the the primary team's "responsibility."

 

[nexus73]

In my hospital, we call the hospitalist and discuss recommendations then usually put orders in ourselves. And document that we discussed recs and hospitalist agrees. Sometimes hospitalist prefers to place orders, or they're right at a computer when I call so it's convenient for them to just do it.

If I put in a note and don't call, the chance the orders ever get entered by the primary team is probably 2%.

Conversely, when I consult a hospitalist for a patient on the psych unit, I prefer them to enter med changes rather than stacking one more thing on my to do list.

 

[Merovinge]

Having multiple teams placing orders is a great recipe for disaster.

We never place orders and I would refuse to do so if asked on grounds it is unsafe. The entire point of having a primary team is to have a single point of contact who, in theory, knows everything going on with a patient. What if two consulting teams simultaneously place conflicting orders?

There's narrow circumstances in which it can make sense--the consulting team placing some highly specific imaging orders, for example--but as a general rule absolutely not.

This was how I trained in med school and residency. As an attending I tried to do this with C/L work and it went over terribly with the hospitalist team. They didn't even want to know what the diagnosis or management was for anything reassembling behavioral health and certainly did not want to enter orders themselves. I would not take another C/L job for the rest of my career, even if it came with a 50% pay raise.

 

[Sushirolls]

Ideal world. Functioning health system and doctors...
Consult orders will come in as consult, consult + management, Management

A patient is a ward. A classic term, meaning they are under the care and 'owned' by one physician. That physician is the captain of the ship and at times may hand off to another. Such as nocturnist service for IM or whatever ICU they might be on, next doc on shift assume their care as the attending of record.

The attending of record, when consulting with other specialists has the option to accept or reject their recommendations. They are responsible to implement their orders. A grey zone exists, where Consult + Management happens, and orders may be entered in (and welcomed) by the attending of record.

Pure consultative service, IMO, has potential to be the best. The Attending of record knows exactly what is going on with their ward, and guides everything. BUT as we've seen some primary services... don't read the notes or implement or pay attention to things... and one of my reasons why I too loathe C/L is they are requested but nothing more than a chart ornament, a sticker to pretty up the chart - but most often ignored. As the consultant this is the better/easier way, because you don't have to put orders, you don't have to risk the liability of following up on those results - or the consequences - of those meds/labs/imaging etc. You simply guide, and walk away, or continue to guide. But if ignored, lower investment, not as concerning - not your patient, not your ward. You also can see more patients, which means you as a resource can stretch further.

Some hospitals, and perhaps the real world, Hospitalist or whatever primary service ... is ... [adjectives here] and the consultants fall into this grey zone trap of placing orders and some how patients find their way eventually being discharged... Best soup to eat from when you are a lawyer.

I once worked an inpatient psych unit where this was in full force... IM during the night would field the psych admissions from ED and admit to psych. They were the attending of record. They were placing orders and responsible for the patient. But they would place an order for Management by psych, and once we rolled in the morning, did consult, we would formally flip over the patient to being psych managed. Great for not having burdensome call at night - because IM hospitalists did the basic work in wee hours. They would some times even keep/manage basic detox patients on the psych unit too, and we would follow as consultants. Psych manages detox the best, but it wasn't an issue big enough to fight about. But the point is, units can have different Attendings - based upon hospital privileges. At times the IM hospitalist service for some patients on IM general floor, would transfer care to psych, sign off, and now psych had a patient simmer on a different unit that we were attending of record for.

 

[FlowRate]

This is really interesting to me. At all of the hospitals that I worked at, consulting teams NEVER put in standing orders. And recs usually did get implemented the majority of the time.

 

[Stagg737]

This is really interesting to me. At all of the hospitals that I worked at, consulting teams NEVER put in standing orders. And recs usually did get implemented the majority of the time.

Where I currently work (~1,000+ bed academic hospital), most medical inpatients I see are fairly complex and have 3+ teams involved in management on top of the primary team, almost all of which will go through residents. While it makes sense for the primary team to manage everything, when the IM docs are managing 10-12 patients with involvement of multiple teams, it's a lot easier for consultants to just place their own orders to make sure it gets done. Some teams/locations in our hospital are opinion only (most ICUs, some heme/onc units) just d/t acuity or need for more stringent filtering of orders.

 

[annoyedpsychiatrist]

In terms of liability I would argue that the role of a consult is to seek advice or expertise, which matches the definition of the word. It does not entail assuming care. The primary care team has a duty to the patient and is ultimately managing the mediactions. The consult team is providing recommendations, that ultimately the primary team can follow or not follow, but if they disagree with psychiatrist, ultimately they are the one going against recommendations made. I would say more liability if the CL psychiatrist starts making multiple orders and establishing clear direct patient care. I think the primary should manage the orders, because I agree multiple teams making multiple orders can be messy.

 

[comp1]

In general...CL recommendations are not very likely to be harmful (relative to pretty much any other specialty outside derm), nor to conflict with other orders. Heck, I mostly make behavioral intervention recommendations to limit Cluster B chaos. Hopefully we're not recommending benzos or MAOi's much on the med surg floors. I've never personally seen a hospital where the psych consultant is uniformly expected to place orders. Sometimes I do, particularly in emergency departments. However, I explain precisely what I'm doing by instant message, phone or in person to the attending and get direct feedback from them about their understanding. If I'm just dropping a note and can't even find the attending, I wouldn't usually place orders. There are also situations like clozapine where the internist literally can't place the orders and I know many hospitals restrict other meds to specialists. Basically what I'm saying is that this is not a black and white area.