Improving Care of Psychiatry Patients: Hospitalists My Kindred Soul

By  |  February 11, 2015 | 

by Dr. Kristen Sparks MD, MPH

I am a psychiatric hospitalist. I didn’t necessarily intend to be, but after residency I gravitated to a large urban inpatient practice. Since then I’ve worked on inpatient psychiatry units in several states and New Zealand. It’s what I’m passionate about and can’t imagine doing anything else.

Over the last several years I’ve been thinking a lot about inpatient psychiatry as a “sub-specialty” of psychiatry. I poked around on the internet and at psychiatry meetings, but nobody was talking about this in psychiatry circles. Of course, one could argue that psychiatrists were among the first hospitalists, as the specialty cut its teeth in asylums of the 18th through mid-20th centuries. Seeming to have lost this in the collective consciousness of the discipline of psychiatry, it seemed my most kindred souls were in hospital medicine, hence my post here on SHM’s blog.

Currently I am practicing at an urban, not-for-profit hospital with 100 inpatient psychiatry beds, through which 4,000 patients pass annually. There are five floors, each with 20 beds. I manage one floor with a PA in a 7-on / 7-off schedule. So, here’s a typical day:

6:30 am — Reviewing charts in the EMR. My particular floor is composed of higher-acuity, lower-functioning patients with an average length of stay of 14 days. Unless it’s my first day on service, I’m not reviewing too many new patients. Instead, I’m focused on notes from the past 24 hours. Did my patient with mania sleep? Was the sexually preoccupied male in behavioral control? How many prns did my psychotic patient require?

While not a medical unit, my floor has its fair share of medical comorbidities — diabetes, hypertension, kidney disease, etc. — which I manage if not too complicated. Otherwise, we have a dedicated behavioral health medicine team that I consult to manage medical conditions. Even so, it is not uncommon to have medical specialty services such as renal, heme/onc, or even hospice managing patients with me.

7:00 am — Out on the unit so I can talk to night staff before shift change about the milieu, as first-hand accounts and handover can give more nuanced data than an EMR, especially important in psychiatry. There are already several patients milling about at the nurses’ station, not a good sign. And, the night charge nurse confirms: No, the manic lady did not sleep at all, was singing all night, and kept lots of other patients awake. No, the sexually preoccupied male, also manic, was not in behavioral control, they had to put him on 1:1 observation overnight to redirect him. At least the floridly psychotic patient, who did receive multiple prns, eventually calmed and slept.

7:15 am — Seeing a couple of the patients I need to make a decision on earlier rather than later: Is the overnight admission with an extensive alcohol abuse history in active withdrawal? Is the chronic schizophrenia patient ready for discharge to the group home today?

8:00 am — Multidisciplinary treatment team meeting with my PA, the charge nurse, two social workers, an occupational therapist, case manager, and, today, a first year resident and fourth year medical student. We spend 45 minutes to an hour reviewing all 20 patients. Particularly on this higher-acuity floor, much of the work of getting an acutely unwell psychiatric patient from admission to discharge is framed within this meeting of the “pit crew,” to borrow Atul Gawande’s idea.

9:00 am — Rounding on the other patients I haven’t yet seen, with a medical student in tow for most of them. Reviewing cases with the resident and PA on those patients they are primarily managing on their own. Opportunistic teaching on mental status exam, interesting findings, psychopathology, psychotropic medications.

Noon — Committee meeting. This is the Mental Health Inpatient Care Pathway and is one of several institutional initiatives to streamline care and reduce variability among the most common diagnoses and procedures throughout the hospital. There are a lot of differences in streamlining a sepsis admission (one of the prior initiatives) compared to a general mental health admission, but the committee has been productive to date and I’m hopeful we will be able to make some substantive changes to improve our processes.

1 pm — Supervision with a PGY-2 resident. All psychiatry residencies generally have two inpatient years, a “therapy” year, and then an elective year. In our program the therapy training happens in the PGY-2 year. Though I use a limited amount of my own psychotherapy experience on my unit (a bit of motivational interviewing, occasional cognitive behavioral therapy techniques), it is refreshing to talk to trainees about transference, reaction formation, and other psychodynamic themes.

2 pm — Finishing up notes from the morning, checking on a functional assessment done by the occupational therapist today, following up with the social worker on a family meeting.

3:30 pm — Meeting with the oncoming afternoon charge nurse, again for milieu management for the evening: We changed the behavioral plan for a borderline patient today and a delusional disorder patient will be coming back to the unit this evening after an infusion on medicine. Fortunately, two of the manic patients have calmed some today, but there is still a psychotic man who keeps threatening peers.

4 pm — Admission from the ED, a patient we know well, manic earlier this year, now quite depressed and suicidal. I double-check her labs before she comes up, as she has a history of psychogenic polydipsia, hyponatremia, and seizure.

5 pm – One last check on the unit to make sure things are under control when I leave for the day. If there are specific labs to follow-up on, or something in particular I need the house officer to know or do, I’ll give direct handover when they come on at 5pm. Today I have one lithium level being drawn later, which the house officer will compare to a nomogram to determine tonight’s dose. The house officer overnight is either a resident or PA/NP, and their primary responsibilities are to do admissions along with cross-over of all the psychiatric floors. There is also an attending psychiatrist on call for the week for back-up.

Well, that’s a fairly typical day in my life. If you’re a psychiatric hospitalist and want to connect with colleagues about issues unique to our work, please contact me at [email protected]. Alternatively, if you know psychiatric hospitalists who may be interested in making this connection, please pass along this post and my email address.

 

sparks_kristen_l_mdDr. Kristen Sparks MD, MPH is a board-certified psychiatrist based in both Minneapolis, Minnesota and Wellington, New Zealand. She received her MD from Ohio State University and trained at the Medical University of South Carolina. She specializes in general adult inpatient practice with an emphasis on schizophrenia and bipolar mania. She has practiced in a wide variety of inpatient settings, including academic institutions, the VA, private-not-for-profit hospitals, and the nationalized health system in New Zealand. She is interested in the rational use of effective medications, while minimizing side effects and enhancing adherence. She is currently involved in growing a network of inpatient psychiatrists to collaborate around the unique challenges and opportunities faced by this subset of psychiatric providers. Her partner, Richard, is also a psychiatrist and they enjoy hiking, biking, skiing, bird watching and traveling – basically anything outdoors, even in the Minnesota winters.

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