by Cheryl Dodds, MD
I am a psychiatric hospitalist, and even though I started being called by that title only a year ago, I have been doing the job for 14 years. I care for psychiatric patients who are no longer safe in the community, either because they are suicidal, homicidal, psychotic or unable to care for themselves safely. When I call to send a patient to the ED or transfer to the inpatient medical service from my psychiatric hospital, the most common question I get is, “You can’t handle that where you are?” Unfortunately, I cannot. Here are some observations about psychiatric care, patients and hospitals to give you perspective on the care we deliver.
Gaining Perspective: Psychiatric patients are still patients. When they present to an acute medical hospital to await a psychiatric hospitalization they are truly miserable and at a place where being alive no longer matters to them. They frequently have experienced a sudden loss or an increase in paranoia or hallucinations. It’s important to remember that they did not ask to have mental illness. The life time mortality rate of the major mental illnesses is 15%. They have real diseases and deserve real treatment. They frequently report feeling invisible in the medical hospital and that staff often ignore their requests, telling them that they have other “real” patients to whom they need to attend.
Length of Stay: An inpatient psychiatric stay is not limited to 72 hours. Regardless of the state, wherever I have worked, patients always seem to arrive having been told that they will only be in a psychiatric facility for 72 hours. When we explain that that is the exception not the rule and patients are discharged when they are better and their treatment complete, the patients are angry and feel betrayed. Please let patients know that, like any hospitalization, the length of their stay will be determined by the treatment team at the treating facility, not the referring facility.
Not Bed-Ridden: Patients do not lie in their beds during the day in psychiatric units. They walk to the cafeteria for meals or to the gym for recreational therapy. They may go to the court yard for pet therapy or to meet with a therapist. They do their own laundry and are expected to go to group therapy several times a day. These activities are a cornerstone of inpatient treatment and an integral part of helping patients get better. If a patient is too medically ill to participate, they will get very little from the treatment.
Psychiatric hospitals are not medical hospitals. They typically are not able to provide IV fluids or IV medication or oxygen therapy, secondary to concerns about ligature risk. In addition, they rarely have access to occupational or physical therapy. Labs are not located in the hospital and have to be sent out. Patients have to be taken out of the building to have an X-ray done. Many facilities use an outside phlebotomist and only draw labs once a day. “Stat lab” is a relative term in a psychiatric hospital. Pharmacists are not in the building 24/7 and have to be called in from home after hours.
Staff Expertise: Psychiatric nurses went into their field to help patients with their emotional disorders and educate them about psychiatric medication. They are spectacular at convincing a paranoid patient to allow an injection of an antipsychotic medication. Wound care, however, is not their forte. When psychiatrists reject patient referrals, secondary to their medical needs, they are doing so to insure that all of the patient’s problems are safely addressed.
Delirium is not Psychosis: Delirium is a medical illness that needs to be treated in a medical hospital. When we receive these folks labelled as “psychotic,” all we can do is send them back to the medical hospital.
No Hidden Agenda: When a psychiatric hospitalist refers a psychiatric inpatient to a medical hospital for admission, there is no hidden agenda. We are willing to take the patient back once their medical issue is resolved. We are not trying to “dump” a difficult patient, we are just making sure the patient receives good care in the right setting. The resistance of psychiatric hospitalists to accept patients with medical complexity is due in part to the resistance we face when patients decompensate and need to go back to the medical hospital.
The Right Bed for the Right Psych Patient: Just because there is an open psychiatric bed does not mean that any patient is appropriate for that bed. All psychiatric patients are not created equal and neither are psychiatric beds. A high functioning 65 year old who has become depressed caring for her spouse with Alzheimer’s will only get worse if admitted to a geriatric unit full of severely demented patients. A woman who has been in an abusive relationship will decompensate if admitted to a psychotic disorders unit with aggressive, paranoid patients. If a patient is not an appropriate fit for the milieu, we risk worsening their psychiatric condition. The acuity of aggressive patients on a psychotic disorders unit can be so high, that it is not safe for patients or staff if all the beds are filled, and admissions have to be limited.
Wean off Benzos and Opiates before Discharge: Many psychiatric hospitalizations could be avoided if the patients had been detoxed while on the medical unit. Frequently, I admit patients with benzodiazepine and/or opiate dependence who were maintained on these medications in the hospital to prevent them from going into withdrawal. Many of these patient could go directly to outpatient or residential substance abuse treatment if their benzodiazepines and/or opiates had been weaned while they were in the medical hospital.
Psychiatric Hospitals do provide medical care. Most psychiatric hospitals have Internists, Family Medicine doctors and Pediatricians on staff who consult on patients and provide medical care. However, because of the limitations of the facilities, the population they treat and the available staff, this practice is more like outpatient primary care than inpatient medicine.
The reality is that many patients require both psychiatric and medical care and getting the patient to the right setting to receive both can be challenging. Psychiatrists serve a population that struggles to access appropriate care for both mental health and physical health. We want the best for our patients and the only way to meet those needs is through integration of physical and behavioral health services and improved communication.