One of the greatest challenges for hospital psychiatrists is helping to treat the patient who has significant medical illness as well as mental illness. This is especially true when the diagnosis is unclear, and the behavioral derangements are the main symptoms of what is likely delirium or other cognitive impairment. Agitation, assaultive behavior, verbal outbursts, and the need for restraint create enough chaos on medical floors to lead to requests or even demands that patients be transferred to psychiatric units. This sometimes occurs even though medical stability has not yet been achieved, and sometimes when the underlying illness would more commonly be dealt with in the general medical hospital were it not for the agitation.
Psychiatric hospitalization generally occurs in either a free-standing psychiatric hospital or a specialty unit within a general hospital. The separateness generally involves giving up many of the capabilities of the general hospital, especially when free-standing facilities are used. Stand-alone psychiatric hospitals often do not have quick access to medical care, and psychiatric nursing staff may be uncomfortable with many “medical” interventions, such as intravenous fluid support, urinary catheterization, pregnancy monitoring, or supplementary oxygen. The same may be true for psychiatric units in general hospitals.
The restrictions on medical interventions frequently come at the insistence of state or local licensing agencies. State inspectors view any sort of tubing or cord as a potential ligature to be used in hanging; the same is true of most types of electric devices that may be manipulated to cause a short-circuit. These well-meaning concerns generally require that patients with intravenous lines or supplementary oxygen or even with an indwelling catheter be maintained on close observation (often 1:1), which causes significant staffing problems. Other medical issues arise because of local hospital policies—nurses on psychiatric units are often not certified to administer certain forms of treatments (eg, chemotherapy or blood transfusions). Either nurses are brought in with the needed certifications, or the patient is moved back to a medical unit.
Moreover, the carved-out nature of behavioral health under many health insurance plans can also create problems. Behavioral health reviewers are often unwilling to authorize care on psychiatric units when the patient is not considered “medically stable” or if it appears that the chief reason for a transfer to a psychiatric unit is related to placement rather than a need for further acute treatment. This is particularly true with certain illnesses such as dementia, traumatic brain injury, autism spectrum disorder, and intellectual disability.
Complex patients in the general hospital with significant agitation require close and frequent follow-up care by the consulting psychiatric team, collaboration with the primary service, and frequent adjustment of medications. There are times when transfer to a psychiatric unit is considered. When it is required, it is generally for 1 of 3 reasons:
1 There is too great a risk of suicide without containment in a secure setting with the ability for constant observation and intervention
2 There is too much agitation or unpredictability, which poses a risk to self or others
3 There is a degree of impairment of judgment that results in a patient being unable to meet his or her basic self-care needs
Dr. Certa is Associate Professor, Psychiatry and Human Behavior, Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, PA. Dr. Certa reports no conflicts concerning the subject matter of this article.