The Medical Care of Psychiatric Inpatients: Suggestions for Improvement
Abstract
Free-standing psychiatric hospitals in the United States have in common the challenge of delivering appropriate, and consistent physical healthcare to a high risk patient population. Patients suffering from severe mental illness may have limited exposure to the healthcare system except in the form of admission to psychiatric facilities yet they are more likely to have serious medical co-morbidities than the general population. Psychiatric institutions faced with limited resources and a paucity of widely accepted models for the delivery of this type of necessary care rely on variable methods of healthcare delivery. This article examines the need for medical care in free-standing psychiatric facilities, existing barriers to the effective delivery of care and ways that institutions can better structure their non-psychiatric medical services.
Patients suffering from severe mental illness are more likely to have comorbid medical conditions and have a mortality rate higher than that of the general population (1, 2, 3, 4). Rates of pulmonary disease, cardiovascular disease, liver disease, and type 2 diabetes are higher in patients with mental illness (2,5). Smoking, poor diet, sedentary lifestyle, and low socioeconomic class, are more common in the mentally ill and contribute to their poor health (6). Side effects of mental illness treatment also confer health risk; recent studies have demonstrated that use of both typical and atypical antipsychotics is associated with weight gain as well as increases in blood glucose and cholesterol levels (7, 8, 9). Further, symptoms of mental illness can be caused by or exacerbated by underlying medical illness (eg, thyroid disease) (10, 11, 12).
Despite the elevated rates of comorbid medical conditions, detection and treatment of physical illness in psychiatric patients is poor (5, 13). It is estimated that between 30% and 47% of patients with physical health issues do not receive treatment for them (3, 11, 13). Factors contributing to the inadequacy of medical treatment among the mentally ill include patients who may be hesitant to seek medical care due to social withdrawal (14), aggressive or uncooperative behavior in the office, and primary care physician attitudes (4, 11).
For many patients, occasional hospitalization in mental health facilities may be their only chance to receive care for medical conditions (12). However, how medical care is provided to psychiatric patients is highly variable. While most free-standing psychiatric hospitals have a medical consultant available, usually an internist or family practitioner, there is no established standard dictating the provision of medical care in psychiatric facilities. Joint Commission on Accreditation of Health Care Organizations (JCAHO) standards for behavioral health institutions state only that such institutions accept for admission and treatment only those patients whose identified treatment needs can be met by the admitting hospital. JCAHO allows that initial screening and assessments should be performed as defined by the individual organization, and that a process should be in place to provide diagnostic services and treatments that cannot be directly provided by the admitting hospital (14). In general, each institution sets its own policies on how medical care will be provided. The result is a wide array of health care delivery systems and an overall lack of structure (11).
A system is required within each hospital for the screening of patients for disease, the evaluation and treatment of patients with medical illnesses, and the transfer of patients to medical/surgical hospitals if a higher level of care is required (11, 15). Several consensus panels have recommended improved monitoring of the physical health of psychiatric inpatients to improve overall patient health (16). Recommendations include regular monitoring of body weight, blood glucose levels, lipids levels, blood pressure and prolactin levels and signs of sexual dysfunction in patients who receive antipsychotic medications (12, 16, 17). Cardiac monitoring to detect QT interval prolongation is also suggested (16). Improving the medical care of psychiatric patients is necessary to improving their functioning and overall quality of life.
Barriers to Medical Care
Psychiatric facilities face barriers in providing medical care to patients. There may be no rooms set aside for the examination and treatment of patients with medical complaints, and equipment may be limited. Laboratory and radiology facilities may be limited or off-site. The hospital pharmacy, geared mainly toward the treatment of psychiatric disorders, may stock only limited quantities or brands of drugs to treat medical conditions.
In terms of staff, psychiatrists may be unable or uncomfortable with providing physical health care (18, 19). Nurses working predominantly in behavioral health may have little experience in the areas of medical or surgical nursing, which may lead to discomfort in dealing with medical issues. Mental health technicians often have limited clinical experience and may have difficulty in recognizing a patient who requires medical care. Physicians accustomed to working in a traditional medical office or hospital setting may be uncomfortable working in this type of environment, making recruitment of medical consultants difficult. Administrators may be unfamiliar with the potential medical needs of patients and may be unacquainted with the development of treatment policies for nonpsychiatric diseases. Further, patients in mental health facilities might be aggressive, uncooperative or demanding. It can even be difficult for the physician to physically locate the patient so that care can be delivered (11).
Suggestions for Improvement
The following are suggestions for improving the delivery of medical care in psychiatric facilities:
Admission policies: Guidelines for admission should be established regarding medical illnesses. Individual institutions should aim to identify the circumstances and medical conditions for which they can provide appropriate care and the cases that require patients be referred to other facilities. Admissions personnel, case workers and administrators that are familiar with the medical limitations of the hospital can reduce the number of medically inappropriate admissions. It is helpful to have a relationship with a local medical hospital or emergency room to which patients that are considered to be in need of a higher level of care may be efficiently referred (15). The extent of medical acuity that can be cared for by a psychiatric facility is limited in large part by the availability of medical equipment and the skill and comfort level of the hospital staff (19). Hospitals may lack the ability to care for patients requiring such interventions as infusion pumps, central catheters, invasive procedures or treatment in an intensive care unit (20).
Admission orders: Since many of the admitting physicians in psychiatric hospitals are not internists or family practitioners, there is often unfamiliarity or discomfort in writing orders to treat medical conditions. To help alleviate this, the admitting physician, after assessing the patient, can use standardized admission orders to deal with common medical disorders. When admitting a diabetic patient for example, standardized admission orders for diet, glucose monitoring and insulin administration can be employed. This helps reduce unnecessary variability in orders, limits use of nonformulary medications, contains cost, and reduces errors (21).
Screening and treatment protocols: Screening protocols for new admits should be established. In an effort to identify previously undiagnosed physical diseases (eg: diabetes, hypertension, thyroid disease) and to establish baseline laboratory data prior to initiating antipsychotic medications. Opinions vary with regard to the most appropriate methods for detecting physical illness in psychiatric patients (16, 22) with some researchers believing that laboratory testing of all patients is of low yield and that thorough history taking and physical examination is able to identify the majority of medical illness (23). Other studies have pointed out that one third of overlooked medical diagnoses are a result of failure to obtain laboratory studies, and that a systematic approach should be taken with all psychiatric patients (24). As mentioned, consensus panels recommend monitoring of blood glucose, body weight, and cholesterol in high-risk psychiatric patients (7, 8, 12). In addition, obtaining a basic metabolic panel, complete blood count, RPR, TSH, liver enzymes and checking pressure at the time of admission may be prudent in identifying undiagnosed medical conditions or when dealing with patients who are unable to provide an adequate medical history. Treatment protocols ensure that the “standard of care” is provided and can also reduce unnecessary testing or medication use (25). Periodic re-evaluation and updating of protocols as new consensus recommendations become available ensures that the care provided remains current.
Team approach: The medical issues encountered by patients with severe mental illness are usually complex, such as a diabetic patient with poor dietary intake secondary to acute psychosis, and must be addressed by taking into consideration many factors. A team approach allows input from staff representing the various disciplines involved in treating the patient (26, 27, 28). Multidisciplinary rounds allow the psychiatrists, medical physicians, caseworkers, pharmacists, nurses and nutritionists etc. to collaborate in patient care (10, 29).
Staff education: A study conducted by Keawe'aimoku Kaholokula et al examined the diabetes care received by inpatients at a large psychiatric hospital and found a lack of adequate knowledge and skills among hospital staff. The authors concluded that there is a need for hospital policies and training to focus on the treatment of diabetes in psychiatric inpatients (28). Several surveys of physicians determined that additional education is needed to train psychiatrists to better provide preventive medical services (18, 19). Regular in-service training for staff members, including nurses, mental health technicians, admissions personnel as well as psychiatrists, can improve an institution's overall familiarity and comfort level in dealing with patients with medical disorders (10). The result is more efficient care, increased patient safety, and the avoidance of unnecessary expense.
Program for outpatient follow-up: For some patients, hospitalization in a psychiatric facility is the only opportunity to receive medical care. The benefits of receiving good medical care as an inpatient can extend beyond the patient's discharge (11). Several studies have demonstrated the feasibility and effectiveness of programs linking patients in drug treatment facilities with primary care (14, 26, 30). Sweeney et al established a program in a drug detoxification unit in which patients were provided with initial medical intervention and outpatient primary care follow-up was arranged. The results of this and similar programs has shown reductions in the consequences of substance abuse, reduced long-term health care costs, development of better patient support systems and improvements in overall patient health (14, 26, 30). Similar programs could be initiated in free-standing psychiatric facilities as a way to reduce the morbidity and mortality in patients with severe mental illness.
Coordination of care: On-site, integrated general medical care has been associated with improved medical outcomes (31). In many mental health facilities, medical care is provided by private medical consultants whose availability may be limited. Having a medical physician, a psychiatrist with training in primary care, or a mid-level practitioner (eg, nurse practitioner) charged with overseeing the provision of nonpsychiatric medical care will help ensure coordination of care (18).
Conclusion
Hospitalization for psychiatric treatment offers an opportunity to provide basic medical care for persons who might otherwise not access the health care system. A standardized approach to medical care, including the timely diagnosis and treatment of nonpsychiatric conditions, would likely improve the overall health of psychiatric patients. Although the available level of medical care, and how that care is provided currently varies widely from facility to facility, there clearly is a need to define standards of care for all psychiatric hospitals. Once established, a proactive, structured plan for providing medical care can help psychiatric facilities directly impact the overall health of patients suffering from mental illness.
