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Pearls


Expediting inpatient admission when it’s needed

Vol. 1, No. 5 / May 2002

A patient becomes a candidate for inpatient care when he or she poses a threat to his or her own safety or to that of others—whether due to chronic psychosis, suicidal tendencies, paranoia, or the health risks of a psychiatric condition such as anorexia nervosa. The threat may be immediate. Still, you may find the path to hospitalization strewn with roadblocks ranging from managed care, to the patient and his or her family, to simple red tape.

If you decide that inpatient care is best for the patient, the following advice may help expedite the disposition process.

Be clear about why admission is needed. Articulating the clinical reasons for hospital care to insurance providers, emergency-room attendings, and inpatient unit directors is an important part of the admission process. The following questions can help determine the need for inpatient care:

  • Is the patient imminently dangerous?
  • Is the patient able and willing to cooperate with a less restrictive course of treatment?
  • Does the patient have a viable support system?

A favorable answer to all three questions generally allows the psychiatrist to avoid hospital treatment.

Armed with historical and clinical data that address these questions, the clinician can effectively explain why inpatient care is indicated. Managed care networks are more likely to approve hospitalization for patients who are acutely dangerous to themselves or others than for patients who are not. The patient's medical history must illustrate the danger of not pursuing inpatient care. Emphasize any recent change in suicidal or homicidal ideation. Document if the patient has ever attempted suicide, or if anyone in his or her family completed a suicide. Also learn if the patient has ever exhibited violence, and watch for a significant change in the patient’s behavior or symptoms (e.g., feelings of extreme paranoia or fear).

Define the goals of hospitalization. Remember that hospitals expect clear, concise goals for treatment. Ideally, an inpatient unit will act as a consultant to a patient’s outpatient clinical therapist. An outpatient or emergency clinician should clarify what is expected during a hospital stay.

Often, one goal is to have the hospital act as a temporary support system. This may occur if the suicidal patient has been evicted from his living quarters, or if he needs further intensive observation because family caregivers are exhausted or ill. In other cases where a worsening mood disorder, psychosis, or agitation is present, close observation and medication may be indicated.

Overall, constant communication and coordination between outpatient decision-makers and inpatient doctors are crucial. Communicate directly with the emergency room if the patient is to be triaged there; this will facilitate effective acute management and will arm personnel with information necessary to formulate the optimal treatment disposition.

Measure the patient’s ability and willingness to follow doctors’ orders. A patient’s unwillingness to cooperate with outpatient care can also help convince decision-makers that the patient should be hospitalized. For example, if a patient with hypomania is attending clinical appointments but is refusing medication, he or she may need more structure to prevent full relapse.

Also, make sure the patient is telling you the whole truth about his or her level of risk. For example, a psychiatrist in the emergency room may consult with police officers who have just picked up a patient; the psychiatrist might learn that the patient had been trying to jump over the railing of a bridge when the police found him—a fact the patient had concealed during the interview. In this situation, such knowledge will help prove that outpatient care is inappropriate.

Dr. Zealberg (Charleston, SC) is former president of the American Association of Emergency Psychiatry and is former director of the Emergency Psychiatry/ Mobile Crisis Program, a joint project of the Medical University of South Carolina and the Charleston Dorchester Community Mental Health Center.

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