Evidence-Based Reviews

Inpatient treatment planning: Consider 6 preadmission patterns

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Reduce assessments, lab tests, and diagnostic confusion.


 

References

Emergency admissions to psychiatric units usually are hectic, with ample opportunities to miss valuable clinical information. In these circumstances, failing to identify key features of the patient’s preadmission history can waste time and misinform treatment.

In our experience, psychiatric inpatients show characteristic trajectories and can be grouped into 6 categories based on preadmission course. Identifying which category best describes a particular patient can help direct your assessment and predict appropriate treatment (Table 1).

Table 1

Treatment planning at psychiatric admission: 6 patient categories*

Patient categoryPrior admission?Outpatient treatment adherence?Stressful life event?Progressive deterioration?Comprehensive workup indicated?
1No; first episode Yes
2YesNo care No; re-establish previously successful treatment, and promote adherence
3YesIncomplete adherence
4YesYesYes No; provide psychosocial support to address stressful event
5YesYesNoYesYes
6Malingering patients either have no psychiatric illness or have psychiatric illness and exaggerate symptoms for secondary gainNo; discharge (or do not admit) those without mental illness; provide psychosocial support for others
* These general categories are not intended to apply to all patients and do not consider predictors of length of stay such as diagnoses, presence of suicidal thoughts/plans, or behavioral disturbances.

Why this system?

In busy academic psychiatry departments—with rotating inpatient attending physicians and multiple outpatient providers—inpatient teams need a treatment framework that will decrease redundant assessments, unnecessary laboratory exams, and diagnostic confusion. We developed the following guide for residents, medical students, and attending physicians who practice in our 20-bed inpatient unit in an urban public hospital, where beds are always at a premium.

No controlled data support this approach. It does not consider predictors of length of stay—such as diagnoses or if patients have suicidal thoughts or behavioral disturbances. This model can be used across a broad range of diagnostic, symptomatic, and behavioral presentations, however, and our residents have found it helps them organize inpatient care.

Category 1: first-time admissions

Patients who never have had psychiatric treatment and are admitted to an inpatient unit usually are experiencing an index psychotic or mood episode. They represent a small fraction of all admitted patients but deserve the most comprehensive medical and psychiatric evaluation. The goal is to establish an accurate diagnosis, which will determine the treatment course.

Evaluation. Obtain a clinical history from the patient and from individuals with corroborating information. Do a comprehensive physical examination, and order a baseline laboratory evaluation, including a complete blood count with differential, comprehensive metabolic panel (CMP), thyroid-stimulating hormone (TSH), and toxicology screen. Add other laboratory tests as indicated by the history and physical exam.

Always obtain brain CT or MRI for an atypical psychosis and probably even for a typical presentation of an index psychotic episode. CT and/or MRI are indicated if mental status, physical, or neurologic examinations reveal focal neurologic deficits.

Order an EEG if you suspect seizures—especially complex partial seizures—or metabolic encephalopathy. Order a lumbar puncture with cerebrospinal fluid analysis and culture if CNS infection is a possibility.

Neuropsychological tests. Psychological testing may include personality tests such as the Minnesota Multiphasic Personality Inventory (MMPI-2) or Millon Clinical Multiaxial Inventory-III and rating scales and instruments to quantify symptom severity (Table 2).

Always administer a Mini-Mental State Examination (MMSE) to assess for cognitive impairment, and use the Blessed Dementia Scale (BDS) if needed.

For suspected delirium, consider the Delirium Rating Scale (DRS) or the updated version, DRS-98. Further neuropsychological testing may be indicated if the patient shows cognitive dysfunction, as may be seen in delirium or dementia (Table 3).

Table 2

How severe are psychiatric symptoms? Consider these rating scales

SymptomClinically useful instruments
AnxietyHamilton Anxiety Rating Scale
Bipolar maniaYoung-Mania Rating Scale (Y-MRS)
DepressionHamilton Rating Scale for Depression (HRSD)
Beck Depression Inventory (BDI)
Montgomery-Åsburg Depression Rating Scale (MADRS)
OCDYale-Brown Obsessive Compulsive Scale (Y-BOCS)
PsychosisBrief Psychiatric Rating Scale (BPRS)
Positive and Negative Syndrome Scale (PANSS)
Scale for the Assessment of Positive Symptoms (SAPS)
Scale for the Assessment of Negative Symptoms (SANS)
Overall symptomatologyClinical Global Impressions (CGI) Scale
Table 3

Tests for patients with cognitive dysfunction, as in delirium or dementia

Symptom domainNeuropsychological tests
Attention and concentrationTrail Making Test, parts A and B
Wechsler Adult Intelligence Scale (WAIS-III): verbal IQ subtests
Boston Naming Test
MemoryWechsler Memory Scale-III
Three Words-Three Shapes memory test
Visual-spatial constructional abilityRey-Osterrieth Complex Figure Test
Benton Visual Form Discrimination Test
WAIS-III performance IQ subtests
Executive function and abstract thinkingWisconsin Card Sorting Test
Stroop Color-Word Test
WAIS-III similarities and comprehension subtests

Categories 2 & 3: readmission for nonadherence

Without outpatient follow-up. Although inpatients are almost always referred for outpatient care after discharge, many do not keep even one outpatient appointment. Patients who have no outpatient follow-up after discharge are twice as likely to be rehospitalized the same year, compared with patients who kept at least one outpatient appointment.1

With outpatient follow-up. Patients who relapse and are readmitted after a period of outpatient treatment probably account for the largest group of psychiatric inpatients. Reasons why outpatients become nonadherent2 and relapse after a period of stable remission are legion (Table 4).3-10

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