The Medical Psychiatry Inpatient Unit Maria I. Lapid and Teresa A. Rummans

ADMINISTRATION

Some medical psychiatry units are based in academic medical centres with full-time faculty, while others are found in private hospitals available to physicians of any specialty (psychiatry, family practice, internal medicine and neurology) with admitting privileges. There are also medical psychiatry units in state hospitals for patients with chronic mental illnesses⁴. There are four types of medical psychiatry units based on level of acuity of medical and psychiatric illness⁵. Type I units primarily provide psychiatric care with a low level of medical acuity. Type II units include general medicine or medical subspecialty units associated with a psychiatric liaison service and provide low levels of psychiatric care to those admitted to the general medical setting. Type III and Type IV units provide care for patients with concurrent and more severe medical and psychiatric problems in a unified setting. Type III units provide care to patients with low to high psychiatric acuity, and medium medical acuity (e.g. a non-compliant, poorly controlled diabetic with borderline personality disorder; a hyponatraemic, agitated schizophrenic patient with primary polydipsia; or a depressed renal failure patient refusing dialysis). Type IV provides care to patients with low to high psychiatric acuity, and medium to high medical acuity (e.g. a patient with chronic factitious disorder/borderline personality disorder who injected him/herself with stool water and is septic; or a delirious patient with a pulmonary embolus; or a ketoacidotic bor-derline/anorectic/bulimic diabetic patient)⁶.

Physical Structure/Layout

The physical environment of a medical psychiatry unit is designed to accommodate patients with medical needs, cognitive impairment, functional impairment and sensory deficits such as hearing or visual impairments. It should also provide safety for those with severe behavioural disturbances in the context of delirium, dementia or other psychiatric illness. Ideally, a medical psychiatry unit is a locked unit, with restricted and secure access for safety and to prevent wandering or elopement. Each bedroom and bathroom should have wall oxygen, an emergency cord and call light. For fall precautions, every bed should have a bed alarm and thin, soft padded strips on the floor to minimize impact of fall and fall-related injuries (these are commercially available). All doors, hallways and the entire unit should be handicap and wheelchair accessible, with handrails, grab bars and safe flooring. A special tub or shower room is designed to keep patients warm, comfortable and safe while showering or bathing. Transfer equipment such as Hoyer lifts enable safe patient transfers with less risk of injury to patients (i.e. falls) and staff (i.e. back injury).

Medical psychiatry units have the capability to access and obtain essential diagnostic work-up required in evaluation of organic causes, including imaging, electroencephalography, electrocardiogram and other laboratories, procedures and tests. Other important distinctions of a medical psychiatry unit from other general psychiatry units include the capability to provide intravenous fluids and drug therapy, nutritional support such as total parenteral nutrition and feeding tubes, surgical wound and drain care, intravenous access and care of peripheral and central lines, oxygen support, dialysis and isolation¹. Medical complications arising from electroconvulsive therapy (ECT) can also be managed on a medical psychiatry unit.

Overall, a medical psychiatry unit provides an environment that is pleasant and accommodating to a patient population with high levels of psychiatric and medical acuity, but at the same time has the essential elements that facilitate the rendering of appropriate medical and surgical services.

Admission Criteria

The focus of care of each medical psychiatry unit across the country is diverse, including elderly, neuropsychiatric or behaviourally disturbed patients, substance abuse, eating disorders, chronic pain, schizophrenia and even patients as young as 13 years old^4,7,8 . Similarly, there is a wide variation in sources of referral, including the general hospital, long-term care facilities (nursing homes, assisted living facilities, memory care units), emergency rooms, outpatient clinics, direct referral from community providers, and tertiary referrals.

Medical psychiatry units maintain a distinctive patient population by virtue of admission criteria⁹. Admission criteria are necessary to ensure that the specialty of the medical psychiatry unit best matches the medical psychiatric problems that require treatment. Criteria for admission specify age, acuity of psychiatric and medical illness, acuity of nursing care, skilled care needs, and other factors. Patients without any concurrent medical illness, or with medical illnesses that are chronic and stable and do not require active intervention, are commonly excluded. Those whose high acuity level of medical illness that exceed the capacity of a medical psychiatry unit to safely manage them on the unit are best admitted to medical surgical services, with the consultation liaison service providing psychiatric care appropriately. Patients with severe behavioural problems should be excluded if there is no available staffing or if the physical environment is inadequate to handle the behaviours. Admissions for psychosocial reasons, in particular severe dispositional problems unlikely to be resolved even with effective psychiatric treatment, should not be accepted¹. A waiting list for admission to the unit should be maintained, and priority given to patients from other psychiatric units within the facility, and those from medical and surgical units in the general hospital.

Despite implementation of admission criteria or a priority system, some admission decisions can still be difficult. It is helpful to have a team (typically a physician and/or an advanced level nurse) review all referrals for admission to ensure compliance to admission criteria and to make gatekeeping decisions. Hospital administration should support the medical director’s authority to decline

inappropriate admissions. Inappropriate admissions are not unexpected, even with admission criteria in place. One study that examined admissions to a medical psychiatry unit that required transfer to medical-surgical units within 48 hours of admission due to acute changes in medical conditions noted that the acute changes occurred after admission and were not foreseeable, although more vigilant screening for pulmonary, cardiovascular, electrolyte and infectious disorders was recommended¹⁰. When inappropriate admissions do occur, mechanisms should be in place to correct the problem, such as facilitating transfers to a more appropriate unit.

The Multidisciplinary Treatment Team

A medical model of diagnosis and treatment is practised in a medical psychiatry unit, because the patients are not only psychiatrically but also medically ill. A multidisciplinary treatment team is necessary in order to address the complex needs of this patient population. Similar to other psychiatric inpatient settings, a medical psychiatry unit utilizes a multidisciplinary treatment team to directly provide comprehensive care to patients in a biopsychosocial model. However, medical psychiatric treatment teams have more experience and expertise in providing care for medically compromised and elderly patients with psychiatric problems. One possible model would comprise a physician trained in medicine and psychiatry, or another would be two physicians, one being a psychiatrist and one being an internist. If the model is a single physician, this person should be trained with subspecialty in psychosomatic medicine, geriatric psychiatry, neu-ropsychiatry, or combined internal medicine and psychiatry. If the model involves a second physician, preferably an internist with specialty training in geriatric medicine, that physician is dedicated to the medical psychiatry unit daily to provide initial and follow-up consultations, to help evaluate and manage acute and chronic medical conditions, urgent or emergent situations, and to conduct medical examinations for clearance for ECT or other procedures.

Psychiatrists commonly lead the multidisciplinary treatment team. It is important for the psychiatrist team leader to have sound medical knowledge of the various aspects of psychiatric interventions (psychotherapy, pharmacotherapy, ECT, behaviour modification etc.), efficiently coordinate patients’ care, communicate effectively, and successfully handle or resolve conflicts within or outside the team.

The other core members of the treatment team include nurses, social workers, pharmacists, therapists and chaplains. The nursing staff is one of the most important factors in the successful operation of a high-level acuity medical psychiatry unit⁵

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