Boarding psychiatric patients on the medical ward

[Pershing]

I work in a 10-bed inpatient psychiatry unit. My hospital is proposing a plan to expand the capacity to 16 psychiatric inpatients by boarding them on the medical ward overnight and have them participate in the therapeutic activities/milieu on the psych unit during the day. There are plans to maintain safety, such as appropriate staffing ratios and sitters when they are on the medical ward (these rooms are not designed for psychiatric inpatients), but I do not feel comfortable with this plan. What are your thoughts about this? I'm not sure if I am willling to take on this type of liability. Also, I have never heard of any other hospital doing this in order to expand their capacity for psychiatric inpatients.

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[Pershing]

not sure this is even legal - are these voluntary or involuntary patients?

Mostly a voluntary patient population.

 

[Shikima]

Going to have sitters on each of them per night and day?

 

[wolfvgang22]

Sounds like a dumb idea to me. They'll regret not retro fitting the rooms and having a locked ward when a patient hangs himself and the family sues the hospital and costs a lot more money than a remodel would.

 

[Pershing]

Going to have sitters on each of them per night and day?

Sitters overnight on the medical ward when they are not on the locked psych unit.

 

[OldPsychDoc]

I take it that there is no Partial Hospitalization Program in this hospital? Because it sounds very much like a PHP + lodging kind of set up, but the medical bed piece would be expensive if there is not a medical justification for hospitalization. Still, sounds like you would essentially be assessing and documenting that the patients are suitable for discharge, then lodging them on medicine here...

I will say that I was a moonlighter long ago at a smallish community hospital with 20-some inpt psych beds, of which 10 or so were on a locked hallway and others, for voluntary patients deemed low-risk, were "open" to the rest of the hospital, just like any other med-surg bed in the hospital. Really, it's just a matter of risk assessment, isn't it?

 

[Bartelby]

Chiming in to agree with the other posters, this sounds like a significant liability issue and is likely to create a number of milieu/clinical problems. Also I wonder how much cost savings you really get by not remodeling and having a 1:1 sitter on each patient going forward?

Is the hospital doing this because there are already a lot of people boarding for days or more for psych and they are just consolidating them in one place and opening up therapeutic services (as in the bed search for psychiatric inpatient placement continues)? If that were the case it could be a different situation.

 

[Pershing]

I take it that there is no Partial Hospitalization Program in this hospital? Because it sounds very much like a PHP + lodging kind of set up, but the medical bed piece would be expensive if there is not a medical justification for hospitalization. Still, sounds like you would essentially be assessing and documenting that the patients are suitable for discharge, then lodging them on medicine here...

I will say that I was a moonlighter long ago at a smallish community hospital with 20-some inpt psych beds, of which 10 or so were on a locked hallway and others, for voluntary patients deemed low-risk, were "open" to the rest of the hospital, just like any other med-surg bed in the hospital. Really, it's just a matter of risk assessment, isn't it?

No PHP at our hospital. Sort of a unique situation as I am at a DoD hospital in a foreign nation. Patients admitted to both the locked ward and medical ward would meet criteria for inpatient psychiatric hospitalization and not be deemed suitable for discharge. I agree that it is a matter of risk assessment, and I would place lower risk patients on the medical ward and higher risk patients on the locked unit if this plan was implemented. I guess the issue is misidentifying the level of risk. If an inpatient suicide occurred on the medical ward, I can see the lawyers asking me why I didn't put them on our locked unit or if our locked unit was full, why I didn't send them to an outside hospital with an available psych bed if I thought they needed inpatient care.

 

[Pershing]

Chiming in to agree with the other posters, this sounds like a significant liability issue and is likely to create a number of milieu/clinical problems. Also I wonder how much cost savings you really get by not remodeling and having a 1:1 sitter on each patient going forward?

Is the hospital doing this because there are already a lot of people boarding for days or more for psych and they are just consolidating them in one place and opening up therapeutic services (as in the bed search for psychiatric inpatient placement continues)? If that were the case it could be a different situation.

Boarding of psych patients in our ED or med/surg wards is not occurring at our hospital. This expansion of beds is largely contingency planning in the event that our psychiatric patient volume exceeds our locked unit's capacity.

 

[st2205]

This sounds expensive. They'll realize that... eventually.

 

[OldPsychDoc]

This sounds expensive. They'll realize that... eventually.

"Sort of a unique situation as I am at a DoD hospital in a foreign nation."
I'm guessing they don't care...

 

[downwithDTB]

Not that it's the right thing to do, and I don't know how *this* particular problem can be averted... but don't patients admitted to medicine, cleared medically, but held psychiatrically (say s/p OD/SA) awaiting dispo to a psych unit sit in medical beds with no medical indication for days to weeks awaiting beds? I saw this all the time on C&L... or even better, just sit in a non-psych emergency room for essentially forever.

I know that the intention here is very different, and thus the liability and legality is probably totally different. But the actual effect is very similar, no? In fact, these patients all had medicine teams and nurses assigned to them on top of the 1:1 if required, so they probably cost who ever paid even more.

 

[nitemagi]

I've seen this at some hospitals, but usually as an approach to overflow, rather than a standing plan for extra beds.

 

[Pershing]

I've seen this at some hospitals, but usually as an approach to overflow, rather than a standing plan for extra beds.

This is more of plan for overflow as our census generally does not exceed the 10-bed capacity of our locked unit. I would be fine with the overflow plan of boarding psychiatric inpatients on the medical ward if I had no better alternatives, but I do have the alternative option of searching for an open psych bed at an outside facility and sending them there.

 

[Pershing]

This sounds expensive. They'll realize that... eventually.

"Sort of a unique situation as I am at a DoD hospital in a foreign nation."
I'm guessing they don't care...

Right on, OPD. Some of my staff think this plan is being advocated because it would actually make the hospital numbers look better. Our medical/surgical wards are not very busy, so why not open it up to extra psych business? You have to keep spending money to justify continued funding, is the theory. I honestly don't think that is why this plan is being proposed, however.

 

[Pershing]

presumably this is cheaper than fee-servicing out to other hospitals

presumably if you're working at a DoD facility you are exempt from liability if there is a bad outcome

Yes, it is probably cheaper than fee-servicing out to other hospitals. I can't be sued because of the Feres doctrine, but I believe my license would still be at risk with the number of investigations that are done for suicides, especially suicides that occur in the hospital. Additionally, we have independent contractor psychiatrists who can be sued by active duty service members or their family members.

 

[Shikima]

Just create a PHP program and you'll be better off. You can create a boarding situation by using unused beds and since you're dealing with DoD monies, it doesn't matter how the beds are utilized. Risk stratify people daily and you can move people in and out of the locked unit as safety issues present themselves. Only use the medicine beds as an overflow with a sitter.

 

[ieatpizza]

x

 

[Pershing]

Just create a PHP program and you'll be better off. You can create a boarding situation by using unused beds and since you're dealing with DoD monies, it doesn't matter how the beds are utilized. Risk stratify people daily and you can move people in and out of the locked unit as safety issues present themselves. Only use the medicine beds as an overflow with a sitter.

Don't give them any ideas! We're too understaffed to create a PHP, and I am not exactly trying to create more work for myself. I get paid less than $150k and already work more than 1 FTE. Sure, I am free of debt, but I owe almost another decade of service.

 

[Shikima]

That's the problem with DoD service obligations. But what you're learning now will be helpful when you enter the 'real world'.

 

[notdeadyet]

. I can't be sued because of the Feres doctrine, but I believe my license would still be at risk with the number of investigations that are done for suicides, especially suicides that occur in the hospital. .

You're right that the Feres doctrine offers no protection for your license. You can face the same risks as anybody else in the case of malpractice.


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[sunlioness]

That's the problem with DoD service obligations. But what you're learning now will be helpful when you enter the 'real world'.

After another decade though. Yikes. At that point, it might make mor sense to stay in a full twenty and retire.


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[Pershing]

Thanks, everyone. I think I am going to brief the hospital leadership that the decision to board on the medical wards vs. transferring to an outside hospital needs to be done on a case-by-case basis, that it should be up to the psychiatrist's clinical judgment about the potential risks and benefits of either option which will be specific to the patients we have at the time, rather then a forced algorithm to overflow psychiatric inpatients on the medical wards.