Who approves hospital admissions

[deleted456421]

Many of the hospitals I work at seem to avoid involving psychiatrists in pre-evaluating admissions. Either a nurse manager accepts them, very rarely after consultation with myself, or someone (often a psych NP) places admission orders from the ED after determining appropriateness. These systems now use centralized "bed management" systems. I'm curious if this is standard practice.

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[robellis]

Many of the hospitals I work at seem to avoid involving psychiatrists in pre-evaluating admissions. Either a nurse manager accepts them, very rarely after consultation with myself, or someone (often a psych NP) places admission orders from the ED after determining appropriateness. These systems now use centralized "bed management" systems. I'm curious if this is standard practice now.

The on-call psychiatrist accepts admissions at my hospital and places admission orders

 

[deleted456421]

The on-call psychiatrist accepts admissions at my hospital and places admission orders

That's the model I was expecting before starting to moonlight. I initially thought the first hospital, with nurse managers clearing admissions, might be an anomaly. But now I've worked at three other hospitals where patients just show up on the unit. At least two places don't involve psychiatrist decision-making at all (that is, during the daytime or weekday shifts before I take over).

 

[MBBSMOM]

Many of the hospitals I work at seem to avoid involving psychiatrists in pre-evaluating admissions. Either a nurse manager accepts them, very rarely after consultation with myself, or someone (often a psych NP) places admission orders from the ED after determining appropriateness. These systems now use centralized "bed management" systems. I'm curious if this is standard practice.

I think it depends on the hospital system. At UHS we had a nursing supervisor accept patients. In other places I've worked at the psychiatrist's are involved in pre-admitting decisions.

 

[comp1]

It should be a collaboration. Nurse managers determine if a unit can actually manage a patient in terms of staffing and the patient's needs. The psychiatrist or mental health NP determines if the patient would benefit from psychiatric admission, often after receiving at least a verbal report from the nurse manager/charge nurse, particularly overnight. If either one isn't involved, it's going to create problems.

 

[Mass Effect]

It should be a collaboration. Nurse managers determine if a unit can actually manage a patient in terms of staffing and the patient's needs. The psychiatrist or mental health NP determines if the patient would benefit from psychiatric admission, often after receiving at least a verbal report from the nurse manager/charge nurse, particularly overnight. If either one isn't involved, it's going to create problems.

Why? The nurse manager/charge nurse should have no say in whether the patient would benefit from psych admission. The ideal set-up is for the psychiatrist to decide if the patient meets inpatient level of care. And if so, then and only then does the nurse manager get involved. If the in-house unit is too acute per nurse manager, then a bed search should be started for another hospital. But there's no sense in waiting for the nurse manager's verbal report before determining if the patient would benefit from admission.

 

[comp1]

What I meant was that the nurse manager does need to be involved to see if the unit can actually accommodate the patient. I agree that RNs in general aren't involved in determining psychiatric benefit, but also if you aren't talking to your RNs about what has happened during past admissions for frequent patients, you're missing out on crucial information.

 

[splik]

its different everywhere but you will find that it is very common for psychiatrists not to be involved in hospital admissions, the nursing staff will review the packets. This is especially true at for profit hospitals where the goal is to fill up beds. I do think physicians should be involved to make sure you don't end up with patients on the unit who have been "medically cleared" when they are not. I've had pts in DKA, end stage liver failure, fulminant TB, acute liver injury, pyelonephritis, and subdural hematoma claimed as medically cleared. Typically, admission decisions are made by whoever is seeing the pts in the ED, not the inpatient psychiatrist, especially for freestanding hospitals.

 

[SpinDktr]

It will also depend on the state laws and legislation. In the state I live in, the only person who has authority to admit to a psychiatric unit is a psychiatrist. Nurse managers, NP's, even other doctors not certified in psychiatry are all out. I don't like a lot of the legislative tape with this, but in my experience most NP's and other providers would not be making good decisions, so it's probably a net positive overall.

 

[NickNaylor]

Some of the local, free-standing psychiatric hospitals also these centralized "bed management systems" as the same physician will be doing doc-to-docs for multiple hospitals at the same time.

At hospitals that I've worked at and hospitals that I've transferred patients to, in general the role of the physician is generally to ensure that the patient is medically stable and that any pertinent issues with respect to medical comorbidities are being effectively managed. Issues related to ensuring that staff can manage the patient, insurance authorization, etc. are handled by other staff.

At the unit that I work on, the nurse has already reviewed the patient's clinicals, verified insurance, and done a nurse-to-nurse before we're even paged about the patient. Consequently, our job is to essentially ensure that nothing is being missed medically and that there are no other big issues that would be exclusionary for the unit that somehow got missed. It'd be extremely unusual for one of the physicians to refuse an admission/transfer at that point. Then again, our nurses are pretty good about screening patients, so I'm sure there some folks that are refused that the physician staff isn't even aware of.

 

[deleted456421]

its different everywhere but you will find that it is very common for psychiatrists not to be involved in hospital admissions, the nursing staff will review the packets. This is especially true at for profit hospitals where the goal is to fill up beds. I do think physicians should be involved to make sure you don't end up with patients on the unit who have been "medically cleared" when they are not. I've had pts in DKA, end stage liver failure, fulminant TB, acute liver injury, pyelonephritis, and subdural hematoma claimed as medically cleared. Typically, admission decisions are made by whoever is seeing the pts in the ED, not the inpatient psychiatrist, especially for freestanding hospitals.

This is why I'm asking. I was surprised to find a patient with a platelet count of 16,000 the other day.

Some of the local, free-standing psychiatric hospitals also these centralized "bed management systems" as the same physician will be doing doc-to-docs for multiple hospitals at the same time.

At hospitals that I've worked at and hospitals that I've transferred patients to, in general the role of the physician is generally to ensure that the patient is medically stable and that any pertinent issues with respect to medical comorbidities are being effectively managed. Issues related to ensuring that staff can manage the patient, insurance authorization, etc. are handled by other staff.

At the unit that I work on, the nurse has already reviewed the patient's clinicals, verified insurance, and done a nurse-to-nurse before we're even paged about the patient. Consequently, our job is to essentially ensure that nothing is being missed medically and that there are no other big issues that would be exclusionary for the unit that somehow got missed. It'd be extremely unusual for one of the physicians to refuse an admission/transfer at that point. Then again, our nurses are pretty good about screening patients, so I'm sure there some folks that are refused that the physician staff isn't even aware of.

Sounds like a good system.

 

[ridethecliche]

The nurse manager accepts patients for inpatient admission at the institution where I'm currently training. We get paged sometimes to look at labs or something if there's something off, but they basically have a checklist of things they need to see before they decide to admit or not. Refusing admission is usually due to lack of staff or patients with history of violence, though the latter thing is changing as we've been taking more invols.

I always found it strange as well, but it was also nice not to be woken up multiple times on call to look through referrals.