What if thread of the week...

[Sushirolls]

So some time back I learned that Critical Care Access hospitals, the tiny 25 bed outposts in the middle of nowhere, have some bed exceptions.

They can expand by 10 for rehab units that PM&R rocks. Or they can expand by another 10 for a psych unit. And these 2 expansions won't risk losing status as a CCAH.

Got me thinking, as an anti-IP, pro-OP doc, if that size could be a recipe for success. I.e. larger for profit 70-110 bed, free standing Psych/Addiction hospitals are rife with issues, IMO. I've seen larger non-profit hospitals with 20-40 beds just neglect/ruin their units and even shut them down.

I think a 2 doc combo in a partnered private practice could be perfect. Even make rules to not consider outside hospital night transfers until getting to unit at 7am or 8am or whenever. Might just be a small enough unit to avoid most bureaucracy.

The likely high occupancy could be a positive buffer for staffing with the CCAH. I.e. the nursing staff are usually rotating from the "ED" to floors, and this could be means to keep people on regular working schedules to absorb the other units ups/down more easily.

Negatives, not exactly going to have the seasoned psych nurse with 20+ years experience.

Chime in: pros/cons, viability, road blocks, etc

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[Celexa]

The single biggest issue I see taking down inpatient psych right now is lack of nursing (both any nursing ie warm bodies, but even when staffed, nurses and techs with actual inpatient psych skills).

Unless you know where and how youre going to train those people, I don't know how you start an inpatient unit. And if your acuity isn't high enough to need that level of specialized nursing care, then you get to the question of does the person need to be inpatient at all.

 

[comp1]

This was hard for me to follow. You want to launch a rural inpatient psych unit attached to a more general hospital? I mean there's a need for beds most places, but I concur that nursing is going to be your limiting factor. It's not a matter of limited admission times. Physician work can be done remotely, nursing can't. It can be hard to find any nurses willing to do inpatient MH, much less skilled ones that don't make the job impossible. It's a pretty dangerous job for nurses. Yes, some ED nurses might be interested, most med-surg will not and med-surg skills don't transfer anyways. Anyways, talk to an inpatient nurse manager about this. The limiting factor isn't physicians or the hospital funding situation (although both will also be hard to manage). It's sometimes hard to conceptualize, but there's usually a reason even really dysfunctional systems (like 125 urban psych hospitals) work the way they do.

 

[Sushirolls]

Just a chin stroking "what if." Not looking to do it.

My understanding of CCAH nursing is they cover the whole hospital based upon where the patients are. They do PACU, ED, IM floor, the OB floor, etc. Isn't really the true division of units like in larger hospitals, as CCAH can have census of like 6. I believe folks go into these locations/jobs knowing they will be floating into different roles often.

The limited admission time is more a function reduce the sleep disruption of being on call Q2 with another doc, or even 1 week stretches, or how ever it gets chunked up with the other doc.

But I do hear what your saying, nursing with coverage, staffing, quality of staff may be the limiting factor that needs a good review before kicking off such a unit.

 

[WisNeuro]

The single biggest issue I see taking down inpatient psych right now is lack of nursing (both any nursing ie warm bodies, but even when staffed, nurses and techs with actual inpatient psych skills).

Unless you know where and how youre going to train those people, I don't know how you start an inpatient unit. And if your acuity isn't high enough to need that level of specialized nursing care, then you get to the question of does the person need to be inpatient at all.

I think the bigger pragmatic problem is MH inpatient units being financial black holes.

 

[whopper]

Will the place have decent IM support? You will get patients with significant medical problems.

I was the medical director at an addiction clinic and got out of it just over a year ago. They wanted to bring in patients near death's door against my recommendation. Several of these patients had to be sent to the ER the second they got to the addiction clinic. Each time I told the administration this was the exact reason why they have to be medically screened before coming in. Adding to the problem the closest hospital were a rural piece of crap hospital that discharged the same patients without stabilizing them back to our addiction clinic.

Despite that this was an ongoing problem the owner of the clinic kept saying he wanted us to take in medically unstable cases. WTF? I told him to change his mind or get a new medical director. They got a new one. Fine with me.

 

[Sushirolls]

In theory, 2 docs running the unit would dictate admission acuity and be able to stick to it.
Being a rural CCAH, there would be FM docs working the ED 24/7, so in theory you have 24/7 medical coverage.

 

[ObsequiousAplomb]

Is this functionally much better than putting together a PHP program or a short-term residential? Areas with these CCAH are probably also just as short-supplied on those. Fewer regulations there, right?

 

[Sushirolls]

PHP I suspect.
Short term residential probably not much better. Any time people are 'wards' and staying overnight some place, rules/regs increase.

 

[comp1]

Oh yeah, that's a good idea. Locally, we do have a significant shortage of residential (non-substance) mental health programs that function between acute inpatient and PHP day programs. The staffing needs are MUCH less for that. I'm guessing there's no PHP for miles and miles around a rural area, so that sounds like a much better idea if allowed.

 

[michaelrack]

So some time back I learned that Critical Care Access hospitals, the tiny 25 bed outposts in the middle of nowhere, have some bed exceptions.

They can expand by 10 for rehab units that PM&R rocks. Or they can expand by another 10 for a psych unit. And these 2 expansions won't risk losing status as a CCAH.



I think a 2 doc combo in a partnered private practice could be perfect. Even make rules to not consider outside hospital night transfers until getting to unit at 7am or 8am or whenever. Might just be a small enough unit to avoid most bureaucracy.

There might be some EMTALA issues to limiting outside transfers to certain hours

 

[Sushirolls]

There might be some EMTALA issues to limiting outside transfers to certain hours

I've seen it done before in a large non-profit Big Box shop.
EMTALA only means a screening examination is to be completed in the ED.
Doesn't mean psych admit gets transferred stat. There is no threat to life or limb. A patient is safe/stable in an OSH ED.
If we're talking Emergencies like brain hemorrhages and those life/brain/limb threatening services are available at a different hospital that has NSx, Interventional Radiology, CT Surgery, etc then that makes sense.
But Psych? nope, that can wait for the morning.

 

[nexus73]

I've seen it done before in a large non-profit Big Box shop.
EMTALA only means a screening examination is to be completed in the ED.
Doesn't mean psych admit gets transferred stat. There is no threat to life or limb. A patient is safe/stable in an OSH ED.
If we're talking Emergencies like brain hemorrhages and those life/brain/limb threatening services are available at a different hospital that has NSx, Interventional Radiology, CT Surgery, etc then that makes sense.
But Psych? nope, that can wait for the morning.

Largely agreed, based on the plain language of EMTALA at least. There was a huge settlement about 5 years ago where CMS and OIG basically redefined legal stability to suit their ambitions of sticking it to a hospital that was stuck boarding psych patients for weeks. Here's an interesting article about it. When is a Psychiatric Patient Stable under Federal Law, EMTALA?

 

[michaelrack]

I've seen it done before in a large non-profit Big Box shop.
EMTALA only means a screening examination is to be completed in the ED.
Doesn't mean psych admit gets transferred stat. There is no threat to life or limb. A patient is safe/stable in an OSH ED.
If we're talking Emergencies like brain hemorrhages and those life/brain/limb threatening services are available at a different hospital that has NSx, Interventional Radiology, CT Surgery, etc then that makes sense.
But Psych? nope, that can wait for the morning.

You are right about the responsibilities of the transferring facility. As far as what you propose, your psych ward would generally play the role of a receiving facility under EMTALA. If your psych ward doen't have the ability/capacity to take patients at night (due to staffing etc), that should be fine under EMTALA. What is not fine would be taking patients from the your own ER at night but refusing to take outside patients at night. It's hard to argue that you don't have capacity/ability if you are taking patients from your own ER.

If EMTALA applies to a psych big box shop (and it generally does if they allow walk-in assesments); I guess they can decide to limit their hours of walk-ins and outside admissions on a regular basis- I am not aware of any that do this, but I guess it is possible. They can also, if close to bed capacity, turn down outside admissions and play games to admit a walk in if necesssary (ie, unblock a room etc)