The problem with inpatient units…

 

Why are many psychiatric units in the United States such miserable places?  That question came up today on Twitter and there was a consensus by the responders.  It is a chronic question that comes up episodically and there are never any good formulations or solutions. I started working on an inpatient unit in 1988 after three years as the medical director of a community mental health center. At the mental health center, I travelled twice a week to an inpatient unit in a small town where I provided the only psychiatric coverage. Without those visits the inpatient unit would have closed. The new position was at an acute care hospital that accepted all of the emergency psychiatric admissions on the east side of St. Paul, Minnesota.  I was on the unit that accepted the most aggressive patients triaged through the emergency department. Over the next 22 years, a number of factors came into play that made that job impossible to do and resulted in my resignation and moving on to an outpatient job. What follows are my observations about what went wrong.     

1:  Management is strictly on a financial basis with minimal to no psychiatric input and no consideration of quality care.  That means administration typically has no expertise in managing the environmental aspects of care apart from blaming inpatient psychiatrists for any complications that occur. The most glaring deficiency is management of violence and aggression.

When I first started out – there was a psychiatrist who headed the department and set all of the administrative policies. There was a business manager who reported to the head of the department. With the advent of managed care, financial managers replaced psychiatrists as department heads and set administrative policy.  The only variation on that theme is a psychiatrist who carries out administrative decisions from the managed care company administration. The expectation is that the psychiatrists working on inpatient units have minimal to no input on administrative decisions that affect them. There is no discussion of the multiple failed administrative policies from business administrators.

2: Financial management dictates that the admission indication and reason for ongoing care is dangerousness loosely defined as a danger to self or others.  Reviewers aligned with the financial interests of the insurance company make this determination using proprietary guidelines by looking at documentation.  At their discretion they can stop payment for any patient who they determine is not dangerous or suicidal enough to be treated on an inpatient unit. That patient is often immediately discharged.

The clearest sign of failed policy from financial administrators is the current standard for inpatient care. That indication is dangerousness. That means a reviewer can say at any time that a patient will no longer be funded because they are no longer dangerous. This criterion is problematic at many levels. First, it is an inappropriate admission standard that makes it more difficult to assess people in the emergency department. Most people in need of psychiatric admission are in distress but not dangerous. It is not appropriate to turn them away if nothing has been done to alleviate their distress.  Second, dangerousness is stigmatizing and perpetuates the myth that people with psychiatric problems are dangerous. Third, there is no objective way to draw a clear line on a day-to-day basis in order to make a rational discharge decision.

3:  As a direct result of #1; aggressive patients are often triaged to the 5-10% of community hospitals in each state that might be able to contain aggression.

This only applies to states with multiple psychiatric hospitals and in some states that is not true.  Even in states with multiple community hospitals, only a minority of those will have psychiatric units. A select few will admit and treat highly aggressive patients. The reason again is financial. It requires specialized and more intense staffing that costs money.

4:  Length of stay (LOS) is short (3-5 days) to optimize profits.

One of the most perverse incentives are DRG payments. The theory is that the average cost and LOS for a specific diagnosis can be estimated by a group of experts. To financial managers that means, the patient must leave by that duration or less and less is much better. During my tenure in acute care reviewers would call me demanding to know “where is the dangerousness?” that necessitated ongoing inpatient care. Carefully explaining that the patient was not stable enough to function outside of a hospital did not count.  As time went by and managed care companies acquired hospitals this review process was internalized. Inpatient psychiatrists now faced case managers in their team meeting who were basically acting like external reviewers. That impacted not only patient care but the morale and enthusiasm of the inpatient team.

5:  The units are managed to keep all of the beds full irrespective of patient need and there are no private rooms.  This often leads to very incompatible roommate and one of them wanting to leave as a result.  The ability to admit patients is often out of the control of the psychiatric staff and is run by administrators.

Since all inpatient psychiatric beds are rationed in the US and kept at an artificially low aggregate number, these beds are at a premium. In any large hospital the emergency department, the consultation liaison teams, and psychiatric outpatient clinicians are all competing for bed space.  From the minute inpatient psychiatrists arrive in the morning they are pressured to discharge people.  The triage system for admissions is often out of control of the psychiatrists. That results in room mate mismatches and patients not being admitted to their desired specialty units. In both of those situations the inpatient staff and psychiatrists have to address the resulting complaints from patients and families including frequent demands for discharge because of these problems.

6:  Patients are discharged before they are stable to optimize profits.

Severe psychiatric problems rarely respond adequately to treatment in 3-5 days. No medication or psychosocial therapy works that fast. In order to meet the artificial time constraints people are treated aggressively with medications – increasing the risk of side effects.  The ability of the patient to care for themselves in a stable environment is less of a priority.

7:  Many inpatient environments are markedly deficient relative to medical/surgical units (less modern, poor air quality, more crowding, different food service)

This may be changing to some extent with the continued closure of inpatient units. Many of them are dated facilities.  In hospitals where medical surgical patients have private rooms that may not exist on psychiatric units.  In hospitals where there is an ala carte food service for medical surgical patients those choices may not exist on inpatient psychiatric units.  There are many rationalizations for these discrepancies, but when you see the glaring deficiencies in person there is clearly a lack of equal treatment.

In addition to the lack of privacy, practically all acute care units in the US are locked. That certainly reduces the elopement risk and may be necessary from a legal standpoint for involuntary patients, but it is possible to have more liberal policies and allow people off the ward for exercise and passes with their family or friends.  Some research suggests that people may do better on an unlocked unit. The overriding financial oversight comes in to play - with many companies saying that if a person doesn't need to be on a locked ward they don't need to be in a hospital.  Another variation on the dangerousness theme. 

8:  Follow up care is typically lacking in availability and intensity.

For a lot of people, quality inpatient assessment and treatment is their one good shot at stabilization and adequate care. There are many people who have severe mood disorders, bipolar disorder, episodes of psychosis, and postpartum mental illness who have never been stabilized on an outpatient basis. Many have been ill for decades.  Adequate inpatient care can make a significant difference but it will not happen in the span of 3-5 days.  Once adequate care has been established, follow up care is a problem. It is more of a problem if the patient is forced to leave before they are stabilized.

9:  Some units have a disproportionate number of involuntary patients undergoing civil commitment. If committed they may face a very long LOS waiting for transfer to a state hospital in a unit that was not designed for long term care.

The most obvious deficiencies of an inpatient unit come into the light when a patient ends up stranded there for a month or two. They start to experience the cramped quarters and lack of leisure time activity as imprisonment. There has been no work done on how to redesign units for people who have to remain there for extended periods.

10:  Even though substance use disorders are a common comorbidity – they are often seen by the insurance company as a reason for immediate discharge from a psychiatric unit, even when relapse is imminent, it is a life-threatening problem, and no residential beds for the substance use disorder are available.

Insurance company reviewers often insist that patients with severe depression and alcoholism or some other substance abuse problem be discharged the next day. That can even occur if the patient was exhibiting suicidal behavior while intoxicated.  Appropriate detoxification and adequate treatment were not a priority – only the reviewer’s idea that the directly observed suicidal behavior was due to acute intoxication. Most inpatient units do not have immediate access to substance use treatment facilities and it is imperative that these patients are detoxed and stabilized prior to discharge. Business and financial pressure backs up all the way through the psychiatric unit to the emergency department where the message becomes – “people with substance use disorders should not be admitted to psychiatric units.”  This can result in high-risk home detox scenarios and continued relapse with less chance of recovery.  Some counites have "non-medical detox" that patients are transferred to.  They are sent back to the hospital in the event that they have continued significant detox symptoms and may be admitted to a medical service or intensive car unit at that time. 

11:  There is often minimal to no contact with the outpatient staff who were treating the patient prior to admission.

Many outpatient psychiatrists are very cynical about inpatient care. First, they have no control over admissions. They may know inpatient colleagues but realize that it is futile to call them in order to admit one of their patients. They have to tell the patient to go to the emergency department and get assessed for admission. Second assuming that goes well – inpatient staff often do not have the time or energy to consult with outpatient docs about the plan. Finally, they receive many of their patients back who have not improved, are still in crisis, but are now taking higher doses of medication. They typically do not get discharge summaries or other paperwork form the hospital including the discharge medications. 

12:  There is often minimal communication with the family and federal privacy regulations are often given as a reason.

Acute inpatient care is often associated with a family crisis and family members want communication with inpatient staff and the inpatient psychiatrist. Work intensity on the inpatient unit along with staff burnout often results in either a lack of communication or a perceived lack of caring by the family. That can add more conflict to the treatment environment.

13:  The psychiatrists working in these settings have an intense work load and get minimal administrative support. In many cases there is a policing attitude on the part of administrators rather than an affiliative effort.  The psychiatrists are policed on the basis of productivity, LOS, and complications – none of which are under their control.  Staff splitting often occurs because of siloed administration that is commonly used by administration to elicit criticism of specific staff psychiatrists.

Instead of being treated like valuable experts with acknowledged expertise, inpatient psychiatrists are treated like production workers. Administrative staff make decisions that lead to the environment seriously deteriorating and often manage that by becoming more authoritarian and rigid.

14:  Medical coverage is not standardized and emergency department triage is often not enough.

Medical coverage varies greatly depending on the hospital and staff availability. Psychiatrists may not ever touch a patient in some settings or in the case of my inpatient unit – they may be responsible for the complete medical and psychiatric care of the patient.  In some settings there are free standing psychiatric hospitals where ill patients have to be sent by ambulance to an emergency department. In other hospitals there is complete access to all medical and surgical specialties.  In recent years another managed care innovation – the hospitalist has come to inpatient psychiatrist units. That basically means the same psychiatrist works 7 days shift on and 7 days off. Medical coverage is still contingent on local conventions. I have not seen it formally studied, but interviewing Internal Medicine hospitalists left me with the impression that cognitive performance dropped off significantly after 5 days.

Whoever is working the acute care units as a psychiatrist the risk for unrecognized physical illness and destabilized medical problems is always very high. In a chaotic, stressful, unpredictable environment a psychiatrist needs to be at the top of his or her game.

15:  There is intense regulatory interference at all levels.

It is often not obvious that all of the factors I am mentioning here are the direct result of government intervention. The federal government invented the rationed managed care system and early in this century turned the reins over to the insurance industry. It is the single largest conflict of interest interfering with quality care in psychiatry today.  Managed care alone is responsible for many inpatient psychiatric units closing. State sponsored units are rationed on the same principles by human services departments. Both have resulted in a large influx of psychiatric patients into jails where most people do not receive adequate care. Further initiatives like regulating the number of ligature points on an inpatient unit have resulted in further unit closures.

16:  Staff turnover:

It takes a mature and often experienced person to work on an inpatient psychiatry unit – irrespective of their profession. The best inpatient units are held together by a team of psychiatrists, nursing staff, social workers, and occupational therapists. I am convinced that I have worked with some of the best folks from all of those professions. But being the best and being mature enough to be empathic with a unit full of people in extreme distress is not enough. The staff have to be supported and given what they need to be successful. Without that support crises start to happen among the staff. How does that look?  It looks like a social worker who has spent all day on the phone calling 25 nursing homes in order to get a patient placed and being told that they are not doing enough and need to work on placing other patients.  It looks like nursing staff having complex patients taking care of too many patients with high acuity and complicated medical problems with not enough staffing. It looks like nursing assistants being falsely accused of wrongdoing and not being supported.  It looks like various staff members experiencing homicidal threats and nobody knowing what to do about it. Those are just a few examples of what leads to staff turnover.

The staff I worked with knew that we were short of resources. They did everything they could to make the environment more supportive for patients and families. At the Christmas Holiday the occupational therapists would organize a celebration and every patient there got a present and was able to participate. Nursing staff organized a used clothes closet so that patients could be resupplied with clothing if necessary. In some cases we raised cash and transportation on the spot for patients who were leaving abruptly, had no way to get back home, and had no money to buy food.  The inpatient staff is a significant human resource but they can’t compensate for decades of rationing and the irrational polices that play out on their units every day.

17.  Competing forces that increase length of stay that are never addressed by managed care companies:

There are many. The most obvious are probate court polices that affect patients being treated on an involuntary status. Any probate court procedure adds about 2 weeks to the length of stay in the place where I worked.  During that time the patient had no obligation to follow treatment recommendations. That could allow any insurance to refuse payment based on the fact no treatment (apart from containment and psychosocial therapies) was being given.  That creates a number of pressures from administrators and an associated bed shortage. If civil commitment does occur that patient may be waiting for weeks to months for transfer to a state hospital. A more proactive approach in this situation would be to do the hearings on an outpatient basis in the context of community treatment.  I never saw that happen.

Many patients need a therapeutic environment to be discharged to.  They are either homeless or not able to function well enough for independent living. The responsibility of insurance and managed care companies ends at the hospital door. If the inpatient staff cannot find a suitable county or charity funded setting many of these patient are discharged to the street.

Even standard discharge planning to an outpatient clinic can be a problem. Many organizations use a guideline that the patient must be seen in clinic 1-2 weeks post discharge. It is difficult if not impossible to get those appointments even if the inpatient unit and outpatient clinic are in the same organization.  In some cases the appointments are months out with no flexibility in the system to accommodate discharged patients.

All of the factors prolonging inpatient stays by delaying treatment or discharge magnify the pressure on inpatient staff.  Ineffective administrators who cannot negotiate contracts or other arrangements with these outside sources of inpatient utilization transfer that burden directly to the inpatient staff.  The only way to compensate is greater patient turnover and more admissions.  That typically is not possible and the inpatient staff are the obvious scapegoats.

18. Lower reimbursement for equivalent service.

In large metropolitan hospitals psychiatry is an invaluable service in terms of patient flow and discharge planning. Patients with overdoses on medical units and various injuries associated with their psychiatric diagnosis on surgical units – need to be rapidly assessed and transferred or discharged from those primary admitting services.  The emergency department needs to admit psychiatric emergencies to inpatient units. These processes are critical to the function of large hospitals.  Despite that fact, psychiatry is reimbursed at much lower levels for the equivalent amount of care provided by other services. This is an artifact of the long standing carve-out mentality of managed care companies.  In the 1980s they made a decision that psychiatric services were not like the rest of medicine and could be paid for by a separate and lower level of reimbursement. Some of my friends in other specialties, know this and they know that in a hospital setting the high margin services (generally proceduralists) transfer at least part of their profit to cover psychiatric services.  This could all be avoided with equitable reimbursement. Without it funding depends on this transfer of funds and generating as much turnover as possible on the inpatient units.

19:  Psychiatric units in hospitals are the only specialty services that are supposed to be all things to all people.

Most specialists have the luxury of admitting people with a fairly well-defined set of problems. Even if the people are diverse – their problems are not and that specialty service is set up to focus on that set of problems. In the case of inpatient psychiatric units – those rules no longer apply. If the patient has a significant medical or surgical problem and a significant psychiatric problem and the staff psychiatrist has no input into the admission decision – that patient may be admitted to psychiatry. As a result, there are a large group of patients on any unit with significant medical problems that are often acute and need close monitoring. Those problems can interfere with both the patient’s ability to participate in any available programming and also make is difficult to assess any treatment progress focused on their primary psychiatric disorder. The array of these problems can range from acute delirium to a terminal illness requiring intensive nursing care. Since psychiatric units are rarely designed, equipped or staffed to provide this level of care these situations place additional stress on the inpatient environment.  Managed care companies may deny reimbursement for this care on the basis that “the patient should be on a medical unit”.  But of course the medical unit sent the patient in the first place.

20:  Decades of admission avoidance has led to a non-functional admission procedure that is focused on hospital administration needs over outpatient staff and patient needs.

Many outpatient psychiatrists have complained to me over the years that it is impossible to get their patients admitted on a timely basis. On the inpatient side it makes complete sense since the inpatient units are managed to maintain full capacity, there is a chronic bed shortage, and the admissions are not in control of the inpatient psychiatrists. That means the only practical way to get a patient admitted is to send them to the emergency department.  That is true even if the outpatient psychiatrist has consulted with inpatient staff who agree with the admission.  The backlog in the EDs is legendary and there are rules in lace to send the patient to a remote hospital even if that hospital is hundreds of miles away.  There are very few people who want to be voluntarily admitted to a psychiatric unit and even fewer who want to be sent to a remote hospital. 

This conflict plays out in other ways.  In the case of patients with severe depression requiring electroconvulsive therapy (ECT) - they typically cannot be directly admitted and may have to go through the emergency department.  Patients with complicated detoxification related problems - like benzodiazepine detoxification prior to surgery with an associated severe psychiatric problem may not be admitted at all.  There are frequent conflicts about admission and discharge times, because the inpatient staff may end up working long hours (12-13/day) indefinitely due to the timing of the admissions and discharges. In some cases, a hospital may close down their bed capacity and divert all of their admissions to a nearby hospital to avoid this problem.  

21:  Admission Avoidance: This has always been a goal of managed care organizations on both the psychiatric services and medical side of the operation.  There has been a long series of interventions to try to compensate for what amounts to a lack of service and spin it in the most positive light.  About 25 years ago in the New England Journal of Medicine there was an article describing what were essentially crisis units that were supposed to divert potentially short stay psychiatric admissions and house them in a less intensive settings with psychiatric services.  Many counties have this kind of service that is paid for by the county so the cost has been shifted away from managed care companies or federal payers.  I recently attended a conference on a “new” model where a large open hospitable room and psychiatric services are provided. Each patient gets their own lounge chair (the photos I saw showed gerichairs).  There were no beds on the unit. Patients were expected to sleep in those chairs if they had to stay overnight.  Nobody on a 72 hour hold or requiring any significant degree of medical care would be admitted to this unit.  The expectation is that most people would be discharged in about 6-8 hours.  The only real difference from the ED is that patients had more immediate access to psychiatry staff and were not just sitting there waiting to be seen at the next transfer. I suppose some might see this as an innovation. I don’t think you can focus on what is needed on an inpatient unit and what those patients need if you are constantly focused on an artificial admission avoidance concept and putting resources into that.  If anything, it suggests that there are not enough staff and resources on inpatient units.

22.  There is a lack of collaboration with outpatient staff:  Good inpatient care proceeds from the assumption that the main focus of treatment is with the primary psychiatrist or treatment team. For me that attitude goes back to an attending physician I worked with as an intern on an Internal Medicine rotation. He let us know about the term “local MD” and why that was a pejorative. He pointed out that it was arrogance and assumed that the inpatient team who had brief contact with the patient knew more about the care of that person than the outpatient physician.  I did not have enough experience at the time to know one way or the other, but over the years have developed a nuanced view of the problem. But I have no doubt that the inpatient process needs to support outpatient care and that unilateral plans from the inpatient side are by definition suboptimal.

By more nuanced there are a number of reasons for a lack of communication. The only acceptable reasons are that the patient does not have outpatient care, the patient refuses to consent to the communication, or the outpatient physician or their proxy cannot be contacted with a good faith effort. Being on both ends of that call - a good faith effort to me means leaving a cell phone number with the message to “call me at any time.”  I have found that effort is required in an era of overproduction and no set times in the outpatient clinic for necessary phone calls.

In addition to the outpatient psychiatrist, consultants also need to be contacted. I have found that direct communication with the patients cardiologist, endocrinologist, nephrologist, primary care physician, and neurologist is necessary. In fact, there are cases where I do not make any changes to the patient’s medications until I have talked with one of these specialists.

In terms of specific outpatient care, a lot of history needs to be reviewed in the case of complex care.  The outpatient clinic can more efficiently send the records after a brief call. What the outpatient psychiatrist wants to see happen and the endpoint of inpatient care are very important areas that need to be covered. On occasion, the patient expresses dissatisfaction with outpatient care and that conversation can occur in a way that does not split care providers.  For example, one common scenario is the patient with a first manic episode after being treated for years for depression in the outpatient clinic.  A neutral discussion of the difficulty of making a bipolar disorder without a clear manic episode may facilitate transition back to the outpatient psychiatrist.  These problems highlight inpatient psychiatrists needing to maintain a realistic outlook on what has been done and what can possibly be done in the future. 

23:  All of the above factors translate to a chaotic and poorly run inpatient units.  There is no overall clinical guidance because it is typically taken away from psychiatrists and placed with administrators who clearly know nothing about inpatient psychiatry.  

Many inpatient units are nerve wracking places. The first order of business for me after a team meeting was to address as many crises on the unit as possible.  That could include agitated and aggressive patients, patients actively harming themselves, patients refusing medical care for a life-threatening illness, patients refusing surgical care for an obvious problem, and instability due to detoxification from alcohol or benzodiazepines. By addressing these crises, I always hoped to bring a measure of comfort and reassurance to the patient and everyone else who was distressed. I hoped to bring the noise level down. I hoped to have all of the biohazardous material cleaned up.  It is without a doubt a very tough job – made tougher by the fact that you only have the illusion of control. The people really responsible for this bedlam are out of touch. I actually had an administrator tell me to imagine that there was a firewall between me and the administrators who made all of the decisions affecting me, my staff, and the patients. That firewall was there to block my input and the input of my colleagues.

I had planned to do inpatient psychiatry until I retired, but I could not take it anymore. The interpersonal dimension was the most draining. Rather than dwell on that I often think about a deluxe psychiatric hospital that I visited instead. Several years out of residency, I was invited down to this campus by the former chief resident from the program I graduated from. It was a modern campus connected by broad boardwalks running to the compass points. My friend’s office was modern, open and airy. He told me about all of the services and activities available to his patients including excellent cuisine in the cafeteria. At the time the length of stay at his hospital was 2-3 months.  He had no concerns that his patients were unstable at the time of discharge and described none of the stressors that were impacting me on a daily basis. He had set office hours and left at a predictable time every day.  In the subsequent blur of my inpatient tenure, I never found out what happened to this hospital. My suspicion is that managed care eventually shut them down.

I don’t believe for a second that psychiatric inpatient units need to be miserable places that patients and their families want to avoid. I don’t believe for a second that they can’t be therapeutic and stimulating for the dedicated staff that work there.    

But that transformation clearly can’t happen if it is run by business administrators empowered by government edicts.

 

George Dawson, MD, DFAPA

Supplementary 1:

Almost exactly 10 years ago, I had an interview about my thoughts on managed care and psychiatry published in the MetroDocs periodical.  You can read it here but it will probably require adjusting the screen view.

Supplementary 2:

 I have also been interviewed on this theme by Awais Aftab, MD for his series Conversations in Critical Psychiatry.  You can read that interview at the following link.

The Bureaucratic Takeover of American Psychiatry

Open Psychiatric Units Mean Fewer Suicides and Elopements ?!!

There is a headline making the rounds in the media about whether or not locked psychiatric units are useful in preventing suicides and "absconding" behavior in inpatient psychiatric units.  Absconding is running away before the formal discharge and in the US it is referred to as elopement.  The media handling of this article is a bit less scholarly than you might expect from the average psychiatrist reading this article.  Even media circulating to psychiatrists sends out the headlines from a news service:  "Locked psychiatric wards may mean more suicide or escape attempts." Since I have spent the majority of my career on locked psychiatric units and consider myself an expert in this area - reading the article and looking at its deficiencies comes naturally to me.

The article looks at a coalition of 22 German psychiatric hospitals and their affiliated psychiatric services.  Sixteen of the hospitals had at least one locked psychiatric unit over the course of the study.  Four hospitals had no locked wards over the course of the study.  One of the hospitals started out with no locked wards but "had to introduce locked wards for legal reasons" in November 2000. organized under a central agency that looks at quality assurance and quality management.  Twenty one of the hospitals participated in data analysis by a central quality assurance/management agency the Dokumentationsverbund Psychiatrie (DVP).  The study period ran from January 1, 1998 to December 31, 2012.  This was  an entirely retrospective analysis based on anonymized data.  During the study period there were 271,128 admissions to locked wards and 78,446 admissions to open wards.

Primary outcome variable was completed suicide and secondary outcome variables were suicide attempts during treatment, elopement without return, and elopement with return.  Some of the characteristics of the populations were described and they appear to have diagnoses similar to what might be found on inpatient units in the US with major difference - some of the primary diagnoses listed would likely not be admitted - like somatoform disorder or personality disorder as a primary diagnosis, but the study says very little about admission criteria.  On American inpatients psychiatric units pure substance use disorders are actively discriminated against, by insurers and government agencies that govern hospitalizations and in the German sample. they constitute 18-25% of the primary diagnoses.  The authors do a statistical comparison between the locked ward and open ward groups across the outcome variables.               

There are two logical flaws with the study and the researchers comment on one.

The first is generalizability of the data.  The authors seem to recognize this in their use of OECD data and the rates of psychiatric bed utilization in Germany (2.8 per 1,000 population) versus the UK (0.5 per 1,000) and the US (0.3 per 1,000)  suggesting that there is greater acuity in the populations with fewer beds and that there is a greater proportion of acutely ill patients.  The other parameter that is critical in American inpatient psychiatry is the number of aggressive and homicidal patients.  At large metropolitan hospitals units comprised almost entirely of highly aggressive patients are not unusual.  Other patients are generally considered too vulnerable to be admitted to these units.

Aggressive behavior can create near riot conditions on units like this and an unlocked door would create numerous situations leading to violent confrontations with staff.  The striking part about this comparison to the German system was that this paper left out all mention of aggression, violence and homicide suggesting that these patients were not being admitted to these hospitals.  The only line containing these words in the entire paper was in one of the references.  That makes this study impossible to compare with any set of metropolitan psychiatric units in the US.  There is the associated question of what the Germans do with their aggressive patients?  Are they sent to forensic hospitals or specialized units?  It would be very unlikely to not encounter thousands of highly aggressive patients in any American sample this large even at a time when the largest psychiatric hospitals in the country are county jails.

The second is that the implicit notion about a randomized controlled trial.  For the reason I previously mentioned it is not likely to be ethical, amenable to human subjects approval or therefore doable.  The authors suggest that being under a mandate to treat all patients in a certain geographic area reduces selection bias.  That is difficult to accept if potential for aggression and overt aggressive behavior is not an admission criteria and if it not compared between the locked and unlocked units.      

That said, what can American psychiatric units learn from the German experience?  The first and most important is that unlocked units are possible.  I worked at a facility that typically had 4 psychiatric units and when we started one unit was open.  It was a transitional unit where people were sent after their acute disorder, agitation, aggressive behavior. and suicide risk was treated but they were not quite ready for discharge.  The management of psychiatric units by business managers eventually dictated that these partially stabilized people should just be discharged - frequently when there had been an almost imperceptible improvement.  This was all based on the fallacious "dangerousness" argument by managed care companies.  They decided about 20-25 years ago that the only reason anyone should be hospitalized on an inpatient psychiatric unit was if they were dangerous to themselves or others.  That also led to locked hospital wards, if not by implication by explicit managed care feedback as in: "If the patient does not need to be on a locked unit - they don't need to be in the hospital and therefore we are denying payment for this admission."  Have these managed care tactics dumbed down inpatient treatment and adversely affected the atmosphere of these units?  Of course it has.  It has created a palpable corrections-like atmosphere in many units.  The only reason people are there is to figure a way to get out.  This reinforces the thought that the people there really don't have any problems in the first place they are just being discriminated against.  So the first lesson from Germany is to restore the running of hospitals to psychiatrists and not business managers.

The second issue is infrastructure and length of stay (LOS).  Most EU countries have significantly more psychiatric beds available to their populations.  The most likely reason is that they are not rationed (nearly out of existence) by managed care companies or the government like they have been in the US.   Lengths of stay are also significantly greater.  The interesting dimensions for comparison would be the functional status of patient at discharge as well as the therapeutic milieu in comparing German to American units.  That would require a more sophisticated research approach but it might bring some science to inpatient psychiatric care.  It would also be interesting to know if the German hospitals have state of the art specialized programs for specific conditions and whether their environment is designed to emphasize the therapeutic rather than containment aspects.

There is also the opportunity to look at the administrative aspects of these units more specifically the impact of a business management approach to a more clinical or at least less of a short term profit approach.

We have all witnessed what healthcare businesses can do to inpatient care in the US - and it is never good. 

George Dawson, MD, DFAPA

References:

1: Huber CG, Schneeberger AR, Kowalinski E, Fröhlich D, von Felten S, Walter M, Zinkler M, Beine K, Heinz A, Borgwardt S, Lang UE. Suicide risk and absconding in psychiatric hospitals with and without open door policies: a 15 year, observational study. Lancet Psychiatry. 2016 Jul 28. pii: S2215-0366(16)30168-7. doi: 10.1016/S2215-0366(16)30168-7. [Epub ahead of print] PubMed PMID: 27477886.

Trauma in Psychiatric Hospitalizations

I read the Shrink Rap blog and found the recent post there on a reaction to one of the blog's posts on the violation that people feel after psychiatric hospitalization.  A direct attack on the author was certainly predictable especially given some of the sources quoted in the article.  As expected none of the author's intentions were captured by these responses.  Her intention was explicitly stated in the following 2 sentences:

"I realize that some people who are involuntarily hospitalized are terribly traumatized, which is why I'm writing the book. I don't think psychiatrists see that and I think if it were figured it into the equation, maybe less people would be involuntarily hospitalized (certainly, no one should be forcibly hospitalized for 'sadness' as one of the MIA commenters put it), other alternatives could be found, and more of an effort would be made to treat those where there are no options but involuntarily hospitalized with respect and kindness."

I worked in an acute care inpatient setting treating very acutely ill patients for 23 years and thought I would give my impressions to the statement about what psychiatrists see or don't see in people who have been acutely hospitalized, especially on an involuntary basis.  I think that there are several critical factors that determine what the experience will be like during those circumstances.  There will be considerable variation in the experience based on how these factors are approached.

1.  The pre-hospital experience

On the units where I worked, voluntary admissions were in the minority.  Most people were brought in to the emergency department (ED) by the police or paramedics.  They are usually involved when there is an acute behavioral change leading to a safety issue.  In that pre-hospital encounter some people are beaten up, maced or tasered by law enforcement.  If that happens and the person is in the ED wearing handcuffs that are too tight it can have an effect on the perception of the hospital and its staff following admission.  It is also an extremely traumatizing experience.  Years of observing this problem led me to problem solve with patients affected by these situations on how they could avoid confrontations with the police.  That is not the only source of trauma prior to admission.  Fights, accidents, self inflicted injuries, and near death experiences with suicide attempts and accidental overdoses can also happen prior to admission.  In some cases, people are transferred from intensive care units where they have been stabilized.

2.  Intoxication states

Intoxication states including alcohol,  cocaine, amphetamines, hallucinogens, and marijuana as well as the associated drug induced mental disorders are overrepresented in the population that gets acutely and/or involuntarily admitted.  People with substance use disorders have been systematically discriminated against by the insurance industry for the past thirty years.  At that time functional detoxification was not allowed and any patient who was intoxicated was generally denied care in psychiatric units by these same companies even if they had a significant psychiatric disorder.  They were supposed to go to "social detox" in county detox units, at least until most counties learned from insurance companies that it is cost effective to not have any resources and just deny care.  That means that today more people never get sober and are more likely to have increasing numbers of encounters with the police.  All it takes is an episode of aggression or suicidal statements while intoxicated and it can lead to transportation to specific psychiatric hospitals that receive patients from the police and paramedics.  In many cases, the hold is dropped after the person is detoxified and they no longer have the behaviors that occur in the intoxication state.  In other cases, there are semi-permanent or permanent changes secondary to the substance use and that results in a longer hospitalization.

3.  Acute psychotic states

Some patients who develop acute psychiatric states can experience similar changes in their conscious state that result in violent or suicidal behavior.  It is common rhetoric to hear that patients with mental disorders are no more likely than non-patients to be violent or aggressive.  Averaged across the entire population that may be true but it is also true that there are very high risk groups of people with mental illness.  The civil commitment laws in most states were designed for this contingency and a lot of these stories make the front pages these days.  Acute agitation and aggression in public or at the time of an emergency call places the person at high risk for a confrontation with the police.  In these confrontations anything can happen.   One of the functions of the hospital staff is to come up with a plan that will minimize any future risk of this kind of confrontation and to immediately address any physical or psychological trauma that occurred prior to admission.  In some cases, ongoing high levels of aggression in the hospital can result in additional physical intervention.  The goal of that physical intervention is much different that the police goals and staff have to be trained to provide this kind of treatment.  Medication can also be administered in emergency situations and according to state statutes to reduce the risk of injury to patients and staff.
   

4.  Suicidal states

One of the more complex aspects of inpatient care is assessing suicide risk and attempting to reduce suicide risk on the inpatient setting.  The problem is complicated by the fact that a lot of people with chronic suicidal thinking are assessed as being acutely suicidal and they are admitted.  In many cases it is a fine line between thinking about injuring or killing yourself every day for years and then one day deciding that you are going to do it.  In many cases people will injure themselves and demand to be released from the hospital.  They will deny making the statements even though the documentation is very clear.  They will be unaware or dishonest about their potential for suicide or self injury.  They may be indignant about being in a hospital even after a serious suicide attempt.  Others have very serious suicidal thinking and are quiet and cooperative but may at very high risk for suicide if they are released prematurely.  The worst case scenario is the person who suicides in the hospital or shortly after release.  The majority of people are able to recognize that there is a problem and work with the staff on resolving it and get released on a voluntary basis as soon as possible.

5.  Friends and family

In many cases of acute involuntary hospitalization, the chain of events starts with a family member or friend long before there is any suggestion of hospital involvement.  Family members often find themselves in the precarious situation of being concerned about the future patient, but not able to do anything about it.  They may have false information and believe that nothing can be done until the person actually "does something."  They are fearful about the patient's behavior and the fact that they have become unpredictable.  In some of these situations the first event leading to the hospital is an act of aggression or a suicide attempt.  The police are called, a crisis intervention team is activated, and the person is placed on a transportation hold and taken to the hospital.

Family members respond differently when the patient is admitted to a psychiatric unit.   Some family members are angry that the patient was admitted and insist that the patient be admitted to a medical or surgical service.  These patients are often geriatric patients who become aggressive at home.  Some families are relieved that the admission occurred and their member is in a safe environment and treatment can start.  Some families do not want the patient to know that they were involved in getting them to the hospital.  Some families get angry and demand that the patient be immediately released.  In some cases family members can become violent and threatening themselves.  Communication with the family can prevent a lot of misunderstandings and give them a clear idea of what the assessment and plan will be.  In some cases, the patient will refuse to sign the necessary releases to allow this communication.        

6.  Probate and criminal court officials

Statutes vary from state to state, but in the two main states where I have worked probate courts make the decisions about involuntary hospitalization, civil commitment, guardianship, involuntary administration of medication,  and conservatorship.  The process is advanced by screeners who gather evidence that can be tested against the statutory language for civil commitment and other proceedings.  Contrary to a recent Internet post on the "medical model", impaired insight is not a criterion for commitment and neither is "sadness" as suggested in the original post.  The probate court staff and not the hospital staff need to come up with all of the actual behavioral evidence to proceed with the original hold order and any further legal proceedings toward civil commitment.

One aspect of these court proceedings that nobody pays much attention to is that (like all American legal activity) these proceedings are contentious.  There are two sides and both sides want to "win" according to that model.  If any paternalism enters into the picture it typically happens when the patient's attorney recognizes that they are too ill to function and strikes some kind of bargain with the court.   Speaking for the clinician side I can say that quality treatment is a more realistic goal than "winning" in any usual sense of the word.   The patient, their family, and their attorney can decide that they will advocate for a position that is the opposite of what the hospital staff recommends.  In that case, there will typically be a lot more emotion than if there is no apparent alignment opposing the treatment team.
   

7.  Medical staff

In addition to the usual medical and psychiatric tasks of diagnosis and differential diagnosis and treatment of these diagnoses, the main task of inpatient staff is to maintain a safe and therapeutic environment.  Given the marginal existence of some of these units that is no easy task.  I can recall working on units where all of the patients stood on the other side of the glass and the activity was dominated by young aggressive men with severe personality and psychiatric disorders.  If an intimidating environment like that is allowed to exist a significant number of people in that environment will be frightened and in some cases traumatized.  Patients who are disruptive due to inappropriate social or sexual behavior or because of dementia can also frighten or anger other patients and that can lead to some level of traumatization or a reactivation of that dynamic.  The staff all need to be acutely aware of these potential problems and act to address them.  This requires an physical presence of medical staff on the unit.  Given the current levels of acuity, inpatient units cannot be run remotely or by administrators.  The medical staff present has to be well trained, comfortable with treating severe psychiatric problems, cohesive, and proactive.

Physical interventions to prevent aggression or self injury are potential flash points for trauma.  Many people who are acutely hospitalized have a high likelihood of past trauma or abuse.  The best overall approach is to keep any physical interventions to the minimum and keep the staff well trained in the concepts or therapeutic neutrality and verbal deescalation. In the cases where physical intervention is required, strict protocols need to be followed and quality assurance programs need to be in place to assure that these measures are kept to the very minimum periods of time.

8.  Relevant demographic factors

The most relevant demographic factor on the part of the patient is a history of abuse, a diagnosis of post traumatic stress disorder and how those variables currently affect them.  Some studies suggest that as many as 30-40% of patients have one or both problems.  The is relevant not only in understanding their current presentation but it should also guide how the staff interact with them.  In an informed environment, with resources it can suggest a course of psychotherapy, but very little psychotherapy typically occurs in most inpatient units.  Sociopathy and psychopathy are also relevant variable, since it is unlikely that people with these problems can be integrated into a population of more vulnerable patients without the odds of victimization being very high.  Substance use issues can also be very disruptive, especially in environments that are not very secure and increase the risk of contraband being brought into the hospital.
     

9.  Personality and anger control factors

Anger is an interesting emotion for a number of reasons.  It is hardly mentioned in psychiatric diagnostic manuals but it plays a significant role in inpatient psychiatry.  An inpatient psychiatrist can walk in and find that most or all of the patients to be seen that day have significant problems with anger.  Anger is frequently seen as a non-specific symptom of psychosis, mania, or personality disorders but it is more complicated than that.  There are often different formulations of anger control problems on inpatient units.  Assuming the person is not intoxicated it can be paranoia, projection, projective identification, grandiosity, irritability and various symptoms associated with the psychiatric syndromes that correlate with anger and aggression.  But there is also the element of anger and how it affects decision making.  If you are angry (irrespective of the real cause) you will have a tendency to see your problems as being attributable to another person and to see that other person as being responsible for your problems.  This means that if you were angry before you were hospitalized you will see the inpatient staff as being responsible for your problems, even though they had nothing to do with the circumstances of admission.  It is also true that is almost all of the situations that I have encountered, the inpatient physician did not initiate the emergency hold.  It is typically initiated by an outpatient or ED physician or in some states - law enforcement.  Most people in this situation can recognize what happened, but some cannot.  Some will remain angry the whole time and for a long time after they are discharged.      

10.  Officials who monitor medical staff and hospitals

There is a long line of administrators whose only job is to make sure that patient rights are guaranteed and that no patient is abused or treated in a disrespectful manner.  The first official is usually a patient advocate who is a permanent employee of the hospital or clinic.  In the state where I work the next line of oversight is an Ombudsman for mental health and developmental disabilities appointed by the governor who has investigative oversight into any hospital or clinic activity that a patient or their family finds to be unacceptable.  The Ombudsman can come in to any facility and interview all of the people involved and make their own determination of the merits of the complaint and what corrective action needs to be taken.  In the case of physicians the Board of Medical Practice (BMP) has ultimate authority over any licensed physician in the state.  All it takes is a brief note on a complaint form to initiate a full investigation into a physician's behavior that involves all of the relevant medical records being sent to the BMP.  Complaints are never questioned as far as their accuracy or coherence.  The physician in question needs to respond in detail to the complaint.  Physicians are never exonerated, a complaint is never assessed as to whether or not it had merit, and complaints are kept on permanent file even if the complaint is dismissed.  A finding against a physician can result in fines and restriction or suspension of their license to practice medicine.

11.  A reasonable discharge plan

In the most straightforward scenarios people sober up and/or resolve their crises and they are discharged as soon as any hold can be dropped.  In the case of acute intoxication states that don't require extensive detoxification it could happen in less than a day.  People are frequently discharged as soon as they are admitted from the ED (they are essentially admitted for a second opinion from a psychiatrist).  In more complex crisis situations, collateral information is usually needed to corroborate the patient's baseline behavior and document whether the relatives have had any concern before the hospitalization.  As noted in the family section, relatives have varying degrees of anger.  Some may show up either demanding the immediate release of the patient or threatening to sue the medical staff if the patient is released and not treated.  In some cases there are threats that legal action will be taken if the patient commits suicide or harms someone.  All of these factors and any medical and psychiatric diagnoses and treatment plans have to be negotiated in the discharge planning.

12.  A general lack of knowledge and sophistication about emergency hospitalization

It should be well known in our society that people are conflicted about mental illness and its treatment.  At the level of the healthcare business there is no conflict.  Healthcare companies are in business to make money and to a large extent that is how people keep circulating in and out of psychiatric hospitals and emergency rooms.  To my knowledge, nobody is ever educated about preventing these kinds of emergencies and avoiding contact with the police and hospitalization.  Instead we seem to have plenty of advocates for more risk rather than less.  That includes the recent pendulum swing toward more permissive attitudes involving drug and alcohol use.  Recognizing that a problem exists that could lead to this pathway is critical for prevention of these episodes and by definition prevention of any trauma that might be incurred on inpatient units.

Conclusion:

All things considered, I encountered very few situations where there was a question of a person being traumatized on an inpatient psychiatric unit where I worked.  I agree that this is an area for further study and that study would need to be carefully done.  I know that many people do not disclose what they were thinking or feeling in the hospital until well after they have been discharged.  A possibly useful approach might be to offer a post discharge assessment that focused only on the issue of trauma that occurred in the hospital and was totally independent of a treatment plan for the primary diagnosis.

In any situation this complex is it possible that some people are traumatized by the experience?  Of course it is.  Is it possible that some people actually create trauma for their fellow patients and staff?  Most definitely.  Is it possible that some if not most people recognize that there were major problems before admission that led to this situation and are able to work with the hospital staff to resolve the situation in a timely manner?  The answer is again - very definitely.  There are a number of mechanisms available to people who feel traumatized or treated unfairly as outlined above.  These safeguards vary from state-to-state but similar agencies are available across the United States.  In the case of Medicare patients, each state also has a unit to investigate complaints of Medicare patients if they believe they have received suboptimal care or care that was in any way abusive.  All of the agencies outside of the hospitals are free of conflict of interest and in many cases they consider it a political plus to take action against any abuse that occurs in a health care facility.  As a past Medicare reviewer, all reviews are conducted by physicians who are carefully screened for any potential conflict of interest.

Utilizing these resources and conducting further research on this problem is the best possible approach.  It is far superior to political debates on the Internet or attacking a person who is interested in studying the problem.

    

George Dawson, MD, DFAPA



References:

1:  Bruce M, Laporte D. Childhood trauma, antisocial personality typologies and recent violent acts among inpatient males with severe mental illness: Exploring an explanatory pathway. Schizophr Res. 2015 Mar;162(1-3):285-90. doi: 10.1016/j.schres.2014.12.028. Epub 2015 Jan 28. PubMed PMID: 25636995.

Supplementary:

I am interested in any additional factors that I may have missed in terms of sources of trauma on inpatient units.  E-mail me what you think and I may include it in an updated table.

The Retirement Party

There aren't too many retirement parties that you can go to and spend a lot of time talking about violence.  I suppose it might happen with law enforcement and the military.  When I went in to psychiatry I never seriously thought about the fact that I might have to go to work every day and face people with serious problems with aggression and violence.  In some cases that would mean seeing people who had threatened to kill me and my family.  It would also mean seeing people with documented incidents of aggression toward others, toward themselves, and toward property.

I went to a retirement party yesterday for a nurse I had worked with in an acute inpatient setting for about 20 years.  Like most of the nursing staff I work with she has excellent skills but was also renown for her sense of humor and positive attitude.  She was the kind of person I counted on when things were particularly grim - a frequent occurrence on inpatients units.  I could only make it to the last 2 hours of the party, so I missed the evening shift who all had to leave and go to work.  There were about 20 people there including a psychiatric colleague who worked with me on that unit and who I have known for 30 years.  I always consider retirement parties to be very happy events.  I have known too many medical professionals who never made it to retirement.  I want everybody to make that goal, especially people I have been in the trenches with.  I previously posted here many times about the inpatient environment and its importance is treating and containing aggression and how that function has been subverted by political and administrative forces and rationed to the point of being minimally effective.  When you are working on an inpatient psych unit, it is a lot like going to war every day.  You are facing many patients who don't want to be there despite significant problems.  Many are involved in contested commitment hearings based on whether they have a suicide or aggression risk.  Many have severe substance use problems that intensify suicidal thinking and aggression.  They are generally not interested treatment for the substance use problems or do not see that as a significant issue.  There are minimal resources to work with.  The team social workers generally don't last too long because there are very few community resources that want to cooperate with discharge plans from acute care psychiatric units.  Everyone is working under an administration that is focused on restricting resources and providing suboptimal care.  Everybody at that party worked with me in that environment at one point or another for 23 years.  At times it was like we were in foxholes under siege for weeks at a time, just looking for a break.

It was good to see everyone in a much less stressful context, but like most groups of people who have been immersed in a high intensity work experience the conversation tends to gravitate back to the humorous and stressful events that we were all a part of.  One of the common threads was aggression.  I learned that one of the nurses had recently been assaulted and sustained broken nose and a traumatic brain injury.  She discussed the incident and her reactions to it.  My psychiatric colleague added her personal experiences with aggression directed toward her.  As I looked around the room, I was aware of the fact that significant physical aggression had occurred toward about 25 % of the people there.  In some cases there were episodes of repeated physical aggression.  At some point in my career,  I realized that there was really nobody who was interested in helping inpatient staff contain aggression.  There are always administrators around who are ready to assign blame.  I can remember one particularly unhelpful "consultation" that suggested that the problem was a lack of rapidly forced medications.  The most recent administrative initiatives have to do with not forcing anything.  Suddenly everyone was supposed to respond to quiet deescalation.  Sitting in a quiet office somewhere and looking at spreadsheets does not lead to any insights into containing aggression on an inpatient unit.  I guess the typical administrator does not realize that.  My realization was that as a team we had to discuss the issues with patients constantly, emphasize the violence risk, emphasize that we did not want anyone to take chances in these situations, and discuss a detailed plan that included ways to approach the patient and their family as much as medication.

About halfway through the party, one of the nurses handed me her iPhone with the the story about a psychiatrist who had shot a patient in a crisis clinic.  It reminded me of the time I had to consider about whether or not to arm myself.  I was after all a tree hugger and a Child of God from the 1970's.  The last thing I wanted to do was have guns in my house.  I was aware of psychiatrists who had been killed by patients, in several cases with firearms.  I had just read an article about a psychiatrist who was also a Sheriff's deputy who carried a handgun.  In my case it was a patient who threatened to shoot me when I was walking out to my car from my clinic.  He made the additional threat to burn down my house and kill my family.   He proved that he knew where to find me by reciting my home address.  Going to work under those conditions every day and treating other aggressive patients is stressful to say the least.  But it is expected of psychiatric staff, in some cases even after they have been assaulted and the patient who initiated the assault is still in treatment.

I have no personal knowledge of the shooting incident but the descriptions suggest common system wide issues that are never well addressed these days.  Rather than speculate about media reports there are some common safeguards that I have learned apply everywhere and serve to contain violence and aggression in clinics and on inpatient units:

1.  The atmosphere - you can't really expect to reduce the potential for violence or aggression unless the environment is adequately managed.  Psychiatrists used to talk about the milieu but that ship has apparently sailed.  The largest professional organization of psychiatrists is silent on inpatient treatment and the treatment of aggression and violence.  The American Psychiatric Association (APA) used to have guidelines on such matters, but nothing has been written in a long time.  I don't know if that is just giving up to the widespread managed care blight or an open acknowledgement of the hopeless situation.  The APA has been reduced to homilies about how increasing access may reduce violent events rather than speciality units set up to treat aggression and violence associated with severe psychiatric disorders.

Inpatient units can literally be staff on one side of the plexiglass and the violent and aggressive patients on the other.  I worked on a unit like that at one point.  We were all shocked one day to learn that we really were not behind plexiglass when a steel chair came flying through a shattering tempered glass window.  It sailed right over my head and I was standing up at the time.  It must take quite a bit of force to throw a steel chair that distance through glass and to that height.  Nursing staff dove for cover with the explosion of the glass.  In addition to the staff it took two Sheriff's Deputies to resolve the situation.   There are any number of reasons given for running units like this and none of them are good.  It puts the patients and staff at risk by eliminating one of the most important aspects of psychiatric care - the interpersonal relationship between patients and staff.  Without it a correctional atmosphere can develop that is more conducive to rioting than treating mental illness.

That same floor had a history of firearm related events.  There was the case of a patient who had a firearm smuggled in.  He held the psychiatric resident hostage and ended up shooting a Sheriff's deputy at the control desk out in the hallway.  When I worked there, I was surprised one morning  to find a number of men on the unit in suits.  I learned they were federal agents.  I was more surprised to find out they were carrying machine guns.  People armed with automatic weapons really do detract from the therapeutic atmosphere of a psychiatric unit.

2.  Relationships - one of the most dangerous situations I have ever been in was ending up on the wrong side of the plexiglass at the wrong time.  The wrong time was at a time I was being blamed for a staffing problem that I really had nothing to do with.  Many people don't know how the attitudes that staff have toward one another can be played out in an intensified version by patients.  I found myself surrounded by 4 young aggressive paranoid and antisocial patients who threatened to beat me up.  After I talked my way out of that situation, my solution at the time was to transfer off that unit with the idea that I would not let that happen again and hopefully pass that knowledge along to other staff.  Unfortunately that same pattern of behavior can occur if it is activated by someone outside of the treatment team.  When that happens it is impossible to deal with in a constructive manner.

3.  Systems issues - the lack of administrative support for any functional approach to aggression is often the biggest obstacle to solving the problem.  This is not an issue in many places where the approach is to kick the can down the road.  Many community hospitals don't accept violent or aggressive patients or even patients who are highly suicidal and may require 1:1 staffing.  They are transferred to tertiary care centers where these problems tend to concentrate.  In those tertiary care centers it is important to segregate patients based on their potential for aggression.  I have heard all kinds of arguments against this procedure  that do not hold water.  I think people may be confused about the segregation issue.  I am  talking about separating men with a high potential for physical aggression from other inpatients who are generally more vulnerable than the average person.  Trying to treat those populations on the same unit is a recipe for disaster.  If the most aggressive mentally ill people in the state are being concentrated in a few hospitals, it is the only safe way to proceed with treatment.  Even then, there needs to be considerable expertise on the part of the staff involved.

4.  Serious administrative deficiencies - I have never seen a clinician with the knowledge required to address any of the above issues in an administrative position.  In an a new twist, there are some hospitals where administrators with no experience at all are charged with running hospitals for patients with severe forms of mental illness and associated aggression.  The commonest excuse for not addressing any of the concerns on this list is finances.  There is not enough money to provide adequate staffing.  In many cases there are now elaborate methods to decide on adequate staffing.  At times the staffing differences between an all male unit housing patients with psychotic and personality disorders with aggressive behavior is not much different from a mood disorders unit where there is practically no aggressive behavior.  Security on the units with a high potential for aggression often depends on other staff being available by cell phone or alarm.  In some cases it is a 911 call to local law enforcement.  I have had to ask that the 911 call be made when an entire male unit essentially rioted and it was no longer safe for the staff.

5.  It is all about the nurses - A key lesson that nobody ever learned in medical school and few physicians seem to learn after is that the only reason anybody needs to be in the hospital is nursing care.  Doctors can go in and out for 20-30 minute blocks and write orders, do procedures, and write prescriptions anywhere.  The nurses are with the patients 24/7.  It follows that one of the primary tasks as a physician is to assist the nurses.  That ranges from taking care of medical and psychiatric problems in a timely manner to backing them up in highly contentious situations.   Nurses are not there to make physicians miserable.  Nurses have an incredibly hard job to do and they know it takes a team effort.  There can't be any "personality conflicts".  In the interest of the team they need to be set aside.

Those are some of the thoughts I had about this party.  Of course I thought about the person being honored and my direct and very positive professional experiences with her.

And I looked around and hoped that everybody there could function as a team, take care of one another, and make it to retirement.

They have nobody else looking out for them.

George Dawson, MD, DFAPA


Supplementary 1:  I had thought about posting the following disclaimer at the top of this post:

"In case you thought this was my retirement party and thought you would enjoy reading about that and rejoicing - you can stop reading right here.  I have not retired and this blog continues...."

But I thought it flowed better the current way.