Psychosomatics 46:65-70, February 2005
© 2005 The Academy of Psychosomatic Medicine
Treatment of Psychiatric Hospital Patients Transferred to Emergency Departments
Patricia H. Bazemore, M.D.,
David F. Gitlin, M.D., and
Stephen Soreff, M.D.
Received Feb. 25, 2004; accepted May 26, 2004. From the Department of Family Medicine and Psychiatry, University of Massachusetts Medical School, Worcester; the Department of Medical Psychiatry, Brigham and Women’s/Faulkner Hospitals, Boston; and Education Initiatives, Faculty Metropolitan College, Boston University, Boston. Address correspondence and reprint requests to Dr. Bazemore, Worcester State Hospital, 305 Belmont St., Worcester, MA 01604; patricia.bazemore{at}state.ma.us (e-mail).
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ABSTRACT
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Two hundred public psychiatric hospitals were surveyed regarding their management of inpatients with serious medical problems. Of the 102 hospitals responding, 98 had a formal arrangement with a medical facility for transfer and treatment. Fifty of the respondents felt they regularly had difficulty in receiving acceptable information from the receiving hospital, and 37 perceived that their patients regularly received less than optimal care. There was a significant direct correlation between difficulty obtaining information and the perception of suboptimal care. Seventy-nine hospitals had developed a referral form for the transfer of information to the receiving facility. The results point to an important area of discontinuity in the care of the seriously mentally ill.
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INTRODUCTION
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Acute medical illness arising in people who are hospitalized for mental disorders represents a treatment challenge. For many years, public psychiatric hospitals provided much of the essential acute medical care, as well as chronic medical management, within the confines of the psychiatric facility. However, with the increasing sophistication and technical advances in medicine, psychiatric facilities have been less able to provide optimal medical care for their patients. This situation was highlighted in the 1980s, with several cases of adverse outcomes in state hospital patients in Massachusetts, which led to increased scrutiny of the quality of medical care being provided in these settings.1 As a result, psychiatric hospitals sought alternative approaches. Furthermore, we were curious to see whether many public mental hospitals ultimately decided to approach the treatment of acute medical illness in psychiatric patients through transfer arrangements with acute care medical facilities.
Psychiatric providers may have reasonably hoped that once transferred to an acute medical facility, their patients would receive the same standard of quality care that other patients receive. However, as with any change, new problems and challenges arose. Many mental health providers anecdotally describe multiple problems with both the process of transfer and the quality of care provided to their patients in these acute medical situations. While multiple factors are likely to be involved, we hypothesized that medical care may be hampered by the stigmatization of mentally ill individuals as well as by practical problems in decision making, transportation, and the transfer of information.
There is a dearth of literature on medical transfers involving public psychiatric hospitals. A few publications exist concerning transfers between nursing homes and general hospitals. These publications are relevant because both nursing homes and long-term psychiatric hospitals have cumbersome medical records as well as patients who are poor historians. Teresi et al.2 identified a bimodal frequency of transfer distribution, with about half of the long-term care facilities having rates of 16% to 22% (low-transfer facilities) and half having rates of 43% to 63% (high-transfer facilities). They attributed the "saved" transfers in the low-transfer facilities to the presence of enhanced medical services on site. One specific characteristic of the low transfer rate of nursing homes was the presence of 24-hour on-site physician coverage. Stark et al.3 studied transfers from long-term care facilities to acute care hospitals in British Columbia, noting that 19.9% of the patients required transfer within the first year of institutionalization. The relevance of this study for long-term hospitalized mentally ill patients is supported by the work of Tariot et al.,4 in which 91% of those in long-term care facilities were diagnosed with at least one psychiatric diagnosis, making nursing homes the institution of choice for the elderly chronically mentally ill. Zarian et al.5 studied medical diagnoses in patients with dementia who were transferred from long-term care to acute care hospitals, concluding that pneumonia and urinary tract infections were the most frequent causes of hospitalization and that sepsis and respiratory failure were the most common causes of death. Heslop et al.6 addressed the transfer of information between psychiatric facilities and hospital emergency departments by developing a screening tool to be used by triage nurses at general hospitals.
The purpose of this study was to test the hypothesis that patients are transferred for acute medical care and that, during the transfer, less than optimum care may occur. In order to carry out the test, the authors mailed a survey (Appendix 1) to 200 public psychiatric facilities. The survey requested statistical information on hospital census and numbers of transfers, transfer agreements and policies, methods of transfer of information, and data about problems with these processes.
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METHOD
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Participants
We selected the facilities to be surveyed from the Substance Abuse and Mental Health Services Administration 1995 Mental Health Directory.7 This directory, the most current available, is printed by the U.S. Department of Health and Human Services and constitutes one of the most comprehensive compendiums of all mental health services in the United States. From this directory, we selected 200 public facilities, representing all 50 states and Puerto Rico.
We conducted a pilot study by sending out 10 questionnaires to different institutions across the country. The questionnaires in this pilot study were addressed "To Whom It May Concern." Although we anticipated that quality assurance, nursing, or medical staff would complete the questionnaire, almost all of the returned questionnaires were filled out by the medical director. As a result of these responses, we addressed the questionnaires in our formal study to the medical director of each facility.
Instrument
A 10-item questionnaire was developed based on the experiences of the authors. Appendix questions were asked regarding how patients with medical problems are handled, patient census data, information about transfer methods, and personal beliefs about patient care. If respondents had an established transfer protocol, we asked them to send us a copy of the document.
A one-page cover letter, which briefly described the purpose of the study, was attached to the questionnaire. A self-addressed stamped envelope was provided to increase the likelihood of response.
Procedure
The 200 questionnaires were mailed as described in August 1997 to be returned by mail or fax before Oct. 15, 1997. From those who did not respond to the first mailing, we telephoned the state mental health offices to determine if those sites were still open. Then the office of the medical director at each facility was called to inform him or her that we had not received the questionnaire that was previously sent in the fall and that the office was being resent the same questionnaire. At this time, the name of the medical director was obtained, and the address of the facility was verified. For the second mailing, the name of the medical director was included in the address to increase the rate of response. The second mailing increased the rate of response from 35% to 51% (of 102 hospitals). More than 40 facilities sent examples of forms used for external consultations or transfers.
In the responses, we found that five sites found "great difficulty" in receiving information from outside facilities. Those facilities were contacted individually by the authors, who spoke with the medical director, who was asked to describe the difficulty in information transfer.
Analysis
Response data from both mailings were compiled into one database. Frequency distributions were conducted with the statistical package SPSS (SPSS, Chicago). This was applied specifically to facilities that managed patients themselves and facilities that responded that they experienced difficulties receiving information "most of the time."
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RESULTS
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Of the 200 facilities surveyed, 102 (51%) responded. Hospitals varied widely in size (Table 1), with the average census of the responding facilities ranging from 0 (recently closed) to as many as 1,300 patients/day. The total average census was 259, with a median average census of 197. Likewise, total 1-year admissions averaged 793 but had a median of 513 patients/year, ranging from 0 to more than 10,000. The total number of transfers for acute medical evaluations revealed a similar pattern. The average number of transfers by the responding facilities was 128, with a median of 50.
In terms of the question whether psychiatric hospitals treat within or refer their medical events to outside providers, we found the following: the vast majority of facilities (98 of 102, 95%) send their patients out to a medical facility when the need for an acute medical evaluation arises (Table 2). Of the facilities that do send their patients out for evaluation, 95% (93 of 98) reported that they use one primary facility rather than a variety of medical settings. Only 5% (five of 98) facilities reported that they provide acute medical evaluation and care within the confines of the psychiatric wards, which included special medical units within the psychiatric hospital. Most of these transferring institutions (93%, N=91 of 98) have developed a formal arrangement with a medical institution. The majority of facilities described having a written (81%, N=79 of 98) or verbal (74%, N=72 of 98) mode of providing information to receiving medical facilities (Table 3). Only 64 of 87 (74%) responders noted having an established protocol for the transfer of those patients, however.
In terms of their satisfaction with the receiving hospital, we found that a sizable number of the psychiatric institutions were less than satisfied with the information they received from the medical facilities regarding the finding and outcome of the medical evaluations. Fully 48% (47 of 97) of the respondents felt they regularly had difficulty receiving acceptable information, with 28% 7 experiencing this much or most of the time.
The data on psychiatric institute satisfaction with the medical care provided for their patients with acute medical problems reveal some potentially disturbing numbers. Thirty-five of 97 responding institutions (36%) felt that their patients regularly received less than optimal medical care when transferred to acute medical facilities, at least in part because they had a mental illness (Table 4). The nature of this less than optimal care is not clear from the data, although frank misdiagnosis of a medical condition was not felt to be a common occurrence by the majority of psychiatric institutions. Only 12 of 93 respondents (13%) noted this with any significant frequency. There was a powerful positive relationship noted between the psychiatric hospitals’ perception of the frequency of optimal care and the difficulties they had in obtaining information from the medical facility. The relationship of perception of the frequency of optimal care and misdiagnosis is also significantly correlated. In other words, when the hospital did not receive information, patients also did not receive optimal care.
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DISCUSSION
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This study began when the authors met to review and discuss two incidents in which psychiatric patients had been transferred from a state hospital to a medical center’s emergency department for treatment of an acute medical condition. In each case, the patient had appeared to receive less than optimal care. The authors—the chief medical officer of a state hospital, the director of consultation and emergency psychiatric services, and the psychiatric quality improvement educator from a state hospital—had a keen interest in looking into quality management issues and opportunities to improve the systems of care for institutional transfers.
The experiences of public psychiatric institutions regarding the nature and quality of acute medical care received by their patients reveal several interesting and, at times, disturbing trends. It is quite clear from this survey that the large majority of public psychiatric facilities obtain acute medical care for their patients by sending them out of the institution to a separate medical facility. In this regard, they no longer function as independent hospitals. Historically, these were self-contained institutions, with many providing all medical, dental, and social services. Worcester State Hospital, one of the oldest psychiatric facilities in the United States, for example, was at one point the maternity center for the psychiatrically ill for the state of Massachusetts. This change may also reflect an increase in reported adverse medical outcomes seen in psychiatric institutions during the 1970s and 1980s, facilitating a change in the process of how medical care was provided for chronically mentally ill inpatients.
Public psychiatric hospitals appear to have recognized and solved the problem of finding an appropriate level of care for acute medically ill patients. Not only do 95% of the institutions send their patients to a specific medical hospital but 93% have actually formalized this relationship. It is likely preferable to have such a standardized approach for acute medical care in place rather than making an individual decision each time the need for transfer occurs.
Yet, problems appear to exist with this current management arrangement. Many psychiatric facilities feel they have received less than adequate communication regarding the evaluation of their referred patients from acute care hospitals, with nearly a third expressing this much if not most of the time. Telephone interviews with the medical directors of the most dissatisfied institutions revealed several potential problems. Prominent among these were that the patients’ mental illness frequently interfered with their ability to communicate (e.g., give a complete history or provide adequate consent for the release of information to their referring facility). The development of formal relationships should include a process of communication to promote the optimal care of the patients.
Of interest is the perception of many psychiatrists and administrators in psychiatric facilities that their patients receive less than optimal care when transferred to acute medical facilities for evaluation and that this occurs, at least in part, because of their mental illness. Almost 40% of the psychiatric institutions responding to this survey report that they believe that their patients’ care is less than optimal on a regular basis. However, only 30% responded that poor care occurs rarely in their experience. It is likely that both stigmatization of mentally ill patients and the inherent difficulties in providing them medical care in an unfamiliar environment contribute to the problems in communication about their acute care. Stigmatization of the mentally ill is a pervasive societal issue, and medical providers are far from immune to this.
It is possible that despite a rate of response greater than 50% to the survey, dissatisfaction with acute medical facilities is overrepresented in the responders. Furthermore, it could also be that the physicians believe that an equal number of nonpsychiatric patients receive less than optimal care in emergency departments.
Many facilities may well recognize that the loss of continuity of care has had some negative impact on the acute medical care of their patients, despite their receiving this care in a more expert medical setting. Addressing the issue of communication between facilities may well be one avenue for improvement that some institutions are now attending to. Given the correlation between formal patterns of communication and the perception of more optimal medical care, this is likely a good place to start. More than 40 facilities actually sent examples of forms used for external consultation or transfer to another hospital. These forms routinely included information regarding current medications, allergies, diagnoses, reason for referral, potential risks and precautions to be taken, skills level on activities of daily living, the name of the physician accepting the patient, the presence or absence of advanced directives, and characteristics of idiosyncratic behavioral disturbances, with recommendations for appropriate management techniques. Less common was information on insurance, type of transportation, laboratory and test results, communication abilities, current guardianship status, and protocols for disclosure of information. Many of these may be particularly useful for emergency departments or inpatient-attending physicians. The lack of this type of information is highly frustrating for the medical physician attempting to care for the patient and contributes to antagonistic relations between medical and psychiatric providers (personal communication, G. Volturo, 1998).
Whether the perception of deficient care is accurate or not cannot be discerned from this survey. However, this perspective, as well as the perceived difficulty with adequate communications from the medical facility, suggests that problematic relationships exist between some facilities around the provision of acute medical care to persistently mentally ill patients. Further research into the specific root causes impeding optimal medical care of the mentally ill is indicated, and efforts at improving care become more important as this population increasingly receives care in a fragmented system.
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CONCLUSIONS
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1. As we suspected, the overwhelming majority of freestanding public psychiatric hospitals transfer their patients for medical treatment to a primary medical center. Furthermore, of interest, 93% also had a formal transfer agreement.
2. We did find, however, a rather wide-ranging perception that the patients transferred from a public psychiatric hospital to a primary medical center received less than optimal care. Furthermore, we discovered that the psychiatric hospitals did not receive what they perceived as adequate medical information about the patients transferred.
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ACKNOWLEDGMENTS
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The authors thank David Greenidge for analyzing the questionnaire data and the Department of Psychiatry at the University of Massachusetts Medical School for its support.
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REFERENCES
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- Patient at WSH chokes to death. Worcester Telegram and Gazette, Aug 10, 1988, p 1
- Teresi JA, Holmes D, Bloom H, Monaco C, Rosen S: Factors differentiating hospital transfers from long-term care facilities with high and low transfer rates. Gerontologist 1991; 31:795–806[Abstract]
- Stark AJ, Gutman GM, McCashin B: Acute-care hospitalizations and long-term care: an examination of transfers. J Am Geriatr Soc 1982; 30:509–515[Medline]
- Tariot PN, Podgorski CA, Blazina L, Leibovici A: Mental disorders in the nursing home: another perspective. Am J Psychiatry 1993; 150:1063–1069[Abstract/Free Full Text]
- Zarian DA, Sebastian AP, Lee S, Kleinfeld M: The causes and frequency of acute hospitalization of patients with dementia in a long-term care facility. J Natl Med Assoc 1989; 81:373–377[Medline]
- Heslop L, Elsom S, Parker N: Improving continuity of care across psychiatric and emergency services: combining patient data within a participatory action research framework. J Adv Nurs 2000; 31:135–143[Medline]
- Center for Mental Health Services: Mental Health Directory, 1995. Compiled by Wirkin MJ, Atay JE, Sonnenschein MA, Manderscheid RW. DHHS Pub. No. (SMA) 95–3048. Washington, DC, Superintendent of Documents, US Government Printing Office, 1995
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ABSTRACT
INTRODUCTION
