Psychosomatics 49:535-537, November-December 2008
doi: 10.1176/appi.psy.49.6.535
© 2008 Academy of Psychosomatic Medicine
Analysis of Transfers From a Medical-Psychiatry Inpatient Unit to a Medical-Surgical Unit Within 48 Hours of Admission
Victoria Passov, M.D., and
James R. Rundell, M.D.
Received February 1, 2007; revised August 27, 2007; accepted September 6, 2007. From the Dept. of Psychiatry, Mayo Clinic, Rochester MN. Send correspondence and reprint requests to Victoria Passov, M.D., Dept. of Psychiatry, Mayo Clinic, 1115 2nd St. NW, Rochester, MN 55901. e-mail: passov.victoria{at}mayo.edu
© 2008 The Academy of Psychosomatic Medicine
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ABSTRACT
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BACKGROUND: Clinical screening of patients being presented for admission to a medical-psychiatric unit (MPU) is important to ensure safe, timely, and effective treatment. OBJECTIVE: Authors determined demographic and clinical characteristics of patients accepted for admission to a private MPU and who required transfer to medical-surgical units within 48 hours of admission. METHOD: Medical records of 1,583 consecutive admissions to the MPU were reviewed. The charts of patients transferred to a higher level of medical or surgical care within 48 hours were evaluated to categorize the reasons for transfers, and these were assessed for preventability. RESULTS: Thirty patients (1.9%) required transfer to a medical-surgical unit. Reasons for transfer included pulmonary, cardiovascular, endocrine, and neurological etiologies. Most transfers (66.6%) were not foreseeable because symptom-onset was after admission. CONCLUSION: Inappropriate MPU admissions may have been avoided by more vigilant screening for pulmonary, cardiovascular, electrolyte, and infectious disorders.
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INTRODUCTION
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Medical-psychiatric units (MPUs), including the inpatient MPU at Mayo Clinic, in Rochester Minnesota, are able to care for patients with a higher medical-surgical acuity than general-psychiatry units.1 Clinical screening of patients being presented for admission to the MPU is important to ensure safe, timely, and effective treatment.2,3
If an admitted patient’s condition exceeds the MPU’s clinical capabilities, he or she must be transferred to the appropriate medical or surgical unit.4 When these transfers occur within 48 hours of admission to the MPU, it is possible that the patient was accepted for admission with a condition that would have been more safely and appropriately managed on a medical or surgical unit to begin with. Alternatively, the condition might have developed after the admission to the MPU.
This study has the following goals: 1) determine the demographic and clinical characteristics associated with patient transfers from Mayo Clinic’s MPU to medical-surgical units within 48 hours of admission; 2) identify potential improvements in patient care and admission screening.
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METHOD
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Clinical records of 1,583 consecutive patients admitted to the MPU between January 2004 and October 2006 were reviewed. The records of those patients (N=30) who required transfer within 48 hours to a medical or surgical service were examined more closely, in addressing the aims of the study.
Data collected for each transferred patient were the following: age, gender, psychiatric admission diagnosis, referral source, clinical service to which the patient was transferred, medical diagnosis requiring transfer, whether there was a death, whether the condition was in retrospect present on admission or arose after admission, and whether the condition was reported to the accepting physician before admission by the referring clinician.
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RESULTS
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Of 1,583 patients admitted, 30 (1.9%) required transfer to a medical/surgical service within 48 hours of admission. The initial psychiatric admitting diagnoses and transfer medical-surgical diagnoses are summarized in Table 1.
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TABLE 1. Medical and Psychiatric Diagnoses in Patients Requiring Transfer to a Medical-Surgical Unit Within 48 Hours of Admission to an Inpatient Medical-Psychiatry Unit
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On review of the clinical records of the transferred patients, it was determined that 66.6% of the transfers were not, in hindsight, preventable, because onset of symptoms happened after the admission to MPU. Of the 30 cases, 10 were potentially preventable and involved either inadequate information received by the accepting physician from the referring physician or inadequate work-up in the emergency department before the inappropriate admission to the MPU.
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DISCUSSION
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Only 1.9% of patients admitted to the MPU were transferred within 48 hours to a medical-surgical service, and only one-third of those for preexisting reasons. However, 10 patients were transferred for reasons that, in retrospect, could have been avoided if key information had been relayed or reported by the sending facility. This is a low rate of avoidable admissions, and it suggests that the system of admission screening at Mayo Clinic is effective, but it serves to remind psychiatrists who accept transfers to an MPU to be vigilant about whether all of the potentially contributory medical problems have been addressed and communicated by the sending facility.
Medical factors associated with rapid transfer out of the MPU were chest pain, shortness of breath, electrolyte abnormalities (specifically sodium or potassium), signs of infection (fever, leucocytosis), and changes in the baseline level of consciousness. These are also the conditions that, in retrospect, were known or should have been known before admission to the MPU. Patients admitted to the MPU with these medical factors are frequently not transferred, but, if they are present at the time an admission is being considered, the referring physician should alert the accepting physician that there is a need for additional scrutiny of the admission. For example, if the patient has one or more of these factors, he or she could be medically evaluated further (e.g., in the Emergency Department) before admission to an MPU.
This study resulted in data that support asking the following screening questions of a referring healthcare provider to assist in deciding whether a patient is appropriate for acceptance for admission to the MPU without further medical screening: 1) Has the patient been complaining of shortness of breath? 2) Has the patient been complaining of chest pain? 3) Has there been a change in the patient’s baseline level of orientation? 4) What are the patient’s vital signs (especially blood pressure and temperature)? and 5) If the patient is in the hospital, request three laboratory values (blood levels: sodium, potassium, leukocyte count), chest X-ray findings, and O2 saturation levels. We believe that these screening questions provide focused and helpful screening information about the patient’s clinical status to help inform the admission acceptance process.
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ACKNOWLEDGMENTS
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Information in this paper was presented in the form of a poster at the 2007 Annual Meeting of the Academy of Psychosomatic Medicine, Amelia Island, FL, November 14–17, 2007.
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REFERENCES
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- Dolinar LJ: Obstacles to the care of patients with medical-psychiatric illness on general-hospital psychiatry units. Gen Hosp Psychiatry 1993; 15:14–20[CrossRef][Medline]
- Felker B, Yazel JJ, Short D: Mortality and medical comorbidity among psychiatric patients: a review. Psychiatr Serv 1996; 47:1356–1363[Abstract/Free Full Text]
- Dickey B, Normand SL, Weiss RD, et al: Medical morbidity, mental illness, and substance use disorders. Psychiatr Serv 2002; 53:861–867[Abstract/Free Full Text]
- Inventor BR, Henricks J, Rodman L, et al: The impact of medical issues in inpatient geriatric psychiatry. Issues Ment Health Nurs 2005; 26:23–46[Medline]
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ABSTRACT
INTRODUCTION
