Hospital psychiatrists often are asked whether a patient with comorbid medical and psychiatric illnesses should be admitted to an inpatient psychiatry unit or to a medical unit. Psychiatric units vary widely in their capacity to manage patients’ medical conditions. Medical comorbidity also is associated with longer psychiatric hospitalizations.1 The decision of where to admit may be particularly challenging when presented with a patient with delirium, which often mimics primary psychiatric illnesses such as depression but will not resolve without treatment of the underlying illness. While diagnosis and treatment of delirium typically occur in the hospital setting, 1 study found that approximately 15% of 199 psychiatric inpatients were delirious and that these patients had hospital stays that were approximately 62% longer than those without delirium.2
When you need to determine whether a patient should be admitted to an inpatient psychiatry unit with a medical consult or vice versa, consider the following 3 Ms and 3 Ps.
Medications. Can medications, including those that are given intravenously or require serum monitoring, be administered on the psychiatric unit? Can the medical unit administer involuntary psychotropics?
Mobility. Does the patient require assistance with mobility? Does the patient pose a fall risk? A physical therapy consult may be helpful.
Monitoring. Suicide risk is the most common indication for patient sitters.3 Would a patient sitter be needed for the patient? On the other hand, can the psychiatry unit manage telemetry, frequent vital signs, or infectious disease precautions?
People. Would the patient benefit from the therapeutic milieu and specialized staff of an inpatient psychiatry unit?
Prognosis. What ongoing medical and psychiatric management is required? What are the medical and psychiatric prognoses?
Placement. To where will the patient be transferred after hospitalization? How does admission to inpatient psychiatry vs medical impact the ultimate disposition?
Help the treatment team make the decision
Determining the ideal patient placement often evokes strong feelings among treatment teams. Psychiatrists can help facilitate the conversation by asking the questions outlined above, and by keeping in mind, “What is best for this patient?”