ELSEVIER

Evolution and Evaluation of a Medical Psychiatric Unit Robert Gertler, M.B., B.S., F.R.A.N.Z.C.P., Elzbieta M. Ko ec-Schrader, BSc. (MED), M.D., M.P.H., and Christopher J. t; lackwell, M.B., B.S.

Abstract: In 2991, the first Medical Psychiatric Unit (MPU) in Australia was established at the Royal Prince Alfred Hos- pital, Sydney. The processes involved in introducing it to the hospital staff and administration, as well as its structure and criteria for admission, are described. Its development was com- pared to the experiences of others in North America over the past 25 years. Thefunctioning of the MPUover the subsequent 2 years was evaluated by assessing demographic and clinical criteria of patients admitted. Data were obtained from patient medical records and compared with similar data on patients admitted to a General Psychiatric Unit (GPU). It was found that patients of the MPU tended to be older, more often male, and suffering from organic brain syndromes and/or alcohol or drug abuse. Despite the multiplicity of diagnoses and the com- plexity of treatment procedures, the MPU patients’ duration of stay was similar to the GPU patients’. The MPU was found to have achieved goals of clinical and cost-effectiveness. It has become an established subunit within the Department of Psy- chiatry.

Introduction

Over the past two decades in Australia increasing numbers of severely ill psychiatric patients have been treated for concurrent medical problems in general hospitals. Patients have either been treated on the medical wards with psychiatric consulta- tion-liaison support provided or, alternatively, they were referred to the psychiatric ward of the

Department of Psychiatry, Royal Prince Alfred Hospital, Camperdown, Australia (RG), Department of Psychiatry, Uni- versity of Sydney, Sydney, Australia (EMK-5), and Central Syd- ney Area Health Service, Sydney Australia (CJB)

Address reprint requests to: Robert Gertler, M.B., B.S., F.R.A.N.Z.C.P., Department of Psychiatry, Royal Prince Alfred Hospital, Missenden Rd., Camperdown NSW 2060 Australia.

26 ISSN 01638343/95/$9.50 SSDI 0163-5343(94)00063-J

general hospital or to a psychiatric hospital when medically stable.

In Australia, psychiatric hospital care is largely state-funded. The number of private psychiatric beds is small and caters almost exclusively to psy- chiatric patients with containable symptoms, i.e., nonviolent, not floridly psychotic, not medically ill. Patients who cannot be managed in the private system are admitted to public psychiatric units, which exist increasingly in regional general hospi- tals as the large psychiatric hospitals are reduced in size or closed. Government funding for general hospitals is limited and there is constant pressure on all beds. This pressure has been heightened in recent years by a shift within the Australian pop- ulation away from private hospital insurance. Pub- lic hospital administrators are constantly seeking ways to reduce the length of admissions and to enhance their cost-effectiveness.

Psychiatric consultation-liaison services are in- creasingly involved in the management of patients admitted to the medical and surgical wards of gen- eral hospitals. However, the degree of interven- tion that these services can provide is limited be- cause of the absence of the psychiatric milieu and ancillary support services. As a corollary of their increased involvement in the general hospital, there is an increased role for these services in the early identification and management of psychiatric problems among medical inpatients.

As a result, greater integration of medical and psychiatric treatment has been sought. Inpatient units specifically designed to cater to this type of patient have been described in North America [l-3]. They range from medical psychiatric sub- units within general psychiatric units to large, ex-

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Evaluation of a Medical Psvchiatric Unit

elusively medical-psychiatric wards [4-6]. Kathol et al. [7] have further classified medical-psychiatric units into four types based on the level of acuity. In the United States such units have been in exis- tence for at least the past decade although their development has generally been restricted to teaching hospital settings [8]. Such a medical- psychiatric unit has not been described in an Aus- tralian general hospital.

At Royal Prince Alfred Hospital a decision was made in late 1990 to establish a small medical- psychiatric unit within the general psychiatric ward. Although psychiatric patients with medical problems had been admitted to this ward since its establishment in 1937, there had been an acceler- ating trend towards more serious medical prob- lems being managed on the unit. As a result, a greater level of medical and nursing expertise was required so that patients with medical and psychi- atric diagnoses could be transfered from the med- ical ward at an earlier stage of their psychiatric treatment.

Evolution of the Medical Psychiatric Unit

The hospital administration, the Division of Inter- nal Medicine, the Department of Psychiatry, and the Division of Nursing were approached and their approval was sought. No administrative obstacles were encountered because it was assumed that our unit would assist in freeing beds for general med- ical and surgical patients. No extra costs were to be incurred in establishing the unit because existing staff would be used. Moreover, it was pointed out that an area of expertise which did not exist else- where in the State would be developed within the Department of Psychiatry.

The proposed subunit was described to the staff in the psychiatric inpatient unit and their approval and cooperation was sought. Nursing staff, whose basic training had been both psychiatric and med- ical, were offered extra training in the administra- tion of medical and surgical techniques and spe- cialized equipment use. In general, the principles described by Stoudemire and Fogel[9,10] covering such issues as patient selection, the number of di- agnostic and therapeutic modalities to be available, relationships between psychiatric and medical staff, and 24-hour medical coverage were to be uti- lized. The Medical Psychiatric Unit (MI-W) was presented to the staff as an additional tertiary ser-

vice they could provide. The decision was then made to establish a four-bed subunit.

The Royal Prince Alfred Hospital Medical Psy- chiatric Unit that was subsequently formed had strong ties to the Psychiatric Consultation-Liaison Service. Its four beds were part of a 3U-bed general psychiatric ward, the remaining beds being used by a general adult psychiatric unit, an eating dis- orders unit, and several smaller specialty units. It followed the Type 1 model described by Hall and Kathol [ll] although the medical component was more consistent with their Type IV in that the medical problems were severe, generally requiring hospital admission in their own right and staff were medically trained with adequate support from the general hospital. In addition, facilities ex- isted on the ward to enable specialized medical, surgical, and diagnostic procedures to be carried out.

Continuing education in the form of in-service seminars and refresher courses was to be provided on a regular basis. Quality assurance measures were to be introduced to incorporate not only such measures but also periodic reviews of the physical suitability of the unit and adequacy of physician participation, as suggested by Kathol et al. [12].

Patients in the MPU participated in existing ward activities such as individual, group, and oc- cupational therapies with non-MI% patients. If necessary, they attended these activities in a wheelchair, or with mobile intravenous equip- ment. The MPU director was a senior psychiatrist assisted by a psychiatric registrar. Other staff in- volved were psychiatric nurses with d special in- terest in this area who were able to administer ad- vanced medical treatment, an occupational thera- pist, a social worker, and a psychologist. A senior internist with a special interest in the area attended weekly unit rounds, although his role was gener- ally to educate and advise future directions for medical management rather than provide ongoing care.

The following criteria for admission were estab- lished: 1) the patient’s medical/surgical problem no longer required acute care on the general ward and residual symptoms or continuing physical care would not interfere with the patient’s participation in the ward therapeutic program; 2) the patient was sufficiently mobile to attend to his/her per- sonal hygiene; 3) the patient was transfered to the MPU on a voluntary basis; 4) the patient was not suffering from drug or alcohol withdrawal, but could have a history of such abuse; 5) nursing staff

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R. Gertler et al.

had performed a pretransfer assessment whenever possible to ensure availability of appropriate nurs- ing expertise and resources so that other patients would not be disadvantaged (e.g., reduced staff numbers at night); and 6) internists and surgeons who had previously cared for the patient on the general wards would continue to supervise the rel- evant aspects of the patient’s management and be available in an emergency either to consult, or if necessary, accept transfer back to their care.

Ultimately, however, the rationale for the unit’s continuation derived from its clinical output and it is this factor that was examined and compared with the output of the General Psychiatric Unit (GPU).

Methodology

The medical records of all the patients discharged from the MPU between January 1991 and January 1993 were used to examine patients’ characteris- tics; these included demographic (sex and age) and clinical (length of stay, referral source, and psychi- atric/medical illnesses) features. Further, according to an expanded version of the Swenson and Mai [2] classification, patients were categorized into four groups of patients: 1) those with chronic psy- chiatric illnesses who developed unrelated medical problems; 2) psychiatric symptoms related to un- derlying medical illnesses (excluding substance abuse); 3) somatic symptoms secondary to under- lying psychiatric disorders; and 4) somatic symp- toms related to substance abuse. Finally, the pa- tients were compared to patients of the GPU ad- mitted during the same period of time.

Statistical analyses were performed using SPSSX [13] and included measures that were both de- scriptive (mean, standard deviation, minimum,

Table 1. Sources of referral

maximum) and comparative (t-test groups, Chi- square).

Results

Over the biennium, 73 patients were discharged from the MPU. The number of patients discharged from the GPU was more than twice as high (173). The percentage of males and females differed be- tween the units. Though there was a similar per- centage of males (N = 39, 53%) and females (N = 34, 47%) in the MPU, only one-third of patients were male (N = 55, 32%) in the GPU (females = 118, 68%). This difference was significant (X2 = 8.96, p < 0.003). Patients across the two units also differed in their ages. The MPU patients were aged 43.7 + 17.7 (17-87) years [mean + SD (min-max)] and were significantly older than the GPU patients who were 38.2 + 15.5 (15-81) years (t-test = 4.6 p < 0.01).

In both units, patients stayed a similar length of time, i.e., an average of 22 + 22.5 (1-133) days in the MPU and 25 + 21.6 (l-110) days in the GPU. Patients were referred from different sources (Ta- ble 1). The majority (63%) of referrals to the MPU came through the Consultation-Liaison Service via the general wards or casualty department, but pa- tients of the GPU were referred from a variety of sources.

The range of psychiatric disorders treated in the two units was extensive (Table 2). The most com- mon admission diagnoses to the MPU were for affective disorders, schizophrenia, organic brain disorders, and substance abuse. The last two were far more common than in the GPU, but the first two were less common (X2 = 32.58, p < 0.00007, df = 8). There were 43 MPU patients (58.9%) with multiple psychiatric diagnoses as compared with

MPU (N = 73) GI’U (N = 173)

N % N %

Accident and emergency 19 26.0 33 19.1 Consultation/Liaison 27 37.0 28 16.2 Outpatients 3 4.1 39 22.5 General practitioner 4 5.5 23 13.3 Private psychiatrist 9 12.3 38 22.0 Other psychiatric hospital, community clinic 11 15.1 12 6.9

x2 = 30.31 df = 5 p < 0.00001

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Evaluation of a Medical Psychiatric Unit

Table 2. Psychiatric diagnoses

MPU (N = 73) GPU (N = 173) -.

N YO N %

Affective disorders Schizophrenia Organic brain disorders Substance abuse Personality disorders Adjustment disorders Somatoform disorders Anxiety disorders Other (OCD, eating disorders, Munchausen)

21 18.1 61 18 15.5 44 22 19.0 19 26 22.4 10

7 6.0 20 7 6.0 10 5 4.3 6 2 1.9 6 8 6.8 9

116 185 x2 = 32.58 df = 8 p < 0.00007

33.0 23.8 10.3

5.4 10.8

5.4 3.2 3.2 4.9

12 GPU patients (6.9%). A broad range of medical problems were managed in the MPU (Table 3). Neurological (e.g., epilepsy, cerebrovascular dis- ease, pituitary adenoma); cardiovascular (e.g., car- diomyopathy, ischemic heart disease, congestive cardiac failure); musculoskeletal (e.g., polymyalgia rheumatica, ankylosing spondylitis, gout); and en- docrine (e.g., hyper- and hypothyroidism, diabe- tes mellitus) were equally represented. Four pa- tients had more than one medical diagnosis. In comparison, only 12 GPU patients (6.9%) had medical illnesses. There were seven patients with the AIDS syndrome (9.1%) who presented because of severe depression or an acute brain syndrome.

When classifying MPU patients in terms of the relationship between their psychiatric and medical disorders, 17 patients (23.4%) presented with clear

Table 3. Medical diagnostic categories

MPU GPU

N % N %

Neurological 13 16.9 5 2.8 Gastroenterological 3 3.9 1 0.6 Musculoskeletal 13 16.9 1 0.6 Reproductive 5 6.5 1 0.6 Pulmonary 5 6.5 1 0.6 Cardiovascular 13 16.9 0 0 Endocrine 12 15.6 1 0.6 Renal 5 6.5 0 0 Immune (AIDS) 7 9.1 0 0 Other 1 1.3 2 1.2 None 0 0 161

73 173

psychiatric illness and coexisting serious medical problems (e.g., major depression and prostatic car- cinoma; diabetes mellitus and chronic schizophre- nia.) Twenty-four patients (32.9%) were found to be suffering from psychiatric illnesses related to primary medical problems (e.g., steroid-induced psychosis in a woman on replacement therapy for panhypopituitarism; organic mood disorder with features of mania and dementia in a man with AIDS). A further 20 patients (27.4%) developed medical problems secondary to an underlying psy- chiatric illness (e.g., a middle-aged, chronic schizophrenic, male who had become alcohol- dependent and had developed severe alcoholic liver disease), and 12 patients (16.9%) developed medical problems secondary to substance abuse (e.g., a young male with a history of recent polysubstance abuse who presented with an acute organic brain syndrome and whose behavior made him unmanageable on a medical ward. )

Discussion

This study describes the first 2 years experience in our Medical Psychiatric Unit. It is the type of unit that is directed by a psychiatrist rather than an internist [5] although with regular attendance and supervision of all medical treatment by the latter. Using an internist in this manner lessened the Unit’s dependence on other consultants and en- abled the unit to be run on psychiitric medical lines.

The MPU is part of a General Psychiatric Ward within a teaching hospital. No additional nursing or paramedical staff were required. The extra train-

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ing provided and the medical support available en- abled us to maintain the same staff/patient ratios and avoid duplication of services and resources, thus highlighting cost effectiveness. The delinea- tion of the extent of the training also helped reas- sure nursing and other staff that the existing ther- apeutic milieu of the psychiatric ward would not be affected adversely.

A major aim in establishing the MPU was to de- crease the total length of stay of patients with both medical and psychiatric problems in the general hospital. Previous studies [6,14] had shown vari- able outcomes for duration of hospital stay for such patients, depending on such factors as nurs- ing staff experience, availability of diagnostic and specialized equipment, and average patient age. The length of stay on our MPU was similar to that in the GPU despite such factors as the multiplicity of diagnoses and more complex care.

A minority of patients (27) who had spent some time on the general wards prior to transfer were able to be moved earlier than in the past. The ma- jority of patients admitted directly to the MPU were treated for concurrent medical problems uti- lizing existing services and did not require transfer to a general ward. In time, with increasing effi- ciency, the average length of stay would probably decrease further, as noted by Young and Harsch ]141*

The degree of severity of the medical illness was a factor that limited admission to the MPU. Pa- tients requiring frequent medical monitoring (e.g., cardiac monitors or pulse oximeters) were ex- cluded, but those requiring less intensive medical care (e.g., blood glucose monitoring, intravenous fluids, supplementary oxygen) were accepted. In all cases, treatment of the patient’s medical illness would, we believe, have required a longer medical admission in the past with psychiatric consulta- tion-liaison attention. Such a process is at times costly and certainly unnecessary if a unit such as ours is available. The MPU was able to cope with patients who suffered from a multiplicity of med- ical diagnoses with ensuing therapeutic complex- ity as well as those whose medical illness was of a relatively straightforward nature. It was able to provide “an economic alternative for consultation- liaison psychiatry” [ 151.

Involving the nursing staff in their own assess- ment of the degree of nursing difficulty prior to admission led to their greater acceptance of, and responsibility for, the care of the MPU patients. The easy access to, and level of communication

with, the internist also led to greater confidence in caring for the MPU patients.

Clinical issues

The relative contribution of the psychiatric and medical illness to a patient’s clinical presentation varied greatly. Many patients admitted to the MPU had longstanding psychiatric illnesses such as ma- jor affective disorders and schizophrenia. This finding is consistent with other studies of Medical Psychiatric Units. However, a significantly higher proportion suffered from more acute illnesses re- lated to their organic brain disorders. This latter group consisted of a high proportion of older males. It also helped account for the fact that the mean age of patients seen on the MPU was greater than on the GPU; however, this fact could also be explained on the basis of a natural increase in physical illness with age. Because of their difficult presentation, this group were better managed in a psychiatric rather than medical setting as soon as their medical condition had been stabilized.

In most instances, medical investigations and treatment had been commenced prior to admission to the MPU; however, in other instances, psychi- atric patients requiring medical management at the time of admission were cared for exclusively on the MPU. The medical management was stabilized or completed by the time of discharge, and transfer to a medical ward was not required. Several patients required surgical procedures during the admission but returned to the MPU at the earliest opportu- nity.

The large number of patients with neurological disorders mirrors the experience of other medical psychiatric units [16]. Their management, which involved neurological, psychiatric, and neuropsy- chological components, led to a better understand- ing of the interplay between their varying symp- toms and hence to a greater likelihood of an understanding of and improvement in their condi- tion.

A small but significant number of HIV-positive patients, most with AIDS-defining illnesses, were admitted to the unit and we expect such patients to continue to present. We believe, they have bene- fited particularly from the investigation and man- agement of their neurological, behavioral, and psychiatric problems in the MPU rather than the general hospital wards. We believe that the admis- sion of these patients to an MPU is preferable be-

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Evaluation of a Medical Psychiatric Unit

cause of the concentration of resources and exper- tise that develops over time.

Education and Research

We agree with Swenson and Mai [2] that an MPU provides an educational forum for psychiatric and medical residents and students. The weekly ward rounds are extremely informative and provide ex- perience in the management of patients with mul- tiple diagnoses which is usually not available on a general psychiatric unit. The regular attendance of the internist broadens training and patient man- agement experiences.

Opportunities exist for research into the highly interesting interface between medical and psychi- atric illness. Patients with multiple diagnoses present complex problems, not only in terms of diagnosis, assessment, and management but also in terms of drug interactions and potential toxicity.

The Royal Prince Alfred Hospital Medical Psy- chiatric Unit provides a valuable treatment re- source in an environment where psychiatric ser- vices are increasingly available only in the general hospital setting. It has an increasing role in the treatment of patients with combined medical and psychiatric conditions who constitute a vulnerable, high-risk category requiring special management skills [17]. Despite its small relative size it has shown that existing psychiatric resources can be efficiently modified to provide a service for such a small, but complex group.

References

1. Harsch HH, Koran LM, Young LD: A profile of ac- ademic medical psychiatric units. Gen Hosp Psychi- atry 13:291-295, 1991

2. Swenson JR, Mai FM: A Canadian medical psychi- atric inpatient service. Can J Psychiatry 32326-332, 1992

3. Young LD, Harsh HH: Inpatient unit for combined

physical and psychiatric disorders. Psychosomatics 27:1,53&O, 1986

4. Goodman B: Combined psychiatric-medical inpa- tient units: the Mount Sinai model. Psychosomatics, 26:179-189, 1985

5. Fogel BS, Stoudemire A, Houpt JL: Contrasting models for combined medical and psychiatric inpa- tient treatment. Am J Psychiatry 142:1@&1089,1985

6. Hoffman RS: Operation of a medical-psychiatric unit in a general hospital setting. Gen Hosp Psychiatry 11:31-35, 1989

7. Kathol RG, Harsch H, Hall RC, Shakespeare A, Coward T: Categorization of types of medical/ psychiatry unit based on level of acuity. Psychoso- matics 33(4):376-386, 1992

8. Harsch HH, Lecann AI’, Ciaccio S: Treatment in combined medical psychiatry units: an integrative model. Psychosomatics 30:312-317, 1989

9. Stoudemire A, Fogel BS: Organisation and develop- ment of combined medical-psychiatric units: part 1. Psychosomatics 27(5):341-345, 1986

10. Fogel BS, Stoudemire A: Organisation and develop- ment of combined medical psychiatric units: part 2. Psychosomatics 27(6):417428, 1986

11. Hall RCW, Kathol RG: Developing a level III/IV medical/psychiatry unit. Establishing a basis, design of the unit and physician responsibility. Psychoso- matics 33(4):368-375, 1992

12. Kathol RG, Harsch H, Hall RC, Shakespeare A, Cowart T: Quality assurance in a setting designed to care for patients with combined medical and psychi- atric disease. Psychosomatics 33(4):387-396, 1992

13. SPSS Incorporation. Statistical Package for Social Science, 13th ed, SESSX. Chicago 11, 1990

14. Young LD, Harsch HH: Length of stav on a psychi- atry-medicine unit. Gen Hosp Psychi;try 11:31-35, 1989

15. Stoudemire A, Hales RE, Thomas CR: Medical- psychiatry units: an economic alternative far consul- tation-liaison psychiatry? Hosp Community Psychi- atry 38(8):815-818, 1987

16. Brooks WB, Finestone DH, Jordan JS, et al: The com- bined medical specialities unit after five vears. N Engl J Med 49:11-16, 1988

17. Dvoredsky AE, Cooley HW: Comparative severity of illness in patients with combined medical and psychiatric diagnoses. Psychosomatics 27(9):625- 630, 1986

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