Such situations can become scary, particularly if someone with psychiatric expertise is not available to intervene. This can be very frustrating for hospitalists who want to provide high-level care but may lack the training needed to be successful with such patients. This can ultimately lead to burnout, says Sarah Rivelli, MD, medical director of psychiatry clinical services at Duke University Hospital and Duke University Medical Center in Durham, N.C.
Another challenge is that although there are protocols in place designed to follow specific steps for patients with physical illnesses or disorders, that’s not the case for psychiatric illness. “Many hospital facilities are not designed, or have yet to implement, protocols to attend to mentally ill individuals,” Dr. Bianco says.
Because of the unpredictability of patients and lack of practice protocols, mental illness can introduce a wild card into the standard treatment process. A more individualized approach with these patients is needed, but with increasing focus on length of stay and operational efficiency, medical and nursing staffs are pressured to do things quickly and to do more with less. It can be very time-consuming for a nurse to have to explain to paranoid patients why they should take their medication or for a phlebotomist to try to calm patients in order to obtain blood. When patients refuse needed tests, or only provide a limited history, the hospitalist ends up working with incomplete information, which makes choosing and monitoring the treatment approach problematic.
A Look at Best Practices
In light of challenges, some best practices have been identified for handling psychiatric patients. As previously mentioned, most hospital staffs have limited formal training in interacting with psychiatric patients. In fact, the American Board of Internal Medicine only devotes 4% of the certification exam to psychiatry.4
Ideally, staff members who care for psychiatric patients will have specialized or additional training in managing patients with psychiatric conditions or comorbidities. Nemours/AIDHC has a committee assigned to evaluate psychiatric patients’ care and help manage them when a behavioral emergency occurs, Dr. Fingado says. This team, which has been trained on de-escalation, restraint techniques and policies, as well as medications to use in these situations, intervenes when patients have an aggressive event that places patients, visitors, or staff at risk. The team includes nursing staff, the hospitalist on-call, and security personnel and involves the social work, psychology, and psychiatry departments.
Training focused on treating patients with psychiatric conditions should include how to recognize substance abuse and treat substance withdrawal because mental illness and substance abuse often track together, Dr. Sussman notes. At St. John’s Episcopal Hospital, patients with chronic mental illness are not the ones who typically become aggressive or violent. Rather, this is more often the case among patients with substance abuse either in states of acute intoxication or withdrawal.
Recently, Dr. Sussman has seen a significant increase in patients who abuse K2, or spice, a synthetic form of cannabis. Side effects of using K2 include rapid heart rate, anxiety, hallucinations, and paranoia to the point of delusional thinking. These side effects can frequently wax and wane for days after the drug is used, and they can be associated with significant psychomotor agitation and assaultive behavior.
When patients abuse flake, another synthetic drug that has been reported in the Southeast, they tend to become very paranoid and violent. “These patients can be extremely unpredictable and aggressive,” he says. “Patients with dementia can be impulsive and aggressive during care, and caution is needed, but it’s not a directed violence like that seen in patients who are agitated secondary to substance abuse.”