It is clear to most of us in hospital medicine that the lines are rapidly blurring between the ED, and the floor, and the ICUs. Some of this has been brought about by the transitional units and the ability to place the patient in the most appropriate area with the correct level of monitoring equipment and nurse-to-patient ratio. Some of this has come about with the increased presence of hospitalists and intensivists in-house to complement the already ever-present ED physicians.

But now there is a movement afoot to both increase the use of observation units (OUs) and to change the physician oversight. Once thought to be an extension of the ED, OUs are now part of the hospitalists’ domain as these patients are thought to be more inpatient-light rather than long-term ED patients. And this makes sense when you realize that hospitalists are better suited to managing patients over time rather than ED physicians who favor shorter term relationships; you’re either admitted or “treated and streeted.”

This is further pushed toward the hospitalists’ realm as some OUs continue to treat patients for up to 48 hours (how can you be in a hospital bed for two days and still not be an inpatient?) and helped by the hospitalist’s 24/7 availability.

Having hospitalists serve as the medical directors for the OUs also makes sense because it gets these patients “out of the ED” from a logistic standpoint and shifts the responsibility to the hospitalist, freeing up the ED physicians to better do their primary job. This is just another in a list of examples of how hospitalists can improve ED throughput.

Further, now that governmental payers require closer on-site management of patients in OUs, this makes it virtually impossible for the outpatient-based primary care physicians to have a significant role.

According to The Advisory Board, Washington, D.C., and others, diseases such as CHF readily treated by hospitalists are well-suited to management in OUs. I thought I’d use CHF as an example of how a well-constructed OU might function. Obviously, there are clear classifications and criteria for those patients who are eligible to have their heart failure managed in an OU. And recent data have shown that appropriate management of CHF in OUs can lead to a lower admission rate, better use of resources, and better outcomes.

The OU setting can deliver a more extended course of therapy than traditionally available in the ED or a physician’s office for patients who may not need an acute hospitalization, but who are decompensating. With the best outcomes, management of CHF in an OU can prevent a hospitalization, delay a revisit to the ED, and improve the quality of the patient’s life by decreasing their symptoms and allowing them more time away form the hospital setting.

Not all patients who present to the ED with worsening CHF are candidates for OU management. Some clearly must be admitted. According to the American Heart Association/American College of Cardiology Guidelines the admission criteria for managing a CHF patient in an OU are:

• Adequate systemic perfusion;
• B-type natriuretic peptide < 100pg/mL;
• CXR consistent with CHF; and
• Demonstration of hemodynamic stability as evidenced by one of the following:

  • Heart rate >50 or <130;
  • Systolic blood pressure >90 and <175; or
  • Oxygen saturation >90%.

As more physicians become aware of the benefits of OU care for these patients, there has been a >9% increase in the number of OU patients in both 2003 and 2004, according to Medicare data. And the increased use is even more dramatic for CHF patients.

As one looks at the elements to design and staff a functioning OU, it is apparent this falls clearly in the hospitalist’s capabilities. The idea is to develop more than just a place to stay longer in the ED, but to create an evidence-based, cost-effective management solution for difficult patients. Key components would include:

• Criteria for admission and exclusion based on risk stratification models;
• Protocols for treatment using evidence-based practice guidelines;
• Clear discharge process supported by patient education materials and discharge criteria; and
• Performance standards and an ongoing data collection and quality improvement process.

CHF is an expensive condition to manage, fraught with frequent episodes of decompensation and admission. This takes an economic toll on the system and results in a poorer quality of life for those patients burdened with the disease. Because many physician offices are not set up to handle patients with increasing symptoms related to CHF, the ED becomes the treatment center of last resort. Thoughtful management of those patients correctly suited to OU care can lead to more directed treatment and avoid hospitalizations that are expensive to the system and unnecessary for the patient.

All data point to an increased prevalence of OUs as more hospitals develop them and more patients are treated in OUs. In addition, professional societies are establishing guidelines and criteria for the appropriate use of OUs for certain ED patients. At the same time, management of patients in the OUs and for the OU itself is evolving to the hospitalist, who is the expert in longitudinal management of the hospitalized (and near hospitalized) patient.

Once again the hospitalist is at the center of new initiatives that are a win-win-win. OUs can minimize the patient’s time away from home, improve their functional capacity, relieve congestion in the ED, allow the ED physicians to concentrate on true ED patients, uncrowd the hospital and the ED and improve throughput, and save the system money. And hospitalists with a plan can make this happen.

Not bad for a specialty that is still the new kid on the block. TH

Dr. Wellikson has been CEO of SHM since 2000.

It is clear to most of us in hospital medicine that the lines are rapidly blurring between the ED, and the floor, and the ICUs. Some of this has been brought about by the transitional units and the ability to place the patient in the most appropriate area with the correct level of monitoring equipment and nurse-to-patient ratio. Some of this has come about with the increased presence of hospitalists and intensivists in-house to complement the already ever-present ED physicians.

But now there is a movement afoot to both increase the use of observation units (OUs) and to change the physician oversight. Once thought to be an extension of the ED, OUs are now part of the hospitalists’ domain as these patients are thought to be more inpatient-light rather than long-term ED patients. And this makes sense when you realize that hospitalists are better suited to managing patients over time rather than ED physicians who favor shorter term relationships; you’re either admitted or “treated and streeted.”

This is further pushed toward the hospitalists’ realm as some OUs continue to treat patients for up to 48 hours (how can you be in a hospital bed for two days and still not be an inpatient?) and helped by the hospitalist’s 24/7 availability.

Having hospitalists serve as the medical directors for the OUs also makes sense because it gets these patients “out of the ED” from a logistic standpoint and shifts the responsibility to the hospitalist, freeing up the ED physicians to better do their primary job. This is just another in a list of examples of how hospitalists can improve ED throughput.

Further, now that governmental payers require closer on-site management of patients in OUs, this makes it virtually impossible for the outpatient-based primary care physicians to have a significant role.

According to The Advisory Board, Washington, D.C., and others, diseases such as CHF readily treated by hospitalists are well-suited to management in OUs. I thought I’d use CHF as an example of how a well-constructed OU might function. Obviously, there are clear classifications and criteria for those patients who are eligible to have their heart failure managed in an OU. And recent data have shown that appropriate management of CHF in OUs can lead to a lower admission rate, better use of resources, and better outcomes.

The OU setting can deliver a more extended course of therapy than traditionally available in the ED or a physician’s office for patients who may not need an acute hospitalization, but who are decompensating. With the best outcomes, management of CHF in an OU can prevent a hospitalization, delay a revisit to the ED, and improve the quality of the patient’s life by decreasing their symptoms and allowing them more time away form the hospital setting.

Not all patients who present to the ED with worsening CHF are candidates for OU management. Some clearly must be admitted. According to the American Heart Association/American College of Cardiology Guidelines the admission criteria for managing a CHF patient in an OU are:

• Adequate systemic perfusion;
• B-type natriuretic peptide < 100pg/mL;
• CXR consistent with CHF; and
• Demonstration of hemodynamic stability as evidenced by one of the following:

  • Heart rate >50 or <130;
  • Systolic blood pressure >90 and <175; or
  • Oxygen saturation >90%.

As more physicians become aware of the benefits of OU care for these patients, there has been a >9% increase in the number of OU patients in both 2003 and 2004, according to Medicare data. And the increased use is even more dramatic for CHF patients.

As one looks at the elements to design and staff a functioning OU, it is apparent this falls clearly in the hospitalist’s capabilities. The idea is to develop more than just a place to stay longer in the ED, but to create an evidence-based, cost-effective management solution for difficult patients. Key components would include:

• Criteria for admission and exclusion based on risk stratification models;
• Protocols for treatment using evidence-based practice guidelines;
• Clear discharge process supported by patient education materials and discharge criteria; and
• Performance standards and an ongoing data collection and quality improvement process.

CHF is an expensive condition to manage, fraught with frequent episodes of decompensation and admission. This takes an economic toll on the system and results in a poorer quality of life for those patients burdened with the disease. Because many physician offices are not set up to handle patients with increasing symptoms related to CHF, the ED becomes the treatment center of last resort. Thoughtful management of those patients correctly suited to OU care can lead to more directed treatment and avoid hospitalizations that are expensive to the system and unnecessary for the patient.

All data point to an increased prevalence of OUs as more hospitals develop them and more patients are treated in OUs. In addition, professional societies are establishing guidelines and criteria for the appropriate use of OUs for certain ED patients. At the same time, management of patients in the OUs and for the OU itself is evolving to the hospitalist, who is the expert in longitudinal management of the hospitalized (and near hospitalized) patient.

Once again the hospitalist is at the center of new initiatives that are a win-win-win. OUs can minimize the patient’s time away from home, improve their functional capacity, relieve congestion in the ED, allow the ED physicians to concentrate on true ED patients, uncrowd the hospital and the ED and improve throughput, and save the system money. And hospitalists with a plan can make this happen.

Not bad for a specialty that is still the new kid on the block. TH

Dr. Wellikson has been CEO of SHM since 2000.

It is clear to most of us in hospital medicine that the lines are rapidly blurring between the ED, and the floor, and the ICUs. Some of this has been brought about by the transitional units and the ability to place the patient in the most appropriate area with the correct level of monitoring equipment and nurse-to-patient ratio. Some of this has come about with the increased presence of hospitalists and intensivists in-house to complement the already ever-present ED physicians.

But now there is a movement afoot to both increase the use of observation units (OUs) and to change the physician oversight. Once thought to be an extension of the ED, OUs are now part of the hospitalists’ domain as these patients are thought to be more inpatient-light rather than long-term ED patients. And this makes sense when you realize that hospitalists are better suited to managing patients over time rather than ED physicians who favor shorter term relationships; you’re either admitted or “treated and streeted.”

This is further pushed toward the hospitalists’ realm as some OUs continue to treat patients for up to 48 hours (how can you be in a hospital bed for two days and still not be an inpatient?) and helped by the hospitalist’s 24/7 availability.

Having hospitalists serve as the medical directors for the OUs also makes sense because it gets these patients “out of the ED” from a logistic standpoint and shifts the responsibility to the hospitalist, freeing up the ED physicians to better do their primary job. This is just another in a list of examples of how hospitalists can improve ED throughput.

Further, now that governmental payers require closer on-site management of patients in OUs, this makes it virtually impossible for the outpatient-based primary care physicians to have a significant role.

According to The Advisory Board, Washington, D.C., and others, diseases such as CHF readily treated by hospitalists are well-suited to management in OUs. I thought I’d use CHF as an example of how a well-constructed OU might function. Obviously, there are clear classifications and criteria for those patients who are eligible to have their heart failure managed in an OU. And recent data have shown that appropriate management of CHF in OUs can lead to a lower admission rate, better use of resources, and better outcomes.

The OU setting can deliver a more extended course of therapy than traditionally available in the ED or a physician’s office for patients who may not need an acute hospitalization, but who are decompensating. With the best outcomes, management of CHF in an OU can prevent a hospitalization, delay a revisit to the ED, and improve the quality of the patient’s life by decreasing their symptoms and allowing them more time away form the hospital setting.

Not all patients who present to the ED with worsening CHF are candidates for OU management. Some clearly must be admitted. According to the American Heart Association/American College of Cardiology Guidelines the admission criteria for managing a CHF patient in an OU are:

• Adequate systemic perfusion;
• B-type natriuretic peptide < 100pg/mL;
• CXR consistent with CHF; and
• Demonstration of hemodynamic stability as evidenced by one of the following:

  • Heart rate >50 or <130;
  • Systolic blood pressure >90 and <175; or
  • Oxygen saturation >90%.

As more physicians become aware of the benefits of OU care for these patients, there has been a >9% increase in the number of OU patients in both 2003 and 2004, according to Medicare data. And the increased use is even more dramatic for CHF patients.

As one looks at the elements to design and staff a functioning OU, it is apparent this falls clearly in the hospitalist’s capabilities. The idea is to develop more than just a place to stay longer in the ED, but to create an evidence-based, cost-effective management solution for difficult patients. Key components would include:

• Criteria for admission and exclusion based on risk stratification models;
• Protocols for treatment using evidence-based practice guidelines;
• Clear discharge process supported by patient education materials and discharge criteria; and
• Performance standards and an ongoing data collection and quality improvement process.

CHF is an expensive condition to manage, fraught with frequent episodes of decompensation and admission. This takes an economic toll on the system and results in a poorer quality of life for those patients burdened with the disease. Because many physician offices are not set up to handle patients with increasing symptoms related to CHF, the ED becomes the treatment center of last resort. Thoughtful management of those patients correctly suited to OU care can lead to more directed treatment and avoid hospitalizations that are expensive to the system and unnecessary for the patient.

All data point to an increased prevalence of OUs as more hospitals develop them and more patients are treated in OUs. In addition, professional societies are establishing guidelines and criteria for the appropriate use of OUs for certain ED patients. At the same time, management of patients in the OUs and for the OU itself is evolving to the hospitalist, who is the expert in longitudinal management of the hospitalized (and near hospitalized) patient.

Once again the hospitalist is at the center of new initiatives that are a win-win-win. OUs can minimize the patient’s time away from home, improve their functional capacity, relieve congestion in the ED, allow the ED physicians to concentrate on true ED patients, uncrowd the hospital and the ED and improve throughput, and save the system money. And hospitalists with a plan can make this happen.

Not bad for a specialty that is still the new kid on the block. TH

Dr. Wellikson has been CEO of SHM since 2000.

When a hospitalist steps outside during a seemingly unending shift, and a city is silent but for the bark of dogs, something is wrong. When he returns not to a scheduled shift, but to an undefined “tour of duty,” something is very wrong. Such has been the case for many hospitalists and healthcare providers along the Gulf Coast since Hurricane Katrina first devastated miles of the coast in August, and then Hurricane Rita hammered home our vulnerability to natural disasters in September. These sentinel experiences offer learning points for our nation’s healthcare system. “Challenges Hospitals Encountered During the 2005 Hurricane Seasons” (p. 8) lists some of the areas in which hospitals and healthcare providers were tested.

Half the Battle: Getting There

Eniola Otuseso, MD, a hospitalist who works in locum tenens positions across the southeast, calls Atlanta home. Her native Nigeria does not have hurricanes—their natural disasters are dust storms and monsoons—so she had never experienced one. The day before Hurricane Katrina hit, Dr. Otuseso had departed for her next job at Cogent Healthcare’s program at St. Dominic-Jackson Memorial Hospital (Miss.). Unable to take the last flight of the day, she packed a rental car and she, her 22-month-old son, and her teenage niece set off on the 380-mile journey to Jackson, Miss. Her account of the ride gives new meaning to the term “Sunday drive.”

MapQuest directions in hand, Dr. Otuseso took I-20 west toward Mississippi. From the road she called the hotel where she had reservations, only to find them canceled due to overbooking. She proceeded with nervous jitters: She had to report to work at 10 a.m. So she found another hotel, spent the night, and set out again at 6 a.m. Monday.

Then she had another problem: Although she thought she was on I-20 west, she had accidentally taken route 59 south—directly into New Orleans and the brunt of the storm. She notified the hospital that she was on the way, and promptly lost phone service. “I realized I needed to turn around and got off at the next exit, but a tree had blocked the road,” says Dr. Otuseso. “No one was around.”

She took the one-way exit back as trees fell around her. Her nervous jitters escalated to panic.

When a tree fell in front of her car, her attempted circumvention landed the car in the mud, and she ran out of gas trying to dislodge it. Miraculously, she had phone service, but the appalled 9-1-1 operators couldn’t help. Finally, a motorist and his adult passenger stopped and offered a ride. Dr. Otuseso and her wards climbed into the good Samaritan’s vehicle, and they were off again. The frequent need to get out of the car to haul trees from the road slowed their journey.

Finally, the mud was too thick and they became stuck. She managed to reach a nearby house on foot, and the owner used his tractor to move the car. He also offered them respite in his home with his wife and baby. A drenched, discouraged Dr. Otuseso and her children accepted the offer and were ferried there by tractor; her previous companions slogged on.

Dr. Otuseso is a graduate of Medical College of Georgia (Augusta). The rural family that housed her was was uneducated in some of the basics of preventive healthcare. Although culturally and in terms of health beliefs Dr. Otuseso and the family that sheltered her could not have been more different, the host family offered remarkable hospitality by providing food and clothing.

“Tragedy brings different people together,” Dr. Otuseso told her niece. The next day, the hurricane had passed, and the host family transported her to Hattiesburg, Miss., a town a mere 100 miles north of New Orleans. She needed basics: shelter and transportation. Hattiesburg’s hotel lacked power and water, and gas was scarce. Eventually, Dr. Otuseso convinced a service station owner to help her retrieve her rental car and fill it with gas. She then set off for Jackson.

On arrival in Jackson, she checked into another hotel with no water or electricity, but eventually made it to work Tuesday. The hospital had electricity and an endless stream of patients. Dr. Otuseso says that her experience made her more empathetic to patients. She could understand the extent of their loss. And after a lifetime of giving to others, she learned to accept help, hospitality, and assistance from others.

In New Orleans

Rob Minkes, MD, chief of pediatric surgery at Louisiana State University and Children’s Hospital (both of New Orleans) started a shift on Sunday, August 28 that became a four-day tour of duty. With him were more than 700 patients, families, and staff. Throughout the ordeal, they had Internet access and intermittent phone service. It was almost business-as-usual: All employees reported for work, and they even performed procedures in the surgical suite.

Once the storm passed, patients of all ages began to appear needing help. With them came strangers who threatened the hospital’s safety Employees could see looters from the windows. Some visitors who had no official purpose roamed the halls causing fear and despair among employees; although they were few and far between, they created chaos. Once the interlopers were escorted out, the hospital locked down. Lacking armed guards, they contacted local, state, and federal authorities for help, but none came.

“The situation became surreal, like a Stephen King novel,” explains Dr. Minkes. “There was just enough of what was normal, but the workplace and general life began to blend into some kind of limbo.”

He praises staff members who kept doing their jobs. The physicians made rounds, the nurses provided care, the housekeepers cleaned. “People can behave commendably in a crisis,” says Dr. Minkes, who noted that Children’s Hospital was well prepared and their disaster training was effective. The hospital was so prepared, in fact, that it was able to divert a fuel shipment that arrived Monday or Tuesday to a nearby facility that had a greater need.

On Wednesday morning, Children’s Hospital lost water pressure, so running water and air conditioning were history. Hospital leadership made the decision to evacuate patients and staff using any available means. Some neighboring hospitals sent helicopters. A convoy of ambulances and SUVs, staffed with care providers using hand-bag ventilators, set out for Baton Rouge. Those patients well enough were discharged. Hospital leadership received word that the National Guard had aircraft at the airport and could take remaining patients if they could be there by 7 p.m.

John Heaton, MD, chief anesthesiologist for Children’s Hospital, led a caravan of 40 cars, trucks, and SUVs to the interstate and onward to the airport. Staff members returned to the hospital despite worsening violence and health hazards in the city. Wednesday turned to the early hours of Thursday with only a few ICU patients remaining at Children’s.

At 4 a.m. a state trooper who came to support a chopper that was evacuating a patient recommended that staff prepare to evacuate at first light because of increasing danger due to flooding and looting in the city. Until then, Children’s had had very little contact with authorities, and basically made its decisions in isolation. One caravan of employees left with a police escort shortly thereafter. The remaining staff made their way unescorted when the last patient left for safety at 8 a.m., leaving a facility that had operated nobly despite Mother Nature’s wrath and security issues. When staff members left, Children’s Hospital had sustained only two broken windows.

Dr. Minkes praises the staff of every department, and indicates that leadership withstood this test. “The day after the hurricane, we were prepared to stay for two to six weeks,” he says.

When asked if he saw any skill used that surprised him in its utility, he hastens to say that they had power and water for most of the ordeal. He noted, however, that their chief of anesthesiology, an ardent fisher and hunter, calculated how high the waters would rise if the levies broke using a tool he retrieved from the Internet. He assured the staff that the water would not reach Children’s Hospital. It helped people’s spirits immensely.

Back to Jackson

Meanwhile, Dr. Otuseso was seeing an influx of patients in Jackson. With her, Lancy Clark, a registered nurse and Cogent Healthcare Program manager who liaises between St.Dominic-Jackson Memorial Hospital’s hospitalists and community physicians, was frankly shocked. The St.Dominic-Jackson facility staff—150 miles from Gulfport—had not thought that the devastation would reach them. It did.

With no electricity or water, St. Dominic-Jackson’s internal and external communication was in a shambles. Their backup: using the telephone, personal cell phones, and overhead page system. Although the county’s priority was to restore power and water to hospitals, its employees were working in the dark. And county-wide gas shortages meant that staff had difficulty reporting to work. Fortunately, the county gave healthcare providers head-of-the-line privileges for fuel.

“I was amazed at how fast people bounced up and worked,” says Clark. “We were all counselors. We often cried with patients as they told us their stories. We used all the resources we could to help emotionally and financially.”

In all of this, the healthcare providers, too, were victims; many have strong roots and family in the devastated communities.

As the adrenaline rush subsided and things started to be a little more normal, care providers began to feel the effects of the strain. All Clark wanted to do was sit in a chair and sink deep into it. Some experts call this compassion fatigue. It is a unique type of burnout experienced by people in fields that provide care for people under extreme circumstances, or the stress of caring for people who are scared, in pain, and/or suffering. Critical incident stress management and debriefing exercises are two ways to alleviate compassion fatigue. Clark indicates that Cogent Healthcare has plans to hold debriefings so they can apply what they learned.

Westward Bound

Some Hurricane Katrina evacuees found their way to Galveston, Texas. Two physicians on the faculty of the University of Texas Medical Branch (UTMB) at Galveston, Janice Smith, MD, and Donna Weaver, MD, worked in a Red Cross clinic assembled in a Methodist church’s indoor racquetball court.

Like hundreds of others, Dr. Smith responded to the call for volunteers early in the process to help the 300 evacuees. She says that there were many bureaucracies, and their nurse-coordinator handled them all well. In terms of challenges, “Every few hours, policies and procedures would change,” says Dr. Smith. “There was no interclinic communication, and roles were unclear. Although it was emotionally difficult seeing patients who had lost everything, that was the easy part compared to dealing with constant change.”

Dr. Weaver, who is codirector for Center for Training in International Health and teaches the Practice of Medicine course at UTMB at Galveston, responded to a request to describe her previous experience in one word: “Nicaragua.”

She often volunteers in Nicaragua (as does Dr. Smith) and in rural U.S. communities they open clinics in people’s homes. Dr. Weaver says the “organized disorganization” of a pharmacy stocked with samples, borrowed supplies and equipment, and no lab facilities created a situation in which physicians had to rely on medical clinical skills. People came with nothing, and medical records were unavailable. The medical history—just what the patient could tell them—was the cornerstone of treatment.

“The low-tech physicians did well,” she says. Listening skills became key. Dr. Weaver intends to reinforce that lesson with her students.

Both physicians could identify gaps that would have been nice to fill. Dr. Smith said that having an on-site dentist would have helped the many people suffering from toothaches. She also appreciates geographic prescribing differences more now, and would have liked to have had a pharmacist there to tell them what certain drugs were or suggest therapeutic alternatives. Dr. Weaver said privacy was at a premium—a situation that was uncomfortable for providers and patients alike. As each day passed, more barriers and walls were rigged to try to improve privacy.

Desk Jockeys No More

Anthony Campbell, RPh, DO, an internist and a pharmacist, and Joseph Matthews, RS, a sanitarian, were deployed together as part of a United States Public Health Service (USPHS) team. They landed in Louisiana to find their accommodations sufficient: a cot in one of five tents at Camp Allen that housed around 125 responders each. Both of these USPHS-commissioned officers had prior hospital-based practices in one of Washington, D.C.’s poorest neighborhoods. It was perhaps this recent experience that made them prime candidates to be plucked from desk jobs and jettisoned back into a stressed clinical milieu. While experience prepared them for the issues of indigence and poverty, it did not temper their reactions to the devastation and exposure to elements.

Their reunion made the task less challenging but the work they did was grueling. Dr. Campbell and Matthews traveled through parishes conducting needs assessments at Red Cross shelters in Washington Parish during the first week. The days were long—sometimes beginning at 5 a.m. and ending after 11 p.m.—and impossibly hot.

Both were impressed with people’s positive attitudes. Many shelters were overcrowded and lacked bathing facilities. Members of the community welcomed displaced people into their homes to shower and took turns preparing copious quantities of food. In a significantly overcrowded shelter, the Federal Emergency Management Agency (FEMA) tried to move people to hotels; often, unrelated people who had been neighbors or who had weathered the storm together would refuse to go unless they could go together. A group of retirees from Maine who were visiting New Orleans, for example, insisted on staying together even if it was in the crowded shelter. This was an unanticipated dynamic.

Matthews talked about what he called, “the changing theater,” a military term that describes the need to change plans frequently when conditions of austerity dictate it. He indicates that many clinicians were unacquainted with the principle of gathering your assets and regrouping when plans take an about-face. That was the case throughout their deployment.

During the second week, Dr. Campbell moved closer to New Orleans, and Matthews went to the area’s largest animal shelter, a place with five huge barns, two filled with horses and three with smaller pets. In the chaos there, his main concern was not the lack of volunteers—they had plenty—but the frequent disregard for human health risks as they handled hungry pets that had been plucked from toxic floodwaters. The need to take universal precautions is not a universal belief. Just trying to get people to wear gloves was an ordeal. The volunteers were often unaware of their own cuts and bruises, and worked relentlessly.

Matthews laughed as he related a story of the volunteers’ compassion. It was late in the evening, and his transport had not arrived. Concerned, he called the base operation and learned that he’d been forgotten. He started to melt down with anger and fatigue. A group of volunteers quickly surrounded him with comfort and reassurance; they thought he was upset because he couldn’t find his pet! It restored his sense of humor and balance.

Meanwhile, Dr. Campbell was knocking on doors in a housing project, looking for people with health needs. Care was centrally located in Washington Parish, but lacking communication methods and transportation, many residents didn’t know about the help offered there. He relied on the project’s resident manager to help his team. The manager often knew who had been evacuated, how many children lived in units, and who was older and remained.

Dr. Campbell cites the heat and incredible stench as indelible memories. His deployment ended in New Orleans. Even in the French Quarter, which sits on higher ground, the air was thick with the smell of rotting food that had been removed from freezers to prevent it from ruining equipment. (Clark in Mississippi also mentioned the memorable foul odor of rotting food.) He understands now why police officers and forensics workers carry Vicks VapoRub to dab under their nose when they find a decomposed body.

Dr. Campbell indicates that the Red Cross shelters needed more trained medical personnel, although they had ample donations of medication from doctors’ offices in the form of samples, and from hospitals and pharmacies. They did not have a pharmacist, however, and he relied on his dual training to provide some of the services that Dr. Smith in Galveston also identified. He was saddened by the devastation. He visited the Superdome and indicates that the debris and human waste told a sad and shocking story.

Patient Satisfaction

Sixty-year-old patient Emelda Zar evacuated from LaFitte, La., before Hurricane Katrina. She landed in a crowded but hospitable shelter in Jackson, Miss. Some days later, her daughter called an ambulance as Zar’s health deteriorated. She was admitted to St. Dominic-Jackson Memorial Hospital and diagnosed with heart failure.

Recently discharged and about to relocate to an apartment and planning to remain in Jackson, she and her grandchildren have nothing but good things to say about the hospital and, in particular, the hospitalists who provided care.

She arrived with no medical records and a serious health problem. Her hospitalists listened and created a care plan. She left the hospital with not only a clear idea of what she needs to do, but with a scheduled follow-up appointment in the community. Like so many of the people we heard about from healthcare providers, she remains upbeat and optimistic.

Progress Notes

Shortly after Dr. Smith and Dr. Weaver were interviewed in Galveston, the news was full of a new threat: Rita. This time, the hurricane’s target was a few hundred miles west of Katrina’s path. Karen Sexton, RN, PhD, vice president and chief executive officer of Hospitals and Clinics for UTMB shared the story of how Katrina changed their response.

During routine monitoring they saw tropical depression #18 develop on Sunday to the point that it was named Rita on Monday, and began to look like trouble for Galveston. By Tuesday, the city mayor had declared a voluntary evacuation, applying one lesson from Katrina: Residents could take their pets in government evacuation vehicles. The university went on emergency status. UTMB looked at decreasing their activity and reducing the hospital census. They sent the students home.

Tuesday night, their hospitalist service and other key physicians wrote transfer summaries for all patients, beginning with those who were gravely ill. This was a change of policy based on their experience with Katrina. They chose to move critically ill patients while they had the greatest control. The pharmacy prepared medication for all patients, and parts of medical records deemed most important were copied.

Wednesday dawned, and it was clear: Rita was coming in as a level 4 or 5 hurricane. For the first time in 114 years of existence, UTMB evacuated under Dr. Sexton’s direction as the incident commander. Using resources sent in part by the governor, their team discharged and evacuated 427 patients in 12 hours.

“We were all a little teary eyed when the first patient left,” says Dr. Sexton. “We knew we had never evacuated before and we knew were making history.”

Key to the success of UTMB’s evacuation were checklists on the units and at two evacuation stations. This, too, was something they learned from Katrina: Track patient disposition and send as much information as possible. With the goal of improving patient safety, UTMB recently started training staff on an aviation model that mimics what the aviation industry does to ensure safety.

They tracked what went with the patient, where the patient went, and that family notifications were done. The staff’s increased awareness and use of checklists were key components for a successful evacuation. No patients were “lost.” As the last patient left, Dr. Sexton found herself with a hospital staffed to support 500 to 700 patients, no patients, and the realization that staff also needed to evacuate but might not be able to navigate the exodus traffic.

Another request to the Texas governor’s office put two C130 cargo planes at their disposal. Staff were given three options: Stay at the hospital, leave of their own accord, or take the C130 to shelter in Houston. One-hundred-thirty-one staff members chose the latter option and left Thursday; the same planes brought them back the following Monday.

During the storm, UTMB’s ED remained open and staffed. It was the only operating ED for miles. A burn victim and several firemen who were harmed fighting a tremendous blaze during the storm on Friday proved that remaining open was the right thing to do to for the community.

Although UTMB lost some equipment, blocks of air conditioning, and some power, administrators believe that they made good decisions and emerged almost unscathed.

“I never felt prouder of our staff,” says Dr. Sexton. “This will be a different place because we all did this together.”

Less than a week later, they continue to treat patients from the community, have started admitting patients, and have welcomed some of their critically ill neonates back.

Conclusion

Who believes weather analysts? Often, we look at unwelcome weather forecasts and dismiss them, thinking that it always sounds worse than it is. Hospitalists and healthcare providers who weathered Katrina and Rita, and who are still working with the aftermath are probably more apt to listen to future dire weather predictions. “Lessons for Hospitalists from the 2005 Hurricane Season” (left) summarizes some of the lessons learned from the 2005 hurricane season to date. Every hospital will have to look at disaster plans and make changes based on what we’ve learned. Self-sufficiency for 48 hours is probably a less-than-ambitious goal; we may need to think in terms of planning for a week or more. Certainly, hospitalists will need to take leadership roles. TH

Contributor Jeannette Wick, RPh, MBA, is a senior clinical research pharmacist at the NIH in Bethesda, Md. The opinions expressed herein are those of the author and not necessarily those of any government agency.

When a hospitalist steps outside during a seemingly unending shift, and a city is silent but for the bark of dogs, something is wrong. When he returns not to a scheduled shift, but to an undefined “tour of duty,” something is very wrong. Such has been the case for many hospitalists and healthcare providers along the Gulf Coast since Hurricane Katrina first devastated miles of the coast in August, and then Hurricane Rita hammered home our vulnerability to natural disasters in September. These sentinel experiences offer learning points for our nation’s healthcare system. “Challenges Hospitals Encountered During the 2005 Hurricane Seasons” (p. 8) lists some of the areas in which hospitals and healthcare providers were tested.

Half the Battle: Getting There

Eniola Otuseso, MD, a hospitalist who works in locum tenens positions across the southeast, calls Atlanta home. Her native Nigeria does not have hurricanes—their natural disasters are dust storms and monsoons—so she had never experienced one. The day before Hurricane Katrina hit, Dr. Otuseso had departed for her next job at Cogent Healthcare’s program at St. Dominic-Jackson Memorial Hospital (Miss.). Unable to take the last flight of the day, she packed a rental car and she, her 22-month-old son, and her teenage niece set off on the 380-mile journey to Jackson, Miss. Her account of the ride gives new meaning to the term “Sunday drive.”

MapQuest directions in hand, Dr. Otuseso took I-20 west toward Mississippi. From the road she called the hotel where she had reservations, only to find them canceled due to overbooking. She proceeded with nervous jitters: She had to report to work at 10 a.m. So she found another hotel, spent the night, and set out again at 6 a.m. Monday.

Then she had another problem: Although she thought she was on I-20 west, she had accidentally taken route 59 south—directly into New Orleans and the brunt of the storm. She notified the hospital that she was on the way, and promptly lost phone service. “I realized I needed to turn around and got off at the next exit, but a tree had blocked the road,” says Dr. Otuseso. “No one was around.”

She took the one-way exit back as trees fell around her. Her nervous jitters escalated to panic.

When a tree fell in front of her car, her attempted circumvention landed the car in the mud, and she ran out of gas trying to dislodge it. Miraculously, she had phone service, but the appalled 9-1-1 operators couldn’t help. Finally, a motorist and his adult passenger stopped and offered a ride. Dr. Otuseso and her wards climbed into the good Samaritan’s vehicle, and they were off again. The frequent need to get out of the car to haul trees from the road slowed their journey.

Finally, the mud was too thick and they became stuck. She managed to reach a nearby house on foot, and the owner used his tractor to move the car. He also offered them respite in his home with his wife and baby. A drenched, discouraged Dr. Otuseso and her children accepted the offer and were ferried there by tractor; her previous companions slogged on.

Dr. Otuseso is a graduate of Medical College of Georgia (Augusta). The rural family that housed her was was uneducated in some of the basics of preventive healthcare. Although culturally and in terms of health beliefs Dr. Otuseso and the family that sheltered her could not have been more different, the host family offered remarkable hospitality by providing food and clothing.

“Tragedy brings different people together,” Dr. Otuseso told her niece. The next day, the hurricane had passed, and the host family transported her to Hattiesburg, Miss., a town a mere 100 miles north of New Orleans. She needed basics: shelter and transportation. Hattiesburg’s hotel lacked power and water, and gas was scarce. Eventually, Dr. Otuseso convinced a service station owner to help her retrieve her rental car and fill it with gas. She then set off for Jackson.

On arrival in Jackson, she checked into another hotel with no water or electricity, but eventually made it to work Tuesday. The hospital had electricity and an endless stream of patients. Dr. Otuseso says that her experience made her more empathetic to patients. She could understand the extent of their loss. And after a lifetime of giving to others, she learned to accept help, hospitality, and assistance from others.

In New Orleans

Rob Minkes, MD, chief of pediatric surgery at Louisiana State University and Children’s Hospital (both of New Orleans) started a shift on Sunday, August 28 that became a four-day tour of duty. With him were more than 700 patients, families, and staff. Throughout the ordeal, they had Internet access and intermittent phone service. It was almost business-as-usual: All employees reported for work, and they even performed procedures in the surgical suite.

Once the storm passed, patients of all ages began to appear needing help. With them came strangers who threatened the hospital’s safety Employees could see looters from the windows. Some visitors who had no official purpose roamed the halls causing fear and despair among employees; although they were few and far between, they created chaos. Once the interlopers were escorted out, the hospital locked down. Lacking armed guards, they contacted local, state, and federal authorities for help, but none came.

“The situation became surreal, like a Stephen King novel,” explains Dr. Minkes. “There was just enough of what was normal, but the workplace and general life began to blend into some kind of limbo.”

He praises staff members who kept doing their jobs. The physicians made rounds, the nurses provided care, the housekeepers cleaned. “People can behave commendably in a crisis,” says Dr. Minkes, who noted that Children’s Hospital was well prepared and their disaster training was effective. The hospital was so prepared, in fact, that it was able to divert a fuel shipment that arrived Monday or Tuesday to a nearby facility that had a greater need.

On Wednesday morning, Children’s Hospital lost water pressure, so running water and air conditioning were history. Hospital leadership made the decision to evacuate patients and staff using any available means. Some neighboring hospitals sent helicopters. A convoy of ambulances and SUVs, staffed with care providers using hand-bag ventilators, set out for Baton Rouge. Those patients well enough were discharged. Hospital leadership received word that the National Guard had aircraft at the airport and could take remaining patients if they could be there by 7 p.m.

John Heaton, MD, chief anesthesiologist for Children’s Hospital, led a caravan of 40 cars, trucks, and SUVs to the interstate and onward to the airport. Staff members returned to the hospital despite worsening violence and health hazards in the city. Wednesday turned to the early hours of Thursday with only a few ICU patients remaining at Children’s.

At 4 a.m. a state trooper who came to support a chopper that was evacuating a patient recommended that staff prepare to evacuate at first light because of increasing danger due to flooding and looting in the city. Until then, Children’s had had very little contact with authorities, and basically made its decisions in isolation. One caravan of employees left with a police escort shortly thereafter. The remaining staff made their way unescorted when the last patient left for safety at 8 a.m., leaving a facility that had operated nobly despite Mother Nature’s wrath and security issues. When staff members left, Children’s Hospital had sustained only two broken windows.

Dr. Minkes praises the staff of every department, and indicates that leadership withstood this test. “The day after the hurricane, we were prepared to stay for two to six weeks,” he says.

When asked if he saw any skill used that surprised him in its utility, he hastens to say that they had power and water for most of the ordeal. He noted, however, that their chief of anesthesiology, an ardent fisher and hunter, calculated how high the waters would rise if the levies broke using a tool he retrieved from the Internet. He assured the staff that the water would not reach Children’s Hospital. It helped people’s spirits immensely.

Back to Jackson

Meanwhile, Dr. Otuseso was seeing an influx of patients in Jackson. With her, Lancy Clark, a registered nurse and Cogent Healthcare Program manager who liaises between St.Dominic-Jackson Memorial Hospital’s hospitalists and community physicians, was frankly shocked. The St.Dominic-Jackson facility staff—150 miles from Gulfport—had not thought that the devastation would reach them. It did.

With no electricity or water, St. Dominic-Jackson’s internal and external communication was in a shambles. Their backup: using the telephone, personal cell phones, and overhead page system. Although the county’s priority was to restore power and water to hospitals, its employees were working in the dark. And county-wide gas shortages meant that staff had difficulty reporting to work. Fortunately, the county gave healthcare providers head-of-the-line privileges for fuel.

“I was amazed at how fast people bounced up and worked,” says Clark. “We were all counselors. We often cried with patients as they told us their stories. We used all the resources we could to help emotionally and financially.”

In all of this, the healthcare providers, too, were victims; many have strong roots and family in the devastated communities.

As the adrenaline rush subsided and things started to be a little more normal, care providers began to feel the effects of the strain. All Clark wanted to do was sit in a chair and sink deep into it. Some experts call this compassion fatigue. It is a unique type of burnout experienced by people in fields that provide care for people under extreme circumstances, or the stress of caring for people who are scared, in pain, and/or suffering. Critical incident stress management and debriefing exercises are two ways to alleviate compassion fatigue. Clark indicates that Cogent Healthcare has plans to hold debriefings so they can apply what they learned.

Westward Bound

Some Hurricane Katrina evacuees found their way to Galveston, Texas. Two physicians on the faculty of the University of Texas Medical Branch (UTMB) at Galveston, Janice Smith, MD, and Donna Weaver, MD, worked in a Red Cross clinic assembled in a Methodist church’s indoor racquetball court.

Like hundreds of others, Dr. Smith responded to the call for volunteers early in the process to help the 300 evacuees. She says that there were many bureaucracies, and their nurse-coordinator handled them all well. In terms of challenges, “Every few hours, policies and procedures would change,” says Dr. Smith. “There was no interclinic communication, and roles were unclear. Although it was emotionally difficult seeing patients who had lost everything, that was the easy part compared to dealing with constant change.”

Dr. Weaver, who is codirector for Center for Training in International Health and teaches the Practice of Medicine course at UTMB at Galveston, responded to a request to describe her previous experience in one word: “Nicaragua.”

She often volunteers in Nicaragua (as does Dr. Smith) and in rural U.S. communities they open clinics in people’s homes. Dr. Weaver says the “organized disorganization” of a pharmacy stocked with samples, borrowed supplies and equipment, and no lab facilities created a situation in which physicians had to rely on medical clinical skills. People came with nothing, and medical records were unavailable. The medical history—just what the patient could tell them—was the cornerstone of treatment.

“The low-tech physicians did well,” she says. Listening skills became key. Dr. Weaver intends to reinforce that lesson with her students.

Both physicians could identify gaps that would have been nice to fill. Dr. Smith said that having an on-site dentist would have helped the many people suffering from toothaches. She also appreciates geographic prescribing differences more now, and would have liked to have had a pharmacist there to tell them what certain drugs were or suggest therapeutic alternatives. Dr. Weaver said privacy was at a premium—a situation that was uncomfortable for providers and patients alike. As each day passed, more barriers and walls were rigged to try to improve privacy.

Desk Jockeys No More

Anthony Campbell, RPh, DO, an internist and a pharmacist, and Joseph Matthews, RS, a sanitarian, were deployed together as part of a United States Public Health Service (USPHS) team. They landed in Louisiana to find their accommodations sufficient: a cot in one of five tents at Camp Allen that housed around 125 responders each. Both of these USPHS-commissioned officers had prior hospital-based practices in one of Washington, D.C.’s poorest neighborhoods. It was perhaps this recent experience that made them prime candidates to be plucked from desk jobs and jettisoned back into a stressed clinical milieu. While experience prepared them for the issues of indigence and poverty, it did not temper their reactions to the devastation and exposure to elements.

Their reunion made the task less challenging but the work they did was grueling. Dr. Campbell and Matthews traveled through parishes conducting needs assessments at Red Cross shelters in Washington Parish during the first week. The days were long—sometimes beginning at 5 a.m. and ending after 11 p.m.—and impossibly hot.

Both were impressed with people’s positive attitudes. Many shelters were overcrowded and lacked bathing facilities. Members of the community welcomed displaced people into their homes to shower and took turns preparing copious quantities of food. In a significantly overcrowded shelter, the Federal Emergency Management Agency (FEMA) tried to move people to hotels; often, unrelated people who had been neighbors or who had weathered the storm together would refuse to go unless they could go together. A group of retirees from Maine who were visiting New Orleans, for example, insisted on staying together even if it was in the crowded shelter. This was an unanticipated dynamic.

Matthews talked about what he called, “the changing theater,” a military term that describes the need to change plans frequently when conditions of austerity dictate it. He indicates that many clinicians were unacquainted with the principle of gathering your assets and regrouping when plans take an about-face. That was the case throughout their deployment.

During the second week, Dr. Campbell moved closer to New Orleans, and Matthews went to the area’s largest animal shelter, a place with five huge barns, two filled with horses and three with smaller pets. In the chaos there, his main concern was not the lack of volunteers—they had plenty—but the frequent disregard for human health risks as they handled hungry pets that had been plucked from toxic floodwaters. The need to take universal precautions is not a universal belief. Just trying to get people to wear gloves was an ordeal. The volunteers were often unaware of their own cuts and bruises, and worked relentlessly.

Matthews laughed as he related a story of the volunteers’ compassion. It was late in the evening, and his transport had not arrived. Concerned, he called the base operation and learned that he’d been forgotten. He started to melt down with anger and fatigue. A group of volunteers quickly surrounded him with comfort and reassurance; they thought he was upset because he couldn’t find his pet! It restored his sense of humor and balance.

Meanwhile, Dr. Campbell was knocking on doors in a housing project, looking for people with health needs. Care was centrally located in Washington Parish, but lacking communication methods and transportation, many residents didn’t know about the help offered there. He relied on the project’s resident manager to help his team. The manager often knew who had been evacuated, how many children lived in units, and who was older and remained.

Dr. Campbell cites the heat and incredible stench as indelible memories. His deployment ended in New Orleans. Even in the French Quarter, which sits on higher ground, the air was thick with the smell of rotting food that had been removed from freezers to prevent it from ruining equipment. (Clark in Mississippi also mentioned the memorable foul odor of rotting food.) He understands now why police officers and forensics workers carry Vicks VapoRub to dab under their nose when they find a decomposed body.

Dr. Campbell indicates that the Red Cross shelters needed more trained medical personnel, although they had ample donations of medication from doctors’ offices in the form of samples, and from hospitals and pharmacies. They did not have a pharmacist, however, and he relied on his dual training to provide some of the services that Dr. Smith in Galveston also identified. He was saddened by the devastation. He visited the Superdome and indicates that the debris and human waste told a sad and shocking story.

Patient Satisfaction

Sixty-year-old patient Emelda Zar evacuated from LaFitte, La., before Hurricane Katrina. She landed in a crowded but hospitable shelter in Jackson, Miss. Some days later, her daughter called an ambulance as Zar’s health deteriorated. She was admitted to St. Dominic-Jackson Memorial Hospital and diagnosed with heart failure.

Recently discharged and about to relocate to an apartment and planning to remain in Jackson, she and her grandchildren have nothing but good things to say about the hospital and, in particular, the hospitalists who provided care.

She arrived with no medical records and a serious health problem. Her hospitalists listened and created a care plan. She left the hospital with not only a clear idea of what she needs to do, but with a scheduled follow-up appointment in the community. Like so many of the people we heard about from healthcare providers, she remains upbeat and optimistic.

Progress Notes

Shortly after Dr. Smith and Dr. Weaver were interviewed in Galveston, the news was full of a new threat: Rita. This time, the hurricane’s target was a few hundred miles west of Katrina’s path. Karen Sexton, RN, PhD, vice president and chief executive officer of Hospitals and Clinics for UTMB shared the story of how Katrina changed their response.

During routine monitoring they saw tropical depression #18 develop on Sunday to the point that it was named Rita on Monday, and began to look like trouble for Galveston. By Tuesday, the city mayor had declared a voluntary evacuation, applying one lesson from Katrina: Residents could take their pets in government evacuation vehicles. The university went on emergency status. UTMB looked at decreasing their activity and reducing the hospital census. They sent the students home.

Tuesday night, their hospitalist service and other key physicians wrote transfer summaries for all patients, beginning with those who were gravely ill. This was a change of policy based on their experience with Katrina. They chose to move critically ill patients while they had the greatest control. The pharmacy prepared medication for all patients, and parts of medical records deemed most important were copied.

Wednesday dawned, and it was clear: Rita was coming in as a level 4 or 5 hurricane. For the first time in 114 years of existence, UTMB evacuated under Dr. Sexton’s direction as the incident commander. Using resources sent in part by the governor, their team discharged and evacuated 427 patients in 12 hours.

“We were all a little teary eyed when the first patient left,” says Dr. Sexton. “We knew we had never evacuated before and we knew were making history.”

Key to the success of UTMB’s evacuation were checklists on the units and at two evacuation stations. This, too, was something they learned from Katrina: Track patient disposition and send as much information as possible. With the goal of improving patient safety, UTMB recently started training staff on an aviation model that mimics what the aviation industry does to ensure safety.

They tracked what went with the patient, where the patient went, and that family notifications were done. The staff’s increased awareness and use of checklists were key components for a successful evacuation. No patients were “lost.” As the last patient left, Dr. Sexton found herself with a hospital staffed to support 500 to 700 patients, no patients, and the realization that staff also needed to evacuate but might not be able to navigate the exodus traffic.

Another request to the Texas governor’s office put two C130 cargo planes at their disposal. Staff were given three options: Stay at the hospital, leave of their own accord, or take the C130 to shelter in Houston. One-hundred-thirty-one staff members chose the latter option and left Thursday; the same planes brought them back the following Monday.

During the storm, UTMB’s ED remained open and staffed. It was the only operating ED for miles. A burn victim and several firemen who were harmed fighting a tremendous blaze during the storm on Friday proved that remaining open was the right thing to do to for the community.

Although UTMB lost some equipment, blocks of air conditioning, and some power, administrators believe that they made good decisions and emerged almost unscathed.

“I never felt prouder of our staff,” says Dr. Sexton. “This will be a different place because we all did this together.”

Less than a week later, they continue to treat patients from the community, have started admitting patients, and have welcomed some of their critically ill neonates back.

Conclusion

Who believes weather analysts? Often, we look at unwelcome weather forecasts and dismiss them, thinking that it always sounds worse than it is. Hospitalists and healthcare providers who weathered Katrina and Rita, and who are still working with the aftermath are probably more apt to listen to future dire weather predictions. “Lessons for Hospitalists from the 2005 Hurricane Season” (left) summarizes some of the lessons learned from the 2005 hurricane season to date. Every hospital will have to look at disaster plans and make changes based on what we’ve learned. Self-sufficiency for 48 hours is probably a less-than-ambitious goal; we may need to think in terms of planning for a week or more. Certainly, hospitalists will need to take leadership roles. TH

Contributor Jeannette Wick, RPh, MBA, is a senior clinical research pharmacist at the NIH in Bethesda, Md. The opinions expressed herein are those of the author and not necessarily those of any government agency.

When a hospitalist steps outside during a seemingly unending shift, and a city is silent but for the bark of dogs, something is wrong. When he returns not to a scheduled shift, but to an undefined “tour of duty,” something is very wrong. Such has been the case for many hospitalists and healthcare providers along the Gulf Coast since Hurricane Katrina first devastated miles of the coast in August, and then Hurricane Rita hammered home our vulnerability to natural disasters in September. These sentinel experiences offer learning points for our nation’s healthcare system. “Challenges Hospitals Encountered During the 2005 Hurricane Seasons” (p. 8) lists some of the areas in which hospitals and healthcare providers were tested.

Half the Battle: Getting There

Eniola Otuseso, MD, a hospitalist who works in locum tenens positions across the southeast, calls Atlanta home. Her native Nigeria does not have hurricanes—their natural disasters are dust storms and monsoons—so she had never experienced one. The day before Hurricane Katrina hit, Dr. Otuseso had departed for her next job at Cogent Healthcare’s program at St. Dominic-Jackson Memorial Hospital (Miss.). Unable to take the last flight of the day, she packed a rental car and she, her 22-month-old son, and her teenage niece set off on the 380-mile journey to Jackson, Miss. Her account of the ride gives new meaning to the term “Sunday drive.”

MapQuest directions in hand, Dr. Otuseso took I-20 west toward Mississippi. From the road she called the hotel where she had reservations, only to find them canceled due to overbooking. She proceeded with nervous jitters: She had to report to work at 10 a.m. So she found another hotel, spent the night, and set out again at 6 a.m. Monday.

Then she had another problem: Although she thought she was on I-20 west, she had accidentally taken route 59 south—directly into New Orleans and the brunt of the storm. She notified the hospital that she was on the way, and promptly lost phone service. “I realized I needed to turn around and got off at the next exit, but a tree had blocked the road,” says Dr. Otuseso. “No one was around.”

She took the one-way exit back as trees fell around her. Her nervous jitters escalated to panic.

When a tree fell in front of her car, her attempted circumvention landed the car in the mud, and she ran out of gas trying to dislodge it. Miraculously, she had phone service, but the appalled 9-1-1 operators couldn’t help. Finally, a motorist and his adult passenger stopped and offered a ride. Dr. Otuseso and her wards climbed into the good Samaritan’s vehicle, and they were off again. The frequent need to get out of the car to haul trees from the road slowed their journey.

Finally, the mud was too thick and they became stuck. She managed to reach a nearby house on foot, and the owner used his tractor to move the car. He also offered them respite in his home with his wife and baby. A drenched, discouraged Dr. Otuseso and her children accepted the offer and were ferried there by tractor; her previous companions slogged on.

Dr. Otuseso is a graduate of Medical College of Georgia (Augusta). The rural family that housed her was was uneducated in some of the basics of preventive healthcare. Although culturally and in terms of health beliefs Dr. Otuseso and the family that sheltered her could not have been more different, the host family offered remarkable hospitality by providing food and clothing.

“Tragedy brings different people together,” Dr. Otuseso told her niece. The next day, the hurricane had passed, and the host family transported her to Hattiesburg, Miss., a town a mere 100 miles north of New Orleans. She needed basics: shelter and transportation. Hattiesburg’s hotel lacked power and water, and gas was scarce. Eventually, Dr. Otuseso convinced a service station owner to help her retrieve her rental car and fill it with gas. She then set off for Jackson.

On arrival in Jackson, she checked into another hotel with no water or electricity, but eventually made it to work Tuesday. The hospital had electricity and an endless stream of patients. Dr. Otuseso says that her experience made her more empathetic to patients. She could understand the extent of their loss. And after a lifetime of giving to others, she learned to accept help, hospitality, and assistance from others.

In New Orleans

Rob Minkes, MD, chief of pediatric surgery at Louisiana State University and Children’s Hospital (both of New Orleans) started a shift on Sunday, August 28 that became a four-day tour of duty. With him were more than 700 patients, families, and staff. Throughout the ordeal, they had Internet access and intermittent phone service. It was almost business-as-usual: All employees reported for work, and they even performed procedures in the surgical suite.

Once the storm passed, patients of all ages began to appear needing help. With them came strangers who threatened the hospital’s safety Employees could see looters from the windows. Some visitors who had no official purpose roamed the halls causing fear and despair among employees; although they were few and far between, they created chaos. Once the interlopers were escorted out, the hospital locked down. Lacking armed guards, they contacted local, state, and federal authorities for help, but none came.

“The situation became surreal, like a Stephen King novel,” explains Dr. Minkes. “There was just enough of what was normal, but the workplace and general life began to blend into some kind of limbo.”

He praises staff members who kept doing their jobs. The physicians made rounds, the nurses provided care, the housekeepers cleaned. “People can behave commendably in a crisis,” says Dr. Minkes, who noted that Children’s Hospital was well prepared and their disaster training was effective. The hospital was so prepared, in fact, that it was able to divert a fuel shipment that arrived Monday or Tuesday to a nearby facility that had a greater need.

On Wednesday morning, Children’s Hospital lost water pressure, so running water and air conditioning were history. Hospital leadership made the decision to evacuate patients and staff using any available means. Some neighboring hospitals sent helicopters. A convoy of ambulances and SUVs, staffed with care providers using hand-bag ventilators, set out for Baton Rouge. Those patients well enough were discharged. Hospital leadership received word that the National Guard had aircraft at the airport and could take remaining patients if they could be there by 7 p.m.

John Heaton, MD, chief anesthesiologist for Children’s Hospital, led a caravan of 40 cars, trucks, and SUVs to the interstate and onward to the airport. Staff members returned to the hospital despite worsening violence and health hazards in the city. Wednesday turned to the early hours of Thursday with only a few ICU patients remaining at Children’s.

At 4 a.m. a state trooper who came to support a chopper that was evacuating a patient recommended that staff prepare to evacuate at first light because of increasing danger due to flooding and looting in the city. Until then, Children’s had had very little contact with authorities, and basically made its decisions in isolation. One caravan of employees left with a police escort shortly thereafter. The remaining staff made their way unescorted when the last patient left for safety at 8 a.m., leaving a facility that had operated nobly despite Mother Nature’s wrath and security issues. When staff members left, Children’s Hospital had sustained only two broken windows.

Dr. Minkes praises the staff of every department, and indicates that leadership withstood this test. “The day after the hurricane, we were prepared to stay for two to six weeks,” he says.

When asked if he saw any skill used that surprised him in its utility, he hastens to say that they had power and water for most of the ordeal. He noted, however, that their chief of anesthesiology, an ardent fisher and hunter, calculated how high the waters would rise if the levies broke using a tool he retrieved from the Internet. He assured the staff that the water would not reach Children’s Hospital. It helped people’s spirits immensely.

Back to Jackson

Meanwhile, Dr. Otuseso was seeing an influx of patients in Jackson. With her, Lancy Clark, a registered nurse and Cogent Healthcare Program manager who liaises between St.Dominic-Jackson Memorial Hospital’s hospitalists and community physicians, was frankly shocked. The St.Dominic-Jackson facility staff—150 miles from Gulfport—had not thought that the devastation would reach them. It did.

With no electricity or water, St. Dominic-Jackson’s internal and external communication was in a shambles. Their backup: using the telephone, personal cell phones, and overhead page system. Although the county’s priority was to restore power and water to hospitals, its employees were working in the dark. And county-wide gas shortages meant that staff had difficulty reporting to work. Fortunately, the county gave healthcare providers head-of-the-line privileges for fuel.

“I was amazed at how fast people bounced up and worked,” says Clark. “We were all counselors. We often cried with patients as they told us their stories. We used all the resources we could to help emotionally and financially.”

In all of this, the healthcare providers, too, were victims; many have strong roots and family in the devastated communities.

As the adrenaline rush subsided and things started to be a little more normal, care providers began to feel the effects of the strain. All Clark wanted to do was sit in a chair and sink deep into it. Some experts call this compassion fatigue. It is a unique type of burnout experienced by people in fields that provide care for people under extreme circumstances, or the stress of caring for people who are scared, in pain, and/or suffering. Critical incident stress management and debriefing exercises are two ways to alleviate compassion fatigue. Clark indicates that Cogent Healthcare has plans to hold debriefings so they can apply what they learned.

Westward Bound

Some Hurricane Katrina evacuees found their way to Galveston, Texas. Two physicians on the faculty of the University of Texas Medical Branch (UTMB) at Galveston, Janice Smith, MD, and Donna Weaver, MD, worked in a Red Cross clinic assembled in a Methodist church’s indoor racquetball court.

Like hundreds of others, Dr. Smith responded to the call for volunteers early in the process to help the 300 evacuees. She says that there were many bureaucracies, and their nurse-coordinator handled them all well. In terms of challenges, “Every few hours, policies and procedures would change,” says Dr. Smith. “There was no interclinic communication, and roles were unclear. Although it was emotionally difficult seeing patients who had lost everything, that was the easy part compared to dealing with constant change.”

Dr. Weaver, who is codirector for Center for Training in International Health and teaches the Practice of Medicine course at UTMB at Galveston, responded to a request to describe her previous experience in one word: “Nicaragua.”

She often volunteers in Nicaragua (as does Dr. Smith) and in rural U.S. communities they open clinics in people’s homes. Dr. Weaver says the “organized disorganization” of a pharmacy stocked with samples, borrowed supplies and equipment, and no lab facilities created a situation in which physicians had to rely on medical clinical skills. People came with nothing, and medical records were unavailable. The medical history—just what the patient could tell them—was the cornerstone of treatment.

“The low-tech physicians did well,” she says. Listening skills became key. Dr. Weaver intends to reinforce that lesson with her students.

Both physicians could identify gaps that would have been nice to fill. Dr. Smith said that having an on-site dentist would have helped the many people suffering from toothaches. She also appreciates geographic prescribing differences more now, and would have liked to have had a pharmacist there to tell them what certain drugs were or suggest therapeutic alternatives. Dr. Weaver said privacy was at a premium—a situation that was uncomfortable for providers and patients alike. As each day passed, more barriers and walls were rigged to try to improve privacy.

Desk Jockeys No More

Anthony Campbell, RPh, DO, an internist and a pharmacist, and Joseph Matthews, RS, a sanitarian, were deployed together as part of a United States Public Health Service (USPHS) team. They landed in Louisiana to find their accommodations sufficient: a cot in one of five tents at Camp Allen that housed around 125 responders each. Both of these USPHS-commissioned officers had prior hospital-based practices in one of Washington, D.C.’s poorest neighborhoods. It was perhaps this recent experience that made them prime candidates to be plucked from desk jobs and jettisoned back into a stressed clinical milieu. While experience prepared them for the issues of indigence and poverty, it did not temper their reactions to the devastation and exposure to elements.

Their reunion made the task less challenging but the work they did was grueling. Dr. Campbell and Matthews traveled through parishes conducting needs assessments at Red Cross shelters in Washington Parish during the first week. The days were long—sometimes beginning at 5 a.m. and ending after 11 p.m.—and impossibly hot.

Both were impressed with people’s positive attitudes. Many shelters were overcrowded and lacked bathing facilities. Members of the community welcomed displaced people into their homes to shower and took turns preparing copious quantities of food. In a significantly overcrowded shelter, the Federal Emergency Management Agency (FEMA) tried to move people to hotels; often, unrelated people who had been neighbors or who had weathered the storm together would refuse to go unless they could go together. A group of retirees from Maine who were visiting New Orleans, for example, insisted on staying together even if it was in the crowded shelter. This was an unanticipated dynamic.

Matthews talked about what he called, “the changing theater,” a military term that describes the need to change plans frequently when conditions of austerity dictate it. He indicates that many clinicians were unacquainted with the principle of gathering your assets and regrouping when plans take an about-face. That was the case throughout their deployment.

During the second week, Dr. Campbell moved closer to New Orleans, and Matthews went to the area’s largest animal shelter, a place with five huge barns, two filled with horses and three with smaller pets. In the chaos there, his main concern was not the lack of volunteers—they had plenty—but the frequent disregard for human health risks as they handled hungry pets that had been plucked from toxic floodwaters. The need to take universal precautions is not a universal belief. Just trying to get people to wear gloves was an ordeal. The volunteers were often unaware of their own cuts and bruises, and worked relentlessly.

Matthews laughed as he related a story of the volunteers’ compassion. It was late in the evening, and his transport had not arrived. Concerned, he called the base operation and learned that he’d been forgotten. He started to melt down with anger and fatigue. A group of volunteers quickly surrounded him with comfort and reassurance; they thought he was upset because he couldn’t find his pet! It restored his sense of humor and balance.

Meanwhile, Dr. Campbell was knocking on doors in a housing project, looking for people with health needs. Care was centrally located in Washington Parish, but lacking communication methods and transportation, many residents didn’t know about the help offered there. He relied on the project’s resident manager to help his team. The manager often knew who had been evacuated, how many children lived in units, and who was older and remained.

Dr. Campbell cites the heat and incredible stench as indelible memories. His deployment ended in New Orleans. Even in the French Quarter, which sits on higher ground, the air was thick with the smell of rotting food that had been removed from freezers to prevent it from ruining equipment. (Clark in Mississippi also mentioned the memorable foul odor of rotting food.) He understands now why police officers and forensics workers carry Vicks VapoRub to dab under their nose when they find a decomposed body.

Dr. Campbell indicates that the Red Cross shelters needed more trained medical personnel, although they had ample donations of medication from doctors’ offices in the form of samples, and from hospitals and pharmacies. They did not have a pharmacist, however, and he relied on his dual training to provide some of the services that Dr. Smith in Galveston also identified. He was saddened by the devastation. He visited the Superdome and indicates that the debris and human waste told a sad and shocking story.

Patient Satisfaction

Sixty-year-old patient Emelda Zar evacuated from LaFitte, La., before Hurricane Katrina. She landed in a crowded but hospitable shelter in Jackson, Miss. Some days later, her daughter called an ambulance as Zar’s health deteriorated. She was admitted to St. Dominic-Jackson Memorial Hospital and diagnosed with heart failure.

Recently discharged and about to relocate to an apartment and planning to remain in Jackson, she and her grandchildren have nothing but good things to say about the hospital and, in particular, the hospitalists who provided care.

She arrived with no medical records and a serious health problem. Her hospitalists listened and created a care plan. She left the hospital with not only a clear idea of what she needs to do, but with a scheduled follow-up appointment in the community. Like so many of the people we heard about from healthcare providers, she remains upbeat and optimistic.

Progress Notes

Shortly after Dr. Smith and Dr. Weaver were interviewed in Galveston, the news was full of a new threat: Rita. This time, the hurricane’s target was a few hundred miles west of Katrina’s path. Karen Sexton, RN, PhD, vice president and chief executive officer of Hospitals and Clinics for UTMB shared the story of how Katrina changed their response.

During routine monitoring they saw tropical depression #18 develop on Sunday to the point that it was named Rita on Monday, and began to look like trouble for Galveston. By Tuesday, the city mayor had declared a voluntary evacuation, applying one lesson from Katrina: Residents could take their pets in government evacuation vehicles. The university went on emergency status. UTMB looked at decreasing their activity and reducing the hospital census. They sent the students home.

Tuesday night, their hospitalist service and other key physicians wrote transfer summaries for all patients, beginning with those who were gravely ill. This was a change of policy based on their experience with Katrina. They chose to move critically ill patients while they had the greatest control. The pharmacy prepared medication for all patients, and parts of medical records deemed most important were copied.

Wednesday dawned, and it was clear: Rita was coming in as a level 4 or 5 hurricane. For the first time in 114 years of existence, UTMB evacuated under Dr. Sexton’s direction as the incident commander. Using resources sent in part by the governor, their team discharged and evacuated 427 patients in 12 hours.

“We were all a little teary eyed when the first patient left,” says Dr. Sexton. “We knew we had never evacuated before and we knew were making history.”

Key to the success of UTMB’s evacuation were checklists on the units and at two evacuation stations. This, too, was something they learned from Katrina: Track patient disposition and send as much information as possible. With the goal of improving patient safety, UTMB recently started training staff on an aviation model that mimics what the aviation industry does to ensure safety.

They tracked what went with the patient, where the patient went, and that family notifications were done. The staff’s increased awareness and use of checklists were key components for a successful evacuation. No patients were “lost.” As the last patient left, Dr. Sexton found herself with a hospital staffed to support 500 to 700 patients, no patients, and the realization that staff also needed to evacuate but might not be able to navigate the exodus traffic.

Another request to the Texas governor’s office put two C130 cargo planes at their disposal. Staff were given three options: Stay at the hospital, leave of their own accord, or take the C130 to shelter in Houston. One-hundred-thirty-one staff members chose the latter option and left Thursday; the same planes brought them back the following Monday.

During the storm, UTMB’s ED remained open and staffed. It was the only operating ED for miles. A burn victim and several firemen who were harmed fighting a tremendous blaze during the storm on Friday proved that remaining open was the right thing to do to for the community.

Although UTMB lost some equipment, blocks of air conditioning, and some power, administrators believe that they made good decisions and emerged almost unscathed.

“I never felt prouder of our staff,” says Dr. Sexton. “This will be a different place because we all did this together.”

Less than a week later, they continue to treat patients from the community, have started admitting patients, and have welcomed some of their critically ill neonates back.

Conclusion

Who believes weather analysts? Often, we look at unwelcome weather forecasts and dismiss them, thinking that it always sounds worse than it is. Hospitalists and healthcare providers who weathered Katrina and Rita, and who are still working with the aftermath are probably more apt to listen to future dire weather predictions. “Lessons for Hospitalists from the 2005 Hurricane Season” (left) summarizes some of the lessons learned from the 2005 hurricane season to date. Every hospital will have to look at disaster plans and make changes based on what we’ve learned. Self-sufficiency for 48 hours is probably a less-than-ambitious goal; we may need to think in terms of planning for a week or more. Certainly, hospitalists will need to take leadership roles. TH

Contributor Jeannette Wick, RPh, MBA, is a senior clinical research pharmacist at the NIH in Bethesda, Md. The opinions expressed herein are those of the author and not necessarily those of any government agency.

Vague laws and debate over use of physical restraint complicate management of dangerous patients. Restraints have historically been over-used in psychiatry, even contributing to patients’ deaths. Still, many psychiatric facilities grapple with a reluctance to use restraint versus a need to protect patients from themselves and from harming others.

The law requires use of “least-restrictive interventions” to manage patients, but clinicians cannot agree on what this term means. This article offers tips to maximize patient safety when using restraints and advice on when to use them.

Psychotic man breaks neck jumping into window

Dane County (WI) Circuit Court

A 40-year-old man was hospitalized during a psychotic episode, in which he acted out aural hallucinations.

The man—who was previously diagnosed with schizophrenia—received a dose of haloperidol, and at least two guards escorted him to a room in the psychiatric unit. While left with a nurse, he tried to smash a window. The nurse hit a panic button to summon help, but the patient climbed on top of his bed and dove headfirst into a shatterproof glass. He fractured his neck and became quadriplegic.

In court, the patient’s attorney argued that the hospital was negligent in its failure to restrain him from harming himself. The patient died shortly after the trial from complications of quadriplegia.

• The jury’s verdict, $13 million, was reduced to approximately $7 million because of a statutory capitation.
  

Dr. Grant’s observations

The legal issue here is not simply whether the staff failed to prevent the patient from harming himself. Instead, the jury believed a reasonable person could have foreseen danger to the patient, thereby deeming the hospital negligent.

I’m not suggesting that all psychotic patients be restrained to prevent litigation. This case, however, illustrates the importance of assessing patients for dangerousness and intervening appropriately. Because the patient acted out his hallucinations and required two guards to escort him to his room, one could argue that one nurse could not adequately manage this patient.

When restraints are necessary, assess and document the patient’s behavior and the reasons that necessitate restraints. In this case, for example, record that medication alone did not sufficiently calm this patient.

One-on-one verbal and behavioral interventions can be effective alternatives to seclusion and restraint (Table 1).^1,2 Predictably, patients respond negatively to restraints, preferring medication instead.⁴ When less-restrictive, behavioral, or pharmacologic measures fail, consider restraints to protect aggressive, assaultive patients.

Table 1

Possible alternatives to restraints

Security personnel asphyxiate woman

Pima County (AZ) Superior Court

A 32-year-old woman with a history of psychiatric disorders was admitted to a county hospital’s psychiatric department. Several guards and security technicians held her face down on the floor for 15 to 30 minutes. The patient struggled to breathe, turned blue, then stopped breathing. She died of asphyxiation.

The estate sued both the county and the security technicians’ employer, claiming the guards were not properly trained on patient restraint.

• A $105,000 settlement with the county was reached; a confidential settlement was reached with the security employer.
  

Dr. Grant’s observations

This case shows how improper use of restraints may result in a successful lawsuit.

In 1998, the Hartford Courant ran a series of articles alleging that seclusion and restraint in a psychiatric setting led to 142 deaths across 10 years.⁵ State and federal legislation passed after the newspaper’s report has focused on protecting patients from improper use of restraints. Be aware of your state’s and hospital’s regulations. The guidelines in Table 2 reflect general policies for using restraints suggested by the Joint Commission on Accreditation of Health-care Organizations.⁶

Restraints should be used only by trained staff and for only as long as the patient is dangerous to self or others. Also assess patients who may be at increased risk for physical or psychological difficulties if restrained or secluded and consider alternate interventions. Generally, restraints should be avoided in patients with the following relative contraindications:

• pregnant
  
• history of breathing problems
  
• head or spinal injuries
  
• history of recent fractures or surgeries
  
• seizure disorder
  
• history of sexual or physical abuse.
  

Table 2

Guidelines for proper restraint use

Unmonitored suicidal man suffocates himself

Tarrant County (TX) District Court

A 26-year-old man in the suicide prevention unit of a community hospital suffocated himself using a vinyl pillowcase from his room and cellophane wrap from the hospital’s kitchen.

For more than 40 minutes before finding the patient dead, staff had not documented checking the patient’s room, which was required every 15 minutes. Paramedics documented the beginning of rigor mortis.

The estate claimed the hospital had not adequately monitored the patient despite clear indications of suicidality. In the days preceding his death, records showed a deteriorating condition related to problems with his companion, who had told him she was leaving the home they shared. He previously attempted suicide when she threatened to move out and had injured himself on similar occasions.

At the time of his death, four staff members were on duty; one claimed to have seen the patient 5 minutes before he was found. The estate contended that more than 1 hour would have been required for rigor mortis to develop.

• A settlement of $1.1 million was reached.
  

Dr. Grant’s observations

Immediately assess suicidal patients and their environment to reduce the risk of self-harm. One-on-one observation has been found to be most effective⁷ and should be required for patients with severe suicide risk. All suicidal patients should (at minimum) be visible to staff members at all times to maintain safety standards.⁷ Frequently document the patient’s location, activities, and behavior.

To ensure a safe environment for suicidal patients, identify and minimize risk factors associated with hospital settings.⁸ For example, access to cellophane wrap in this case should have been blocked. Ensure that suicidal patients cannot reach materials they could use to harm themselves such as pillowcases, drapery cords, ingestible cleaning supplies, shower curtains and rods, and breakable objects.

Vague laws and debate over use of physical restraint complicate management of dangerous patients. Restraints have historically been over-used in psychiatry, even contributing to patients’ deaths. Still, many psychiatric facilities grapple with a reluctance to use restraint versus a need to protect patients from themselves and from harming others.

The law requires use of “least-restrictive interventions” to manage patients, but clinicians cannot agree on what this term means. This article offers tips to maximize patient safety when using restraints and advice on when to use them.

Psychotic man breaks neck jumping into window

Dane County (WI) Circuit Court

A 40-year-old man was hospitalized during a psychotic episode, in which he acted out aural hallucinations.

The man—who was previously diagnosed with schizophrenia—received a dose of haloperidol, and at least two guards escorted him to a room in the psychiatric unit. While left with a nurse, he tried to smash a window. The nurse hit a panic button to summon help, but the patient climbed on top of his bed and dove headfirst into a shatterproof glass. He fractured his neck and became quadriplegic.

In court, the patient’s attorney argued that the hospital was negligent in its failure to restrain him from harming himself. The patient died shortly after the trial from complications of quadriplegia.

• The jury’s verdict, $13 million, was reduced to approximately $7 million because of a statutory capitation.
  

Dr. Grant’s observations

The legal issue here is not simply whether the staff failed to prevent the patient from harming himself. Instead, the jury believed a reasonable person could have foreseen danger to the patient, thereby deeming the hospital negligent.

I’m not suggesting that all psychotic patients be restrained to prevent litigation. This case, however, illustrates the importance of assessing patients for dangerousness and intervening appropriately. Because the patient acted out his hallucinations and required two guards to escort him to his room, one could argue that one nurse could not adequately manage this patient.

When restraints are necessary, assess and document the patient’s behavior and the reasons that necessitate restraints. In this case, for example, record that medication alone did not sufficiently calm this patient.

One-on-one verbal and behavioral interventions can be effective alternatives to seclusion and restraint (Table 1).^1,2 Predictably, patients respond negatively to restraints, preferring medication instead.⁴ When less-restrictive, behavioral, or pharmacologic measures fail, consider restraints to protect aggressive, assaultive patients.

Table 1

Possible alternatives to restraints

Security personnel asphyxiate woman

Pima County (AZ) Superior Court

A 32-year-old woman with a history of psychiatric disorders was admitted to a county hospital’s psychiatric department. Several guards and security technicians held her face down on the floor for 15 to 30 minutes. The patient struggled to breathe, turned blue, then stopped breathing. She died of asphyxiation.

The estate sued both the county and the security technicians’ employer, claiming the guards were not properly trained on patient restraint.

• A $105,000 settlement with the county was reached; a confidential settlement was reached with the security employer.
  

Dr. Grant’s observations

This case shows how improper use of restraints may result in a successful lawsuit.

In 1998, the Hartford Courant ran a series of articles alleging that seclusion and restraint in a psychiatric setting led to 142 deaths across 10 years.⁵ State and federal legislation passed after the newspaper’s report has focused on protecting patients from improper use of restraints. Be aware of your state’s and hospital’s regulations. The guidelines in Table 2 reflect general policies for using restraints suggested by the Joint Commission on Accreditation of Health-care Organizations.⁶

Restraints should be used only by trained staff and for only as long as the patient is dangerous to self or others. Also assess patients who may be at increased risk for physical or psychological difficulties if restrained or secluded and consider alternate interventions. Generally, restraints should be avoided in patients with the following relative contraindications:

• pregnant
  
• history of breathing problems
  
• head or spinal injuries
  
• history of recent fractures or surgeries
  
• seizure disorder
  
• history of sexual or physical abuse.
  

Table 2

Guidelines for proper restraint use

Unmonitored suicidal man suffocates himself

Tarrant County (TX) District Court

A 26-year-old man in the suicide prevention unit of a community hospital suffocated himself using a vinyl pillowcase from his room and cellophane wrap from the hospital’s kitchen.

For more than 40 minutes before finding the patient dead, staff had not documented checking the patient’s room, which was required every 15 minutes. Paramedics documented the beginning of rigor mortis.

The estate claimed the hospital had not adequately monitored the patient despite clear indications of suicidality. In the days preceding his death, records showed a deteriorating condition related to problems with his companion, who had told him she was leaving the home they shared. He previously attempted suicide when she threatened to move out and had injured himself on similar occasions.

At the time of his death, four staff members were on duty; one claimed to have seen the patient 5 minutes before he was found. The estate contended that more than 1 hour would have been required for rigor mortis to develop.

• A settlement of $1.1 million was reached.
  

Dr. Grant’s observations

Immediately assess suicidal patients and their environment to reduce the risk of self-harm. One-on-one observation has been found to be most effective⁷ and should be required for patients with severe suicide risk. All suicidal patients should (at minimum) be visible to staff members at all times to maintain safety standards.⁷ Frequently document the patient’s location, activities, and behavior.

To ensure a safe environment for suicidal patients, identify and minimize risk factors associated with hospital settings.⁸ For example, access to cellophane wrap in this case should have been blocked. Ensure that suicidal patients cannot reach materials they could use to harm themselves such as pillowcases, drapery cords, ingestible cleaning supplies, shower curtains and rods, and breakable objects.

Vague laws and debate over use of physical restraint complicate management of dangerous patients. Restraints have historically been over-used in psychiatry, even contributing to patients’ deaths. Still, many psychiatric facilities grapple with a reluctance to use restraint versus a need to protect patients from themselves and from harming others.

The law requires use of “least-restrictive interventions” to manage patients, but clinicians cannot agree on what this term means. This article offers tips to maximize patient safety when using restraints and advice on when to use them.

Psychotic man breaks neck jumping into window

Dane County (WI) Circuit Court

A 40-year-old man was hospitalized during a psychotic episode, in which he acted out aural hallucinations.

The man—who was previously diagnosed with schizophrenia—received a dose of haloperidol, and at least two guards escorted him to a room in the psychiatric unit. While left with a nurse, he tried to smash a window. The nurse hit a panic button to summon help, but the patient climbed on top of his bed and dove headfirst into a shatterproof glass. He fractured his neck and became quadriplegic.

In court, the patient’s attorney argued that the hospital was negligent in its failure to restrain him from harming himself. The patient died shortly after the trial from complications of quadriplegia.

• The jury’s verdict, $13 million, was reduced to approximately $7 million because of a statutory capitation.
  

Dr. Grant’s observations

The legal issue here is not simply whether the staff failed to prevent the patient from harming himself. Instead, the jury believed a reasonable person could have foreseen danger to the patient, thereby deeming the hospital negligent.

I’m not suggesting that all psychotic patients be restrained to prevent litigation. This case, however, illustrates the importance of assessing patients for dangerousness and intervening appropriately. Because the patient acted out his hallucinations and required two guards to escort him to his room, one could argue that one nurse could not adequately manage this patient.

When restraints are necessary, assess and document the patient’s behavior and the reasons that necessitate restraints. In this case, for example, record that medication alone did not sufficiently calm this patient.

One-on-one verbal and behavioral interventions can be effective alternatives to seclusion and restraint (Table 1).^1,2 Predictably, patients respond negatively to restraints, preferring medication instead.⁴ When less-restrictive, behavioral, or pharmacologic measures fail, consider restraints to protect aggressive, assaultive patients.

Table 1

Possible alternatives to restraints

Security personnel asphyxiate woman

Pima County (AZ) Superior Court

A 32-year-old woman with a history of psychiatric disorders was admitted to a county hospital’s psychiatric department. Several guards and security technicians held her face down on the floor for 15 to 30 minutes. The patient struggled to breathe, turned blue, then stopped breathing. She died of asphyxiation.

The estate sued both the county and the security technicians’ employer, claiming the guards were not properly trained on patient restraint.

• A $105,000 settlement with the county was reached; a confidential settlement was reached with the security employer.
  

Dr. Grant’s observations

This case shows how improper use of restraints may result in a successful lawsuit.

In 1998, the Hartford Courant ran a series of articles alleging that seclusion and restraint in a psychiatric setting led to 142 deaths across 10 years.⁵ State and federal legislation passed after the newspaper’s report has focused on protecting patients from improper use of restraints. Be aware of your state’s and hospital’s regulations. The guidelines in Table 2 reflect general policies for using restraints suggested by the Joint Commission on Accreditation of Health-care Organizations.⁶

Restraints should be used only by trained staff and for only as long as the patient is dangerous to self or others. Also assess patients who may be at increased risk for physical or psychological difficulties if restrained or secluded and consider alternate interventions. Generally, restraints should be avoided in patients with the following relative contraindications:

• pregnant
  
• history of breathing problems
  
• head or spinal injuries
  
• history of recent fractures or surgeries
  
• seizure disorder
  
• history of sexual or physical abuse.
  

Table 2

Guidelines for proper restraint use

Unmonitored suicidal man suffocates himself

Tarrant County (TX) District Court

A 26-year-old man in the suicide prevention unit of a community hospital suffocated himself using a vinyl pillowcase from his room and cellophane wrap from the hospital’s kitchen.

For more than 40 minutes before finding the patient dead, staff had not documented checking the patient’s room, which was required every 15 minutes. Paramedics documented the beginning of rigor mortis.

The estate claimed the hospital had not adequately monitored the patient despite clear indications of suicidality. In the days preceding his death, records showed a deteriorating condition related to problems with his companion, who had told him she was leaving the home they shared. He previously attempted suicide when she threatened to move out and had injured himself on similar occasions.

At the time of his death, four staff members were on duty; one claimed to have seen the patient 5 minutes before he was found. The estate contended that more than 1 hour would have been required for rigor mortis to develop.

• A settlement of $1.1 million was reached.
  

Dr. Grant’s observations

Immediately assess suicidal patients and their environment to reduce the risk of self-harm. One-on-one observation has been found to be most effective⁷ and should be required for patients with severe suicide risk. All suicidal patients should (at minimum) be visible to staff members at all times to maintain safety standards.⁷ Frequently document the patient’s location, activities, and behavior.

To ensure a safe environment for suicidal patients, identify and minimize risk factors associated with hospital settings.⁸ For example, access to cellophane wrap in this case should have been blocked. Ensure that suicidal patients cannot reach materials they could use to harm themselves such as pillowcases, drapery cords, ingestible cleaning supplies, shower curtains and rods, and breakable objects.

Hospital work in psychiatry has a long, proud tradition. The severely mentally ill were housed in asylums in the historical past. In fact the origin of the word “bedlam” is derived from the pronunciation of Bethlehem and came to be synonymous with chaos. Bethlehem was the name of an insane asylum in London. Some aspects of current psychiatric hospital care still feel like bedlam.

A typical day for an inpatient psychiatrist involves rounding individually after a team meeting with social workers, nurses, and other members of the treatment team to determine events and observations during the previous 24 hours. The primary reasons for admission to inpatient services are imminent risk to self or others (suicide or homicide), psychotic disorders with inability to function, or severe anxiety or depression with inability to function. Geriatric units often deal with behavioral dyscontrol secondary to dementing illnesses or other neurologic disorders.

PSYCH ADMISSIONS

Practically speaking, the vast majority of admissions result from concerns related to the safety of the patient or others. For inpatient psychiatry the focus is acute stabilization and safety. This focus on stabilization often involves collaborating with outpatient members of the patient’s treatment team, including case managers and outside psychiatrists and therapists. Involving family in obtaining the patient’s collateral history is vital. The goal is to develop a treatment plan to address support, reasons for suicide, access to means for suicide, and treat underlying psychiatric syndromes.

Nonadherence to medication is another primary reason for admission. Patients with bipolar disorder, depression, and schizophrenia often stop taking their medications. Some of this is related to the underlying illness, while some is related to difficulties associated with medication side-effect profiles. Often, psychotic patients may have a fairly dramatic change in control of their symptoms after restarting their previous medications.

PSYCHIATRISTS IN HOSPITALS

Primary hospital work is not uncommon in the United States. A common arrangement is for a single psychiatrist or small group of psychiatrists to primarily manage an inpatient practice and see outpatients in the afternoon, depending on the size of the hospital.

Many psychiatrists lack interest in inpatient work, however. This lack of interest is related to the severity of symptoms, legal interface, call, and challenges with coordinating inpatient care with an outpatient practice.

The advantages of a dedicated psychiatric hospital practice are the same as for other hospitalists: The hospitalist develops both efficiencies and best practices based on seeing severe and complex problems repeatedly. They may also have knowledge of the community resources for the severely ill, which private outpatient psychiatrists may not be familiar with.

Psychiatric hospital work is always interesting and a great opportunity to work with severely ill patients who can be helped dramatically. The treatment is team-focused and offers the chance to work closely with social work, nursing, occupational therapy, psychology, and the community. It also allows for experience working with lawyers and the court system on a regular basis. Additionally, there’s often an opportunity to develop expert witness skills in some settings.

Academically, inpatient work is critical to resident and medical student education. It provides a chance for developing physicians to see and understand the realities and suffering associated with mental illness and their medical basis.

Psychiatric hospital medicine is emotionally intense work. Burnout is a major concern.

Many patients are not in the hospital voluntarily and don’t have insight into their illness. Nonadherence to treatment is common and the factor behind many admissions. Behaviorally, patients may be out of control from psychosis or severe personality disorders. Many have traumatic psychosocial histories and lack social supports. A number face legal charges. The intensity of practice is also due to the pressures of time, shortages of services for the mentally ill as outpatients, and pressures from both managed care and regulatory agencies.

EVOLUTION OF THE SPECIALTY

The state of hospital psychiatry has changed greatly in the past 40 or 50 years. The introduction of the antipsychotics solely for schizophrenia means we can now treat those previously thought untreatable. With the discovery and application of other treatments for mental illness, a movement developed to end the institutionalization of the mentally ill and integrate them back into the community. Other societal forces include the patient rights movement that has led to changes in the law and a needed focus on the rights of the mentally ill—both for minimums of treatment provided and protection against unnecessary hospitalization. State and federal budgetary and managed care pressures have also contributed to the remarkable changes in hospital psychiatry.

This combination of changes from medical, legal, societal, and fiscal forces has slashed the number of available inpatient beds and lengths of stays. In 1970 there were 413,066 state and county psychiatric inpatient beds in the United States.1 By 2000 that number had decreased to 59,403. There has been a moderate increase in private and community psychiatric beds in response. However, even considering this increase, the total number of beds in 1970 was

524,878 and the total in 2000 was 215,221. There have been continued reductions in beds since then nationally. Along with this decrease in psychiatric beds has come a dramatic shift in average length of stay as well. The general average length of stay in the United States is less than one week for psychiatric hospitalization.

The hope with decreasing the number of beds has been that a focus on community-based treatment and programs to support those with severe mental illness would be available to meet the needs of the severely mentally ill. Unfortunately, though the intent and goals were laudable, those programs have not developed as hoped. Current challenges for the seriously mentally ill include lack of parity for mental illness for insurance, continued pressure on private psychiatric beds to fill in the gaps of services not met by the community along with continued cuts in state and federal funding for inpatient psychiatric care.

This decrease in beds combined with decreased average length of stay and an increase in population has led to more and more pressure on the limited psychiatric beds available. It’s not uncommon now for patients to remain in the emergency department for 24 hours or longer waiting for a psychiatric bed. Along with these pressures has come decreased availability of inpatient substance abuse treatment, the ubiquitous comorbidity. Managed care review of inpatient stays on an almost daily basis, and the ever-increasing demands of documentation to meet regulatory requirements have also increased pressures on hospital psychiatry.

TYPES OF PSYCH HOSPITALIST PROGRAMS

As a result of the trends mentioned above, a variety of psychiatric hospitalist practice settings now exist. They include private and community psychiatric hospitals, academic center hospitals, state hospitals, Veterans Affairs and military hospitals, and—the most rapidly growing sector—correctional psychiatry in state and federal prison systems.

Correctional settings, such as jails and prisons, have been estimated by the Bureau of Justice Statistics to have a prevalence of inmates with mental illness between 7% and 16%.2 The rate of mental illness in inmates is approximately two to three times that of the general population for major mental illnesses such as schizophrenia, bipolar disorder, and major depressive disorder. The mentally ill in prison are more likely to be homeless, medically ill, and chemically dependent than the general population, as well.

Mentally ill inmates serve longer prison sentences on average than their mentally healthy peers. Mentally ill inmates are involved more commonly in disciplinary problems in prison also.

Overall, approximately 60% of mentally ill inmates receive some sort of mental health treatment while in custody. Two-thirds of inmates receiving treatment are in facilities that do not specialize in mental health treatment. Of state prisons, 155 specialize in mental health treatment—out of more than 1,500 facilities surveyed.3 Twelve facilities have mental health treatment as their primary function. Fewer than 2% of state inmates were housed in a mental health unit providing 24-hour care.

Psychiatric hospitalists in specialized treatment correctional settings have the opportunity to perform assessments and provide treatment to a patient population with a prevalence and severity of psychopathology that is not commonly seen in community psychiatric inpatient or outpatient practice today.

CRYSTAL BALL

Inpatient psychiatry will continue to be important in the future. There are great challenges ahead but the need for dedicated hospital psychiatrists won’t go away and will probably increase. The pressures on the shrinking number of inpatient beds will continue to grow. The lack of outpatient services in general and intensive outpatient services available to transition patients to on discharge is frustrating. The continued de-emphasis on availability of substance abuse treatment continues to perplex. TH

Dr. Lineberry is medical director, Psychiatric Acute Care Program, Mayo Psychiatry and Psychology Treatment Center, St. Mary’s Hospital, Rochester, Minn. Dr. Shine is senior associate consultant, Psychiatric Acute Care Program, Mayo Psychiatry and Psychology Treatment Center, St. Mary’s Hospital, Rochester, Minn.

REFERENCES

1. Manderscheid RW, Atay JE, Hernandez-Cartagena MR, et al. Substance Abuse and Mental Health Services Administration, Center for Mental Health Services, U.S. Department of Health and Human Services. Mental Health, United States, 2002. Chapter 18. Highlights of organized mental health services in 2000 and major national and state trends. Available at www.mentalhealth.org/publications/allpubs/SMA04-3938/. Last accessed July 29, 2005.
2. Bureau of Justice Statistics, Department of Justice. Mental health and treatment of inmates and probationers. Available at www.ojp.usdoj.gov/bjs/pub/pdf/mhtip.pdf. Last accessed July 29, 2005.
3. Bureau of Justice Statistics, Department of Justice. Mental health treatment in state prisons. Available at www.ojp.usdoj.gov/bjs/pub/pdf/mhtsp00.pdf. Last accessed July 29, 2005.

Hospital work in psychiatry has a long, proud tradition. The severely mentally ill were housed in asylums in the historical past. In fact the origin of the word “bedlam” is derived from the pronunciation of Bethlehem and came to be synonymous with chaos. Bethlehem was the name of an insane asylum in London. Some aspects of current psychiatric hospital care still feel like bedlam.

A typical day for an inpatient psychiatrist involves rounding individually after a team meeting with social workers, nurses, and other members of the treatment team to determine events and observations during the previous 24 hours. The primary reasons for admission to inpatient services are imminent risk to self or others (suicide or homicide), psychotic disorders with inability to function, or severe anxiety or depression with inability to function. Geriatric units often deal with behavioral dyscontrol secondary to dementing illnesses or other neurologic disorders.

PSYCH ADMISSIONS

Practically speaking, the vast majority of admissions result from concerns related to the safety of the patient or others. For inpatient psychiatry the focus is acute stabilization and safety. This focus on stabilization often involves collaborating with outpatient members of the patient’s treatment team, including case managers and outside psychiatrists and therapists. Involving family in obtaining the patient’s collateral history is vital. The goal is to develop a treatment plan to address support, reasons for suicide, access to means for suicide, and treat underlying psychiatric syndromes.

Nonadherence to medication is another primary reason for admission. Patients with bipolar disorder, depression, and schizophrenia often stop taking their medications. Some of this is related to the underlying illness, while some is related to difficulties associated with medication side-effect profiles. Often, psychotic patients may have a fairly dramatic change in control of their symptoms after restarting their previous medications.

PSYCHIATRISTS IN HOSPITALS

Primary hospital work is not uncommon in the United States. A common arrangement is for a single psychiatrist or small group of psychiatrists to primarily manage an inpatient practice and see outpatients in the afternoon, depending on the size of the hospital.

Many psychiatrists lack interest in inpatient work, however. This lack of interest is related to the severity of symptoms, legal interface, call, and challenges with coordinating inpatient care with an outpatient practice.

The advantages of a dedicated psychiatric hospital practice are the same as for other hospitalists: The hospitalist develops both efficiencies and best practices based on seeing severe and complex problems repeatedly. They may also have knowledge of the community resources for the severely ill, which private outpatient psychiatrists may not be familiar with.

Psychiatric hospital work is always interesting and a great opportunity to work with severely ill patients who can be helped dramatically. The treatment is team-focused and offers the chance to work closely with social work, nursing, occupational therapy, psychology, and the community. It also allows for experience working with lawyers and the court system on a regular basis. Additionally, there’s often an opportunity to develop expert witness skills in some settings.

Academically, inpatient work is critical to resident and medical student education. It provides a chance for developing physicians to see and understand the realities and suffering associated with mental illness and their medical basis.

Psychiatric hospital medicine is emotionally intense work. Burnout is a major concern.

Many patients are not in the hospital voluntarily and don’t have insight into their illness. Nonadherence to treatment is common and the factor behind many admissions. Behaviorally, patients may be out of control from psychosis or severe personality disorders. Many have traumatic psychosocial histories and lack social supports. A number face legal charges. The intensity of practice is also due to the pressures of time, shortages of services for the mentally ill as outpatients, and pressures from both managed care and regulatory agencies.

EVOLUTION OF THE SPECIALTY

The state of hospital psychiatry has changed greatly in the past 40 or 50 years. The introduction of the antipsychotics solely for schizophrenia means we can now treat those previously thought untreatable. With the discovery and application of other treatments for mental illness, a movement developed to end the institutionalization of the mentally ill and integrate them back into the community. Other societal forces include the patient rights movement that has led to changes in the law and a needed focus on the rights of the mentally ill—both for minimums of treatment provided and protection against unnecessary hospitalization. State and federal budgetary and managed care pressures have also contributed to the remarkable changes in hospital psychiatry.

This combination of changes from medical, legal, societal, and fiscal forces has slashed the number of available inpatient beds and lengths of stays. In 1970 there were 413,066 state and county psychiatric inpatient beds in the United States.1 By 2000 that number had decreased to 59,403. There has been a moderate increase in private and community psychiatric beds in response. However, even considering this increase, the total number of beds in 1970 was

524,878 and the total in 2000 was 215,221. There have been continued reductions in beds since then nationally. Along with this decrease in psychiatric beds has come a dramatic shift in average length of stay as well. The general average length of stay in the United States is less than one week for psychiatric hospitalization.

The hope with decreasing the number of beds has been that a focus on community-based treatment and programs to support those with severe mental illness would be available to meet the needs of the severely mentally ill. Unfortunately, though the intent and goals were laudable, those programs have not developed as hoped. Current challenges for the seriously mentally ill include lack of parity for mental illness for insurance, continued pressure on private psychiatric beds to fill in the gaps of services not met by the community along with continued cuts in state and federal funding for inpatient psychiatric care.

This decrease in beds combined with decreased average length of stay and an increase in population has led to more and more pressure on the limited psychiatric beds available. It’s not uncommon now for patients to remain in the emergency department for 24 hours or longer waiting for a psychiatric bed. Along with these pressures has come decreased availability of inpatient substance abuse treatment, the ubiquitous comorbidity. Managed care review of inpatient stays on an almost daily basis, and the ever-increasing demands of documentation to meet regulatory requirements have also increased pressures on hospital psychiatry.

TYPES OF PSYCH HOSPITALIST PROGRAMS

As a result of the trends mentioned above, a variety of psychiatric hospitalist practice settings now exist. They include private and community psychiatric hospitals, academic center hospitals, state hospitals, Veterans Affairs and military hospitals, and—the most rapidly growing sector—correctional psychiatry in state and federal prison systems.

Correctional settings, such as jails and prisons, have been estimated by the Bureau of Justice Statistics to have a prevalence of inmates with mental illness between 7% and 16%.2 The rate of mental illness in inmates is approximately two to three times that of the general population for major mental illnesses such as schizophrenia, bipolar disorder, and major depressive disorder. The mentally ill in prison are more likely to be homeless, medically ill, and chemically dependent than the general population, as well.

Mentally ill inmates serve longer prison sentences on average than their mentally healthy peers. Mentally ill inmates are involved more commonly in disciplinary problems in prison also.

Overall, approximately 60% of mentally ill inmates receive some sort of mental health treatment while in custody. Two-thirds of inmates receiving treatment are in facilities that do not specialize in mental health treatment. Of state prisons, 155 specialize in mental health treatment—out of more than 1,500 facilities surveyed.3 Twelve facilities have mental health treatment as their primary function. Fewer than 2% of state inmates were housed in a mental health unit providing 24-hour care.

Psychiatric hospitalists in specialized treatment correctional settings have the opportunity to perform assessments and provide treatment to a patient population with a prevalence and severity of psychopathology that is not commonly seen in community psychiatric inpatient or outpatient practice today.

CRYSTAL BALL

Inpatient psychiatry will continue to be important in the future. There are great challenges ahead but the need for dedicated hospital psychiatrists won’t go away and will probably increase. The pressures on the shrinking number of inpatient beds will continue to grow. The lack of outpatient services in general and intensive outpatient services available to transition patients to on discharge is frustrating. The continued de-emphasis on availability of substance abuse treatment continues to perplex. TH

Dr. Lineberry is medical director, Psychiatric Acute Care Program, Mayo Psychiatry and Psychology Treatment Center, St. Mary’s Hospital, Rochester, Minn. Dr. Shine is senior associate consultant, Psychiatric Acute Care Program, Mayo Psychiatry and Psychology Treatment Center, St. Mary’s Hospital, Rochester, Minn.

REFERENCES

1. Manderscheid RW, Atay JE, Hernandez-Cartagena MR, et al. Substance Abuse and Mental Health Services Administration, Center for Mental Health Services, U.S. Department of Health and Human Services. Mental Health, United States, 2002. Chapter 18. Highlights of organized mental health services in 2000 and major national and state trends. Available at www.mentalhealth.org/publications/allpubs/SMA04-3938/. Last accessed July 29, 2005.
2. Bureau of Justice Statistics, Department of Justice. Mental health and treatment of inmates and probationers. Available at www.ojp.usdoj.gov/bjs/pub/pdf/mhtip.pdf. Last accessed July 29, 2005.
3. Bureau of Justice Statistics, Department of Justice. Mental health treatment in state prisons. Available at www.ojp.usdoj.gov/bjs/pub/pdf/mhtsp00.pdf. Last accessed July 29, 2005.

Hospital work in psychiatry has a long, proud tradition. The severely mentally ill were housed in asylums in the historical past. In fact the origin of the word “bedlam” is derived from the pronunciation of Bethlehem and came to be synonymous with chaos. Bethlehem was the name of an insane asylum in London. Some aspects of current psychiatric hospital care still feel like bedlam.

A typical day for an inpatient psychiatrist involves rounding individually after a team meeting with social workers, nurses, and other members of the treatment team to determine events and observations during the previous 24 hours. The primary reasons for admission to inpatient services are imminent risk to self or others (suicide or homicide), psychotic disorders with inability to function, or severe anxiety or depression with inability to function. Geriatric units often deal with behavioral dyscontrol secondary to dementing illnesses or other neurologic disorders.

PSYCH ADMISSIONS

Practically speaking, the vast majority of admissions result from concerns related to the safety of the patient or others. For inpatient psychiatry the focus is acute stabilization and safety. This focus on stabilization often involves collaborating with outpatient members of the patient’s treatment team, including case managers and outside psychiatrists and therapists. Involving family in obtaining the patient’s collateral history is vital. The goal is to develop a treatment plan to address support, reasons for suicide, access to means for suicide, and treat underlying psychiatric syndromes.

Nonadherence to medication is another primary reason for admission. Patients with bipolar disorder, depression, and schizophrenia often stop taking their medications. Some of this is related to the underlying illness, while some is related to difficulties associated with medication side-effect profiles. Often, psychotic patients may have a fairly dramatic change in control of their symptoms after restarting their previous medications.

PSYCHIATRISTS IN HOSPITALS

Primary hospital work is not uncommon in the United States. A common arrangement is for a single psychiatrist or small group of psychiatrists to primarily manage an inpatient practice and see outpatients in the afternoon, depending on the size of the hospital.

Many psychiatrists lack interest in inpatient work, however. This lack of interest is related to the severity of symptoms, legal interface, call, and challenges with coordinating inpatient care with an outpatient practice.

The advantages of a dedicated psychiatric hospital practice are the same as for other hospitalists: The hospitalist develops both efficiencies and best practices based on seeing severe and complex problems repeatedly. They may also have knowledge of the community resources for the severely ill, which private outpatient psychiatrists may not be familiar with.

Psychiatric hospital work is always interesting and a great opportunity to work with severely ill patients who can be helped dramatically. The treatment is team-focused and offers the chance to work closely with social work, nursing, occupational therapy, psychology, and the community. It also allows for experience working with lawyers and the court system on a regular basis. Additionally, there’s often an opportunity to develop expert witness skills in some settings.

Academically, inpatient work is critical to resident and medical student education. It provides a chance for developing physicians to see and understand the realities and suffering associated with mental illness and their medical basis.

Psychiatric hospital medicine is emotionally intense work. Burnout is a major concern.

Many patients are not in the hospital voluntarily and don’t have insight into their illness. Nonadherence to treatment is common and the factor behind many admissions. Behaviorally, patients may be out of control from psychosis or severe personality disorders. Many have traumatic psychosocial histories and lack social supports. A number face legal charges. The intensity of practice is also due to the pressures of time, shortages of services for the mentally ill as outpatients, and pressures from both managed care and regulatory agencies.

EVOLUTION OF THE SPECIALTY

The state of hospital psychiatry has changed greatly in the past 40 or 50 years. The introduction of the antipsychotics solely for schizophrenia means we can now treat those previously thought untreatable. With the discovery and application of other treatments for mental illness, a movement developed to end the institutionalization of the mentally ill and integrate them back into the community. Other societal forces include the patient rights movement that has led to changes in the law and a needed focus on the rights of the mentally ill—both for minimums of treatment provided and protection against unnecessary hospitalization. State and federal budgetary and managed care pressures have also contributed to the remarkable changes in hospital psychiatry.

This combination of changes from medical, legal, societal, and fiscal forces has slashed the number of available inpatient beds and lengths of stays. In 1970 there were 413,066 state and county psychiatric inpatient beds in the United States.1 By 2000 that number had decreased to 59,403. There has been a moderate increase in private and community psychiatric beds in response. However, even considering this increase, the total number of beds in 1970 was

524,878 and the total in 2000 was 215,221. There have been continued reductions in beds since then nationally. Along with this decrease in psychiatric beds has come a dramatic shift in average length of stay as well. The general average length of stay in the United States is less than one week for psychiatric hospitalization.

The hope with decreasing the number of beds has been that a focus on community-based treatment and programs to support those with severe mental illness would be available to meet the needs of the severely mentally ill. Unfortunately, though the intent and goals were laudable, those programs have not developed as hoped. Current challenges for the seriously mentally ill include lack of parity for mental illness for insurance, continued pressure on private psychiatric beds to fill in the gaps of services not met by the community along with continued cuts in state and federal funding for inpatient psychiatric care.

This decrease in beds combined with decreased average length of stay and an increase in population has led to more and more pressure on the limited psychiatric beds available. It’s not uncommon now for patients to remain in the emergency department for 24 hours or longer waiting for a psychiatric bed. Along with these pressures has come decreased availability of inpatient substance abuse treatment, the ubiquitous comorbidity. Managed care review of inpatient stays on an almost daily basis, and the ever-increasing demands of documentation to meet regulatory requirements have also increased pressures on hospital psychiatry.

TYPES OF PSYCH HOSPITALIST PROGRAMS

As a result of the trends mentioned above, a variety of psychiatric hospitalist practice settings now exist. They include private and community psychiatric hospitals, academic center hospitals, state hospitals, Veterans Affairs and military hospitals, and—the most rapidly growing sector—correctional psychiatry in state and federal prison systems.

Correctional settings, such as jails and prisons, have been estimated by the Bureau of Justice Statistics to have a prevalence of inmates with mental illness between 7% and 16%.2 The rate of mental illness in inmates is approximately two to three times that of the general population for major mental illnesses such as schizophrenia, bipolar disorder, and major depressive disorder. The mentally ill in prison are more likely to be homeless, medically ill, and chemically dependent than the general population, as well.

Mentally ill inmates serve longer prison sentences on average than their mentally healthy peers. Mentally ill inmates are involved more commonly in disciplinary problems in prison also.

Overall, approximately 60% of mentally ill inmates receive some sort of mental health treatment while in custody. Two-thirds of inmates receiving treatment are in facilities that do not specialize in mental health treatment. Of state prisons, 155 specialize in mental health treatment—out of more than 1,500 facilities surveyed.3 Twelve facilities have mental health treatment as their primary function. Fewer than 2% of state inmates were housed in a mental health unit providing 24-hour care.

Psychiatric hospitalists in specialized treatment correctional settings have the opportunity to perform assessments and provide treatment to a patient population with a prevalence and severity of psychopathology that is not commonly seen in community psychiatric inpatient or outpatient practice today.

CRYSTAL BALL

Inpatient psychiatry will continue to be important in the future. There are great challenges ahead but the need for dedicated hospital psychiatrists won’t go away and will probably increase. The pressures on the shrinking number of inpatient beds will continue to grow. The lack of outpatient services in general and intensive outpatient services available to transition patients to on discharge is frustrating. The continued de-emphasis on availability of substance abuse treatment continues to perplex. TH

Dr. Lineberry is medical director, Psychiatric Acute Care Program, Mayo Psychiatry and Psychology Treatment Center, St. Mary’s Hospital, Rochester, Minn. Dr. Shine is senior associate consultant, Psychiatric Acute Care Program, Mayo Psychiatry and Psychology Treatment Center, St. Mary’s Hospital, Rochester, Minn.

REFERENCES

1. Manderscheid RW, Atay JE, Hernandez-Cartagena MR, et al. Substance Abuse and Mental Health Services Administration, Center for Mental Health Services, U.S. Department of Health and Human Services. Mental Health, United States, 2002. Chapter 18. Highlights of organized mental health services in 2000 and major national and state trends. Available at www.mentalhealth.org/publications/allpubs/SMA04-3938/. Last accessed July 29, 2005.
2. Bureau of Justice Statistics, Department of Justice. Mental health and treatment of inmates and probationers. Available at www.ojp.usdoj.gov/bjs/pub/pdf/mhtip.pdf. Last accessed July 29, 2005.
3. Bureau of Justice Statistics, Department of Justice. Mental health treatment in state prisons. Available at www.ojp.usdoj.gov/bjs/pub/pdf/mhtsp00.pdf. Last accessed July 29, 2005.