Geri-Psych Admissions: Where's the Line?

[sideshowstarlet, BSN, RN]

Hello, nurses, nursing students, and interested lurkers! It's been a while since I logged on, but this site was very helpful when answering my question about spinal headaches. I'm back again, this time to the psych nursing thread with another question I can't seem to find the answer to.

Previously, when I lived in a smaller city and worked in a SNF/nursing home, there was a resident with a lot of behaviors, which seemed to get worse as time went on. She was paranoid, constantly accusing staff of stealing her things (part of this was the fact that she was legally blind, and part of this was the fact that she would set something down, but not remember where she put it. Sometimes she would get aggressive. I never worked the hall where she lived, but I interacted with her sometimes. We got along pretty well, I guess. She would usually end up saying she loved me and I was so sweet. Then, the next day, she would see me and ask if I was new here.

One weekend (I was off, but I heard about it), her behaviors got so bad that her PCP wanted her admitted to an inpatient psych unit. The story was either the resident refused and the husband backed her up, or the husband refused because the resident didn't want to go (This happened years ago, and I wasn't directly involved, so I don't remember some of the specifics). So, the only way would have been through an involuntary admission/being committed. The process would have required a judge, and how many judges work weekends? So, she stayed. Doc ordered IM Zyprexa. Apparently, they were either unable to hold her down and give it to her or the resident just refused. One way or the other, the weekend day nurse had marked it as "Refused."

For part of the night, the resident was... Okay. Not sleeping, up in wheelchair, talking to herself, but not aggressive. When she got bad, the night nurse ended up giving the Zyprexa. There had been some improvement after that. The resident even ended up sleeping a bit. Apparently, she was bright-eyed and bushy-tailed the morning after, despite only getting a few hours of sleep.

To make a long story short (too late), the psych ward said they couldn't admit her, because her behaviors come from UTI. This woman had chronic UTIs. She took a pill every day for it, rather than being on a 7-10 day cycle of antibiotics. She was allowed to straight-cath herself. So, she stayed.

I ended up quitting shortly afterwards due to issues not related to this resident (new owners, new management, worse staffing, and I was getting burned out by the SNF/LTC world) and got a job in med surg. Not sure what happened to that woman.

Anyway, I can understand needing a patient to be medically stable before being admitted to a behavioral hospital or psychiatric unit. You don't want a patient with an art line on the psych ward just because he has a history of anxiety/depression.

However, recently, some co-workers were discussing some patients with mental illness they had cared for in the past. I didn't bring up the resident I wrote about; I was just listening. At one point, one of the nurses talked about a man who had dementia and was on suicide precautions. She was not working on any kind of mental health ward at the time. She was doing either med surg or tele, iirc. She mentioned that the Geri-Psych unit wouldn't take him because he had dementia. Yet, the pt was still a danger to himself, or why else would he be on suicide precautions?

I tried googling, but I couldn't find anything about a dementia dx precluding someone from being admitted to a Geri-Psych unit. Does anyone know where the line is when it comes to refusing admissions to the psych floor? Is there a consistent standard, or does it vary by facility? Will all geri-psych wards refuse a patient who has a dx like dementia or UTI?

[Sour Lemon]

Short answer: It varies quite a bit from facility to facility.

[brownbook]

Short answer: It varies quite a bit from facility to facility.

This times a hundred.

Read The House of God, it's a humorous fictional account of interns and residents in a big hospital. The residents/interns learn to "turf". Assess a patient on whatever unit the resident is responsible for, change the patient's diagnosis so the patient is "turfed", transferred, to a different unit.

They also learn to be "The Wall", come up with any and every reason to refuse an admit to what ever service they are covering.

It sounds like this is what you are dealing with.

[GeminiNurse29]

Our geri psych unit doubled as the medical unit at the forensic facility I was at. Oh if only society knew their aggressive demented granny was on the same unit as a guy who had killed someone or attempted to...all hell would break loose. Anything more complicated than a catheter or ostomy was sent out. Patients were aggressive (we got the ones nobody wanted due to their behaviors) and nobody wants the liability of someone on suicide precautions trying to strangle themselves or another patient with a line or something. If they were at the hospital more than 3 days, they were discharged due to their bed being in hot demand.

[Oldmahubbard]

As a Psych NP in LTC, I deal with my local geri-psych unit on a near weekly basis. I will try to keep this brief, but working with them is usually frustrating. Admissions there appear to be based on random factors, which way the wind blows on Tuesday, and what mood their social worker is in that day. The clinical situation hardly seems to matter.

On the other hand, I appreciate their honesty in refusing to admit patients who are well known to them, compliant with two or more antipsychotics, and yet remain severely mentally ill. The assessment that the "pt is at baseline" is correct.

When they do admit my residents, much of the time, the patient comes back in the same condition he left. I have known them to start patients on 4 new drugs in 10 days, and pronounce the person improved, although it is clearly not the case. They don't contact the pt's family or health care proxy to discuss what they are prescribing, and they hand out antipsychotics to demented elderly people as though there were no black box warning.

Here is a recent example. I was treating a 60 y/o female for schizoaffective disorder, bipolar type, which was a diagnosis borne out clinically. She was prescribed clozaril and lamictal, and behaviorally stable, although occasionally inappropriate. Then she was moved to Enriched Housing, where the staff and pharmacy could no longer coordinate the labs and the medication. She started missing doses of clozaril on a frequent basis. There was always some problem, pharmacy was a nightmare and nurses were quitting or getting canned. I started the patient on zyprexa, and then unknown to me, she wasn't getting that either, as the insurance had refused it. Long story short, the patient became manic, and aggressive. She was admitted to the geri-psych unit.

Although they had my notes which clearly indicated that we could not manage weekly clozaril patients in this setting, they started her back on clozaril AND lexapro. Lexapro in a manic patient.

I question if they have the slightest idea of what they are doing. Unfortunately, the psychiatrist there is a well known local whack job.

Unfortunately, I can't answer your question about the criteria for admission. In my state, experienced NPs do not need a collaborator per se, but we are required to "maintain a relationship with a hospital", whatever that means. This geri-psych unit allows me to check that box and otherwise, it is useless.

To be fair, they don't have any magic answers that I don't know about.

In this area, no judges get involved unless the patient has committed a serious crime. Then the patient is on the corrections system where ironically they receive better care.

[pixierose, BSN, RN]

Short answer: It varies quite a bit from facility to facility.

^^ Yep.

I worked Geri-psych. We admitted dementia patients with SI, yes. But, my unit had to inquire long and hard as to the patients' baseline. This was due to beds; patients with dementia cost quite a bit but don't bring in and stayed a while (3 weeks +) with little improvement. We were only 21 beds, and "Geri" starts at 55+.

We once had someone stay for 90+ days ... then they showed up at the ED from the LTC several weeks later looking to be readmitted. They were denied; rationale was that if 90+ days didn't help, our facility wasn't the best fit.

I held a high regard for the social workers, psychiatrists and fellow nurses on that unit; with so few beds, we did need to be careful on who was admitted, but we didn't deny Willy nilly either. I think it can be like anywhere in mental health; there is so few beds and too much demand.

[Orca, ADN, ASN, RN]

Having been on the receiving end of situations like this, what I often found was that the LTC staff wanted a vacation from a particular patient, so they would work to get them admitted to geropsych. Some facilities would admit to us and then refuse to take the patient back when treatment was done, leaving our unit program staff to secure placement - a pure dump job. One facility even went so far as to have their employee bring the patient to the ER and then leave. I'm not convinced that this was legal.

To be fair, some geropsych units have cultivated this kind of behavior by accepting virtually anyone who has Medicare. The last geropsych unit that I worked on was notorious for this. Trying to conduct programming on this unit was a nightmare. Working with patients who have traditional mental health issues (depression, anxiety, etc.) isn't easy when they are mixed with those with profound dementia. Some geropsych units literally can't decide whether they are mental health units or Alzheimer's crisis stabilization units. The two populations don't mix well. My unit once admitted a patient with end stage Huntington's chorea, which we weren't going to fix with any therapy that I can think of. She had Medicare, though, so in she came. One of the most disruptive patients I have ever worked with. I can't imagine being there during that time as a patient and trying to resolve a mental health issue.

One particular evening we were convening group to discuss depression. While the patients were filing in, an Alzheimer's patient walked in, shoved the table and knocked down two of the more coherent residents who were minding their own business. Fortunately no fractures out of this.

[Oldmahubbard]

Having been on the receiving end of situations like this, what I often found was that the LTC staff wanted a vacation from a particular patient, so they would work to get them admitted to geropsych. Some facilities would admit to us and then refuse to take the patient back when treatment was done, leaving our unit program staff to secure placement - a pure dump job. One facility even went so far as to have their employee bring the patient to the ER and then leave. I'm not convinced that this was legal.

To be fair, some geropsych units have cultivated this kind of behavior by accepting virtually anyone who has Medicare. The last geropsych unit that I worked on was notorious for this. Trying to conduct programming on this unit was a nightmare. Working with patients who have traditional mental health issues (depression, anxiety, etc.) isn't easy when they are mixed with those with profound dementia. Some geropsych units literally can't decide whether they are mental health units or Alzheimer's crisis stabilization units. The two populations don't mix well. My unit once admitted a patient with end stage Huntington's chorea, which we weren't going to fix with any therapy that I can think of. She had Medicare, though, so in she came. One of the most disruptive patients I have ever worked with. I can't imagine being there during that time as a patient and trying to resolve a mental health issue.

One particular evening we were convening group to discuss depression. While the patients were filing in, an Alzheimer's patient walked in, shoved the table and knocked down two of the more coherent residents who were minding their own business. Fortunately no fractures out of this.

Thank you. There are no easy answers in this population.

[pinkiepieRN]

If someone purely has a psych dx of dementia, I'm not sure that an inpatient stay would do much for them. I worked at a facility in the past that had two geri-psych wings: geri-psych mood disorders and geri-psych psychotic/dementia. Patients with dementia often aren't appropriate for a general psych floor because medication management is difficult and they're not really able to benefit from groups or the milieu environment. Generally I'd say that someone could be accepted to a facility with mild dementia and an underlying mood d/o dx but not something like advanced Alzheimer's because it's just not likely to be therapeutic or helpful for anyone. Suicide precautions also aren't necessarily indicative of the need for an acute inpatient psych stay - but the increased monitoring and interventions would obviously set off some alarm bells and you'd hope that the provider checks their psych meds or sets up follow-up/after-care. Also, I think it would be best for a patient to complete tx for their UTI to see if the confusion/agitation allays with resolution of the UTI.

[jodispamodi]

when I worked on geri-psych we took patients with dementia all the time, it seemed if someone with a medical dx had a comorbidity of dementia they ended up on our unit. But each geropysch unit has their own criteria about who is appropriate for that unit.

[needlesmcgeeRN, ASN, RN]

We have admissions of patients with dementia. I don't think these admissions are appropriate for our unit. Why do SNFs have special units, if not to provide specialized care to seniors with dementia? We currently have a patient with dementia with no underlying psych concern. Makes no sense.

[sideshowstarlet, BSN, RN]

Thank you for the thoughtful comments, everyone. Having never worked in psych, I never thought about how someone with severe dementia would disrupt the therapeutic milieu staff tried to set up, along with not being as responsive to redirection. I remember reading something a while back written by someone caring for a family member with dementia. When he exhibited behaviors, she would try to bribe him to stop. But, he wasn't with it enough to associate behaving well with a reward. So she would just give him the sweet, game, music, etc to distract him rather than use it as a reward. This caused a decrease in behaviors. I guess a traditional psych ward would use the rewards system, which someone with severe dementia wouldn't be able to follow. I never thought of that until now.

Figuring out meds must be incredibly difficult when even freaking Benadryl is on the Beer's List.

The patient I was talking about frequently refused meds. She was on (iirc) macrobid every day for chronic UTI. But it was hit or miss whether she took her meds.

This wasn't a specialized unit. This was a plain old skilled nursing unit. We had a slew of residents with severe dementia, needing pretty much constant supervision, as well as the usual host of med/surg patients. This facility had a memory support unit, but it was described as "A Confused Hilton"- basically an Assisted Living unit for people with dementia.

Again, thank you all for your insight! I really appreciate it!