The Geezer’s Dirty Dozen on the Medical-Psychiatry Unit

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This is a Dirty Dozen on the Medical-Psychiatry Unit. The Med-Psych Unit has been in operation at the University of Iowa Hospitals & Clinics for many more years than I have been there and it was started by Dr. Roger G. Kathol, MD, CPE, who now is the principal leader of Cartesian Solutions, see link Cartesian Solutions – Home Page. When I was a resident physician, Roger would read selections from Galen to us during rounds on the Med-Psych Unit. I’ve posted about the unit both under the name of Complexity Intervention Unit (CIU), the name he now prefers, and the Med-Psych Unit, which is easier for me to say.

Adding value to the care of patients with concurrent medical and psychiatric illness on an MPU unit should start with properly defining what an MPU is. There are misconceptions held by some. One physician apparently held the opinion that it would not be feasible to use both internists and psychiatrists(Serby 2006). In fact, at least one Midwestern academic center routinely uses this staffing model, The University of Iowa. Physician graduates of combined residency programs in internal medicine and psychiatry are also eligible. Another model employs a part-time internist who rounds daily on all patients in the MPU. Alternatively, the unit could be run by a general psychiatrist comfortable with some medical complexity while requesting medical specialist consultation routinely for the more difficult patients. Apparently Dr. Serby at the time of his interview was not aware of the Type IV medical-psychiatry unit beds at The University of Iowa Hospitals and Clinics (UIHC). In his opinion, “any patient requiring telemetry and those with unstable vital signs are unacceptable” for admission to a medical-psychiatry unit(Serby 2006). The only medical-psychiatry unit Dr. Serby was aware of was at Bellevue Hospital in New York. He frankly admitted he was unaware of any other MPUs in the U.S. The UIHC and the UI College of Medicine collaborated to create the medical-psychiatry unit in 1986 and it was one of the first medical-psychiatry units opened. It is the only such resource in the state of Iowa.  As of 2009, it has grown from 12 to 15 beds, including telemetry capability. And while it does not accept patients who are hemodynamically unstable, many of them have fluctuating vital signs due to a variety of medical problems including complicated alcohol withdrawal. Dr. Serby further stated that patients who require oxygen, intravenous tubing, and who require seclusion or restraints and who are highly agitated “are especially dangerous in this kind of milieu”(Serby 2006). The physician who participated in this interview was associate chairman and professor of psychiatry and behavioral sciences at a major U.S. medical center.

It’s not possible to google a list of medical-psychiatric units in the U.S. or in the world. There is no known recent tally (personal communication from Roger Kathol, 8/24/2010). So it’s not surprising that no one knows how many of these units are in operation.

In fact, the name “complexity intervention unit” is now preferred over “medical-psychiatry unit” because it’s a better description of the interaction of physical and psychiatric illness, and social and health care system barriers and challenges(Kathol, Kunkel et al. 2009). Complexity Intervention Units (CIUs) are optimally based in general hospital rather than in psychiatric settings for several reasons. Many of the so-called MPUs are located in psychiatric units where the ability to provide aggressive treatment of medical disorders is necessarily limited. Per-diems for CIUs based under psychiatry is limited because they are paid through Managed Behavioral Health Organizations (MBHOs) from which reimbursements are lower. It is impossible to provide the kind of intensive medical and psychiatric interventions that many patients need on general medical units with psychiatric consultation. Nurses on medical units are not trained to provide supportive psychotherapy and studies have shown that compliance with consultant recommendations hovers around 50%.

Combined rather than sequential treatment is more efficient and effective. Clinically, it’s frequently the case that patients with comorbid psychiatric and medical illness likely do worse both mentally and physically because, on the medical side, expertise is lacking on managing and even recognizing such problems as delirium and depression. On the psychiatric side, after transfer from a medical unit, not uncommonly, exacerbation of medical complications may go unrecognized or are incompletely addressed.

Core and essential features of the CIU include:

1.            Both medical and psychiatric safety features in the physical structure

2.            Consolidated general-medical and psychiatric policies and procedures

3.            Location in the general hospital under medical bed licensure and with psychiatric bed attributes

4.            Moderate-to-high medical and psychiatric acuity capability

5.            Physicians from combined residencies general medicine and psychiatry co-attending model with consistent communication and coordination of medical and psychiatric care

6.            Nurses and other staff cross-trained in medical and psychiatric assessments and               interventions(Kathol, Kunkel et al. 2009)

Close management of triage to the CIU is critical if it is to add value not only to patients but to control hospital costs. The focus should be to provide care for the 2%-4% of patients admitted to general hospitals who are too complicated to manage on either psychiatric or medical units. They typically have longer lengths of stay, suffer worse clinical outcomes, and are discharged to more restrictive outpatient settings when using traditional sequential treatment techniques(Amos, Kijewski et al. 2009). Ideally, they should be admitted to the CIU from the first day of hospitalization.

By definition, CIUs that would bring the most value would be capable of providing the highest level of general medical and psychiatric care. Formerly, these were called the Type IV MPUs, with the levels specified as:

–        Type I: low to high psychiatric with no or low medical acuity

–        Type II: medium to high medical with no or low psychiatric acuity

–        Type III:  high psychiatric with medium medical acuity

–        Type IV:  high psychiatric with high medical acuity(Kathol, Harsch et al. 1992)

Examples of acute medical and psychiatric capability would be managing peripheral and central intravenous lines and administering intravenous Haldol for delirium. Although there are no published data to support the claim, integrated care in such units could shorten average lengths of stay (with caveat noted above) and cut costs considerably in complex patients.

This begs the question of why there are not more of these units in existence. One of the more important barriers is that reimbursements for general medical and psychiatric services are from segregated and competing budgets. In Kathol’s view, despite the challenge of maintaining financial viability, requests for consultation from him and his company for assistance in setting up CIUS are increasing. Reasons for the upsurge are said to be rising recognition that the costs of creating a CIU may not necessarily outpace the cost of constant observation and extended lengths of stay for complex comorbid patients hospitalized within a diagnosis-related group (DRG) system(Amos, Kijewski et al. 2009).

The value of the CIU as an educational venue cannot be overstated. Primary care and psychiatry residents learn a great deal about the interaction of medical and psychiatric disorders in an environment that fosters both/and rather than either/or thinking—by necessity. They learn that delirium can mimic nearly any other psychiatric disorder, and that delirium can kill. They learn that certain medical illnesses sometimes present with psychiatric symptoms and that self-destructive behaviors mediated by psychiatric disorders can lead to life-threatening medical illness. These are all but impossible to manage anywhere but in a CIU.

Each and every clinician, nurse, and trainee experiences the CIU in a unique way. The culture demands a more flexible approach to medical and psychiatric disorders.

Slide 3: This is an overview of medical-psychiatry units, defined as hospital units where patients with both complex, comorbid medical and psychiatric illnesses can be cared for, optimizing evaluation and treatment of both in a concurrent, rather than sequential way. The Med-Psych Unit at The University of Iowa Hospitals and Clinics is a Type IV unit, able to accommodate those with non-critical care level but severe medical problems co-occurring with severe psychiatric illness.

Slide 4: The way to think about combined, complex medical and psychiatric illness is illustrated on this slide. It’s not a dichotomous model; it’s integrative. I want to emphasize that not just medical and psychiatric illness are considered and managed, but social, occupational, and spiritual components must be understood and addressed as well.

Slide 5: These are statistics about the units which are not, as of this writing to my knowledge, classified in a searchable database at an official level. The numbers are not current and may not be accurate.

Slide 6: This slide gives a short description of the Medical-Psychiatry Unit at the University of Iowa. It has been recently updated and modernized with the addition of telemetry capability. A specialist with dual board certification in internal medicine and psychiatry can staff the unit as physician leader. Alternatively, it can be co-staffed by an internist and a general psychiatrist such as myself. I’ve been co-staffing the unit regularly for the last 16 years and have a deep respect for my colleagues from the medicine side who team up with me.

Slide 7: This slide reiterates the importance of the administrative structure and setting of the Med-Psych Unit and points out the training of nurses who take care of both the medical and psychiatric issues of patients hospitalized there.

Slide 8: This slide points out the importance of maintaining clear guidelines about which patients are most likely to get maximum benefit from the unit which drives the triage process, which is managed by the faculty rather than resident physicians.

Slide 9: It’s vital to guide physicians in training about how to most effectively communicate about patients with the multidisciplinary team, paying close attention to clear descriptions that integrate factors from the medical, psychiatric, social, and even spiritual realms that bear importantly on the healing of patients and building a practical treatment plan which will help patients move forward.

Slide 10: This slide just outlines the typical presentation format for history and physical presentations on the Medical-Psychiatry Unit.

Slide 11: It’s vital for every team member to do his or her part in the service of helping the patients heal. In a patient-centered, team-based model, the group functions best when the importance of respect, professionalism, and clear communication with the end in mind is clear to all stakeholders.

Slide 12: This is a slide with acknowledgments to Dr. Kathol and the nurse leaders who have acted as consultants to other hospitals who have expressed interest in starting their own Med-Psych Units or in improving the integration of medical and psychiatric care for patients in the general hospital. Useful resources include:

Amos, J. J., M.D.,, V. Kijewski, M.D., , et al. (2009). The Medically Ill or Pregnant Psychiatric Inpatient. Principles of Inpatient Psychiatry. F. Ovsiew and R. L. Munich. Philadelphia, Wolters Kluwer; Lippincott Williams & Wilkins: 333-343.

Kathol, R. G. and S. Gatteau (2007). Healing body and mind : a critical issue for health care reform. Westport, Conn., Praeger Publishers.

Kathol, R. G., H. H. Harsch, et al. (1992). “Categorization of types of medical/psychiatry units based on level of acuity.” Psychosomatics 33(4): 376-386.

Kathol, R. G., E. J. S. Kunkel, et al. (2009). “Psychiatrists for Medically Complex Patients: Bringing Value at the Physical Health and Mental Health/Substance-Use Disorder Interface.” Psychosomatics 50(2): 93-107.

Serby, M. J., M.D. (2006). A case for medical-psychiatric units. Clinical Psychiatry News, International Medical News Group. ( web link: A case for medical-psychiatric units | Clinical Psychiatry News | Find Articles)

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