Surviving State Hospital Employment

Lessons From My Clinical Director
The First 4 Weeks: State Hospital Psychiatric Admissions Chronicles

I’m the new Admissions Unit doctor, having been reassigned from the Children’s Unit which was closed by the State on June 30, 2002. The state decided it will no longer hospitalize children and closing the unit will be the best way for the hospital to stay within its budget. The Admissions Unit had been without a doctor for almost a year. When the assigned doctor quit, the position was not filled. The thinking was that this will narrow the budget deficit. To continue operating the Admissions Unit the other doctors were asked to cover the enormous workload on rotation on top of their more than full schedules on their respective Treatment Units. So my arrival was met with great relief and earnest anticipation that the perennial and myriad problems in admissions will be solved, once and for all. This great expectations of course doomed my chances of integrating smoothly into the milieu from the beginning.

I wanted to meet jointly with the Clinical Director and the Program Manager for orientation to my new assignment before my arrival but this was never scheduled. On my first day I expressed my request again to the Program Manager asking her to schedule a joint meeting with the Clinical Director. Then the Grady van arrived dropping off 9 patients which occupied me for the rest of the morning, skipping lunch until very late because another group of 4 patients came after them. Earlier before the patients arrived I expressed my preference that the staff complete their contacts with and have the PE ( physical examination) ready before I see the patient. In this manner I will have on hand the necessary information I will need to evaluate and decide on the patients admission to the hospital. With 9 patients in the waiting room and 1 staff out on sick leave and another out on personal leave and 1 nurse practitioner to complete physical examinations, it took a long time before the completed contacts were turned over to me for evaluation. It was obvious that I will just have to go ahead and see the patients and let everyone catch up on what they have to do to complete the admissions process. Somehow the waiting room was cleared and each patient was evaluated and sent to their respective destinations.

The next day my Clinical Director wanted to meet with me to orient me to my new position. But it appears the Program Manager had already met with him and her own Supervisor to discuss my first day at work. My Clinical Director wanted to be helpful and wanted to advise me as to what qualities I should develop so I can perform well in my position. He said that I should be flexible. It seems I trespassed on some inviolable principle when I said I wanted all preliminary information and processing completed before I see the patient, never mind that I actually violated my own declaration and accommodated to the situation when it became apparent quickly that it was not going to work given the shortage of staff and the volume of patient.

Within the same week I was called again by my Clinical Director because it seems I’m making a lot of non-admit dispositions. Apparently this puts a lot of stress on staff because they have to make several phone calls to complete discharge recommendations for outpatient follow-up and in some cases they have to look up resources for transportation or housing. But what’s most stressful it seems is when a patient makes repeated inquiries from staff as to when they can go home or when they request to make phone calls to tell families and to arrange pick-up, and when some of them became really impatient and became belligerent and demanding. My clinical director again wanted to help me become successful in my new position and offered his advise that maybe I should not make too many non-admits in one day and if I have to maybe I should not tell the patient first until staff had made their contacts and completed their paperwork and was ready to attend to the patient. I felt caught in a bind now with this advice because he just told me to be flexible, and in being flexible I was seeing the patients before the staff had seen them when there are several waiting and pacing up and down in the waiting room. I said I can follow administrative directives to make admit/non-admit decisions based on what’s not stressful for staff and maybe outside the clinical criteria for hospitalization but I wanted a written policy which applied to all doctors. And as far as not telling patients about a non-admit disposition until much later, I said that may be hard to accomplish as feedback is given to the patient in the course of the evaluation to help the patient gain an understanding of the problem and simultaneously education is provided in the interventions necessary to apply to the problem. If the patient is waiting without information about his disposition, it seems to me he might be more anxious to know and approach the staff repeatedly anyway to find out what the doctor decided. This to me does not solve the problem of stress for the staff because a patient is asking or demanding when he can leave to go home. Besides it does not respect the patient as an equal partner in the decisions made about him, and also it does not respect patient wishes to be in touch with significant others right away who might be waiting to know and many are anxious to notify for pick-up right away as some may have to come from great distances, and many may have to call several sources to find someone able to pick them up, or they may have to use public transportation and desires to leave before traffic gets bad. That’s why they want to have as much lead time as possible. So I said I cannot comply. However, I told my clinical director that I was mindful that the Admissions Unit is short-staffed and that is the reason there is a back-log of processing patients and, therefore I inform patients that there are other procedures we have to complete before they can be sent to their destinations and for them to please wait until the staff can attend to them But the back-log in admissions can be 6 hours on some occasions and surely that’s unreasonable for anyone to wait patiently.

Then there’s these 2 children who came within the 2nd week of my assignment. You must remember that the State decided not to hospitalize children anymore and the Children’s Unit is closed. There is an involved policy governing the admissions of these children requiring pre-certification from several agencies and division heads, and no children should present themselves in admissions without going through this process. Both these children managed to by-pass the process so they were at our door. With one, after lengthy and multiple phone calls involving numerous department heads, administrators and myself, a resolution was provided by the community agencies.The patient was returned to be managed in the community. The Community Mental Health System took active responsibility in this instance because the child was developmentally disabled and the State mandate is to serve these children in the community primarily. This was not well-received by the parents but they were assured by the community agency director that the necessary service will be provided. This was appropriate clinically, the child’s interests will be best served outside of the hospital. However, the final outcome was not achieved until after several hours of negotiations. And when the decision arrived the child was very restless and the parents frustrated.
The 2nd child came because her local community agency did not know that the State no longer hospitalizes children. Her case manager thought that we admit children to the adolescent unit then send them to Central State. She did not know that she has to obtain pre-certification from her Director and 2 other State division people before sending any child and it was a Friday and her supervisor was gone and she had no one to consult with. The child was a previous patient on the Children’s Unit so I know her and the problem well. She needed to return to her previous medications and does not need hospitalization, it is a non-admit. But the mother could not pick her up, she was exhausted, she will have to drive from a distance, but she’ll call her case manager and see what is possible. Since the situation appeared uncertain I decided to admit the child for 24 hours to allow for discharge planning. In the meantime the child was very restless in the waiting area not designed for children to wait in and had become very hyperactive and impulsive and started grabbing at anything she can find. She found a pin from the crevices of the floor and started to put it in her mouth, she saw a cord dangling from the TV and she pulled it. She did not respond to verbal structuring. Then the mother called and said she found a resource and someone will pick up the child, but clearly it will be several hours more as they were coming from another county. I cancelled admission and wrote medication orders to manage the child in the waiting area until her pickup arrived. The child balked at taking the medication but finally cooperated and in half an hour she was calm and able to sit still and watch TV as she waited. I understood when I returned Monday that the child waited a long time and the medication effect was wearing off by the time her pick-up arrived. That week I was summoned to a summit meeting to address these two situations. In attendance were the hospital CEO, my Clinical Director, the Nurse Executive, the Program Managers for the 2 Developmental Disabled Units, the Adolescent Unit Program Manager, and my Program Manager. The Adolescent Unit psychiatrist should have been there also but no one informed him. It seems, the discussion suggested, that the particular situation could have been managed better in admissions if I had ordered medications sooner or just admitted the patient. Thankfully, the group also recognized that the Admissions Unit is not set-up with children in mind and the staffing pattern does not allow for supervision tasks. Until the Children’s Unit closed these children were routed to the unit directly for processing, bypassing admissions and therefore there were no procedures in place in the area to manage them..The meeting ended with a task for me to write a policy on the management of children in admissions.

During this first 2 weeks I was also getting calls from various areas in the hospital to take care of patients from the Treatment Units and was sent an employee 10 minutes before my scheduled departure to evaluate for work-related injury. I requested a meeting with my Clinical Director to clarify what my duties are. He said that the unit psychiatrists actually should be available to take their staff calls and if they are not around the 2nd call doctor takes the call but if the request will only take up a few minutes of my time that I should just take care of it rather than have the staff spend time tracking down where their doctors or the 2nd call are. And regarding employee work injury there are assigned doctors on a workmen’s compensation panel who are supposed to be called but only until 3:30 PM to give them enough time to complete evaluation without delaying their scheduled departure at 4:30 PM. The admissions doctor will be called after 3:30 PM, the policy states, never mind that the admissions doctor has the same departure time of 4:30 PM as the other doctors. I requested a review of these policies and suggested an equitable change and asked that the procedures be disseminated again for staff and doctor review. My Clinical Director declined changing the policy at this time but suggested that if I didn’t want to satisfy the improper request I can tell them so. What I learned from my Clinical Director here is that as admissions doctor I should develop graciousness so staff and other doctors are not inconvenienced and if I wanted to follow policy I take the consequences of being unaccommodating.
I was reviewing the previous day’s census when my Program Manager rushed into the consultation room to ask me to drop everything and come check this patient about to get off the ambulance because she thinks this is an inappropriate patient to be admitted here. I said the ambulance can let her off and I’ll evaluate the patient. She said I have to decide before the ambulance leaves so if I didn’t admit the patient the ambulance can just take her back, and that the previous admissions doctor did it this way all the time. She was so insistent that I go with her to confront this situation at the ambulance level. What was so problematic apparently was because the patient was in a wheelchair and “ we don’t admit patients in wheelchairs here”. When I went out to the ambulance dock I met a patient who was about 300 lbs and uses a motorized wheelchair which had run out of batteries and needed recharging. She can ambulate short distances and was not in any acute physical discomfort and did not have any acute medical problems, but I couldn’t evaluate her psychiatric status by just eyeballing her so I said the ambulance can go and they can leave the patient. Besides the ambulance crew wanted to know if they did not leave the patient where would they take her? They clarified that their responsibility was only to transport the patient safely.
The patient didn’t met criteria for acute psychiatric hospitalization. She had a complement of outpatient resources with regular psychiatric follow-ups and case management from her community mental health center and in fact she had a clinic appointment that afternoon. The patient was agreeable with the decision to go home, and wanted to keep her clinic appointment. However, she needed transportation since her wheelchair did not have sufficient electrical charge to allow her to get on the bus, which she was accustomed to using. The staff effort to secure transportation for her failed. No cabs would take her, and an ambulance was out of the question since this was not an emergency. In the meantime she was charging her wheelchair batteries while waiting in admissions and may be able to use it briefly. The staff devised a plan to transport to the bus stop just outside of the hospital gates but this required navigating a road uphill for about 500 yards The staff thought that hospital security police may allow the use of their handicap-equipped van which they agreed to do however, the van was outside the premises and they had no idea when it will be available. In the meantime, we were planning for the patient to keep her 2:30 PM outpatient appointment and by this time it was way past. Now the goal is for the patient to just get on the bus before dark so she can get home safely. The staff thought they could push the patient manually in her wheelchair if they can get assistance from security police to manage traffic on the main road so the patient can cross to the bus stop opposite the hospital gates. The police chief said it can’t be done as she won’t jeopardize her officers’ lives exposed to that dangerous traffic in front of the hospital. I became aware of all these maneuverings when the staff, in frustration came to me for help because, they didn’t know what else to do. As what seems to be always the case, these types of novel situations present themselves when key managers are not available and the staff did not have information as to who is covering in their absence. I stepped out of my role and became involved and tried to accommodate the staff. In the nick of time before the staff pushed the patient up the road, a handicap-equipped van became available from one of the hospital departments. The Program Manager arrived after all these was resolved and immediately she was displeased by the way this was handled, even before inquiring as to what efforts her staff had applied first and intimated that it was a problem because of my actions, after all she thought that I shouldn’t have let the patient off the ambulance in the first place. When my Clinical Director summoned me the next day it was to review what I presumed was the Program Managers critique of my part in the situation. I came away feeling that the report was accepted as is because his advice was for me to essentially stick to my function as a psychiatrist and limit myself to merely evaluating patients and making clinical decisions and I gather not to get involved in anything else.
You know working in admissions is like what Forrest Gump said, “ It’s like opening a box of chocolates, you never know what you’ll gonna get!” And I wonder what Forrest Gump would say about my Clinical Director. I don’t’ know if he’s wise man or a fool, but one thing is for certain: he’s definitely a State Bureaucrat!