Let's talk about inpatient psych admissions!
Tales from the HospitalI know - weird first post for a blog. But as you will soon find out, sometimes inspiration strikes and in an ADHD fueled fervor, I need to carpe diem before the inspiration is gone.
So today, let's talk about inpatient psychiatric admissions.
You might be familiar with this concept from popular TV shows. Someone has a psychotic break, or manic episode, or attempts to take their own life, and they're admitted involuntarily to an inpatient psychiatric hospital. In the TV shows, it always appears so seamless. There just so happens to be a psychologist (it's always a psychologist on TV; in practice it's always masters level clinicians) standing by outside the door to do a full assessment. They're immediately swept away by multiple patient care techs into the unit where a bed is prepped for them. There's only one active meltdown on the floor at a time. Everyone is med compliant. They're fully staffed with enough nurses to maintain a lovely 5:1 ratio 🤣
Life is obviously not like the TV shows.
I wanted to share my experience working in inpatient psychiatric admissions so that 1) you know what to expect should you ever find yourself or a loved one in this situation, and 2) to shed some light on what goes on behind the scenes. This is why you're waiting 3 hours to be seen.
From 2021 to 2023, I worked as an assessment and intake clinician at a large psychiatric hospital (72 beds) that was part of the Springstone group. At the time, it was still a privately owned hospital; that changed in early 2023 when Lifepoint Health, a giant private equity healthcare conglomerate, swallowed up Springstone. But my private equity hatred is a rant for another day.
The intake department reminds me of the stock trader bullpens from the 80's. You know the scenes in Wall Street (the movie) where Bud Fox is furiously calling investors to sell them on this or that stock? That's what it was like. One room, multiple computers stationed around the periphery, tons of people in various stages of chaos, five conversations going on at once. We were staffed with clinicians (who had mental health licenses) and clerks (usually bachelor's graduates who functioned as our assistants). On a good day, during the day you'd have 5-8 clinicians from the hours of 9am to 9pm. Folks called out often and, as with many psychiatric facilities, we were constantly understaffed. To fill in the need, PRN clinicians were offered shifts.
I was technically a PRN clinician, but I never once lacked work. I could have worked every single day of the week if I wanted to, but this was during (one of many) eras in my life where I worked two full time jobs. So when I came in for PRN shifts, it was usually for overnights. I got PRN differential ($1), weekend differential ($2), and overnight differential ($3). They could stack, so on a particular day I could be making an additional $6/hr on top of my regularly hourly salary which was already fairly good ($35/hr, or the equivalent of $72,000 a year).
Night shifts could be nice in some ways. The hospital is quiet; most patients are asleep or trying to. Sometimes there were long stretches of time without patients so I could get some studying or online shopping done.
But more often than not, night shifts were chaotic. Often, I would be the only person working in the intake department overnight. The raucous bullpen of the afternoon hours turning eerily silent. I would come in at 10pm to a waiting room full of patients and a group of clinicians who were wrapping up their 9am-9pm shifts. My intake clerk would stay until midnight, when she too would leave (bless her heart, sometimes she stayed as late as 2am to help me).
Great. There's one me, and lots of patients who are actively psychotic, actively suicidal, etc. just chilling in the waiting room. We were a walk-in facility, which means we had to adhere to EMTALA laws. Even if I looked at someone in the face and knew they wouldn't be an admission, I still had to do the entire assessment process before transferring. We also took appointments - people calling in to our phone lines and getting scheduled a time to arrive. The call center never knew how busy our waiting room was, so people would show up at their designated time only to have to wait 3 hours anyway.
Yep, 3 hours. A full assessment and intake, if done thoroughly, can take up to 3 hours. Full biopsychosocial assessment (usually 45 minutes), submitting a request for consult with the telehealth psychiatrist (probably a resident who's moonlighting; it would usually take 30 mins for them to call back), the actual consult (30 mins). You're already at 1 hour and 45 minutes.
And then the paperwork. It's not as simple as just signing your name on the dotted line. There's a lot of legal paperwork (especially for involuntary folks), but also a lot of clinical and administrative paperwork. I had to generate their chart in our EMR and billing system. Print out their hospital bracelet. Add them to the bed board. Write a summary sheet for the nursing staff. This could take another half hour or so. After all that song and dance was done, I called down to the unit to give report to the charge nurse.
Sometimes crises happen on the units, so the charge nurse isn't available. I cannot transfer a patient from intake into the unit without giving report. More waiting. I let the house supervisor know in the meantime. Once the report is done, now I have to wait for a tech to come down and physically guide the patient back. More waiting. After another half hour, congrats - you are now admitted!
If all goes well, this will take 2.5 hours. After the patient is out of your department, the night clinician is also responsible for calling in and getting the authorization from the insurance company (another 15-30 minutes). My day job was utilization management, so this was second nature for me. For clinicians who don't do this often, it could be a literal hour of trying to figure out who to call, what to fax, or what online portal to use.
Now you might be wondering... there's only one me, and last we checked there were 10 psychotic patients in the waiting room... and only 10 hours in an overnight shift (10pm-8am for me). If each patient takes 3 hours, then..... the math ain't mathing.
If you were a seasoned intake clinician, you could get to the point where you can juggle 2-3 patients at once. Give paperwork to one patient to sign while you do a consult on another. Generate all the EMR business on one while calling for transfer on another. But this still doesn't shave off much time, and has the added risk of silly mistakes (like admitting a woman to the men's unit; been there done that) or worse - HIPAA violations.
By this point, all the impatient, psychotic patients are calling for your head or trying to physically force their way in (futile; it's badge access). You get really good at using your stern adult voice, identifying signs of incoming aggression, and not letting things get to you. You develop a very strong rapport with the night house supervisor and the charge nurses.
Once you've worked in inpatient psychiatry, there is really nothing else that you'll be scared of.
By the time 8am rolled around, I would be so exhausted. Yet, I would drive home, crash for 4 hours, and then get up for my day job.
(Transfers are another beast, and deserve their own entry. Transfers really expose the underbelly of psychiatric treatment and how hospitals cherry pick their patients, even if they aren't supposed to. But that's for another day...)