What is involved in being admitted to a psychiatric hospital?

The process of admission to a psychiatric hospital or clinic can be daunting especially if the person has not visited a mental health facility before or if he/she is being admitted involuntarily. This section will help to explain the different steps that occur and what to expect during the process. If at all possible, having someone with you during this time is useful. A friend or relative can provide support and is often able to give useful information to the admitting team. They may ask questions on the patient's behalf about issues that the patient may feel too nervous or embarrassed to ask about. They can alsohelp the patient clarify and remember information that is explained to him/her that might otherwise be forgotten.

This section is divided into the following sections:

Assessment of the patient.

• Admission assessment
• Physical examinations and investigations

Admission to the hospital ward

• Arriving onto the ward
• Observations
• Professionals in the hospital setting
• The multidisciplinary treatment team
• Medications

1. How is the patient assessed?

1a. Admission assessment

The first thing to happen is the assessment process and this may occur in a General Hospital Emergency Department or in a separate Psychiatric Unit Outpatient Department, depending on the public mental health system. The first person to talk to the new patient may be the reception staff in the Emergency Department. They need to ascertain the degree of emergency, that is, how quickly the patient should be seen. This is called triage. Psychiatric emergencies that require urgent attention include suicidal actions and acute psychotic symptoms with obvious behavioral disturbance. In these cases an Emergency Department doctor will see him/her as soon as possible.

Acute life threatening medical emergencies will, however, usually take priority and there can sometimes be a wait. The Emergency Department doctor will ask questions of the patient and the caregivers to ascertain the nature of the problem or symptoms.

It may then be decided that the person does not need to see a psychiatrist. However, if admission to the hospital is recommended, then a psychiatric registrar will then see him/her. Having already seen a doctor prior to seeing the psychiatric registrar, the patient may find this second review repetitive and frustrating. It is, however, the registrars (and their psychiatric consultant who, on the basis of his/her detailed and specialist knowledge of mental illness, make the final decision on the benefits of hospitalization. Decisions about patient admissions are thorough and the emergency doctor (who may have limited experience with mental illness) may confer with other professionals.

The psychiatric registrar will also want to talk to friends or a family member and the patient's GP if they are available. This happens so that all the issues are carefully assessed and the appropriate options decided upon and discussed with the patient and the caregivers (the patient may be too ill to participate fully in this discussion but every attempt will be made to involve him/her). This process takes time and patience is required.

1b. Physical examination and investigations

Physical examination and certain investigations are always required in order to exclude a physical cause for the symptoms. This is a very important part of the initial assessment for anyone presenting at a hospital or clinic with acute psychiatric symptoms. It is common practice for all new admissions to a psychiatric ward to undergo a CT Head scan and an EEG (Electroencephalogram) together with certain blood tests as part of the physical screening process.

It is important to establish that mental symptoms do not result from abnormalities of the thyroid gland, therefore, thyroid function tests are usually undertaken. In other parts of the world, where mental symptoms may commonly result from certain infections or parasitic conditions such as malaria, appropriate tests will be carried out as part of this assessment phase and these are normally done in the first few days following admission. It is vital that such physical causes be detected or excluded and these can include conditions such as brain tumors, strokes, diabetes and various types of epilepsy.

Other blood tests may also be taken at the time of the initial assessment or the next day when you are on the ward. These tests are done for a number of reasons including reviewing liver and kidney function. This can be important if the treatment involves taking medication that may affect either of these organs or if the patient has a pre-existing liver or kidney problem that requires an adjusted dosage of medication. Anemia and vitamin deficiencies are among other conditions that can affect mental state.

Arriving on the ward

Although this process may differ depending on whether the admission is voluntary or involuntary, generally, the same things are covered at some point in the process. The nursing staff usually undertake various procedures once the patient is on the ward.

The main issues and reasons for admission.

• For safety reasons, any medications and potentially dangerous items such as matches, lighters, pocketknives, etc. will be removed. Medication handed in at the time of admission, is not returned when the patient is discharged. These medications may be unsuitable for his/her condition and it is considered to be unsafe to return the medication to the patient.
• Items of value, such as jewellery or large sums of money, will be placed into a locked storage facility. These items can be accessed during certain hours in the hospital and they will be returned upon discharge.
• Involuntary patient rights under the Mental Health Act will be clarified.
• A room will be provided. Ideally, all services would like to provide each person with his/her own room but this is not always possible so some patients may have to share with another person of the same sex. Most units are mixed but single-sex wards do exist in some areas.
• The primary nurse will be introduced. Many services provide one primary nurse plus one secondary nurse to care for patients (nursing staff work either a morning, afternoon or night shift).
• The use of alcohol and/or illicit drugs is prohibited in a hospital. Most hospitals will have signs up stating the procedure if an inpatient uses such substances. In some cases, use can lead to discharge, particularly for a voluntary patient.
• Treatment may include medication and therapy groups so it is important to take part in all aspects of the management plan.
• Visiting times are often kept to the evening. During the day patients may be required to participate in therapy groups and to be available to be seen by a psychiatrist and other staff. If families have difficulties in attending at these times, in most cases, something can be worked out by talking to the primary nurse.

Observations

These can involve physical observations such as measurements of blood pressure, temperature and pulse. These observations may be important if the patient has just been started on new medication, which can cause side effects such as changes in blood pressure, etc. If he/she has had problems with appetite, nursing staff will be asked by a doctor to monitor the intake of food and fluids to ensure the patient is eating and drinking enough. In such a case, the patient may need to be weighed regularly. This is particularly important when treating eating disorders such as anorexia nervosa and bulimia.

Other observations may be carried out by nursing staff including attendance at therapy groups and movements on the ward, sleeping patterns and how the patient's symptoms have change during the day. A lower level of observation will require the staff to be aware of patients' whereabouts at all times, therefore, checks may be done every 15 or 30 minutes.

Intensive nursing and observation may be required and this would be carried out by a mental health nurse who would stay with the patient at all times. Staff may assess that more intensive nursing is required and decide that the patient's needs are better served in the Intensive Care Unit (ICU). This is normally a smaller unit with fewer beds and a higher ratio of nursing staff. People in the ICU may have been admitted under the Mental Health Act (i.e. an involuntary admission) so the doors to this unit are usually locked.

Medications

In hospital settings, all medications are written up on a medication prescription sheet. All medications are written on such sheets in order for nursing staff to administer them accurately. This ensures that the right person takes the right amount of the right medication at the right times of day. This sheet also includes medications that the patient may administer, such as over-the-counter medication including the oral contraceptive pill and Ventolin inhalers.

The medical staff will discuss any changes to medications. If the patient is allergic to any drug, it is vital that he/she talks with the doctor or nurse and describes the symptoms experienced. If he/she is very anxious or aroused the patient can request, or the medical staff may prescribe, medications such as a sedative. This is called 'PRN' or 'as required' medication.

Patients in a hospital have the right to read their medical notes, however, they are normally required to make formal application for such access (patients do not have to give a reason for wanting to read the files). After the application is received the hospital may be required to make the file (usually a photocopy) available within a certain period of time. Under certain circumstances not all of the notes will be supplied. This is done because certain entries in files may be detrimental to the patient's health or to the success of the treatment process or may be of possible danger to third parties.