Institutional Best Practices for Treating Schizophrenia - Episode 16

Protocols for Frequently Hospitalized Patients

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Joe Avelino, RN, BSN, MHSA, CPHQ, and Rahn Bailey, MD, DFAPA, explain protocols a practice can follow when managing a patient with schizophrenia who is frequently hospitalized or has other medical conditions.

Peter Salgo, MD: I can hear similar clinicians saying, “You’re going to put somebody on an LAI [long-acting injectable]. Now they get sick with something else, not their schizophrenia. They come in with an MI [myocardial infarction], diabetes out of control, urinary tract infection, and they’re septic. Doesn’t the LAI, which is on board long term, complicate everything? Or do I just treat as if the LAI is not there? Is there something I have to worry about?”

Joe Avelino, RN, BSN, MHSA, CPHQ: I can comment because on the hospital acute care side, it’s a med-psych facility. The way we manage these dual diagnoses is to first handle the acute care component. Let’s say a patient has hypertension or diabetes or needs a neurology consult. We consider that as the acute care site admission. Once we stabilize that, we admit them on our behavioral side of the unit, because we have an 84-bed acute care with 137 beds on the behavioral health side and then manage that accordingly. But in this case, what’s interesting is when the patient is admitted in the acute care side; the internist is the primary physician. If it’s primarily behavioral health, the psychiatrist is the admitting and the internist is considered the consultant. 

Peter Salgo, MD: The question that’s going to come up—and we have to answer it for the internists, cardiologists, and nephrologists—is, “Can I continue giving the injectable? Do I have to call in the psychiatrist to consult? Will this injectable interfere with a therapy that I want to give for the problem that’s brought the patient to the hospital this time?” These are all legitimate questions. How do you integrate all this into the health care system?

Joe Avelino, RN, BSN, MHSA, CPHQ: I don’t think our internists—I can speak to my facility. My internists and my specialists don’t know the LAIs. This is where—

Peter Salgo, MD: That’s my point.

Joe Avelino, RN, BSN, MHSA, CPHQ: Wait a minute. They would recommend this patient because the “behavior” probably needs a psych consult. I’m not aware of any of my internists or my specialists recommending or initiating orders for LAIs.

Peter Salgo, MD: What you’re saying is psychiatrists are specialists. You can go ahead and take care of the diabetes and get the psychiatrist on board to help you modulate the LAIs at the same time, work as a team. Now there’s a thought, Henry. You mentioned the team about an hour ago.

Rahn Bailey, MD, DFAPA: Right. It’s the same here. Primary care doctors are not going to write for LAI. I have 2 doing inpatient physicals in my hospital every day and 2 doing outpatient, family medicine doctors. What they should understand is how those medicines work and interact with the medicines they’re using. What they also should do is be sure that the patient is not only medically stable but that we have them on a trajectory toward better overall medical outcomes. I’m regularly still surprised by how often in psychiatry we tolerate patients with high blood pressure, diabetes out of control, and all these things if they have chronic mental illness. Our patients deserve, as we have discussed today, the same level of high-quality medical intervention as they do psychiatric. The team approach is key, but there must be psychiatrists as the team lead.

Peter Salgo, MD: What strikes me—I’m an internist and intensivist. It just strikes me that when you set up a silo that says psychiatry and psychiatric illness is different from everything else, you’re setting yourself up for trouble and you’re setting the patient up for trouble. Once you recognize that psychiatric illnesses have a neurological basis, this is a good thing. When we all work together as physicians treating all these things as a team, it strikes me, is the patient going to do better? This makes sense to me. What do you think?

Henry Nasrallah, MD: Let me mention something that can address another hidden advantage of the long-acting injectables. Many times, when a patient with schizophrenia gets medically ill, they get hospitalized on an internal medicine floor, they stop all the medications, just like that. Whether they’re taking antipsychotics, antianxiety drugs, or antidepressants, they just stop everything, which I find almost abominable. I never stop my patients admitted to psychiatry receiving epilepsy medication. I don’t stop them, but they do. We keep telling them, “Do not stop these medications. The patient will relapse.” If the patient is taking LAIs, there’s nothing to stop. They can go in and have their surgery, have their internal medicine treatment; nobody can stop anything. They remain well. It protects them through thick and thin, including admissions for other conditions.

Peter Salgo, MD: I guess you really get questions about this patient having an LAI on board: “If I have to give a vasopressor, is that going to be an issue?” You have to be ready with answers for that.

Henry Nasrallah, MD: We can certainly communicate to the colleague who’s asking this question: what are the LAIs, their benefits, and their safety. They’re all approved by the FDA. We have several on the market, and no matter which 1 we use, they all work, and they all are tolerable. Otherwise, the FDA would never have approved them.

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Transcript Edited for Clarity