Stanford Inpatient Psychiatry
Clinics and Services
Stanford Hospital - Adult Locked Inpatient Psychiatry (H2 )
H2 is the acute, inpatient adult psychiatry ward for Stanford Hospital. Residents usually spend two months on this required rotation during the PGY2 year. The typical patient on this locked unit arrives on or meeting criteria for an involuntary legal 'hold.' The acuity and severity of illness among H2 patients is often high; this can create a stressful work environment which can be exacerbated by the rapid turnover rate. Despite these factors the staff maintains a calm, structured environment that is beneficial to both patient and resident. Therefore, H2 provides an exciting, challenging and very educational experience that is essential to residency training in psychiatry.
Patient care on H2 is delivered in an interdisciplinary fashion with the team comprising nurses, social workers, occupational therapists, psychiatric pharmacists and attending physicians. The two residents on H2 usually carry between 3 and 6 patients. Residents spend 8-10 hours weekly in seminars and case conferences, including 3 hours per week Attending Rounds, 1 hour per week Chief Resident Rounds, 1.5 hours per week Chairman's Rounds and 1 hour per week Journal Club.
The patient population is 60% female and 40% male; 80% Caucasian, approximately 6-8% African-American, 4-7% Hispanic and 5-9% Asian-American. Age range is from 18 years old to 80-plus, with a median age of 30-35. Non-exclusive diagnostic/treatment groupings include: affective disorders 70%, psychotic disorders 30%, geriatric diagnoses including dementia 3%, eating disorders 2%, personality disorders and traits 50-60%. Treatment issues include suicidal ideation in approximately 80% of patients and assaultive behavior in approximately 10%.
Stanford Hospital - Comprehensive Medicine Unit (G2/CMU)
This 20 bed open unit is designed to treat mid-acuity psychiatric patients, as well as those presenting with concomitant medical and psychiatric disorders. Patients are evaluated and treated by an interdisciplinary team that includes: social work, occupational therapy, physical therapy and nutrition if necessary. Patients are encouraged to attend the groups designed to teach them coping skills and prepare them for returning to the community. The ward milieu includes cognitive behavior therapy, occupational therapy activities and community meetings. A full lisitng of group activities on the ward can be found at the following link: Stanford Inpatient Groups.
By virtue of being an open med-psych ward Axis I diagnoses of this inpatient population break down as follows: depression associated with medical illness (15%), eating disorders (20%), organic brain disorders (15%), chronic pain and somatoform disorders (25%), chemical dependency (15%), other (10%) This inpatient service offers a unique learning experience for psychiatric residents to gain experience treating patients with combined medical and psychiatric diagnoses. Residents here are responsible for initial workup of patients being admitted, whether they come from our emergency departement of outside clinics. Furthermore, they are responsible for developing and coordinating the patients' biopsychosocial treatment plan, from admission to discharge. As a result residents have an opportunity to collaborate with a multidisciplinary team comprised of psychologists, physical therapists, occupational therapists and nurses who are cross-trained in medicine and psychiatry ( See Treatment Team ). Residents also serve as psychiatric consultants for patients admitted through the Stanford Pain Management Service ( See http://paincenter.stanford.edu )
Additional learning opportunities include attending rounds daily and chairman rounds once per week. During chairman's rounds an interesting patient is selected and interviewed by the group. After the interview there is discussion regarding differential diagnosis and treatment. The daily responsibilities of the resident also include contacting with the referring or follow-up physicians, arranging and attending family meetings, and maintaining contact with the other team members.
Stanford Geropsychiatry Inpatient Service
The Geropsychiatry Program at Stanford offers evaluation, diagnosis and treatment of psychiatric disorders in elderly patients. Common diagnoses include depression, anxiety, adjustment disorder and cognitive impairment. Inpatient, partial hospitalization and outpatient services are available. The geropsychiatric inpatient program is designed to provide crisis intervention, comprehensive diagnostic evaluation and state-of-the-art treatment. Partial hospitalization offers geropsychiatric patients intermediate care, which includes therapy groups focusing on such issues as adjustment to late life, activity structuring, cognitive training for age-associated memory impairment, dealing with grief and coping with physical illness. The outpatient program is geared toward diagnostic evaluation, psychopharmacologic treatments and short-term psychotherapies including cognitive-behavioral approaches. Geropsychiatry at Stanford, in collaboration with Veterans Administration Medical Center, is a center of leading-edge research on three of the most common psychiatric syndromes in the elderly: dementia, depression and anxiety. Studies are exploring new and effective diagnostic and treatment methods for these disorders. Another important focus of research is pharmacologic versus non?pharmacologic treatment approaches in geriatric depression and anxiety.
This service is an 8-10-bed program located on wards G2 or H2, depending on patient acuity. Residents on this service care for all patients over 65 years of age admitted to the inpatient psychiatry units. Faculty members help instill in residents their particular expertise in dealing with biopsychosocial problems of old age, refined use of psychopharmacology in the elderly, and dealing with complex issues interfacing medical-psychiatric illnesses.
Psychiatric Emergency Service
During regular hours the consult resident evaluates psychiatric patients presenting to the Stanford Emergency Department, at all other times the on-call resident bears the primary responsibility. Attending psychiatric staff and the Chief Residents provide phone supervision and back-up for the on-call resident. Residents spend most of their time learning to triage and respond to acute psychiatric emergencies in the setting of evaluating neurological and medical issues. They learn to gather corroborative histories from family, friends, outpatient medical and mental health providers, and law enforcement agencies to complete psychiatric evaluations. Management options learned include evaluation for legal holds, crisis intervention, appropriate pharmacotherapeutic treatments, and disposition planning and coordination. Residents also learn to collaborate with other medical specialties, nursing staff, social workers. On average a resident can expect to evaluate approxiamtely three patients in the ED during a five hour call shift. The patient population encountered is approximately 63% female, 27% male. Patients from all socioeconomic backgrounds are seen in the emergency room, ranging from homeless to professionals. The breakdown of primary diagnosesis approximately: 30% affective disorders, 25% schizophrenic/psychotic disorders, 10% primary substance abuse, 10% adjustment disorders, 10% organic mental disorders, 10% personality disorders, 5% eating disorders and anxiety disorders. Of the patients evaluated 42% discharged to the community, 44% of patients are admitted to the Stanford inpatient psychiatric wards, 12% of patients are transferred to county psychiatric hospitals or VA hospital and 2% of patients are admitted to a Stanford non-psychiatric ward (medicine, neurology, surgery, trauma, etc.). Naturally, comorbid aubstance abuse and/or AXIS II pathology is very common. In addition, residents attend clinically based teaching rounds held each morning (Monday - Friday) with the Stanford Hospital Psychiatry Chief Resident. Saturday and Sunday mornings, rounds take place at 8AM with the faculty Attending on-call. Other case specific teaching takes place at the time of the patient interviews. Discussion centers around case presentations of all patients seen on the call shift. On weekends, the faculty interview and see patients with the residents, as appropriate. (Also see On-Call duties)
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