The fee for psychiatric emergencies and physical complications established in 2008 is an epoch-making hospital fee that has the capacity to greatly increase the income of the psychiatric ward of general hospitals. This hospital fee is the general hospital version of the hospital fee for psychiatric emergencies established in 2002. The origins of the fee’s complicated facility standards can be traced to the designated hospitalization system for compulsory hospitalization of the Mental Health Act in 1950, and to the notification of the Administrative Vice-Minister of Health and Welfare in 1958; this notification was a so-called psychiatric hospital exception, which introduced the hospital fee in order to independently treat patients of the general ward and the psychiatric ward in the general hospitals. Although only nine hospitals apply the fee at present, it is our desire that the medical fee be revised in the future in order to take advantage of having a psychiatric unit in general hospitals.
There is a great need for general hospitals to manage psychiatry emergencies and physical complications in psychiatric patients. However, the number of psychiatric wards at general hospitals has been decreasing. Under these circumstances, Yokohama City has promoted “the core hospital design”, in which psychiatric wards were established in general hospitals. Yokohama City Minato Red Cross hospital was opened as one of the core hospitals in Yokohama, and has engaged in treating psychiatry emergencies and physical complications in psychiatric patients. We can only manage the physical complications of psychiatric patients by close collaboration with general medical services and the application of nurses in psychiatric wards. A new medical service fee system was established in 2008. Although it has made some progress, it still does not properly reflect the staff assignment standard. The administration organization needs to further evaluate the psychiatry departments of general hospitals in order to guarantee an adequate number of psychiatric staff, and to promote a society in which citizens can live a safe public life, with or without mental disorders.
Osaka City General Hospital is a large metropolitan general hospital with 1063 beds. This hospital also serves as a regional critical care center and has psychiatric wards for adult and child/adolescent psychiatry. In the year 2010, adult psychiatry had a closed ward containing 33 beds, including two secured beds and six private beds. In April 1996, we started to provide critical care and involuntary admission services for psychiatric patients in the city of Osaka. In October 2003, we started to provide inpatient treatment for psychiatric patients with physical complications who had been referred by psychiatric hospitals in Osaka Prefecture. However, as reported previously, providing inpatient care for psychiatric patients with physical complications posed a major challenge for many hospitals, and our hospital was no exception. In 2008, the regulating authority introduced a new hospital fee system for inpatient care of psychiatric patients requiring critical care or treatment for physical complications. Thereafter, we began to prepare for this new system. After considerable discussion of all problem areas, including the architectural layout of the ward, we increased the number of private beds in the psychiatric ward. Thus, the ward now has 28 beds, including 2 secured beds and 14 private beds (six of these 14 beds were prepared for the physical complication treatment unit). Finally, we were able to meet all of the requirements for the new fee system. In September 2012, we started using the new system of a “hospital fee for inpatient care of psychiatric patients requiring critical care or treatment for physical complications.”
The Nara Medical University Hospital is the only general hospital in Nara Prefecture with a psychiatric ward. Therefore, our hospital has assumed an important role in the treatment of psychiatric patients with physical comorbidities. Our hospital has provided psychiatric emergency care and treatment for physical comorbidities since April 1, 2011, the first among all the university hospitals in Japan. In this study, we investigated the demographic characteristics of inpatients between April 1, 2011 and March 31, 2013. A total of 373 patients were admitted during those two years, and 28.4% of them had physical comorbidities. The most common diagnoses according to the International Classification of Diseases (ICD)-10 were schizophrenia spectrum disorders (35.1%), followed by affective disorders (25.5%). The most common physical comorbidity was conditions requiring surgery (36%), followed by serious endocrine or metabolic disease (12%). This paper describes the status, future prospects, and problems relating to psychiatric emergencies and treatment for physical comorbidities, as well as provides suggestions for the importance of such practices in university hospital psychiatry.
Since May 2010, the psychiatric ward of our hospital has been certified as a ward for psychiatric emergencies and comorbid psychiatric and physical illness. This led to a considerable increase in treatment costs for patients. Inpatient treatment for individuals with comorbid psychiatric and physical illnesses requires highly specialized nursing skills, given the variety and complexity of such conditions. We also admit patients presenting with psychiatric emergencies without any physical complaints. We have made various attempts to provide high-quality nursing care to all our patients. From our experiences, the following points have proven beneficial and are considered to be essential: (1) adequate staff strength, (2) acquisition of physical and psychiatric nursing skills, (3) communication among nursing staff to facilitate common knowledge of patient information and the sharing of other specialized information, and (4) Inter-disciplinary collaboration.
Although Informed Consent is regarded as one of the most important processes for medical ethics, both patients and health care providers might not realize the importance. In the aged society, it is urgent that we support decision making of patients with dementia who do not have the capacity to understand the advantage and disadvantage of their treatment options. We as psychiatrists should understand this situation and help less capable patients choose their treatment options.
We report a case that we practiced a grief care by the team, who are in bereaves state because of the family suicide and considered about supporting the natural grief work. In this case, she could not follow the normal grieving process of her eldest son's suicide. She showed a variety of PTSD symptoms, and was treated with multidrug therapy. The reason why we felt the importance of psychological intervention was because of her wandering in the midnight and refuge from suicide attempts. Because she could not organize her feelings, including the feeling of self-condemnation, we felt the need of psychological intervention. There is the psychotherapy, which could be effective to complicated grief and PTSD. Also, the importance of psychological education has been demonstrated. There has been an improvement in the symptoms by conducting the division roles in the implementation to the grief care of the team. We could support the natural grief work by practicing semi-structured grief care with team to the family, who are in the situation of complicated grief, bereaves state to the self-death.