CLINICAL HANDBOOK OF SCHIZOPHRENIA

34. Emergency, Inpatient, and Residential Treatment 343tients be offered the option of voluntary admission even when there are grounds forinvoluntary admission. Clinical judgment and experience is required here, and there maybe differences in local rules and regulations governing these decisions. For patients withstate-appointed conservators of person, the conservator can authorize admission to thehospital.The rules for involuntary commitment, as well as for the different types of commitmentand lengths of time, are set by the states, and vary from state to state. Generally,there are three reasons for commitment—danger to self, danger to others, or inability tocare for oneself (grave disability). Usually several different specific time lengths for the involuntarycommitment period are available. There is often one type of short-term commitmentfor further medical evaluation and treatment, and rapid stabilization (usually fora period of days, often 3 days), and another type that may often follow the shorter one,involving a longer period (in terms of weeks) for more comprehensive evaluation and furthertreatment stabilization. Of course, involuntarily committed patients still have rights,which in some cases may include the right to refuse medication. In California, for example,a special hearing is required to medicate patients who refuse treatment, even if theyare involuntarily committed.The Goals of Treatment and the Interdisciplinary Treatment PlanThe primary goals of treatment in an inpatient setting are stabilization and discharge.Discharge planning begins with the very first encounter with the patient; primary problemswith clearly identifiable goals should be ascertained. At the interdisciplinary treatmentplanning meeting, which takes place as early as possible in the admission process,these goals should be formalized and the approaches to treatment documented. A dischargedate set at this time can always be modified later, depending on clinical improvement.The Physical Structure of an Inpatient Psychiatric FacilityOnce again, an inpatient unit should be designed with safety in mind. Critical issues includevisibility, access, and a generally safe environment with breakaway fixtures andother safety features. Visibility can be optimized by having a centrally located nursing stationwith large windows. Group rooms should be comfortable, quiet, and designed withminimal likelihood for distraction. In areas in which there are culs-de-sac or other placeswith poor visibility (e.g., seclusion rooms), mirrors or closed-circuit cameras can be used.Facilities that accept involuntary admissions generally have available seclusion roomsthat are designed to provide minimal environmental stimulation, thus allowing for environmentalstabilization of patients in acute psychiatric states. Special guidelines, regulations,and accountability practices required for seclusion vary from facility to facility butgenerally adhere to Joint Commission on Accreditation of Healthcare Organizations(JCAHO) standards.Length-of-Stay IssuesOne of the biggest challenges in the development of inpatient treatment programs is theneed to provide a therapeutic experience despite patients’ length of hospital stay, whichhas shortened over the years. Many facilities are still utilizing treatment models (e.g., certainforms of group treatment) designed to be administered over weeks, even though thelength of stay may only be on the order of 7–10 days. The program design must take into