Proactive Integration of Mental Health Care in Hospital Medicine: PRIME Medicine

Screening and Intervention to Prevent Violence Against Health Professionals from Hospitalized Patients: A Pilot Study

BACKGROUND

Health care providers, particularly nursing staff, are at risk of physical or emotional abuse from patients. This abuse has been associated with increased use of physical and pharmacological restraints on patients, poor patient outcomes, high staff turnover, and reduced job satisfaction.

METHODS

In this study, a multidisciplinary team at Tufts Medical Center implemented the Brøset Violence Checklist (BVC), a screening tool administered by nurses to identify patients displaying agitated behavior. Patients who scored high on the BVC received a psychiatry consultation, followed by assessments and recommendations. This tool was implemented in an inpatient medical setting in conjunction with a one-hour de-escalation training led by nursing and Public Safety. The intervention design was executed through a series of three distinct Plan-Do-Study-Act cycles.

RESULTS

This study measured the number of BVCs completed and their scores, the number of psychiatric consults placed, the number of calls to Public Safety, the number of staff assaults, nursing restraint use, and staff satisfaction. During the study period, restraint use decreased 17.6% from baseline mean and calls to Public Safety decreased 60.0% from baseline mean. In the staff survey, nursing staff reported feeling safer at work and feeling better equipped to care for agitated patients.

CONCLUSION

The BVC is an effective, low-cost tool to proactively identify patients displaying agitated or aggressive behavior. Simple algorithms for next steps in interventions and training help to mitigate risk and increase feelings of safety among staff. Regular psychiatric rounding and the identification of champions were key components in a successful implementation.

An Observational Study of Proactive and On-Request Psychiatry Consultation Services: Evidence for Differing Roles and Outcomes

BACKGROUND

Proactive psychiatric consultation services rapidly identify and assess medical inpatients in need of psychiatric care. In addition to more rapid contact, proactive services may reduce the length of stay and improve staff satisfaction. However, in some settings, it is impractical to integrate a proactive consultation service into every hospital unit; on-request and proactive services are likely to coexist in the future. Prior research has focused on changes in outcomes with the implementation of proactive services.

OBJECTIVE AND METHODS

This report describes differences between contemporary proactive and on-request services within the same academic medical center, comparing demographic and clinical data collected retrospectively from a 4-year period from the electronic medical record.

RESULTS

The proactive service saw patients over four times as many initial admissions (7592 vs. 1762), but transitions and handoffs between services were common, with 434 admissions involving both services, comprising nearly 20% of the on-request service's total contacts. The proactive service admissions had a shorter length of stay and a faster time to first psychiatric contact, and the patients seen were more likely to be female, of Black race, and to be publicly insured. There were over three times as many admissions to psychiatry from the proactive service. The on-request service's admissions had a longer length of stay, were much more likely to involve intensive care unit services, surgical services, and transfers among units, and the patients seen were more likely to die in the hospital or to be discharged to subacute rehabilitation.

CONCLUSIONS

Overall, the results suggest that the two services fulfill complementary roles, with the proactive service's rapid screening and contact providing care to a high volume of patients who might otherwise be unidentified and underserved. Simultaneously, the on-request service's ability to manage patients in response to consult requests over a much larger area of the hospital provided important support and continuity for patients with complex health needs. Institutions revising their consultation services will likely need to consider the best balance of these differing functions to address perceived demand for services.

Improving Employee Safety Through a Comprehensive Patient Behavioral Program

BACKGROUND

Health care workers in the United States are facing increasing rates of exposure to aggressive behavior, resulting in an increase in employee injuries related specifically to patient behavioral events. By leveraging interprofessional collaboration and system-level innovation, we aimed to reduce the rate of employee injuries related to patient behavioral events at a children's hospital by 50% over a 3-year period.

METHODS

An interdisciplinary quality improvement team comprising physicians, behavior analysts, nursing, and other key stakeholders developed a comprehensive behavior program in our children's hospital. The team developed 5 key pillars: aggression mitigation tools, clinical resources, advanced training, screening and management, and behavior emergency response. The outcome measure was rate of reported employee safety events related to patient behavioral events. This was tracked via prospective time series analysis statistical process control chart using established rules to detect special cause variation.

RESULTS

The average rate of employee injuries resulting from patient behavioral events decreased from 0.96 to 0.39 per 1000 adjusted patient-days, with special cause variation observed on a statistical process control U-chart. This improvement has been sustained for 16 months. Staff members who experienced injuries included nurses and patient technicians, with common antecedents to injuries including medical interventions or patient requests that could not be safely met.

CONCLUSIONS

A unified and multimodal system aimed to address pediatric patient behavioral events can reduce employee injuries and foster a culture of employee safety in the pediatric inpatient setting.

Using Discrete Form Data in the Electronic Medical Record to Predict the Likelihood of Psychiatric Consultation

BACKGROUND

Manually screening for mental health needs in acute medical-surgical settings is thorough but time-intensive. Automated approaches to screening can enhance efficiency and reliability, but the predictive accuracy of automated screening remains largely unknown.

OBJECTIVE

The aims of this project are to develop an automated screening list using discrete form data in the electronic medical record that identify medical inpatients with psychiatric needs and to evaluate its ability to predict the likelihood of psychiatric consultation.

METHODS

An automated screening list was incorporated into an existing manual screening process for 1 year. Screening items were applied to the year's implementation data to determine whether they predicted consultation likelihood. Consultation likelihood was designated high, medium, or low. This prediction model was applied hospital-wide to characterize mental health needs.

RESULTS

The screening items were derived from nursing screens, orders, and medication and diagnosis groupers. We excluded safety or suicide sitters from the model because all patients with sitters received psychiatric consultation. Area under the receiver operating characteristic curve for the regression model was 84%. The two most predictive items in the model were "3 or more psychiatric diagnoses" (odds ratio 15.7) and "prior suicide attempt" (odds ratio 4.7). The low likelihood category had a negative predictive value of 97.2%; the high likelihood category had a positive predictive value of 46.7%.

CONCLUSIONS

Electronic medical record discrete data elements predict the likelihood of psychiatric consultation. Automated approaches to screening deserve further investigation.

Proactive and integrated consultation-liaison psychiatry for older medical inpatients: A mixed methods description of training, care provided and clinician experience in the HOME study

OBJECTIVES

To describe the practical experience of delivering a proactive and integrated consultation-liaison (C-L) psychiatry service model (PICLP). PICLP is designed for older medical inpatients and is explicitly biopsychosocial and discharge-focused. In this paper we report: (a) observations on the training of 15 clinicians (seven senior C-L psychiatrists and eight assisting clinicians) to deliver PICLP; (b) the care they provided to 1359 patients; (c) their experiences of working in this new way.

METHOD

A mixed methods observational study using quantitative and qualitative data, collected prospectively over two years as part of The HOME Study (a randomized trial comparing PICLP with usual care).

RESULTS

The clinicians were successfully trained to deliver PICLP according to the service manual. They proactively assessed all patients and found that most had multiple biopsychosocial problems impeding their timely discharge from hospital. They integrated with ward teams to provide a range of interventions aimed at addressing these problems. Delivering PICLP took a modest amount of clinical time, and the clinicians experienced it as both clinically valuable and professionally rewarding.

CONCLUSION

The experience of delivering PICLP highlights the special role that C-L psychiatry clinicians, working in a proactive and integrated way, can play in medical care.

Early liaison psychiatry consultations and general hospital readmission: A retrospective cohort study

BACKGROUND

Readmission rates are under growing scrutiny as an indicator of quality of care as much as a potential source of savings. Patients with comorbid psychiatric conditions are more likely to be readmitted, so Consultation-Liaison Psychiatry (CLP) may play a role in lowering readmission rates.

METHOD

In this retrospective cohort study conducted in a general hospital in Paris, France, all consecutive adult inpatients referred for the first time to CLP from January 2008 to December 2016, were included. The main outcomes were 30-day and 7-day readmissions in the same hospital, excluding iterative and planned stays. The objective of this study is to determine whether the timing of psychiatric consultations is associated with 30-day and 7-day readmission rates.

RESULTS

A total of 4498 inpatients (2298(51·1%) women, age = 59·8(±19·3) years) were referred to CLP. Adjusting for age, sex, place of residence, year of admission, type of ward, psychiatric diagnosis and disease severity, later consultation was associated with higher 30-day and 7-day readmission rates (adjusted Odds Ratio [95% confidence interval]:1.21[1·10-1·33] and 1·26[1·11-3·13], respectively). Further adjusting for length of stay, the association remained significant for 7-day readmission (1.28[1·05-1·57]). After stratification on the length of stay, for stays in the highest tercile (i.e., >21 days) an intervention after day 3 (versus before) was associated with 30-day and 7-day readmission rates of 15·8% versus 8·6%(1·81 [1·11-3·13]) and 4·9% versus 1·8%(2·98[1·16-9·88]), respectively.

CONCLUSION

Earlier psychiatric consultation was associated with fewer 30-day and 7-day readmissions. Interventional studies are needed to show that proactive CLP teams could help general hospitals to improve quality of care and make significant economic savings.