Proactive Psychiatric Consultation Services Reduce Length of Stay for Admissions to an Inpatient Medical Team

Proactive Psychiatry: Innovating the Delivery of Consultation-Liaison Services in a Pediatric Hospital

BACKGROUND

The benefits of a proactive consultation-liaison (C-L) psychiatry service have been well-documented in the adult population, including decreased length of stay, increased satisfaction among physicians, and enhanced collaborative care. However, there is no available research on the effectiveness of this model in pediatric hospitals.

OBJECTIVE

This study compared patients ages 5-18 years on a general medical floor receiving a proactive psychiatry consult to concurrent controls receiving no consult and to historical controls receiving traditional reactive consults.

METHOD

New admissions to two pediatric general medical hospital teams were reviewed on weekday mornings to identify those with active psychiatric concerns. Adjusted negative binomial regression was used to compare the primary outcome of hospital length of stay between the proactive (n=65), concurrent control (n=63), and reactive historical control (n=45) groups. Patient satisfaction, hospitalist satisfaction, and recommendation concordance (degree to which psychiatry recommendations were implemented by the primary team) were also compared between groups as secondary outcome measures.

RESULTS

After adjusting for age, sex, race, insurance type, reason for consult, and medical diagnosis, concurrent control patients had 14% (p = 0.295) longer mean length of stay than proactive consults and historical controls had twice (p < 0.001) the mean length of stay of those with proactive consults. Response rate for patient satisfaction scores was low, but responses were modestly more favorable among patients who received proactive C-L services. Based on nine paired pediatric hospitalist pre- and post- surveys, follow-up surveys were statistically significantly more favorable after a proactive psychiatry consult service was introduced. Concordance of recommendations was observed to be higher for proactive consults than concurrent controls for diagnoses and non-medication (other) recommendations.

CONCLUSION

The positive impact of a proactive C-L psychiatry consultation model was observed in a pediatric hospital and was associated with a lower length of stay than concurrent controls and historical reactive consults, higher hospitalist satisfaction among paired responses, and greater concordance of diagnosis and other non-medication recommendations.

Patient and Medical Unit Staff Experiences of Proactive and Integrated Consultation-Liaison Psychiatry in The HOME Study: A Qualitative Investigation

BACKGROUND

Consultation-liaison (C-L) psychiatry services aim to help general hospital staff provide better care for their patients. Recently, many inpatient C-L psychiatry services have adopted proactive and integrated approaches to achieve this aim. Despite these developments, there have been no interview-based studies of patients' and staff members' experiences of the new approaches.

OBJECTIVE

To gain an in-depth understanding of patients' and medical unit staff members' experiences of a proactive and integrated C-L psychiatry service for older medical inpatients (Proactive Integrated C-L Psychiatry [PICLP]).

METHODS

We conducted an interview-based qualitative study with thematic analysis. The participants were patients and staff who had experienced PICLP during The HOME Study, a randomized trial that evaluated PICLP in 24 medical units of three UK general hospitals.

RESULTS

We conducted 97 interviews: 43 with patients or their proxies (family members who were interviewed on behalf of patients with significant cognitive impairment) and 54 with staff members of all relevant disciplines. Patients and staff both described how PICLP was a helpful addition to medical care and discharge planning. It enhanced the medical unit team's ability to address psychological, psychiatric, and social needs and provide patient-centered care. They welcomed proactive biopsychosocial assessments and the broader perspective that these offered on patients' complex problems. They also valued the integration of C-L psychiatrists into the unit teams and their daily contact with them. For patients, it fostered a therapeutic relationship and helped them to be more engaged in decisions about their medical care and discharge planning. For staff, it enabled ready access to psychiatric expertise and training opportunities. The few reported experiences of PICLP being unhelpful were mainly about the greater number of clinicians involved in patients' care and a lack of clarity about professional roles in the integrated team.

CONCLUSIONS

We found that older inpatients and medical unit staff experienced PICLP as both acceptable and generally helpful. Our findings add to the existing evidence for the benefits of proactive and integrated C-L psychiatry services.

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.

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.

Psychiatric Consults Associated With Longer Length of Stay in Trauma Patients-A Retrospective Study

INTRODUCTION

Mental illness is a risk factor for intentional and unintentional injury and is associated with readmission. The impact of psychiatric consults on length of stay (LOS) of trauma patients is still undergoing study.

METHODS

Trauma registry at Ascension St. Mary's of Saginaw, a community level 2 trauma center, was queried. Further chart review was performed to demographically characterize the control and intervention groups. Univariate and multivariate regression was performed to identify the association between psychiatric consultation and LOS while considering demographic variables and Injury Severity Score.

RESULTS

A total of 661 patients were identified with trauma and a documented mental health disorder. 612 did not receive a psychiatric consultation and 49 did. The group without a psychiatric consultation had a mean and median LOS of 6 d and 4 d, respectively, compared to 12 d and 10 d for those with a psychiatric consult (P < 0.0001). Mean ISS scores comparable across all groups. Delirium was associated with the highest LOS with a mean of 17.25 d and a median of 14.5 d. All 11 patients transferred to a psychiatric facility at discharge received a consult for self-harm.

CONCLUSIONS

Psychiatric consultations were associated with lengthened stay of trauma patients independent of initial injury severity and documented mental health disorders, and more transfers to inpatient psych facilities. This represents an important prognostic factor for a patient's course of care and suggests that trauma physicians should be well-versed at identifying mental health issues which may require early intervention, as well as managing delirium.

An overview of the rehabilitation and psychiatric diagnoses of patients referred to a psychiatry consult liaison service at an inpatient rehabilitation hospital

BACKGROUND

Patients presenting for inpatient rehabilitation following injury or illness are commonly affected by comorbid psychiatric illness. Currently, little is known about the utilization of a psychiatry consult service in an inpatient rehabilitation hospital.

OBJECTIVE

To identify which rehabilitation patient populations most frequently received psychiatric consultation and recognize the most common psychiatric comorbidities after the implementation of a psychiatry consult liaison (PCL) service.

DESIGN

A retrospective observational study in the form of a chart review examining the utilization patterns of a psychiatric consultation liaison service in the inpatient rehabilitation setting. Chart review was performed to extract patient demographics (age and sex), rehabilitation diagnosis, cause of rehabilitation diagnosis (intentional, accident, self-inflicted, or disease), reason for referral to psychiatry, and psychiatric diagnosis on initial consultation. Statistical software was used for statistical analysis to answer the pre-specified research questions.

SETTING

A 178 bed, free-standing, academic rehabilitation hospital located in an urban Canadian center.

PATIENTS

Any patient admitted to the inpatient rehabilitation hospital who received a psychiatric consultation between September 2016 and December 2019 was eligible for inclusion.

RESULTS

A total of 1016 charts were reviewed in the initial chart review and  1008 were included. The most common rehabilitation diagnoses that were associated with a psychiatric consult were (% admissions receiving consultation): amputations (38%); burns (35%), neurologic disorder (28%), deconditioning (14%), and musculoskeletal injury (7%). Although 20% of patients did not meet criteria for a psychiatric diagnosis, most common psychiatric diagnoses included mood disorder, adjustment disorder, neurocognitive disorder, and delirium.

CONCLUSION

There are significant perceived needs for psychiatric services in the inpatient rehabilitation setting. Although some patient groups such as patients with amputations, burns, and trauma may exhibit the highest utilization, the service supports mental health needs from many patient groups.

Drug Safety Profiles of Geriatric Patients Referred to Consultation Psychiatry in the Emergency Department-A Retrospective Cohort Study

OBJECTIVE

Geriatric patients account for a significant proportion of the collective treated by psychiatric consultation service in hospitals. In the Emergency Department (ED), psychotropic drugs are frequently recommended, notwithstanding their extensive side-effect profiles. This study sought to investigate medication safety of geriatric patients referred to psychiatric consultation service in the ED.

METHODS

Medication lists of 60 patients from the general internal medicine and trauma surgery EDs referred to psychiatric consultation service were analyzed. Utilizing PRISCUS list and Fit fOR The Aged (FORTA) classification, prescriptions of potentially inappropriate medications (PIMs) were assessed.

RESULTS

84 drugs were newly prescribed following psychiatric consultations. The total number of drugs per patient was 5.4 ± 4.2 before psychiatric consultation and 6.5 ± 4.2 thereafter (p < .001). 22.6 % of the newly recommended drugs were PIMs according to the PRISCUS list, while 54.8 % were designated as therapeutic alternatives to PIMs. 54.8 % and 20.2 % of the newly recommended drugs were FORTA category C and D drugs, respectively. An average of 1.2 ± 1.7 drug-drug interactions (DDIs) existed before psychiatric consultation and 1.3 ± 1.9 DDIs thereafter (p = .08).

CONCLUSION

The majority of newly recommended drugs by psychiatric consultation service in the ED were designated as suitable therapeutic alternatives to PIMs according to the PRISCUS list, but had comparatively unfavorable ratings according to the FORTA classification, demonstrating discrepancies between these two PIM classification systems. Physicians delivering psychiatric consultation services in the ED should not solely rely on one PIM classification system.

Implementing a workflow-integrated motivational interviewing training program for psychiatry trainees on an inpatient consultation-liaison rotation: lessons learned

Background

Effective consultation-liaison psychiatry (CLP) is proactive, collaborative, and requires providers to have proficiency with therapeutic skills beyond nosology and medication management. Motivational interviewing (MI) is an evidenced-based intervention that should be considered essential for CLP trainees to learn. Given that the demands of training and patient care are already experienced as stressful for many psychiatry trainees, the authors endeavored to create a MI training program that was integrated into trainees' normal CLP workflow.

Method

Twenty-two trainees on an inpatient CLP rotation participated in a six-week MI training program that was incorporated into their regular workflow. The program included didactic sessions with role-playing, as well as on-demand between-session coaching via an expert in MI. Trainee participation and perceptions of MI were measured via a questionnaire that was administered prior to each training session.

Results

Trainee participation in the didactic sessions was inconsistent. Questionnaire data revealed positive baseline perceptions of motivational interviewing and its usefulness in inpatient medical settings. Additionally, as trainees participated in the program, perceived knowledge of motivational interviewing as well as awareness of motivational issues among their patients increased. Finally, participation in program was not perceived as disruptive to daily workflow for the participants.

Discussion

This the first documented attempt at implementing a MI training program for CLP trainees that was integrated into their regular workflow. Preliminary data identified some encouraging trends, but also unexpected challenges. These lessons could inform how these types of training programs are implemented moving forward.

The impact of rounds with a psychiatry team in the intensive care unit: A prospective observational pilot study evaluating the effects on delirium incidence and outcomes

BACKGROUND

Delirium in the intensive care unit (ICU) is a common but serious condition that has been associated with in-hospital mortality and post-discharge psychological dysfunction. The aim of this before and after study is to determine the effect of a multidisciplinary care model entailing daily ICU rounds with a psychiatrist on the incidence of delirium and clinical outcomes.

OBJECTIVE

To assess the impact of a proactive psychiatry consultation model in the surgical ICU on the incidence and duration of delirium.

METHODS

This was a prospective, single institution, observational controlled cohort pilot study of adult patients admitted to a surgical ICU. A control group that received standard of care (SOC) with daily delirium prevention care bundles in the pre-intervention period was compared to an intervention group, which had a psychiatrist participate in daily ICU rounds (post-intervention period). The primary outcome was delirium incidence. The secondary outcomes were: delirium duration, ventilator days, hospital and ICU length of stay, and in-hospital mortality.

RESULTS

A total of 104 patients were enrolled and equally split between SOC and intervention groups; 95 contributed to analysis. The overall incidence of ICU delirium was 19%. SOC and intervention groups had similar rates of delirium (21% vs 18%, p = 0.72). None of the secondary outcomes statistically significantly differed between the two groups.

CONCLUSION

Delirium in ICU patients is a potentially preventable condition with serious sequelae. There was no difference in delirium incidence or duration between patients receiving SOC or patients who had multidisciplinary rounds with a psychiatrist.

Implementation of an Automated Sepsis Screening Tool in a Children's Hospital Emergency Department: A Cost Analysis

OBJECTIVE

To determine the effect of implementation of an automated sepsis screening tool on the median cost of affected patient encounters.

STUDY DESIGN

This retrospective cohort study used propensity score-matched comparison groups to assess the difference in median cost for comparable affected patient encounters before and after the implementation of an automated sepsis screening tool in a large US children's hospital emergency department (ED) with >90 000 annual visits. All patient encounters in 2018 impacted by the automated sepsis screening tool were included and compared with a propensity score-matched comparison group drawn from patient encounters in 2012 that might have been affected by the screening tool had it been active at that time. The main outcome was the change in the median cost for comparable affected patient encounters.

RESULTS

The overall median cost for those affected by an automated sepsis screening tool decreased by 21.2%, from $6454 (IQR, $968-$21 697) to $5084 (IQR, $802-$16 618). The median cost for encounters with an associated International Classification of Diseases sepsis code decreased by 51.1%, from $58 685 (IQR, $32 224-$134 895) to $28 672 (IQR, $16 796-$60 657).

CONCLUSIONS

The median cost for comparable patient encounters decreased with implementation of an automated sepsis screening tool in the pediatric ED. Costs were decreased even more substantially for patients with sepsis. In addition to improving outcomes, an automated sepsis screening tool appears to be at least cost-effective and may be cost-saving, an incentive for more widespread use of this technology.

Promoting patient and nurse safety: testing a behavioural health intervention in a learning healthcare system: results of the DEMEANOR pragmatic, cluster, cross-over trial

Background

Based on clinical staff safety within a learning healthcare system, the purpose of this study was to test an innovative model of care for addressing disruptive behaviour in hospitalised patients to determine whether it should be scaled up at the system level.

Methods

The Disruptive bEhaviour manageMEnt ANd prevention in hospitalised patients using a behaviOuRal (DEMEANOR) intervention team was a pragmatic, cluster, cross-over trial. A behavioural intervention team (BIT) with a psychiatric mental health advanced practice nurse and a social worker, with psychiatrist consultation, switched between units each month and occurrences of disruptive behaviours (eg, documented violence control measures, violence risk) compared. Nursing surveys assessed self-perceived efficacy and comfort managing disruptive patient behaviour.

Results

A total of 3800 patients hospitalised on the two units met the criteria for inclusion. Of those, 1841 (48.4%) were exposed to the BIT intervention and 1959 (51.6%) were in the control group. A total of 11 132 individual behavioural issues associated with 203 patient encounters were documented. There were no differences in the use of behavioural interventions, violence risk or injurious behaviour or sitter use between patients exposed to BIT and those in the control group. Tracking these data did rely on nursing documentation of such events. Nurses (82 pre and 48 post) rated BIT as the most beneficial support they received to manage patients exhibiting disruptive, threatening or acting out behaviour.

Conclusions

The BIT intervention was perceived as beneficial by nurses in preparing them to provide care for patients exhibiting disruptive, threatening or acting out behaviour, but documented patient behaviour was not observed to change.

Trial registration number

NCT03777241.

An Economic Evaluation of a Proactive Consultation-Liaison Psychiatry Pilot as Compared to Usual Psychiatric Consultation On-Demand for Hospital Medicine

BACKGROUND

A growing literature demonstrates the value of the Proactive Consultation-Liaison (C-L) Psychiatry model for healthcare systems through reductions in hospital length of stay (LOS). Few studies include financial outcomes. We evaluated the return on investment (ROI) of a one-year Proactive C-L Psychiatry pilot on a hospital medicine unit.

METHODS

We used a pre-post method with an active comparison of three hospital medicine units with regular psychiatric consultation on-demand. We staffed the Pilot unit with one full-time psychiatrist who focused on early case finding, close communication with unit staff, frequent follow-up visits, and proactive discharge planning. We assessed the one-year change in mean LOS for all patients receiving psychiatric consultation, from which we estimated the direct contribution margin (DCM) from bed backfills and the program's return on investment (ROI).

RESULTS

On the Pilot unit, the percent of discharges that received psychiatric consultation increased from 7.34% to 13.79%, and the LOS for patients consulted on declined by a mean of 1.82 days (P<0.05), as compared to an increase of 0.15 days (P>0.05) on the usual care units. The Pilot unit reduction in LOS saved 451.71 days total, allowing for 73.81 bed-backfills, a DCM of $419,343 (95% confidence interval, $50,754 to $787,933), a net DCM of $298,245 (-$70,344 to $666,835) and ROI of 132% (-31% to 295%).

CONCLUSION

This study strengthens existing evidence for the relative cost-effectiveness of Proactive Consultation-Liaison (C-L) Psychiatry for hospital medicine compared to usual psychiatric consultation on-demand.

A Model Program to Manage Behavioral Emergencies and Support Nurses in the Medical Setting

Medically hospitalized individuals have high rates of comorbid psychiatric, substance abuse, and behavioral disorders. Disruptive and sometimes aggressive behaviors may arise when mental health needs of patients go unrecognized or are inadequately addressed. Health care workers experience the most workplace violence compared with other professions, with nurses and nursing aides at highest risk. A Behavioral Emergency Support Team (BEST) model can be an effective approach to providing a customized response to a patient's agitation through identification of underlying clinical and environmental contributors to the onset of aggression as well as to provide behavioral education and support of nursing staff. Results from 2 years of BEST model use resulted in 124 events among 96 patients of whom 19 had repeated events. The most common reasons for codes were aggression (79%) and elopement threat/attempt (45%), and the most frequent patient diagnosis was cognitive impairment (54%). Development of a BEST model provides support to nurses that is not otherwise available for events that are disruptive to care in inpatient medical settings and help minimize the occurrence of workplace violence.

The effectiveness of inpatient consultation-liaison psychiatry service models: A systematic review of randomized trials

OBJECTIVE

To systematically review randomized trials of the effectiveness of inpatient Consultation-Liaison (C-L) Psychiatry service models in improving patient outcomes, reducing length of hospital stay and decreasing healthcare costs.

METHOD

We searched databases including Ovid Medline, Ovid Embase, Ovid PsycINFO and EBSCO CINAHL for relevant trials. Two independent reviewers assessed articles and extracted data. The review is registered with PROSPERO, number CRD42019120827.

RESULTS

Eight trials were eligible for inclusion. All had methodological limitations and all were published more than ten years ago. None reported clear evidence that the C-L Psychiatry service model evaluated was more effective than usual medical care alone. All the service models tested focused on providing a consultation for patients identified by screening. Clinical heterogeneity precluded meta-analysis.

CONCLUSION

Whilst we found no evidence that any of the inpatient C-L Psychiatry service models evaluated is effective, the sparseness of the literature and its methodological limitations preclude strong conclusions. The trials do, however, suggest that purely consultation-based service models may not be effective. A new generation of robust clinical trials of a wider range of C-L Psychiatry service models is now required to inform future service developments.

Consultation-liaison psychiatry in Japan: a nationwide retrospective observational study

BACKGROUND

Consultation-liaison psychiatry (CLP)-professional psychiatric care provided to coordinate with surgical or medical treatment of inpatients with psychiatric disorders-was included in universal health coverage in Japan in 2012. Despite evidence of benefits of CLP, basic data and geographic distribution information regarding CLP at the national level remain unclear. This study aimed to 1) identify the geographic disparity of CLP in Japan and 2) investigate the association between number of consultations per CLP patient and region.

METHODS

We retrospectively analyzed anonymized data retrieved from the Japanese administrative inpatient database regarding inpatients who were provided CLP between April 2012 and March 2017. Demographic characteristics were summarized and geographic disparity by prefecture was visualized for fiscal years 2012 and 2016; we also summarized the data according to region. Multivariate linear regression analysis was used to investigate association between the number of consultations per CLP patient and region after adjusting for covariates.

RESULTS

Data from a total of 46,171 patients who received 138,866 CLP services were included. Results revealed more patients aged 75-84 years received CLPs than any other age group (29.7%) and the overall male/female ratio was 53:47 in 2016. In 2012 and 2016, 24.2 and 30.7% of CLP patients, respectively, were transferred to other hospitals; 9.7 and 8.8%, respectively, discharged due to the death. CLP services were provided in 14 prefectures in 2012 and 33 by 2016; 14 prefectures had no available CLP services. After adjusting for covariates, Tohoku (β = - 0.220, p < 0.034), Chugoku (β = - 0.160, p < 0.026), and Shikoku (β = - 0.555, p < 0.001) had a significant negative correlation with the number of consultations per CLP patient compared with Hokkaido region (an adjusted R square (R2) = 0.274).

CONCLUSIONS

Our study clarified the characteristics of patients in Japan who received CLPs and the geographic disparity in CLP services. Although 5 years had passed since CLP was introduced, the results imply wide availability of CLP nationally. The analysis data provided may inform future policies to improve CLP services.

An Innovative Model of Behavior Management to Address Behavioral Emergencies in the Acute Medical Inpatient Setting: Pilot Data

Workplace violence in healthcare is a significant and costly problem. The majority of violent events that occur in the medical inpatient setting are perpetrated by patients against staff and occur during a behavioral emergency. The primary purpose of this study was to evaluate the impact of an innovative model of behavior management on occurrence of behavioral emergencies and staff comfort and competence in managing difficult patient behaviors. This model consists of primary, secondary, and tertiary interventions provided by a clinical psychologist which include proactive training for hospital staff and consultation-liaison services for behavior management. Forty-six staff at the University of Virginia Medical Center completed a 1-h training on preventing and managing difficult patient behavior. Self-report data on comfort and competence in managing challenging patient behaviors was collected at baseline, immediately following the intervention, and one and three months post-intervention. Behavioral emergencies were tracked for the intervention unit and a comparison unit. The occurrence of behavioral emergencies decreased by 50% in the three months following the intervention compared to a 142% increase on the comparison unit. Staff reported the greatest increase in confidence from baseline to three months post-intervention on caring for patients with psychiatric illnesses, managing verbal abuse, being supported by medical center leadership, having clear roles and responsibilities, and effectiveness of the skills and strategies used to manage difficult patient behavior. The results of this study provide preliminary support for the use of a comprehensive model for managing the behavioral needs of medical inpatients.

Association between the timing of consultation-liaison psychiatry interventions and the length of stay in general hospital

BACKGROUND

Psychiatric comorbidities are frequent in patients admitted in general hospital and are associated with greater lengths of stay (LOS). Early consultation-liaison psychiatry (CLP) interventions may reduce the LOS but previous studies were underpowered to allow subgroup analyses and have generally not considered the severity of the condition for which patients were admitted ('disease severity').

AIMS

To investigate the association between the timing of CLP interventions and LOS in a general hospital.

METHOD

We retrospectively included 4500 consecutive patients admitted in non-psychiatric wards of a university hospital between 2008 and 2016 who had a first CLP intervention. We used general linear models to examine the association between the referral time, defined as log(days before the consultation)/log(LOS), and log(LOS), adjusting for age, gender, year of admission, place of residence, main psychiatric diagnosis, admission to the intensive care unit (ICU), main physical condition and disease severity.

RESULTS

Referral time was associated with log(LOS) (β = 0.31; P <0.001), notably for older patients (β = 0.43; P <0.001) and those admitted to the ICU (β = 0.50; P <0.001), but not for those with psychotic disorders (β = -0.20; P = 0.10). The association was confirmed when considering the expected LOS for each patient. For instance, for an expected LOS of 10 days, a CLP intervention on day 3 compared with day 6 was associated with a reduction of the actual LOS of 2.4 days.

CONCLUSIONS

Earlier CLP interventions were associated with a clinically significant shorter LOS in a large population even after adjusting for disease severity. Early CLP interventions may have benefits for both patients and health-related costs.

Impact of Psychiatric Diagnoses and Treatment on Postoperative Outcomes Among Patients Undergoing Surgery for Colorectal Cancer

OBJECTIVE

Psychiatric diagnoses may be a risk factor for poor colorectal cancer (CRC) surgery outcomes. The authors investigated the risk of psychiatric diagnoses and benefit of mental health treatment for surgery outcomes among CRC patients.

METHODS

This retrospective cohort study of patients undergoing CRC surgery in the 2000-2014 period identified documentation of psychiatric diagnosis and mental health treatment (no treatment, medication only, psychotherapy only, or both medication and psychotherapy) 30 days before surgery. Associations between psychiatric diagnoses, mental health treatment, and postoperative outcomes (postoperative complications, length of stay [LOS], and 90-day readmission rate) were evaluated with multivariable generalized estimating equations.

RESULTS

Among 58,961 patients undergoing CRC surgery, 9,029 (15.3%) had psychiatric diagnoses, 4,601 (51.0%) of whom received preoperative mental health treatment (90.0% psychiatric medication, 6.7% psychotherapy, and 3.0% medication and psychotherapy). Patients with psychiatric diagnoses had an increased risk for postoperative complications (odds ratio [OR]=1.09, 95% confidence interval [CI]=1.03-1.15) and 90-day readmission (OR=1.11, 95% CI=1.06-1.17) compared with patients without psychiatric diagnoses. Patients with psychiatric diagnoses who received no mental health treatment or only medication had a 7%-17% increased risk for postoperative complications and 90-day readmission compared with patients without psychiatric diagnoses. Patients who received medication only also had a 4% increase in LOS relative to patients without psychiatric diagnoses. Patients with psychiatric diagnoses receiving only psychotherapy and patients without psychiatric diagnoses had similar postoperative outcomes.

CONCLUSIONS

Preoperative psychiatric diagnoses were associated with worse postoperative outcomes. Surgical quality-improvement efforts should focus on identifying patients with preoperative psychiatric diagnoses and addressing these conditions presurgery.

Clinical Profile and Length of Hospital Stay in a Sample of Psychogeriatric Patients Referred to Consultation Liaison Psychiatric Unit

Background and objectives: There has been a recent increase in older patients admitted to general hospitals. A significant percentage of hospitalized older patients are ≥75 years old, which differ from the patients aged 65 to 74 years old in terms of functional status at patient discharge. This study aims to compare sociodemographic, clinical features, and factors associated with length of hospital stay in youngest-old and oldest-old populations of inpatients referred to the consultation liaison psychiatry unit. Material and methods: This is an observational, cross-sectional, retrospective, and comparative study. We obtained data from a sample of 1017 patients (≥65 years) admitted to a general hospital and referred from different services (medicine, surgery, etc.) to the consultation liaison psychiatry unit. The sample was divided into two groups of patients: youngest-old (65–74 years) and oldest-old (≥75 years). Psychiatric evaluations were performed while the patients were on wards at the hospital. Psychopharmacs were started as needed. A comparative analysis was carried out and predictive factors related to length of hospital stay were calculated. Results: The reference rate to consultation liaison psychiatry unit was 1.45% of the total older patients hospitalized. Our study demonstrates differences between the groups of older people: the oldest-old group were mainly female (p < 0.001), had more previous psychiatric diagnoses (p < 0.001), physical disabilities (p = 0.02), and neurocognitive disorders (p < 0.001), they used more antipsychotics (p < 0.001), and more frequently had a discharge disposition to a nursing home (p = 0.036). The presence of physical disability (beta = 0.07, p < 0.001) and logtime to referral to consultation liaison psychiatry unit (beta = 0.58, p < 0.001) were associated with increased length of hospital stay. Conclusions: Youngest-old and oldest-old people should be considered as two different types of patients when we consider clinical features. The time to referral to consultation liaison psychiatry unit seems to be a relevant factor associated with length of hospital stay.

Proactive Consultation-Liaison Psychiatry: American Psychiatric Association Resource Document

In 2019, the American Psychiatric Association Council on Consultation-Liaison (C-L) Psychiatry convened a work group to develop a resource document on proactive C-L psychiatry. A draft of this document was reviewed by the Council in July 2020, and a revised version was approved by this Council in September 2020. The accepted version was subsequently reviewed by the American Psychiatric Association Council on Health Care Systems and Financing in November 2020. The final version was approved by the Joint Reference Committee on November 24, 2020, and received approval for publication by the Board of Trustees on December 12, 2020. This resource document describes the historical context and modern trends that have given rise to the model of proactive C-L psychiatry. Styled as an inpatient corollary to outpatient collaborative care models, proactive C-L provides a framework of mental health care delivery in the general hospital designed to enhance mental health services to a broad range of patients. Its 4 elements include systematic screening for active mental health concerns, proactive interventions tailored to individual patients, team-based care delivery, and care integration with primary teams and services. Studies have found that proactive C-L psychiatry is associated with reduced hospital length of stay, enhanced psychiatric service utilization, reduced time to psychiatric consultation, and improved provider and nurse satisfaction. These favorable results encourage further studies that replicate and build upon these findings. Additional outcomes such as patient experience, health outcomes, and readmission rates deserve investigation. Further studies are also needed to examine a broader array of team compositions and the potential value of proactive C-L psychiatry to different hospital settings such as community hospitals, surgery, and critical care.

Proactive Integrated Consultation-Liaison Psychiatry: A new service model for the psychiatric care of general hospital inpatients

OBJECTIVE

To describe a new service model for the psychiatric care of general hospital inpatients, called Proactive Integrated Consultation-Liaison Psychiatry ('Proactive Integrated Psychological Medicine' in the UK).

METHOD

The new service model was developed especially for general hospital inpatient populations with multimorbidity, such as older medical inpatients. Its design was informed by the published literature and the clinical experience of C-L psychiatrists. It was operationalized by a process of iterative piloting.

RESULTS

The rationale for the new model and the principles underpinning it are outlined. Details of how to implement it, including a service manual and associated workbook, are provided. The training of clinicians to deliver it is described. The effectiveness and cost-effectiveness of this new service model is being evaluated. Whilst we have found it feasible to deliver and well-accepted by ward teams, potential challenges to its wider implementation are discussed.

CONCLUSION

Proactive Integrated Consultation-Liaison Psychiatry (PICLP) is a fusion of proactive consultation and integrated care, operationalized in a field-tested service manual. Initial experience indicates that it is feasible to deliver. Its effectiveness and cost effectiveness for older patients on acute medical wards is currently being evaluated in a large multicentre randomized controlled trial (The HOME Study).

Proactive Psychiatry Intervention Using a Nurse-Led Behavioral Response Model for Hospitalized Patients With Behavioral Disturbances

BACKGROUND

The health care sector has one of the highest rates of workplace violence, putting staff at risk and impeding care. To deliver quality health care, staff need targeted resources. This article describes a program to improve staff safety and reduce barriers to care for patients with behavioral disturbances.

PROGRAM DESCRIPTION

A nurse-led behavioral response team was created to identify high-risk patients and offer prompt targeted interventions. The Behavioral Optimization and Outcomes Support Team (BOOST) was implemented in November 2012, in conjunction with a proactive model of care, enabling psychiatric intervention. Advanced practice nurses in psychiatry respond to requests from staff on medical/surgical units to assist with management of behavioral disturbances.

METHODS

Consultation and intervention data were reviewed, and staff satisfaction surveys were completed to evaluate the program.

RESULTS

The program has contributed to staff feeling more supported and safer at work. There has also been a reduction in staff's experience of perceived burden in the care of patients with behavioral disturbances although they are caring for more of these patients.

CONCLUSIONS

Although violence risk in health care continues to be a significant issue, programs to intervene early can be effective in supporting staff to minimize these risks.

Psychiatric symptoms among patients with acute abdominal pain

Background: Abdominal pain is a common cause of visits to emergency facilities. It is related to psychiatric disorders in primary care, but it is unclear if this also holds in emergency departments.Objective: Is to explore potential differences between diagnostic groups in patients with acute abdominal pain in an emergency ward regarding concurrent somatic-and psychiatric symptoms, 'Length of stay' (LOS) and perceived health.Method: The patients (N = 137) were divided into three groups; organic dyspepsia, specific abdominal diagnoses, and non-specific abdominal pain. The Prime-MD results for extra gastrointestinal symptoms (outside the gastrointestinal tract), psychiatric symptoms, frequency of symptoms, self-reported health, and LOS within the month before admittance were compared between the diagnostic groups.Results: There was a significant positive correlation between the number of physical extra gastrointestinal and psychiatric symptoms (p < .001), especially regarding anxiety (p < .001) and depression (p = .002). Patients with organic dyspepsia reported significantly more total (p = .016), extragastrointestinal (p = .026) (chest pain; p = .017, dizziness; p = .004, palpitations; p = .005, insomnia; p = .005 and worries; p = .001), and summarized anxiety and depression symptoms (p = .001-0.002) besides poorer general health (p < .001) compared to other abdominal conditions. Also, organic dyspepsia patients needed longer hospital stay than the non-specific abdominal group (p = .002) but similar to the specific abdominal disorders group.Conclusion: Organic dyspepsia is accompanied by more co-occurring physical, anxiety and depression symptoms as well as poorer perceived health than other abdominal pain conditions and comparably increased LOS. This suggests that psychiatric consultations might be beneficial for diagnosing and treating psychiatric comorbidity in emergency care.

Integration of a proactive, multidisciplinary mental health team on hospital medicine improves provider and nursing satisfaction

OBJECTIVE

Psychiatric comorbidity among hospital medicine patients is common and often complicates care delivery and compromises outcomes. Team-based, proactive consultation-liaison (CL) psychiatry has been shown to reduce hospital length of stay (LOS) and care costs, but staff satisfaction with this model has not been explored in detail. Here we evaluate its impact on hospital medicine provider and nurse satisfaction.

METHODS

We implemented a team-based proactive CL service that reviews all admitted hospital medicine patients across 3 units for psychiatric comorbidity and provides unit-wide integrated mental health care. Hospital medicine staff completed surveys before and after a 6-month pilot phase: 10-item provider surveys covered resource adequacy, safety, time for healthcare improvements, and burnout; 26-item nurse surveys included the same 10 items plus 8 on behavioral health assessment competency and 8 on intervention competency. Additionally, we characterized psychiatric comorbidity, calculated consultation latency and volume and also average LOS during these 6 months.

RESULTS

The provider response rate was 57% (20/35 before; 21/37 after) and roughly a third for nurses (32/~90 and 31/~90, respectively). Providers rated 9 of 10 items as improved, including one on burnout. Nursing satisfaction improved similarly but with lower effect sizes. During the pilot (n = 1590), 71% had chart-identified psychiatric comorbidity. Consultation latency decreased by 0.86 days; consultation rate increased nearly 3-fold; and average LOS decreased by 0.33 days.

CONCLUSIONS

Team-based proactive CL psychiatry enhances provider and nurse satisfaction and may even reduce provider burnout. We also confirmed that this model is associated with reduced average LOS.

Challenges of Establishing a de novo Consultation-Liaison Psychiatry Service in a Tertiary Hospital: Practical considerations and challenges

Consultation-liaison psychiatry (CLP), also known as psychosomatic medicine, is a subspecialty of psychiatry that focuses on the care of patients with mental health disorders and general medical/surgical conditions. Integrating CLP services facilitates diagnosis and management of patients with complex comorbidities. This article aimed to report the practical considerations and challenges associated with establishing a de novo CLP service in a tertiary hospital in the Gulf region. This includes discussing the rationale and clinical and educational benefits as well as the resources required for establishing a CLP service.

The Disruptive bEhavior manageMEnt ANd prevention in hospitalized patients using a behaviORal intervention team (DEMEANOR) study protocol: a pragmatic, cluster, crossover trial

BACKGROUND

Disruptive behavior in hospitalized patients has become a priority area of safety concern for clinical staff, and also has consequences for patient management and hospital course. Proactive screening and intervention of patients with behavioral comorbidities has been reported to reduce disruptive behavior in some settings, but it has not been studied in a rigorous way.

METHODS

The Disruptive bEhavior manageMEnt ANd prevention in hospitalized patients using a behaviORal intervention team (DEMEANOR) study is a pragmatic, cluster, crossover trial that is being conducted. Each month, the behavioral intervention team, comprising a psychiatric-mental health advanced practice nurse and a clinical social worker, with psychiatrist consultation as needed, rotates between an adult medicine unit and a mixed cardiac unit at Vanderbilt University Medical Center in Nashville, TN, USA. The team proactively screens patients upon admission, utilizing a protocol which includes a comprehensive chart review and, if indicated, a brief interview, seeking to identify those patients who possess risk factors indicative of either a potential psychological barrier to their own clinical progress or a potential risk for exhibiting disruptive, aggressive, or self-injurious behavior during their hospitalization. Once identified, the team provides interventions aimed at mitigating these risks, educates and supports the patient care teams (nurses, physicians, and others), and assists non-psychiatric staff in the management of patients who require behavioral healthcare. Patients who are both admitted to and discharged from either unit are included in the study. Anticipated enrollment is approximately 1790 patients. The two primary outcomes are (1) a composite of objective measures related to the patients' disruptive, threatening, or acting out behaviors, and (2) staff self-reported comfort with and confidence in their ability to manage patients exhibiting disruptive, threatening, or acting out behavior. Secondary outcomes include patient length of stay, patient attendant (sitter) use, and the unit nursing staff retention.

DISCUSSION

This ongoing trial will provide evidence on the real-world effectiveness of a proactive behavioral intervention to prevent disruptive, threatening, or acting out events in adult hospitalized patients.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT03777241. Registered on 14 December 2018.

The effect of a hospital liaison psychiatry service on inpatient lengths of stay: interrupted time series analysis using routinely collected NHS hospital episode statistics

BACKGROUND

The purpose of the study was to determine whether establishment of a specific liaison psychiatry service designed to offer a rapid response with facilitated hospital discharge led to reduced acute hospital length of inpatient stay.

METHODS

We used interrupted time series based upon routine NHS data from secondary care service in two acute general hospitals, for all adult (16+ years) inpatient admissions (114,029 inpatient spells representing 70,575 individual patients) over 3 years.

RESULTS

Length of stay reduced over time in both hospitals. Against a background of falling length of stay across the study period, there was no discernible effect of the rapid access/early discharge liaison service on length of stay, either as a step change or linear decline. This finding held for all patients and for those over 65 years and those discharged with a mental health diagnosis.

CONCLUSIONS

Using routine NHS data for a whole hospital it was not possible to replicate a previous report that a rapid access liaison psychiatry service for inpatients produces substantial reductions in length of stay, and commissioners of services should be cautious of claims to the contrary. Further research to determine if there is an effect for sub-groups will require major improvements in the way co-morbid mental disorders are coded in NHS practice.

Predictors of Disagreement Between Diagnoses From Consult Requesters and Consultation-Liaison Psychiatry

We evaluated disagreement between reported symptoms and a final diagnosis of depression, anxiety, withdrawal, psychosis, or delirium through regression models assessing individual and combined diagnoses. Highest disagreement rates were reported for services classified as others (88.2%), general surgery (78.5%), and bone marrow transplant (77.7%). Disagreement rates varied widely across different diagnoses, with anxiety having the highest disagreement rate (63.3%), whereas psychosis had the lowest disagreement rate (10.6%). When evaluating kappa coefficients, the highest agreement occurred with diagnoses of withdrawal and psychosis (0.66% and 0.51%, respectively), whereas anxiety and depression presented the lowest values (0.31% and 0.11%, respectively). The best-performing predictive model for most outcomes was random forest, with the most important predictors being specialties other than the ones focused on single systems, older age, lack of social support, and the requester being a resident. Monitoring disagreement rates and their predictors provides information that could lead to quality improvement and safety programs.

An evaluation of proactive psychiatric consults on general medical units

OBJECTIVE

Recent studies have shown an association between proactive psychiatric consultation on medical units and shorter length of stay. The aim of this study was to assess the impact of implementing a proactive psychiatric consult service on general medical units in an urban teaching hospital on length of stay and qualitative measurement of satisfaction of adequacy of psychiatric services.

METHODS

Bivariate and multivariate analyses of demographic, clinical and outcome data were performed comparing patients seen by the proactive psychiatric consult team, patients seen contemporaneously on other general medical units by a traditional, reactive consult team and patients seen the prior year on the proactive intervention units by the reactive consult team. Length of stay was the primary outcome examined. Regression modeling was performed to assess further the relationship of length of stay with the three groups. Nursing and physician staff were queried before and after intervention regarding satisfaction with psychiatric resources on the intervention units.

RESULTS

Patients seen by the proactive team had shorter length of stay than those seen by contemporaneous reactive consult team (p = 0.005) or the prior year by the reactive team on the intervention units (p = 0.005). There was no significant difference between the latter two groups. Time to consult was also shorter for patients seen through the proactive model than the reactive model on other units at the same time (0.01) or the preceding year (<0.001). Nursing and physician satisfaction with psychiatric help increased significantly in three of four measures.

CONCLUSIONS

Proactive psychiatric consultation in our study correlated with shorter time to consult, shorter length of stay, and improved staff satisfaction compared to a reactive consult model.

A systematic review of proactive psychiatric consultation on hospital length of stay

OBJECTIVE

Roughly half of general hospital patients may have a psychiatric issue that impacts care, yet most of these are not recognized during hospital admission. Proactive mental health screening offers an opportunity for timely identification and clinical attention to improve outcomes.

METHOD

We conducted a PRISMA systematic review of Pubmed, Embase, PsycINFO, and Cochrane Library for proactive models of psychiatric consultation to reduce hospital length of stay (LOS) in adult inpatients. For each study, we evaluated the level of evidence and defined the study sample, means of group allocation, screening process, interventions, and outcomes.

RESULTS

Of the 12 included studies, the 8 whose screening was informed by clinicians with mental health care expertise or whose providers were integrated with primary services reported a reduction in LOS. Two of these also reported favorable cost-benefit analyses. All positive studies represent versions of either psychiatrists embedded within medical or surgical settings or a multidisciplinary team-based model.

CONCLUSIONS

Proactive CL psychiatry with clinically-informed screening and integrated care delivery appear to reduce LOS. Further studies are needed to explore a broader range of outcomes, hospital populations beyond hospital medicine, and additional benefits of proactive integrated mental health care in the general hospital.

The HOME Study: study protocol for a randomised controlled trial comparing the addition of Proactive Psychological Medicine to usual care, with usual care alone, on the time spent in hospital by older acute hospital inpatients

BACKGROUND

Prolonged acute hospital stays are a major problem for older people and for health services. Failure to effectively manage the psychological and social aspects of illness is an important cause of prolonged hospital stays. Proactive Psychological Medicine (PPM) is a new way of providing psychiatry services to medical wards. PPM is proactive, focussed, intensive and integrated with medical care. A major aim of PPM is to reduce the time older people spend in hospital because of unmanaged psychological and social problems. The HOME Study will test the effectiveness and cost-effectiveness of PPM.

METHODS/DESIGN

A two-arm parallel-group randomised controlled superiority trial, with a linked health economic analysis and an embedded process evaluation, will be conducted at three sites. A total of 3588 participants will be recruited and randomised to usual care or usual care plus PPM. The primary outcome is the number of days spent as an inpatient in a general hospital in the month (30 days) post-randomisation. Secondary outcomes for each participant (measured at 1 and 3 months) include quality of life, independent functioning, symptoms of anxiety and depression, cognitive function, and their experience of the hospital stay.

DISCUSSION

The trial has been designed to produce findings that are generalisable to all older medical inpatients (including those with cognitive impairment). It will provide information on the effectiveness and cost-effectiveness of PPM, which we hope will be of value to patients, clinicians, managers and service planners.

TRIAL REGISTRATION

ISRCTN86120296 . Registered on 3 January 2018.

Characterization of high healthcare utilizer groups using administrative data from an electronic medical record database

Background

High utilizers (HUs) are a small group of patients who impose a disproportionately high burden on the healthcare system due to their elevated resource use. Identification of persistent HUs is pertinent as interventions have not been effective due to regression to the mean in majority of patients. This study will use cost and utilization metrics to segment a hospital-based patient population into HU groups.

Methods

The index visit for each adult patient to an Academic Medical Centre in Singapore during 2006 to 2012 was identified. Cost, length of stay (LOS) and number of specialist outpatient clinic (SOC) visits within 1 year following the index visit were extracted and aggregated. Patients were HUs if they exceeded the 90th percentile of any metric, and Non-HU otherwise. Seven different HU groups and a Non-HU group were constructed. The groups were described in terms of cost and utilization patterns, socio-demographic information, multi-morbidity scores and medical history. Logistic regression compared the groups’ persistence as a HU in any group into the subsequent year, adjusting for socio-demographic information and diagnosis history.

Results

A total of 388,162 patients above the age of 21 were included in the study. Cost-LOS-SOC HUs had the highest multi-morbidity and persistence into the second year. Common conditions among Cost-LOS and Cost-LOS-SOC HUs were cardiovascular disease, acute cerebrovascular disease and pneumonia, while most LOS and LOS-SOC HUs were diagnosed with at least one mental health condition. Regression analyses revealed that HUs across all groups were more likely to persist compared to Non-HUs, with stronger relationships seen in groups with high SOC utilization. Similar trends remained after further adjustment.

Conclusion

HUs of healthcare services are a diverse group and can be further segmented into different subgroups based on cost and utilization patterns. Segmentation by these metrics revealed differences in socio-demographic characteristics, disease profile and persistence. Most HUs did not persist in their high utilization, and high SOC users should be prioritized for further longitudinal analyses. Segmentation will enable policy makers to better identify the diverse needs of patients, detect gaps in current care and focus their efforts in delivering care relevant and tailored to each segment.

Electronic supplementary material

The online version of this article (10.1186/s12913-019-4239-2) contains supplementary material, which is available to authorized users.

Need analysis for a new high acuity medical psychiatry unit: which patients are considered for admission?

BACKGROUND

The study aims were: to estimate the proportion of patients with an indication for admission to a new high acuity Medical Psychiatric Unit (MPU), to explore the reasons for MPU-admission according to different health disciplines, and to check for differences in patient characteristics. The results of this study are to be utilized in the proposed establishment of a high-acuity MPU in a University Medical Center. Such a unit currently does not exist at Erasmus MC.

METHODS

Hospital in-patients were included if they received psychiatric consultation from the Psychiatric Consultative Service (PCS). As part of the study protocol, psychiatrists, other medical specialists, and nurses determined the need for admission to the proposed MPU. Patient groups were compared with respect to diagnoses, socio-demographic characteristics and patient routing.

RESULTS

One hundred and fifty-one patients were included, 43% had an indication for MPU-admission, for the other patients PCS involvement was sufficient. There was agreement on suicide attempts as a reason for MPU-admission. For psychiatrists, the need for further diagnostic evaluation was a common reason for MPU admission, while other medical specialists more often emphasized the need for safety measures. Patients with an unplanned hospital admission had a higher chance of MPU eligibility (OR = 2.72, 95% CI 1.10-6.70). The main psychiatric diagnoses of MPU-eligible patients were organic disorders (including delirium), mood disorders, and disorders related to substance abuse. The most common diagnoses found were similar to those in previous research on MPU populations.

CONCLUSION

Different medical disciplines have different views on the advantages of MPUs, while all see the need for such facilities. The proposed MPU should be able to accommodate patients directly from the Emergency Unit, and the MPU should provide specialized diagnostic care in an extra safe environment.

Waiting it out: consultation delays prolong in-patient length of stay

BACKGROUND

Decreasing delays for hospitalised patients results in improved hospital efficiency, increased quality of care and decreased healthcare expenditures. Delays in subspecialty consultations and procedures can cause increased length of stay due to reasons outside of necessary medical care.

OBJECTIVE

To quantify, describe and record reasons for delays in consultations and procedures for patients on the general medicine wards.

METHODOLOGY

We conducted weekly audits of all admitted patients on five Internal Medicine teams over 8 weeks. A survey was reviewed with attending physicians and residents on five internal medicine teams to identify patients with a delay due to consultation or procedure, quantify length of delay and record reason for delay.

RESULTS

During the study period, 316 patients were reviewed and 48 were identified as experiencing a total of 53 delays due to consultations or procedures. The average delay was 1.8 days for a combined total of 83 days. Top reasons for delays included scheduling, late response to page and a busy service. The frequency in length of consult delays vary among different specialties. The highest frequency of delays was clustered in procedure-heavy specialties.

CONCLUSION

This report highlights the importance of reviewing system barriers that lead to delayed service in hospitals. Addressing these delays could lead to reductions in length of stay for inpatients.

Length of hospital stay and dementia: A systematic review of observational studies

OBJECTIVE

Hospitalizations of people with dementia (PWD) are often accompanied by complications or functional loss and can lead to adverse outcomes. Unsystematic findings suggest an influence of comorbidities on the extent of differences in the length of hospital stay (LOS). This systematic review aimed to identify and evaluate all studies reporting LOS in PWD as compared to PwoD in general hospitals.

METHODS

A systematic review of observational studies using PubMed and ISI Web of Knowledge. Inclusion criteria comprised original studies written in English or German, assessment of diagnosis of dementia, measurement of LOS, and comparison of people with and without dementia.

RESULTS

Fifty-two of 60 studies reported a longer hospitalization time for PWD compared to PwoD. The extent of the difference in LOS varied between and within countries as well as by type of primary morbidity (eg, injuries, cardiovascular diseases). The range of the LOS difference for studies without restriction to a primary morbidity was -2 to +22 days after matching or adjustment for a variable number and selection of potentially relevant covariates. For studies with injuries/fractures/medical procedures and infectious/vascular disease as the primary morbidity, the range was -2.9 to +12.4 and -11.2 to +21.8 days, respectively.

CONCLUSIONS

The majority of studies reported a longer hospitalization of PWD compared to PwoD. Length of hospital stay seems to be influenced by a variety of medical, social, organizational factors, including reasons for hospital admission, whose role should be explored in detail in further research.

The Impact of Designated Behavioral Health Services on Resource Utilization and Quality of Care in Patients Requiring Constant Observation in a General Hospital Setting: A Quality Improvement Project

Constant observation (CO) is a common economic burden on general hospitals. A quality improvement (QI) project focusing on behavioral health (BH) management of this population was piloted using a novel BH protocol for the proactive assessment and management of all patients requiring CO. The impact on CO-cost and length of stay (LOS) was assessed. Data on demographics, diagnoses, psychopharmacologic treatment, complications and clinical setting were collected and analyzed for all CO-patients over a 6-month period. Cost and LOS data were compared with a similar sequential group prior to project implementation. Out of the 533 patients requiring CO during the study period, 491 underwent the protocol. This QI-project resulted in a significant reduction in the average monthly CO-cost by 33.06% and a 15% reduction in LOS without any increase in complications.

Performance of an emergency department observation unit protocol in reducing length of stay for acetaminophen overdose: a retrospective study

Introduction

Acetaminophen is one of the most common causes of poisoning among developed countries. The emergency department observation unit (EDOU) has been increasingly used in the management of various conditions to reduce hospitalisation but its efficacy in not well studied in management of poisoned patients. In this study, we aim to study the effectiveness of our EDOU in the management of acetaminophen overdosed patients.

Results

Medical records of patients admitted from the emergency department from 2012 to 2016 for acetaminophen overdose were reviewed. One hundred ninety-five patients presenting with acetaminophen overdose were admitted to the EDOU while 184 were admitted to the general ward. Of these, 27 patients admitted to EDOU did not meet the admission criteria for it while 71 patients who met EDOU criteria were admitted to the ward instead. For patients who fulfilled EDOU admission criteria, median length of stay for EDOU patients was 23 h (IQR 19–24) while that for those admitted to the ward was 66 h (IQR 62.5–88.3).

Conclusion

The EDOU is a safe alternative to hospitalisation for patients presenting with acetaminophen poisoning. It is also associated with a shorter length of stay for such patients. Further studies need to be done to assess the cost-effectiveness of EDOU for management of patients presenting with acetaminophen overdose.

Impact of Behavioral Health Screening on Proactive Identification of Patients at Risk for Hospital Readmission

Improving the ability to predict which patients are at increased risk for readmission can lead to more effective interventions and greater compliance with CMS Hospital Readmissions Reduction Program (HRRP) requirements. This study evaluated the performance of a risk model that used data from a health system's electronic medical record (EMR) to predict all-cause readmission among adult inpatients with acute medical conditions, with a specific focus on the impact of including behavioral health screening data. The study included 39,155 unique adult patients admitted during 2015 to 4 acute care inpatient facilities within a nonprofit community-based health care system. The risk model integrated a comprehensive set of data elements including demographics, psychosocial characteristics, medical history, assessment results, and clinical events. Predictive models were constructed using a multivariable logistic regression with a stepwise selection approach. Among study participants, the mean age was 62.9 years, 48.0% were male, 31.2% had comorbid psychiatric conditions, and 6986 had medical conditions/procedures subject to HRRP penalties. Results from exploratory predictive analyses demonstrated that any patients with a Serious Mental Illness (SMI) diagnosis were 28% more likely to be readmitted within 30 days, and the likelihood of readmission associated with SMI increased to 56% for patients with medical conditions subject to HRRP penalties. As health care systems face increasing pressures to reduce readmissions and avoid CMS HRRP financial penalties, study results indicate the importance of including behavioral health data from EMRs and screening assessments for all inpatients to improve discharge planning and patient outcomes.

Evaluation of the value of team-based psychiatric consultation in a general hospital setting

Background With the increase use of pay for performance in healthcare, 30-day readmissions after discharges are critically important. Objective A team-based psychiatric consultation approach was tested in an inpatient hospital setting. This is the first study that examines 30-day readmission rate with this approach. Methods In this quality improvement study, 164 patients received a team-based psychiatric consultation that included daily meetings during the weekdays between psychiatrists and hospitalists and 436 received care of treatment-as-usual or traditional consultation-liaison services. Results Overall 30-day readmission rate was not significantly different between intervention and nonintervention groups. However, in subgroups with high risk of mortality or severe illness, the intervention group had a 0% 30-day readmission rate for both high risk of mortality and severe illness subgroups, while the nonintervention group's readmission rate was 5% for high risk of mortality group and 3% for severely ill patients. Annual hospital cost saving is estimated between a quarter million and 1.5 million dollars for these subgroups. Conclusion The team-based psychiatric consultation approach demonstrated the potential for substantial cost savings in providing care for patients with high risk of mortality and severe illness. Thus, this intervention may be very useful in caring for patients with complex chronic conditions.

Psychiatric consultation requests by inpatient medical teams: an observational study

Background

We describe the way psychiatric issues are addressed by inpatient medical teams through analysis of discussions of patients with behavioral health concerns and examination of teams’ subsequent consultation practices.

Methods

We observed morning rounds for nine inpatient medical teams for approximately month-long periods, for a total of 1941 observations. We compared discussions of patients admitted for behavioral health related medical conditions between those who did and did not receive a psychiatric consultation, developing categories to describe factors influencing consultation or other management.

Results

Out of 536 patients, 40 (7.5%) received a psychiatry consult. Evaluation of a known concern (i.e., substance use, affective disorder, or suicidal ideation) was the most common reason for referral (41.7%). Requests for medication review were second (30.6%). Thirty patients with concomitant behavioral and medical health issues did not receive a psychiatry consult. Cirrhosis with active substance use was the most common medical diagnosis (15), followed by alcohol withdrawal (9).

Conclusions

Four primary themes emerged from our data: positive identification of behavioral health issues by physicians, medication management as a primary reason for referral, patient preference in physician decision-making, and poor management of substance abuse. Our results identify two potential areas where skills-building for inpatient physicians could have a positive impact: management of medication and of substance abuse management.

Discharge Delays for Patients Requiring In-Hospital Guardianship: A Cohort Analysis

OBJECTIVE

To assess nonclinical factors delaying hospital discharge of guardianship patients.

DATA

Utilization review data over 3 years.

DESIGN

Retrospective cohort study.

ANALYSIS

Mann-Whitney test was used to compare patients' medically unnecessary days (MUD) of hospitalization with additional subcategories of delays-defined as beyond clinicians' control.

FINDINGS

Overall median number of MUD was 19.5; 14 of 48 patients were additionally delayed while awaiting long-term care Medicaid approval (N = 7, 50%), pending insurance (N = 3, 21%), social or transportation difficulties (N = 3, 21%), or preadmission review (N = 1, 7%). The median number of MUD for the 14 delayed patients was 63, a difference of 53 days compared with the routine guardianship cohort (P < .0001) and $5.5M in net revenue opportunity.

CONCLUSIONS

Nonclinical discharge delays for guardianship patients are costly and potentially unavoidable. Further exploration into policy change is therefore recommended.