Proactive C-L Psychiatry Beyond Academic Hospital Settings: A Pilot Study of Effectiveness in a Suburban Community Hospital

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.

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.

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.

Telemedicine Psychiatric Consultation on an Inpatient Obstetrical Labor and Delivery Unit

BACKGROUND

Limited access to mental health resources has challenged clinicians in delivering early behavioral health interventions to perinatal populations. We describe telepsychiatry consultations to a rural hospital's labor and delivery unit.

OBJECTIVE

To demonstrate how consultation-liaison services during peripartum hospitalization could meet this need.

METHODS

One-year data from electronic medical records of women who were at risk of postpartum syndromes and offered a telepsychiatry consult was extracted and reviewed.

RESULTS

A total of 85 consults were conducted via telepsychiatry primarily for depression, anxiety, and medication management. Bedside psychotherapeutic interventions and education were provided to 63 patients, medications were initiated for 32 patients, and outpatient referrals were made for 47 patients.

CONCLUSIONS

Our results indicate that consultation-liaison telehealth can successfully engage at-risk mothers in psychiatric treatment. Given accelerated telemedicine efforts due to the COVID-19 pandemic, improving access to telepsychiatry for rural, peripartum populations is an important area of development.

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.