The development of clinical indicators for a consultation-liaison service

Clinical audit of the Consultation-Liaison psychiatric service of a metropolitan hospital

OBJECTIVE

The primary objective of this study was to use clinical indicators to track changes in efficiency of a Consultation-Liaison service as part of a clinical audit cycle.

METHODS

This was a clinical audit cycle. The auditing phase involved measuring the efficiency of the service. The 'intervention' was simply the team's awareness and involvement in tracking these statistics. Subsequently, these indicators were re-audited.

RESULTS

In the initial audit cycle, 315 referrals to the C-L service were audited over a 3 month period, showing a 24 hour time-to-seen rate of 80% and a 36 hour time-to-seen rate of 89.2%. Upon re-auditing of 112 referrals following our intervention, 24 hr timeliness had risen to 92% and 36 hr timeliness had risen to 96.4%.

CONCLUSION

The measuring of clinical indicators of efficiency in C-L may give service improvement personnel a reflection of the functionality of a C-L service. By involving team members in the measuring and tracking of these indicators, we may be able to boost overall clinical efficiency and outcomes.

Comparison of consultation-liaison psychiatry services for inner-city, district or regional general hospitals using a common tool: Does one size fit all?

OBJECTIVE

Consultation-liaison psychiatry (CLP) services vary in terms of structure, function and responsiveness. It is not known whether evaluation measurements can be meaningfully compared across different CLP services to assess value and efficiency. The aim was to develop and test a common tool for measuring process and outcome measures in CLP.

METHODS

A data collection tool was developed using the literature and consultation with CLP clinicians. The tool was used to prospectively gather referral data, response times, health utilisation data and functional outcomes for individuals referred over seven months to three different CLP teams, servicing inner city, district and regional areas.

RESULTS

The structure, staffing, liaison attachments and scope of practice varied between the services. The regional CLP service attended seven hospitals and had the highest referral rate and largest inpatient population pool. The three services received referrals for similar reasons and made similar diagnoses. Multimodal management was the norm, and CLP facilitated follow-up arrangements upon discharge. Only the district CLP service saw all emergency referrals within an hour. Age and need for an interpreter did not affect response times.

CONCLUSION

Despite local differences in geography, CLP roles, hospital and community mental health service pathways and patient populations, the CLP data collection tool was applicable across sites. Staff resourcing and referral demand are key determinants of CLP response times.

Wand A. Quality indicators for a consultation-liaison psychiatry service

Purpose

– Consultation-liaison psychiatry (CLP) researchers have not yet developed accepted quality indicators to measure efficiency or effectiveness. The purpose of this paper is to combine objective and subjective quality indicators to assess hospital-based CLP service utilisation, efficiency and effectiveness.

Design/methodology/approach

– Service utilisation rate was calculated over the service's first four years. Patient characteristics and objective quality indicators relating to response timeliness in 2012 were examined. Totally, 41 staff and 52 consecutive patients completed evaluation surveys to subjectively evaluate effectiveness.

Findings

– The utilisation rate increased initially and then slightly declined to 1.03 per cent of all hospital admissions. In 2012, 91.5 per cent were seen on the same referral day and 99.4 per cent by the next day. The benchmark for urgent referrals was not met (77.4 per cent). Patients rated involvement with the CLP service a positive experience (90 per cent), but were less clear about follow-up plans (68 per cent). Staff believed that the service improved the patients’ hospital course (98 per cent) and was communicated well (93-95 per cent). Only 63 per cent agreed that relevant CLP education was provided and 76 per cent rated follow-up plans as clear.

Originality/value

– This CLP service was evaluated by measuring utilisation rates, referral response timeliness and consumer feedback. Referral to contact time is a useful objective quality indicator but should be combined with subjective yet standardised measures surveying service recipients (patients and referring staff) to be comprehensive and meaningful.

Developing performance indicators for homeless outreach psychiatric services

OBJECTIVE

Performance indicators (PIs) aim to improve services by measuring key activities in a way that allows comparison over time, between services and against benchmarks. This paper describes the development and implementation of Homeless Psychiatric Service PIs and explores their potential benefits and limitations.

METHOD

We collected descripton of quality service from key stakeholders. We identified eight key parameters, from which PIs were developed and tested over a 12-month period.

RESULTS

The use of the PIs led to increased awareness of the practice being measured. PIs were used to stimulate practice changes. They played a positive role in team dynamics and were useful in clarifying team aims and identity. The main challenge to their use was the burden of data collection and analysis.

CONCLUSION

Homeless service PIs can assist in determining how well the programs are performing in activities that are relevant to clients and non clinical services for the homeless. With the movement of homeless clients away from inner urban areas, homeless performance measures may aid teams to develop the capacity to work effectively with homeless clients.

Clinical indicators for routine use in the evaluation of early psychosis intervention: development, training support and inter-rater reliability

AIM

Clinical practice improvement carried out in a quality assurance framework relies on routinely collected data using clinical indicators. Herein we describe the development, minimum training requirements, and inter-rater agreement of indicators that were used in an Australian multi-site evaluation of the effectiveness of early psychosis (EP) teams.

METHODS

Surveys of clinician opinion and face-to-face consensus-building meetings were used to select and conceptually define indicators. Operationalization of definitions was achieved by iterative refinement until clinicians could be quickly trained to code indicators reliably. Calculation of percentage agreement with expert consensus coding was based on ratings of paper-based clinical vignettes embedded in a 2-h clinician training package.

RESULTS

Consensually agreed upon conceptual definitions for seven clinical indicators judged most relevant to evaluating EP teams were operationalized for ease-of-training. Brief training enabled typical clinicians to code indicators with acceptable percentage agreement (60% to 86%). For indicators of suicide risk, psychosocial function, and family functioning this level of agreement was only possible with less precise 'broad range' expert consensus scores. Estimated kappa values indicated fair to good inter-rater reliability (kappa > 0.65). Inspection of contingency tables (coding category by health service) and modal scores across services suggested consistent, unbiased coding across services.

CONCLUSIONS

Clinicians are able to agree upon what information is essential to routinely evaluate clinical practice. Simple indicators of this information can be designed and coding rules can be reliably applied to written vignettes after brief training. The real world feasibility of the indicators remains to be tested in field trials.

Consultation-liaison psychiatry in a maternity hospital

OBJECTIVE

The aim of the study was to describe referral patterns of maternity inpatients to the consultation-liaison psychiatry (CLP) service at a large women's hospital in metropolitan Melbourne, Australia.

METHOD

Clinicians recorded socio-demographic data, referring unit, consultee's reason for referral, psychiatric diagnosis made, and treatment provided for all maternity inpatients referred from 2004 to 2008.

RESULTS

Main reasons for referral were detection of depression, past psychiatric history, and concern regarding a woman's coping. Most common diagnoses were depression, substance use disorders and anxiety disorders. Many women referred for assessment while inpatients were initially seen in the antenatal period.

CONCLUSIONS

Pregnant women referred to a CLP service present with a range of mental health problems, most often depression, anxiety and substance use disorders. Many of these problems are evident in and require intervention during the antenatal period as well as at the time of confinement. CLP services to maternity hospitals should be provided in the antenatal as well as the inpatient setting.

Audit of an inpatient liaison psychiatry consultation service

PURPOSE

The purpose of this paper is to examine an audit that was performed of all patients referred to a liaison psychiatry inpatient consultation service which sought to establish a baseline for demographics, type of referral, and management of referrals, with a view to introducing improved evidence-based treatments. It also aims to examine timeliness of response to referrals benchmarked against published standards.

DESIGN/METHODOLOGY/APPROACH

All inpatient referrals to a liaison psychiatry service were recorded over a six-month period, including demographics, diagnosis, management and timeliness of response to referrals. The data were retrospectively analysed and compared against international standards.

FINDINGS

A total of 172 referrals were received in the six months. Commonest referral reasons included assessments regarding depressive disorders (23.8 per cent), delirium/other cognitive disorders (19.2 per cent), alcohol-related disorders (18.6 per cent), anxiety disorders (14.5 per cent), and risk management (12.2 per cent). Evidence-based practices were not utilised effectively for a number of different types of presentations. A total of 40.1 per cent of referrals were seen on the same day, 75.4 per cent by the end of the next day, and 93.4 per cent by the end of the following day.

PRACTICAL IMPLICATIONS

Use of a hospital protocol for management of delirium may improve outcomes for these patients. Evidence-based techniques, such as brief intervention therapies, may be beneficial for referrals involving alcohol dependence. Referrals were seen reasonably quickly, but there is room for improvement when compared with published standards.

ORIGINALITY/VALUE

This paper provides valuable information for those involved in management of liaison psychiatry consultation services, providing ideas for development and implementation of evidence based practices.

A 12-month follow up of the implementation of clinical indicators in a consultation-liaison service

OBJECTIVES

This paper reviews the use of clinical indicators in a consultation-liaison (C-L) service over a 12-month period at the Royal Melbourne Hospital, Melbourne, Australia.

METHOD

Clinical indicators and C-L data were collected during the 1999 calendar year. A review of the process was conducted during and after completion of the 12-month period.

RESULTS

The system was found to be practical and useful. The use of clinical indicators led to the identification of problems and stimulated effective interventions. The use of the clinical indicators was associated with improvement in communication between C-L staff, parent units and practitioners providing follow-up.

CONCLUSIONS

The implementation of a database and clinical indicators was a useful addition to the C-L service. The use of clinical indicators was effective in improving clinical performance. These benefits need to be balanced against increased administrative burden.