Guidelines and Evaluation: Improving the Quality of Consultation-Liaison Psychiatry

An Audit of Inpatient Consultation-Liaison Psychiatry Services at an Inner New York City Safety Net Hospital

Background Our study's primary objective is to audit the resource utilization of a consultation-liaison (CL) psychiatry service in an inner New York City safety net hospital. This cross-sectional, observational study was conducted as a subset of a quality improvement project at the hospital to investigate the characteristics of the emergent nature of consults, types, and the specialty from which the referral was placed to the CL services. This study aims to improve the efficacy of our consult process by improving the appropriateness and precision of consult requests. Methodology This cross-sectional, observational study was reviewed and approved by the Institutional Review Board under a quality improvement exemption. The study investigated the EPIC electronic medical record data for characteristics of consult referrals in the third quarter of 2019 from July 1, 2019, to September 30, 2019. A total of 629 consults were recorded during this period. We excluded follow-up calls, duplicate data rows, and patients with missing data points; the final consults were 421. Patients who required more than one new consult (follow-up excluded) within 90 days were considered; thus, the total number of patients who were included in the study was 327. Results Of the 421 consults identified in the dataset for review, only 45.8% were valid consults, 32.8% were not valid, and 21.4% were uncertain. Further, the most common department from which consults were placed was Medicine (73.2%), followed by Surgery (12.8%), Obstetrics/Gynecology (9%), Critical Care (3.6%), and, finally, Pediatrics (1.4%). Conclusions The study overviews the quality of general consults for the CL psychiatry service and how the CL staff manages it. It also provides an idea about the number of consults that can be comprehensively addressed.

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.

Implementation of the CLiP database

PURPOSE

The purpose of this paper is to review the findings from an audit of the implementation of a consultation-liaison psychiatry (CLiP) database in all inpatients referred to a CLiP service at the largest hospital in Malaysia with the aim of improving the quality CLiP services.

DESIGN/METHODOLOGY/APPROACH

All inpatient referrals to the CLiP team were recorded over a three-month period and compared to previous audit data from 2017. Four audit standards were assessed: the reporting of referrals, timeliness of response indication of reason for referral and presence of a management plan.

FINDINGS

The compliance of reporting using the CLiP form was 70.1 per cent compared to 28 per cent in the audit data from 2017 after interventions were conducted. Analysis of the completed CLiP form reveals that 89 per cent of referrals were seen within the same working day. All referrals included the reason for referral. The most common reason for referral was for depressive disorders, but post-assessment, delirium was the most common diagnosis. In total, 87.8 per cent satisfied the audit criteria for a completed written care plan.

ORIGINALITY/VALUE

Specialised CLiP services are relatively new in Malaysia and this is the first paper to examine the quality of such services in the country. Interventions were effective in improving the compliance of reporting using the CLiP database. The findings suggest that the CLiP services are on par with international audit standards. Furthermore, data from this clinical audit can serve as a benchmark for the development of national operating policies in similar settings.

Benchmarking a liaison psychiatry service: a prospective 6-month study of quality indicators

Aims and Method

There are no national standards to evaluate the quality of delivery of in-patient liaison psychiatry services in general hospitals in the UK. In order to benchmark our service against best international practice, we adapted quality indicators from two peer-reviewed studies from Australia and Switzerland and monitored our performance standards over a period of 6 months.

Results

There were 145 patients assessed over the study period. We set a priori target of 90% achievement on indicators in the areas of timeliness of response to all referrals, timeliness of response to referrals following self-harm and quality of supervision of junior medical staff attaining 93.8, 87.5 and 89.6% respectively.

Clinical Implications

We demonstrated that we provided a reasonably responsive consultation–liaison service with high levels of supervision of junior staff. National bodies should develop benchmarks in this area so that services can demonstrate the quality of their service and learn from others' good practice.

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.

A descriptive study of a unique multi-ethnic consultation-liaison psychiatry service in Honolulu, Hawaii

OBJECTIVE

To provide a descriptive characterization of the CL Psychiatry service at a major medical center in Honolulu, Hawaii. We hypothesized differing demographic trends than seen nationally and internationally, an increasing prevalence of elderly and substance abusing patients, and increasing consultation requests related to these issues.

METHODS

Retrospective data was gathered from 180 randomly selected patient records, identified as having a request for inpatient psychiatric consultation on the medical-surgical floors during identical 3-month periods in 2000 and 2005. Descriptive statistics were calculated. Chi-square and ANOVA were used to compare differences across time.

RESULTS

There were no significant differences by age, reason for referral, or diagnoses between the 2 years. Patients age 65 years and older accounted for only 16.6% of the consults. Caucasians accounted for 45.6% of consultations despite low prevalence rates in the population. Hawaiian/Pacific Islander (15%), Japanese (12.5%), Filipino (5.6%), and other Asians (10.6%) accounted for the majority of remaining patients. Depression/anxiety (27.4%), alcohol/drugs (21.8%), and agitation/ psychosis (20.5%) were the most frequent reasons for consultation. Substance use (32.5%), mood (16%), and cognitive (14.1%) disorders were the top diagnoses.

CONCLUSIONS

As expected, the patient demographic data reflects a unique patient population served by the QMC CL service. Much of the consultation process, diagnoses, and treatment, however, are in line with our Mainland counterparts. There were no major differences in trends over time.

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.

Changes to inpatient consultation-liaison psychiatry service delivery over a 7-year period

OBJECTIVE

The aim of this paper was to examine the effect of changes to a consultation-liaison (C-L) service at Maroondah Hospital on referral and service delivery patterns across a period of 7 years. There is no national benchmarking of C-L service. Local services respond to local political and service demands. There have been significant changes to the C-L service at Maroondah Hospital between 1999 and 2006. During the intervening years, psychogeriatric referrals have been included and gazetting of general hospital beds has resulted in detention of patients under the Mental Health Act (MHA).

METHOD

Clinical audit data from assessments by the C-L service during the above period were entered into a database and analysed.

RESULTS

The annual referral rate increased as did the mean age of referred patients. The main reason for referral changed from suicide evaluation and history of psychotic symptoms to depression. Referral lag time did not change significantly. A higher proportion of patients received a single consultation and a greater number required psychiatric inpatient care.

CONCLUSION

The nature of referral changed towards older, sicker patients and away from younger, suicidal patients which, together with an increased referral rate, significantly increased demand on available resources.

Examining models of mental health service delivery in the emergency department

The purpose of the present paper was to review the current models of mental health service delivery used in the emergency department (ED) setting. A search was conducted of the nursing and medical literature from 1990 to 2007 for relevant articles and reports. Consideration was also given to the global and local context influencing contemporary mental health services. Wider sociopolitical and socioeconomic influences and systemic changes in health-care delivery have dictated a considerable shift in attention for mental health services worldwide. The ED is a topical location that has attracted interest and necessitated a response. The mental health liaison nurse (MHLN) role embedded within the ED structure has demonstrated the most positive outcomes to date. This model aims to raise mental health awareness and address concerns over patient-focused outcomes such as reduced waiting times, therapeutic intervention and more efficient coordination of care and follow up for individuals presenting to the ED in psychological distress. Further research is required into all methods of mental health service delivery to the ED. The MHLN role is a cost-effective approach that has gained widespread approval from ED staff and mental health patients and is consistent with national and international expectations for mental health services to become fully integrated within general health care. The mental health nurse practitioner role situated within the ED represents a potentially promising alternative for enhanced public access to specialized mental health care.