Consultation-liaison psychiatry services: Difference in the patient profile while following different service models in the medical emergency

Pattern of Inpatient Consultation-liaison Psychiatry Utility in a Tertiary Care Hospital

Background

Consultation-liaison psychiatry (C-LP) is an interface between physical and psychological health where the psychiatrists become a part of the medical team for a holistic approach in the treatment of the patient.

Aims

Our study aimed to see the pattern and utility of C-LP services among inpatient referrals to the department of psychiatry.

Settings and Design

This observational descriptive study recorded inpatient referrals to the department of psychiatry of a tertiary care hospital for 2 months.

Subjects and Methods

The Mini-International Neuropsychiatric Interview (M. I. N. I.) was administered for identifying the comorbid psychiatric diagnoses.

Results

Most of the received inpatient referrals were for male patients (73.7%) in the age group of 30-60 years (58%). Overall, the referral rate was significantly higher from the emergency department and intensive care units (ICU) (50%), followed by specialty (medicine and surgery) wards (20%) and super specialty (cardiology, gastroenterology, and oncology) wards (16%). Altered sensorium and restlessness were the most common reasons for referral (42%), followed by alcohol/drug withdrawal (21.6%), somatic complaints (7.3%), sadness of mood, disturbed sleep, and deliberate self-harm (6% each). Substance use disorders, including alcohol and opioid (32%), delirium (25%), and depression (19%), were among the most common psychiatric diagnoses seen in the referred patients.

Conclusions

The pattern observed indicates that most inpatient referrals for psychological evaluation are received for altered sensorium from emergency and ICU than wards. The utility of C-LP helps to understand the reciprocal interdependence between the medical illness and the psychiatric comorbidity.

Interventions to improve consultations in the emergency department: A systematic review

OBJECTIVES

Emergency department (ED) consultations with specialists are necessary for safe and effective patient care. Delays in the ED consultation process, however, have been shown to increase ED length of stay (LOS) and contribute to ED crowding. This review aims to describe and evaluate the effectiveness of interventions to improve the ED consultation process.

METHODS

Eight primary literature databases and the gray literature were searched to identify comparative studies assessing ED-based interventions to improve the specialist consultation process. Two independent reviewers identified eligible studies, assessed study quality, and extracted data. Individual or pooled meta-analysis for continuous outcomes were calculated as mean differences (MDs) with 95% confidence intervals (CIs) using a random-effects model was conducted.

RESULTS

Thirty-five unique comparative intervention studies were included. While the interventions varied, four common components/themes were identified including interventions to improve consultant responsiveness (n = 11), improve access to consultants in the ED (n = 9), expedite ED consultations (n = 8), and bypass ED consultations (n = 7). Studies on interventions to improve consult responsiveness consistently reported a decrease in consult response times in the intervention group with percent changes between 10% and 71%. Studies implementing interventions to improve consult responsiveness (MD -2.55, 95% CI -4.88 to -0.22) and interventions to bypass ED consultations (MD -0.99, 95% CI -1.43 to -0.56) consistently reported a decrease in ED LOS; however, heterogeneity was high (I²  = 99%). Evidence on whether any of the interventions were effective at reducing the proportion of patients consulted or subsequently admitted varied.

CONCLUSIONS

The various interventions impacting the consultation process were predominately successful in reducing ED LOS, with evidence suggesting that interventions improving consult responsiveness and improving access to consultants in the ED also improve consult response times. Health care providers looking to implement interventions to improve the ED consultation process should identify key areas in their setting that could be targeted.

Analysis of the care provided over a six-month period by the liaison psychiatry unit at a general hospital in Lima, Peru

INTRODUCTION

Consultation-liaison psychiatry is a branch of clinical psychiatry that enables psychiatrists to carry out a series of activities within a general hospital. The number of liaison psychiatry units around the world has increased significantly, and Peru is no exception. However, this development is heterogeneous and unknown, so recent study reports are required to reveal the characteristics and details of the clinical care services provided by these units.

AIM

To describe and report the socio-demographic and clinical characteristics of patients evaluated in the Liaison Psychiatry Unit of the Guillermo Almenara Irigoyen National Hospital in Lima, Peru, and to analyse the symptomatic and syndromic nature of the identified conditions.

METHODS

Cross-sectional descriptive study. Referrals to the Liaison Psychiatry Unit of the Guillermo Almenara Irigoyen National Hospital between May and October 2019 were studied, and a factor analysis of the symptoms was conducted.

RESULTS

In a total of 400 referrals evaluated, the average age was 58 ± 17.09 years and 61.5% of the patients were women. The rate of psychiatric consultation was 2.73%. Internal medicine (13.9%) was the service that most frequently requested a psychiatric consultation. The disorder most frequently diagnosed was anxiety (44%), and the symptoms most frequently found were depression (45.3%), insomnia (44.5%), and anxiety (41.3%). The most used treatments were antidepressants (44.3%). The exploratory factor analysis of the symptoms showed three syndromic components: delirium, depression, and anxiety.

CONCLUSIONS

The typical patient of this sample is a woman in her late 50s, suffering from a non-psychiatric medical illness, and with anxiety disorders as the main diagnosis resulting from the psychiatric consultation.

Analysis of the Care Provided Over a Six-Month Period by the Liaison Psychiatry Unit at a General Hospital in Lima, Peru

INTRODUCTION

Consultation-liaison psychiatry is a branch of clinical psychiatry that enables psychiatrists to carry out a series of activities within a general hospital. The number of liaison psychiatry units around the world has increased significantly, and Peru is no exception. However, this development is heterogeneous and unknown, so recent study reports are required to reveal the characteristics and details of the clinical care services provided by these units.

AIM

To describe and report the socio-demographic and clinical characteristics of patients evaluated in the Liaison Psychiatry Unit of the Guillermo Almenara Irigoyen National Hospital in Lima, Peru, and to analyse the symptomatic and syndromic nature of the identified conditions.

METHODS

Cross-sectional descriptive study. Referrals to the Liaison Psychiatry Unit of the Guillermo Almenara Irigoyen National Hospital between May and October 2019 were studied, and a factor analysis of the symptoms was conducted.

RESULTS

In a total of 400 referrals evaluated, the average age was 58±17.09 years and 61.5% of the patients were women. The rate of psychiatric consultation was 2.73%. Internal medicine (13.9%) was the service that most frequently requested a psychiatric consultation. The disorder most frequently diagnosed was anxiety (44%), and the symptoms most frequently found were depression (45.3%), insomnia (44.5%), and anxiety (41.3%). The most used treatments were antidepressants (44.3%). The exploratory factor analysis of the symptoms showed three syndromic components: delirium, depression, and anxiety.

CONCLUSIONS

The typical patient of this sample is a woman in her late 50s, suffering from a non-psychiatric medical illness, and with anxiety disorders as the main diagnosis resulting from the psychiatric consultation.

Profile of Patients Seen in Consultation-Liaison Psychiatry in India: A Systematic Review

OBJECTIVES

This review aimed to evaluate all the published studies from India conducted in the consultation-liaison (CL) psychiatry setting to identify the diagnostic patterns and referral rates in this setting. Understanding the same can help in organizing the services and knowing the training needs.

MATERIALS AND METHODS

A thorough literature search was done in August 2020 using different search engines (PubMed, Medknow, and Google Scholar). This was followed by an individual search of various Indian Psychiatry journals and a hand search of references in the available articles. Only those studies that described patients referred to psychiatry services from various specialties were included.

RESULTS

A total of 33 studies were selected for the review. More than half of them were published in the last 5 years. Studies have primarily reported psychiatric profile medically ill inpatients referred to CL psychiatry services, with the majority of the studies reporting the number of patients seen for the duration of at least 1 year. The referral rates for inpatients across different institutes have varied from 0.01% to 3.6%. The referral rates from emergency set-ups have varied from 1.42% to 5.4%, and in outpatients, from 0.06% to 7.17%. The most commonly diagnosed psychiatric disorders across different studies include depression; organic disorders, including delirium; substance use; intentional self-harm; and anxiety disorders.

CONCLUSIONS

A limited number of studies have reported the profile of patients seen in CL psychiatry setups. Available data from these studies suggest that referral rates to psychiatry services from other specialists are dismal. There is an urgent need to change the focus of psychiatry training at both undergraduate and the postgraduate levels to enhance the psychiatric knowledge of physicians to improve psychiatry referrals.

Consultation-liaison psychiatric service utilization by suicide attempters

CONTEXT

There is sparse Indian literature on consultation-liaison psychiatric (CLP) service utilization by suicide attempters who generally present first to the accident and emergency departments and are seen by the psychiatrist only after the initial stabilization.

AIMS

The aim of the study is to study the psychiatric referral, review, and psychopharmacological intervention rates among suicide attempters and to study factors associated with psychiatric referral.

SETTINGS AND DESIGN

Retrospective, medicolegal case register-based, explorative analysis of suicide attempters presents to a rural tertiary care hospital in south India.

SUBJECTS AND METHODS

Eight hundred and twenty-nine medicolegal case files of individuals whose diagnosis was recorded as either suicidal attempt, deliberate or intentional self-harm, and poisoning or hanging were analyzed for different variables.

STATISTICAL ANALYSIS USED

Descriptive frequencies, Pearson's Chi-square and logistic regression analysis to know the association of psychiatric referral with different variables, were performed using the Statistical Package for the Social Sciences, version 16.

RESULTS

A little more than half of the suspected suicide attempters (51.4%) were referred for psychiatric review, and majority of those referred (93.7%) were reviewed by the psychiatrist. Psychiatric referral was significantly associated with a relatively younger age, positive past and family history of suicidal behavior, mode of attempt (pesticide poisoning and attempted hanging were more likely to be referred), and a longer duration of hospitalization.

CONCLUSIONS

The low referral rate but an overwhelming review rate among those referred shows that probably referrer factors are responsible for this and so CLP for suicide attempters needs to be strengthened by sensitizing the referring doctors on the importance of the psychiatric referral and the need to avoid discharge within the first 24 h.

Clinical and care intensity differences among patients suffering from somatic diseases electively referred to a consultation and liaison service

Background This investigation mainly explores possible care differences among patients hospitalized because of medical conditions being electively referred to a psychiatric-psychosomatic consultation and liaison service. Methods A four-year survey ( N = 2518 individuals) based on clinical and care variables selected from the basic documentation.

STATISTICS

Chi-square tests, analysis of variance, logistic and multivariate regression analyses, considering statistical modeling assumptions. Results A current psychiatric comorbidity has been found in 75% (less in cancer patients), mainly adjustment and anxiety (45%), mood (22%), and organic mental disorders (12%). The functioning score (Global Assessment of Functioning) was 59.4 and was especially low in patients suffering from unclear medical conditions. The performance status (Eastern Cooperative Oncology Group) amounted to 1.63 and was especially high in patients suffering from orthopedic conditions, infections, and cancer. Each patient received on average of 2.26 (SD = 2.81) contacts and 111 minutes (SD = 160) of total treatment time. In multivariate models, care differences among medical conditions are reduced. Men and older people have received less than the average amount of treatment, but psychiatrically comorbid patients and those with lower functionality and performance status have received more intensive psychological support. Conclusions As a quality feature of consultation and liaison service, patients suffering from psychiatric comorbidity, lower functionality, and lower performance status receive more intensive care and more post-discharge recommendations. Cancer patients and patients with pain as a leading diagnosis as well as strained mothers of hospitalized children have received more intensive treatment by consultation and liaison service despite lower psychiatric comorbidity levels. More attention has to be paid to men and older people independently of their physical condition.

Reasons for referral and diagnostic concordance between physicians/surgeons and the consultation-liaison psychiatry team: An exploratory study from a tertiary care hospital in India

BACKGROUND

Very few studies have evaluated the reasons for referral to consultation-liaison (CL) psychiatry teams.

AIM

This study aimed to evaluate the psychiatric morbidity pattern, reasons for referral and diagnostic concordance between physicians/surgeons and the CL psychiatry team.

MATERIALS AND METHODS

Two hundred and nineteen psychiatric referrals made to the CL psychiatry team were assessed for reason for referral and diagnostic concordance in terms of reason of referral and psychiatric diagnosis made by the CL psychiatry team.

RESULTS

In 57% of cases, a specific psychiatric diagnosis was mentioned by the physician/surgeon. The most common specific psychiatric diagnoses considered by the physician/surgeon included depression, substance abuse, and delirium. Most common psychiatric diagnosis made by the CL psychiatric services was delirium followed by depressive disorders. Diagnostic concordance between physician/surgeon and psychiatrist was low (κ < 0.3) for depressive disorders and delirium and better for the diagnosis of substance dependence (κ = 0.678) and suicidality (κ = 0.655).

CONCLUSIONS

The present study suggests that delirium is the most common diagnosis in referrals made to CL psychiatry team, and there is poor concordance between the psychiatric diagnosis considered by the physician/surgeon and the psychiatrist for delirium and depression; however, the concordance rates for substance dependence and suicidal behavior are acceptable.

Clinical outcome and predictors of adverse events of an enhanced older adult psychiatric liaison service: Rapid Assessment Interface and Discharge (Newport)

Background

Hospitals are currently admitting an increasing number of older people, and more than one-third could have an underlying mental health problem. The existing Older Adult Mental Health (OAMH) liaison service was increasingly unable to meet the escalating needs of older and frail patients. Therefore, the service was modernized and enhanced on an “invest-to-save” principle to provide a prompt holistic assessment for older adults with mental health problems. The objective of this study was a service evaluation to appraise clinical outcome, minimize the length of stay, and measure the predictors of adverse outcomes to streamline this enhanced service.

Materials and methods

Patient demographics, social care needs, comorbidity burden (Charlson comorbidity index, CCI), and functional status (Barthel index, BI) were recorded from November 2014 to February 2015. Frailty status (frailty index, FI) was measured by an index (Rockwood index) of accumulated deficits. The outcomes were compared with the previous OAMH liaison service data over the same period a year earlier.

Results

The new Rapid Assessment Interface and Discharge service assessed 339 patients compared to 179 by the previous liaison team over the 4-month period. Mean age was 82.18±8.04 years, with 60% women; preadmission BI was 14.96±4.35, and admission BI was 11.38±5.73 (P<0.001, paired t-test); mean CCI was 1.66±1.53, and mean FI was 0.34±0.99, and 80% were on polypharmacy. The direct discharges from front door were increased by 7%. The mean hospital stay reduced from 35 to 20 days in acute site and from 108 to 47 days in long-stay wards. The cost benefits were based on the mean reduction in hospital stay (41.8 days) and admission reduction (2.2 days), leading to a total annualized bed savings of 44 days. FI was the most highly significant factor between patient groups with a good and poor outcome (P=0.00003, independent groups t-test, t=−4.38, df 98).

Conclusion

Prompt mental health assessments for acutely unwell frail older people are not only cost effective but also improve clinical outcomes.