Psychosomatics 42:404-410, October 2001
© 2001 The Academy of Psychosomatic Medicine
Implementation of a Psychiatric Consultation Service
A Single-Site Observational Study Over a 1-Year-Period
Albert Diefenbacher, M.D.
Received November 2, 2000; revised May 11, 2001; accepted May 16, 2001. From the Department of Psychiatry and Psychotherapy Ev. Krankenhaus Königin Elisabeth Herzberge, Herzbergstr. 79 D-10362 Berlin; Department of Psychiatry of the Free University of Berlin. Address correspondence and reprint requests to Dr. Diefenbacher. E-mail: a.diefenbacher{at}keh-Berlin.de
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ABSTRACT
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This study describes changes in consultation process variables and referral patterns after implementation of a psychiatric consultation service at a university hospital in Germany. Two hundred eighty consecutive medical-surgical inpatient referrals for psychiatric consultation during a 1-year period were documented prospectively with a structured database. Changes took place in referral patterns and in psychiatric interventions and recommendations but not in psychiatric diagnoses. In addition, information is given on psychiatric and psychosomatic consultation service delivery in Germany.
Key Words: Psychiatric Consultation Service • Generel Hospital • Consultation Process
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INTRODUCTION
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Studies on the effects of establishing psychiatric consultation-liaison (C-L) services in general hospitals uniformly report ensuing changes in patterns of referral and care. For example, they report rises in referrals to the C-L service or changes in referral patterns, with an increase in referrals for depression and a decrease in referrals for delirium.1–6 Most of these studies observed distinct changes only after several years of work, adding to the prevailing opinion in C-L psychiatry that changes in the culture of cooperation of medical-surgical and psychiatric specialties usually take several years.7,8 Of note, however, a very small number of studies reported on changes in psychiatric consultation service delivery that occurred during shorter time periods (e.g., looking at 1- or 2-year periods immediately after the start of a psychiatric consultation service). These studies in fact point to the possibility of short-term changes, especially a rise in C-L referral rates or an increase in referrals for psychoactive substance use.9–12 None of these studies, however, investigated changes in the consultation process itself in more detail. In addition, these studies were hampered by retrospective data collection and by not using a structured data collection system.
The following study describes the first year of work of a newly installed psychiatric consultant at a large university hospital in Germany, the Rudolf Virchow Hospital (RVH) in Berlin, with prospective data collection using a comprehensive internationally approved structured documentation system. The results show how changes in referral patterns and in the consultation process itself developed during that period.
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PSYCHIATRIC AND PSYCHOSOMATIC C-L SERVICE DELIVERY IN GERMANY
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To help elucidate the background and history of C-L service at RVH in Berlin, this section offers some brief information on psychiatric C-L service delivery and the coexistence of psychiatric and psychosomatic C-L services in Germany. In most regards, the hospital is quite typical for psychiatric C-L service delivery in Germany.
Despite a steadily increasing interest in C-L psychiatric service delivery in Germany, there still is a lack of general hospital-based C-L psychiatric services. The only survey (limited to western Germany) showed that only 15% of general hospitals in western Germany had in-hospital mental health services, the majority hence being served haphazardly by psychiatrists based in private practice outside the hospitals.13 By and large, this is quite typical for other German-speaking countries as well: in Switzerland, psychiatric C-L services are available in 40% of all internal medical departments and hospitals, with only one-third of them employing a full-time psychiatric-psychosomatically trained attending, while the rest make use of part-time consultants.14 A similar situation can be found in Austria: 4% of general hospitals are served by regional state mental hospitals, while the majority employ private practice-based psychiatrists on a part-time basis. Full-time C-L psychiatrists are hardly available.15
Furthermore, for historical reasons, Germany, has a dichotomy of psychiatric and psychosomatic departments.13,16,17 Of note, although nearly all university hospitals have psychiatric as well as psychosomatic departments, within general hospitals there are many more psychiatric than psychosomatic departments. The last survey (carried out by the end of the 1980s) found 11 psychosomatic departments, as opposed to 78 psychiatric departments, in (nonuniversity) general hospitals.18 Today (2001) the number of general hospital psychiatric departments has risen to about 160.16,17 It is estimated that 95% of existing in-hospital C-L services are provided by psychiatry, and, with some overlap, 20% by psychosomatics.13 Plans to increase the number of psychosomatic departments in general hospitals are controversial.
Within the European Consultation-Liaison Workgroup Study (ECLW), a cluster analysis on variations in the characteristics of patients referred to 56 C-L services in 11 European countries yielded two types of service provision: one "psychosomatic" and one "psychiatric."19 Psychosomatic service delivery was largely a German peculiarity, with those services virtually seeing no deliberate self-harm patients, only a low percentage of substance-abuse patients and a very low percentage of patients with organic mental syndromes. Their main focus was on dealing with unexplained physical complaints.19 This type of service delivery, on the other hand, is an important function of psychiatric C-L services, which also could be demonstrated in the comparison of a psychiatric and a psychosomatic C-L service in two Berlin university hospitals.20,21 Psychosomatic and psychiatric services differ (e.g., with regard to the amount of psychotropic drug prescription for similar diagnostic groups), but the few comparative studies don't consider measures of severity of illness of the diagnostic groups compared.20–22
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THE PSYCHIATRIC C-L-SERVICE AT THE RVH IN BERLIN
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Around 1990, psychiatric departments in general hospitals were still rare in Germany. RVH, originally a nonuniversity inner-city hospital, had neither a psychiatric nor a psychosomatic department on its premises. Psychiatric consultations had been carried out in in a number of ways (e.g., by ordering psychiatrists from the state mental hospital responsible for psychiatric care of the district where the hospital was situated or by ordering psychiatrists from the local public health office). Without specifically designated manpower, such tasks usually were regarded as onerous by (duty) psychiatrists and psychosomaticists alike.23 After the RVH was incorporated into the Free University of Berlin in successive steps over several years beginning in the late 1980s, psychiatrists were ordered from the outpatient clinic of the psychiatric department of the Free University, a stand-alone psychiatric and neurological hospital located 8 kilometers from the RVH. Furthermore, psychosomaticists (i.e., psychotherapeutically trained psychiatrists or internists, or psychologists) could be ordered from the psychosomatic department of the Free University, also located 8 kilometers from the RVH in another hospital building. This department had liaison activities with the liver transplantation and hematology groups of the RVH. There was no formal cooperation between the psychiatric and psychosomatic departments, and, as both departments were located in separate hospitals, informal contacts rarely occurred.
The psychiatric C-L service at the RVH was staffed with one psychiatric attending who, apart from having received formal training in psychiatry and psychodynamic psychotherapy (individual and group), had several years of formal training in neurology and neurosurgery and with a state license in psychiatry, psychotherapy, and neurology. Total man power for the service, which operated during regular work hours, was 0.75 full-time equivalent (FTE) including an 8-hour liaison with the multidisciplinary pain clinic of the hospital. (The liaison service to the pain clinic had been started and run by another psychiatrist and was continued by the author. Only inpatients were documented in this report, so this liaison part of the C-L service will not be referred to in the following.) Consultations were ordered by the RVH wards by telephone via the outpatient clinic of the psychiatric department, where the consultant was situated. There was no designated room for the C-L service on the premises of the RVH. Medical and surgical services of the RVH were not asked about their expectations with regard to the service, nor was there an evaluation at the end of its first year. By and large, this situation was quite typical for psychiatric consultation in Germany, and it is only since the mid-1990s that C-L psychiatric issues have gained more importance in the German psychiatric community.16,17
Comparative reviews of the study population and consultation process variables at RVH and another nonuniversity general hospital in Berlin have been reported elsewhere.24 In short, this C-L service was quite typical with regard to patients seen and interventions made compared with other German25–27 and international C-L services.19,28,29 For example, patients with organic mental syndromes or depressive syndromes were referred most often, followed by patients with substance use and depressive disorders (for a comparative overview of German-speaking C-L services, compare Diefenbacher16,17). The caseload is high compared with international standards but again is quite typical for psychiatric consultation services in Germany, where even higher caseloads are not uncommon.18,24,27 There are no norms in Germany as to how many C-L psychiatrists should be provided per general hospital beds. Despite the low manpower in German psychiatric C-L service delivery, its main focus is usually on individual patients and not on teams (personal communications).
This author originally chose a medical model to foster understanding of psychiatric thinking among nonpsychiatric physicians.30 There was no German textbook on C-L psychiatry and only sparse literature, so, for the most part, U.S. C-L psychiatric literature was used as clinical references and for the structuring of administrative issues.30,31 For example, consultation notes were designed according to the proposals of Stotland and Garrick,31 with a focus on a complete description of the psychopathological syndrome, one or more psychiatric diagnoses (according to ICD-10), and written advice for further laboratory tests or the prescription of psychotropic drugs.32 The consultant used an active approach to engage nonpsychiatric staff, leaning on concepts such as the operational group and general systems theory, as developed and applied for the C-L psychiatric setting in the general hospital.33,34 In pracice, this meant an active approach in clarifying a consultee's question in personal communication because the consultees' reasons for referral often were not clear-cut (e.g., "psychosis,?" or even just "?").32,35 The author's approach, together with similar experiences and practices of other C-L psychiatrists in Germany, has been published in the first two German C-L psychiatric textbooks,32,36 chapters for textbooks of internal medicine37 and psychiatry38, and in an annual seminar series by the German Psychiatric Association (Deutsche Gesellschaft für Psychiatrie, Psychotherapie und Nervenheilkunde [DGPPN]). In addition, a proposal for a curriculum in C-L psychiatric training for psychiatric residents has been published which drew heavily from the Academy of Psychosomatic Medicine's recommended guidelines for C-L psychiatric training in psychiatric residency programs.39,40 Apart from invited symposia at the annual scientific meetings of the DGPPN, there now is one DGPPN-sponsored annual meeting dedicated to C-L psychiatric topics.
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PATIENTS AND METHODS
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This is a single-site observational study, conducted at the RVH an inner-city tertiary care hospital of the Free University of Berlin with 1,142 beds and about 20,000 annual inpatient admissions. The study period was from April 1, 1991, to March 31, 1992.
As data collection was part of the European C-L Workgroup (ECLW) study,41,42 the Patient Registration Form (PRF) of the ECLW was used for the documentation of the consultation episodes.43,44 The author was approved in the ECLW reliability test, which consisted of completing the PRF and giving an ICD-10 psychiatric diagnosis for 13 precoded vignette cases.43 In addition, as the author was appointed coordinator of the ECLW-Berlin study site for the participating psychiatric consultants, sessions with psychiatrists of another general hospital psychiatric department were organized during the study period in order to check reliability in completing the PRF.
Two hundred eighty inpatients consecutively referred for psychiatric consultation were seen by the attending psychiatrist. Although other authors used 6-month intervals,9–11 we divided our 1-year study period into three periods of 4 months each, as differences between the initial and final parts of the implementation phase of the consultation service were of interest. Eighty-eight patients were referred in the first, 85 in the second, and 107 in the third 4-month period. As part of the holidays fell into the first two periods, this cannot be taken as an actual increase in referrals.
There were no remarkable changes in hospital policies with regard to the task of the psychiatric C-L service during the 1-year period and no noticeable change in the working style or referral patterns of the psychosomatic department during the study period.
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RESULTS
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General data are presented in Table 1. There was no significant change in the age of patients referred for consultation, in gender distribution, or in the frequency of primary reasons for referral during the study period. The scope of referrals from different medical-surgical departments remained stable, apart from an increase in referrals from infectious disease and a decrease in referrals from dermatology. Type of referrals (urgent, same day, or routine, i.e., within 48 hours) showed different developments in different treatment settings. Although routine referrals from intensive care units increased slightly, urgent and/or same-day consults for general medical-surgical wards tripled from 8.6% to 25.3%, accompanied by a relative decrease in urgent/same-day and routine consult requests, respectively. There was no change in psychiatric diagnoses or in the comorbidity of patients referred using a count approach (i.e., the number of somatic and/or psychiatric diagnoses assigned to individual patients remained the same over the study period.
Psychological interventions (e.g., "counsel, inform, advice, support" as coded in the PRF) that were solely addressed to the patient decreased from 18.2% at the beginning of the observation period to 3.7% at the end, whereas psychological interventions that were addressed to the patient and the medical-surgical teams increased from 68.2% to 84.1%. As all these interventions were carried out by the consultant in person, concordance was not an issue. The willingness to get in contact with office-based psychiatrists involved in the primary care treatment of referred patients nearly tripled, from 5.7% to 15.9%, and the psychiatric consultant was increasingly involved in the discharge planning of the patients referred (from 23.9% to 35.5%). These latter recommendations were made in oral and written form only, but they were not not checked for concordance.
There were no changes of lagtime and length of stay (LOS) of the total group of patients referred during the 1-year period (Table 2). It may be worthwhile noting, however, that mean lagtimes pointed to differential developments between medical-surgical departments, with a slight increase for referrals from general medicine (from 12.4 to 14.6 days) but a marked decrease for cardiology for example (from 24 days to 13 days), approaching the mean lagtime of 14.5 days of all consultation patients. Of note, the average LOS of all inpatients of the RVH was 12.8 days during the study period.
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DISCUSSION
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This study has some limitations. It is a single-site observational study without a control group. On the other hand, confining the study to the work of a single consultant, who for the documentation of the data collected took part in the reliability trials of a well-designed international study,41–44 should have allowed reasonable consistency of the data gathered, as reported in previous studies.5 Keeping in mind that this study is a "case report" of a single psychiatric consultation service, some tentative conclusions may be proposed.
First, during the 1-year study period no changes could be found in the main reasons for referral, in somatic and psychiatric diagnoses, or in syndromes and comorbidity, supporting other authors' views that such parameters are not sufficient to detect developments of psychiatric consultation services.5 On the other hand, there were effects on some psychiatric interventions and recommendations during the 1-year observation period. Most importantly, the target of the consultant's psychological interventions did change until the end of the study period: interventions directed solely at single patients decreased, while those directed at patients as well as their teams increased. One might suppose that this shift may have occurred only due to a decision by the psychiatrist. But looking back at the beginnings of C-L psychiatry,47 it is well known that a consultant actively has to engage and influence nonpsychiatric staff and try to clarify and meet their needs; otherwise, referrals might fall off. As these patient- and/or staff-centered interventions were carried out by the psychiatrist in person, the change reported may indicate growing willingness of staff members to listen to the C-L psychiatrist proposals and conceptualizations.
Furthermore, there were differential effects on the urgency of the consult requests. Although their was a slight increase in routine consults from the ICUs until the end of the study period, urgent and/or same-day consults for other medical-surgical wards nearly tripled (Table 1). Vaz and Salcedo9 have argued that a drop in urgent consults reflects a greater tolerance for mental health problems by medical staff. Given the differential results of our study for settings like ICUs as opposed to general wards, one is tempted to offer an additional explanation. It was the experience of this consultant that getting more routine consult requests from the ICU symbolized the adoption of psychiatry as a less alien player in this setting. For general wards, however, increasing urgent and/or same-day consults was tantamount to upgrading psychiatry with regard to what "really" mattered for their patients treatment.
What might have contributed to the changes described? Corresponding to the proposals of Meyer and Mendelson,33 the active engagement of the consultant, in elaborating and clarifying management problems, may have enabled nonpsychiatric staff to become more comfortable with the identification, formulation, and acceptance of a psychiatric approach to their patients. In addition, an active approach to the management of patients with organic mental syndromes, with the psychiatrist sometimes leading nonpsychiatric staff directly in diagnostic and therapeutic issues at the bedside, may have helped to demonstrate that psychiatry is not confined to interpretation and long-term change but can be of immediate usefulness to medical patients (compare corresponding case reports48,49). Furthermore, nonpsychiatric staff were instructed in the use of screening devices for psychological symptoms, such as a short form of the Mini-Mental State Exam to facilitate the detection of organic mental syndromes.50 Taken together, a strategy of providing "help to self-help" to nonpsychiatric staff might have contributed to some of the changes seen during the study period.
In addition, special offers such as a liaison activity to an AIDS-day care unit within the department of infectious disease, (two to three visits per month) shortly after the beginning of the study period may have contributed to a better awareness of the C-L service, an increase in inpatient referrals, and a decrease in lagtime of referrals from that department (Table 2).
In sum, this report indicates that it is possible to change dynamics in a general hospital, or at least in a part of it, within relatively short time periods. To achieve such a goal, however, is an active task for psychiatric consultants, as—given the continual skepticism of nonpsychiatric physicians for psychiatry as a discipline51—the mere availability of a psychiatric C-L service does not necessarily lead to its utilization, even after longer time periods.52 Furthermore, this study emphasizes the usefulness of a structured database for the monitoring of C-L services over time using patient and process variables. Although this effort may be worthwhile in itself for purposes of quality assurance and with regard to demonstrating workload and activities of a C-L service,45,46 this report emphasizes that changes in C-L service development actually may be detected by looking at consultation process variables with a reliable and standardized instrument.
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ACKNOWLEDGMENTS
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Data collection for this study took place in the German C-L Study, as a part of the ECLW study on "The effectiveness of mental health consultation and liaison service delivery in the general hospital" (supported by the Robert Bosch Stiftung and the European Union [COMAC-Health Service Research - MRA*-340-NL).41–44 The authors thank the ECLW study centers in Amsterdam and Freiburg for carrying out the data clearing procedures. This study was approved by the Ethics Committee of the Free University of Berlin.
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ABSTRACT
INTRODUCTION
