Psychosomatics 46:425-430, October 2005
doi: 10.1176/appi.psy.46.5.425
© 2005 Academy of Psychosomatic Medicine
Guidelines and Evaluation: Improving the Quality of Consultation-Liaison Psychiatry
Marc Archinard, M.D.,
Patricia Dumont, B.Sc. (Soc.), and
Nicolas de Tonnac, M.D.
Received March 15, 2004; revision received Aug. 18, 2004; accepted Nov. 16, 2004. From the Liaison Psychiatry Unit, Reception, Emergency, and Psychiatric Liaison Service, Department of Psychiatry, Geneva University Hospital, Geneva. Address correspondence and reprint requests to Ms. Dumont, Unité de Psychiatrie de Liaison, 51 Boulevard de la Cluse, 1205 Geneva, Switzerland; patricia.dumont{at}hcuge.ch (e-mail).
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ABSTRACT
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Previous research has shown that residents in the consultation-liaison unit of Geneva University Hospital did not meet proposed guidelines on three counts: quickness of response to emergency situations, reporting cases to supervisors, and consulting with supervisors on major issues. The introduction of daily meetings between residents and supervisors improved the level of compliance with guidelines, from 69.2% to 82.6% for quickness of response, from 57.6% to 97.3% for reporting cases to supervisors, and from 25.0% to 98.0% for consulting with supervisors on major issues. Periodical evaluation would thus appear to enhance performance.
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INTRODUCTION
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The availability of resources for liaison psychiatry varies greatly from one country to another1 but within Switzerland,2 it also varies from one hospital to another. As a result, practices and guidelines are also diverse.1,3 According to the European Collaborative Liaison Work group study,4 "Knowledge about the quality and quantity of psychiatric and psychological service delivery in the general hospital setting is very limited." This article reports on a quality study carried out in the Liaison Psychiatry Unit (LPU) of the Reception, Emergency and Psychiatric Liaison Service at Geneva University Hospital.
The LPU provides services for all requests for intervention made by a physician for one of its patients in any clinical setting of the hospital. The diverse clinical settings are situated in three separate buildings (Cantonal Hospital, the rehabilitation clinic, and the maternity ward). The LPU does not have psychiatric beds in the hospital. The psychiatric intervention is made in the service requesting the intervention (Appendix 1). The LPU has six residents (internal medicine residents undertaking a 1-year training in psychiatry and other residents specializing in psychiatry) and three registrars (recognized specialist psychiatrists) for the day-to-day clinical care of adult patients treated at the hospital. They work under the responsibility of three senior psychiatrists in charge of the three different loci and the chief psychiatrist, who is responsible for the LPU. Approximately 5% of admissions are referred to the LPU.
The evaluation and treatment process implemented by LPU collaborators complies with international definitions.4,5 In this article, we refer particularly to the "characteristics of an effective psychiatric consultant" and to "keys to establishing a successful consultation-liaison service."5 The fact that many practitioners are involved in the treatment process, acting in diverse clinical settings—to which must be added the various types and levels of training among the nine LPU collaborators concerned—could alter compliance with the process described in Appendix 1 and, as a consequence, the homogeneity and quality levels of clinical practice.
Since evaluation of the latter parameters depends mainly on the daily supervision of house residents by supervising psychiatrists (the three registrars, with assistance from other senior psychiatry staff), such day-to-day management cannot provide a global image of the situation, and some problems may occasionally defy identification. Therefore, we undertook an independent evaluation of the consultation-liaison process to detect discrepancies between everyday clinical practice and LPU standards. This project, which was carried out in two stages, was aimed at the following:
1. Improving the clinical practice of the nine collaborators who provide consultations to patients hospitalized in seven medical departments of Geneva University Hospital
2. Providing a final draft of guidelines on consultation-liaison procedures to increase the homogeneity of implementation and to facilitate transmission to new residents
3. Allowing reasoned modification of these guidelines to optimize the services rendered to patients (consultations) and to Geneva University Hospital units that request those services (liaison); this would also increase the didactic efficiency of LPU collaborators for the benefit of their nonpsychiatrist colleagues
4. Serving other departments that offer consultation-liaison services (especially psychiatric emergency, child or geriatric psychiatry, and geriatrics)
To achieve these goals, we examined the day-to-day consultation-liaison practices of the six residents and their supervision by three registrars over a period of six months. This first study on the quality of liaison psychiatry (unpublished 2002 study by P. Dumont, M. Sartori, and C. Frick) was carried out in 2001 on 417 patients and provided a detailed picture of how liaison psychiatry is undertaken. It showed that there is a wide variation in adherence to standards by residents. Although it showed high satisfaction regarding patient consultations, contacts with departments requesting services, and administrative follow-up work as well as consultation reports, the following points were found lacking:
1. There was until then no explicit definition of what qualified as an emergency among requests for LPU intervention for a hospitalized patient (outside on-call duty hours)
2. The proportion of new cases reported to the supervising psychiatrist by the resident (57.6%) was insufficient in comparison with the expected standard value (at least 95%)
3. The proportion of patients actually seen by the resident, together with the supervisor physician, was insufficient, even though the situation of these patients warrants such dual supervision in view of the criteria defined for this purpose (ability to discriminate, suicide risk, involuntary hospitalization, or other forensic problems); according to the study, only 25% of the cases falling into this category were examined together with the supervising psychiatrist.
Of necessity, the strategies elaborated to correct this situation were diverse. In October, at the start of the academic year, we informed all nine LPU participating physicians about new operating procedures and provided them with guidelines. We reminded them that supervision was both compulsory and useful and decided on permanent checks of the lists of situations reported to the supervising psychiatrists, based on requests for consultations. The aim of the present study was to remedy the problems mentioned and to assess the impact of the strategies that had been set up.
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METHOD
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Data Collection
Every evening, the secretarial staff listed the requests received during the day (new cases: patients who had not been seen at the LPU for 1 year). This list included the following information:
1. Patient number
2. Date and time of request
3. Physician to whom the request was forwarded (or who received it directly)
4. Date and time of consultation
5. Whether or not it was an emergency (if the emergency criterion is not on the current list, specify the criterion used)
6. Supervising psychiatrist to whom the case was reported
7. Whether the situation necessitated a visit together with the supervising psychiatrist (if the criterion for such a dual visit is not on the current list, specify the criterion used)
This list was forwarded every morning to a senior psychiatrist (other than the three supervisors) who was in charge of the daily meeting for the following purposes:
1. To review the situations from the previous day that were reported to the supervising psychiatrist
2. If necessary, to allow the resident to explain why the case was not reported
3. To define the attitude of the "resident/supervising psychiatrist" dyad regarding cases not yet seen
These parameters were recorded on a grid filled out by the senior physician responsible for the daily report then forwarded to the person in charge of data collection and analysis. The data (stripped of patient identification) were used to establish the following:
1. Whether the list of emergency criteria must be expanded
2. The proportion of emergency cases seen within the allotted time
3. The proportion of cases forwarded to the supervising psychiatrist
4. The proportion of cases seen jointly
5. Whether the list of situations requiring a consultation with the supervising psychiatrist (joint visit) must be expanded
6. The reasons for which instructions were not followed
Degree of Improvement Expected
1. At least 95% of the requests for consultation that were classified as emergencies by the resident should be treated within 2 hours of notification; at least 95% of the situations ratified as emergencies should correspond to the criteria appearing on the LPU list. The list of criteria was regularly adjusted according to need.
2. At least 95% of new situations should be reported to the supervising psychiatrist.
3. At least 95% of the patients whose situation required it should be seen with the supervising psychiatrist (dual visit). The list of criteria for a consultation with the supervising psychiatrist was adjusted according to need.
4. Handwritten notes in medical files provide information needed for immediate decision making regarding the care of a patient. They should therefore be forwarded for checking to the supervising psychiatrist on the day of consultation.
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RESULTS
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Between Oct. 1, 2002, and June 10, 2003, the LPU received 414 calls for new patients. Our data concern 265 patients at Cantonal Hospital, 62 at the rehabilitation clinic, and 86 at the maternity ward.
The average response time improved considerably in comparison with 2001. Table 1 shows that 93.0% of the cases were seen within 36 hours, which is close to expected standards (95%). The LPU residents classified 46 requests (11.1%) as emergencies (Table 2). Although 95.7% of the emergency cases were seen on the same day, the 2-hour response time was respected in only 82.6% of the cases, less than the established standard. Furthermore, all situations classified as emergencies were in agreement with the criteria appearing on the list drawn up after the first study. All emergency requests received on a Friday were seen on the same day, in agreement with standards.
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TABLE 2. Number of Emergency Cases, Discrepancies Between Physician Requests and Patient Visits, Cases Reported to the Supervising Psychiatrist, and "Joint Visits" by the Supervising Psychiatrist and Consultation-Liaison Psychiatrists
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Nearly all cases (97.3%) were reported by the residents to their supervising psychiatrists, which is in agreement with the standards (Table 2). This is an excellent result in comparison with that of 2001 (57.6%).
Of 414 consultation-liaison requests reported, 51 (12.3%) presented criteria requiring a joint visit with the supervising psychiatrist (Table 2); 50 of those 51 cases (98.0%) were seen with the supervising psychiatrist—the standard (95%) was therefore reached. In addition, 94 cases not presenting criteria leading to a joint visit were nevertheless seen by the supervising psychiatrist. In all, 144 cases (34.8% of all cases recorded) were seen jointly. Only in two instances was there no forwarding of handwritten notes to the supervising psychiatrist.
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DISCUSSION
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The strategies used in the present investigation resulted in an improvement of services provided by residents in the areas of intervention. Response time has fallen considerably in comparison with the 2001 results and is very close to reaching standard values, even though there is still some way to go.
A major consequence of drawing up a list of emergency criteria has been to lower the number of cases considered emergencies. The fact that LPU residents were able to rely on specific instructions (as defined at the end of the first study, Appendix 2) probably helped them make a better classification of requests, even though the services issuing those requests tend to consider them all emergencies. Daily checks at the morning meeting confirmed that the criteria used were valid. Even if this reduction in the number of cases considered emergencies did not entail reaching the standard (95% of cases treated within 2 hours of a request), there was a marked improvement on this point in comparison with the 2001 results (69.2%). It is necessary to continue impressing the importance of rapid response time on residents since both the quality of clinical care and the continuity of a working relationship with the services issuing requests depend on this rapid response. The speed in evaluating psychiatric cases and taking charge of them contributes to the global efficiency of hospitalization.1,6,7
Verification of clinical activities of residents by their supervisors is essential to the quality of consultation-liaison services. In our study, nearly all cases (97.3%) were reported to the supervising psychiatrists by the residents. During the first study, only four such situations of ten were not discussed with a supervising psychiatrist—a highly unsatisfactory state of affairs—although preliminary discussions had shown LPU supervisors as confident that at least 90% of the cases had been reported to them. What is at stake regarding supervision includes the quality of care, the safety of patients, and the training of residents. The decisions taken at the beginning of the academic year were effective: to give clearer instructions in this regard, to emphasize both the compulsory aspects (for clinical and medical-legal reasons) and the educational aspects (for physicians in connection with their training) of supervision by the supervising psychiatrist, and finally, to check the list of the cases reported to the supervising psychiatrists on a permanent basis from the requests for consultations.
This set of procedures, combining both instructions and checking, must be maintained if we wish these results to persist in the future. The unwillingness of residents to invest time and energy in training programs organized by an institution is well known, as is the ineffectiveness of the strategies used to encourage and/or control their participation. In the case of the LPU, the very nature of clinical work—with residents scattered among the other departments of the hospital—makes it easier to forgo supervision. It is incumbent upon the supervising psychiatrists themselves to reevaluate the quality of their supervision in terms of checking and teaching but also to support residents more efficiently and to take into better account the stress involved in the latter’s work.
Psychiatric evaluation of the ability to discriminate, the risk of suicide, the necessity of depriving people of freedom for treatment purposes (involuntary hospitalization), or other forensic problems requires systematized procedures, adequate training, and a high level of experience. For all these reasons, LPU standards stipulate that in at least 95% of these cases, the resident must examine or reexamine the patient with the supervising psychiatrist and not merely report on the case to the latter. As for the previous point, results obtained during the first study (24.7% compliance) were of concern. For the next years, however, they were satisfactory: among the cases that required a dual visit, the procedure was respected in all but one case (50 cases of 51). In addition, 94 cases for which the criteria requiring a dual visit with the supervising psychiatrist were not present were nonetheless seen jointly. In this area as well, the strategy focused both on a reminder of the policies that had been defined and on the adoption of an attitude more specifically oriented toward checking. The supervising psychiatrists’ motivation to see these standards enforced—which, by definition, requires a maximum of availability on their behalf—must be maintained in the future.
Carrying out the quality study was a very positive experience; the collective effort devoted to the explicit definition of the study’s objectives and guidelines, as transmitted to the residents and registrars, allowed us to clarify essential aspects of our practice. During the study, registrars and residents reported on their activity on a quasi-daily basis, thus increasing their awareness of the successive stages of their interventions.
The need to develop guidelines for liaison psychiatry has been a constant preoccupation of academic and professional organizations, both in Europe and in the United States, for the last 15 years or so.8,9 During the same time, various programs for residents active in liaison psychiatry have been presented. The guidelines of the Academy of Psychosomatic Medicine10 and most of the existing training programs refer to the problems raised in both areas by our previous study, as well as to the remedies proposed in the present study.11,12 Emphasis has been placed on obtaining from the residents precise and easily observable behavior data,13 similar to those described in our project. The way we proceeded, by introducing the guidelines and setting up a study to examine the adherence to these standards at the same time, was effective as a didactic process for all of the LPU collaborators and as an evaluation of the LPU performances.
The problem of noncompliance to the guidelines by physicians of all specialties has often been evoked in the professional literature.14 Such divergences from standards can represent real barriers to actual improvements in care,15,16 and this question should also therefore be investigated with respect to liaison psychiatry. In our study, the combination of the daily meetings and the emphasis on both the compulsory and the educational aspects of supervision helped the residents report their clinical activities to their supervisor and induced the supervisors to dedicate more time to daily supervision.
The results confirmed the need to define standards based on LPU practices and on the requirements of the departments that request services. The relevance of each standard must be thought through carefully, including cases in which the study showed that the standard has been attained. In cases where it had not, it is a fortiori necessary to define what measures to take and to evaluate these measures.
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ACKNOWLEDGMENTS
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Supported by the Quality Bureau of Geneva University Hospital.
Dr. Archinard died in May 2003.
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REFERENCES
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- Mayou R, Huyse F, European Consultation/Liaison Work Group: Consultation/liaison psychiatry in Western Europe. Gen Hosp Psychiatry 1991; 13:188–208[CrossRef][Medline]
- Collectif 2000: Prise de position des membres de l’Association Suisse des Professeurs Titulaires de Chaires de Psychiatrie [Statement by the members of the Swiss Association of Full Professors of Psychiatry]. Med Hyg (Geneva) 2000
- Strain JJ: Liaison psychiatry, in Textbook of Consultation-Liaison Psychiatry. Edited by Rundell JR, Wise MG. Washington, DC, American Psychiatric Press, 1996, pp 38–51
- Lobo A, Huyse FJ, Herzog T, Malt U, Opmeer BC, European Consultation/Liaison Work group: The ECLW Collaborative study II: patient registration form (PRF) instrument, training and reliability. J Psychosom Res 1996; 40:143–156[CrossRef][Medline]
- Shakin Kunkel EJ, Thompson TL II: The process of consultation and organization of a consultation-liaison psychiatry service, in Textbook of Consultation-Liaison Psychiatry. Edited by Rundell JR, Wise MG. Washington, DC, American Psychiatric Press, 1996, pp 12–23
- Saravay SM, Lavin M: Psychiatric comorbidity and length of stay in the general hospital: a critical review of outcome studies. Psychosomatics 1994; 35:233–252[Abstract/Free Full Text]
- Katon WJ: Cost-offset and cost-effectiveness in psychiatric consultation-liaison: which paradigm to use to justify services, in Proceedings of the 152nd Annual Meeting of the American Psychiatric Association. Washington, DC, APA, 1999
- Wulsin LR: An agenda for primary care psychiatry. Psychosomatics 1996; 37:93–99[Abstract/Free Full Text]
- Stoudemire A, Bronheim H, Wise TN: Why guidelines for consultation-liaison psychiatry? (editorial) Psychosomatics 1998; 39:S3-S7
- Gitlin DF, Schindler BA, Stern TA, Epstein SA, Lamdan RM, McCarty TA, Nickell PV, Santuilli RB, Shuster JL, Stiebel VG: Recommended guidelines for consultation-liaison psychiatric training in psychiatry residency programs: a report from the Academy of Psychosomatic Medicine Task Force on Psychiatric Resident Training in Consultation-Liaison Psychiatry. Psychosomatics 1996; 37: 3–11
- Johnson W, Frankel B, Muskin P, Schubert DS, Cohen-Cole S, Roberts J: Assessing residents’ performance in C-L psychiatry: work in progress. Gen Hosp Psychiatry 1994; 16:88–95[CrossRef][Medline]
- Rigatelli M, Ferrari S, Uguzzoni U, Natali A: Teaching and training in the psychiatric-psychosomatic consultation-liaison setting. Psychother Psychosom 2000; 69:221–228[CrossRef][Medline]
- Jin C, Novik S, Saravay S: Consultation-liaison psychiatry training and supervision results in fewer recommendations for constant observation. Gen Hosp Psychiatry 2000, 22:359–364
- Ellrodt AG, Conner L, Riedinger M, Weingarten S: Measuring and improving physician compliance with clinical practice guidelines: a controlled interventional trial. Ann Intern Med 1995; 122:277–282[Abstract/Free Full Text]
- McIsaac WJ, Goel V, To T, Permaul JA, Low DE: Effect on antibiotic prescribing of repeated clinical prompts to use a sore throat score: lessons from a failed community intervention study. J Fam Pract 2002; 51:339–344[Medline]
- Roduit J, Jornod P, Dorta N, Blum AL, Dorta G: Antibiotic prophylaxis of infective endocarditis during digestive endoscopy: over- and underuse in Switzerland despite professed adherence to guidelines. Endoscopy 2002; 34:322–324[CrossRef][Medline]
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ABSTRACT
INTRODUCTION
