Educational Impact on Delirium in the Medical Intensive Care Unit by a Psychiatric Liaison?

I ran across an interesting article the other day about what educational impact a psychiatric liaison had on beliefs and attitudes about delirium among nurses and internal medicine residents in a medical intensive care unit (MICU) [1].

The short answer: not much at all. This is despite the willingness of the MICU staff to host the psychiatric consultant to round with them once a week for 9 months, offering impromptu 3-5 minute talks about delirium, including how to distinguish it from primary psychiatric disorders. The method included preintervention and postintervention surveys, and remember, this was to assess attitudes and beliefs of nurses, internal medicine residents–not actual knowledge so much.

The telling conclusive remark by lead author, Dr. Scott Beach, MD:

Though this intervention was reported subjectively as being “very helpful” in terms of enhancing the overall care of patients and appeared to improve relations between medicine and psychiatry, thus fulfilling the goals of the liaison intervention, the presence of a psychiatry consultant rounding with the intensive care unit team once weekly for 9 months appeared to be insufficient to meaningfully affect the attitudes and beliefs of trainees and nurses regarding delirium.

While the project may have fulfilled one of the “…goals of the liaison intervention…” by opening the door to building a constructive working relationship between psychiatric consultants and internal medicine physicians, it missed on the most important one–changing the culture of medicine regarding the recognition, management, and prevention of delirium, a major safety problem in all hospitals. He acknowledges that in the last sentence of the discussion:

Finally, given the frequent rotation of trainees through the intensive care unit, successful interventions may benefit from a “train-the-trainer” mindset and involve targeting of critical care attending physicians and nursing leadership to further embed educational objectives and effect a culture change from within (boldface mine).

Marilyn Ferguson

“No one can persuade another to change. Each of us guards a gate of change that can only be opened from the inside. We cannot open the gate of another, either by argument or emotional appeal.”

I have marveled at the difference between implementation and education in delirium prevention for years.  Education is simply not sufficient by itself. I have remarked to critical care teams that “a psychiatrist is an anomaly in the ICU.” I truly believe, because of scope of practice limitations, most psychiatrists are in the worst position to guide internists on how to prevent and treat delirium. I realize one thing. We may be better at recognizing what delirium is not–a primary mental disorder. The point of that remark is to highlight the main reason why I think psychiatrists are continually called about delirium in the critical care unit or anywhere else in the general hospital for that matter. Delirium, because it affects all areas of the brain, mimics a host of psychiatric disorders because of the dramatic changes it produces in affect, behavior, and cognition. It quacks like a duck; therefore it must be a duck.

The problem with that attitude is that treating delirium as if it were the primary psychiatric disorder it mimics does nothing to reverse the underlying emergency medical cause of all the quacking. And it looks like the strategists who make psychiatrists the lead ducks in teaching health care professionals about delirium have laid a colossal egg as far as creating substantial change in the medical culture. blue billed duckI have quacked myself blue in the bill about delirium for my entire career as have, I’m sure, many of my colleagues in consultation psychiatry, including Dr. Beach, whose tenacity I admire. He and his co-authors created a psychiatric liaison.

Attempting to create a psychiatric liaison service, even temporarily, is a monumental undertaking nowadays in this rapidly changing health care system. “A liaison service requires manpower, money, and motivation…the psychiatric consultant…must be able to attend rounds, discuss patients individually with house officers, and hold teaching sessions for nurses”…”In epidemiologic terms liaison psychiatry attempts to deal with the denominator of the prevalence of psychiatric morbidity in the medical setting, whereas consultation psychiatry, by the very nature of the referral process, is involved only with the numerator.”–James J. Strain, MD.

The liaison idea has great merit, and so does helping internists find champions within their own ranks who will own and drive the mission to prevent delirium.

1. Beach, S. R., MD,, D. T. Chen, MD,, et al. (2013) Educational Impact of a Psychiatric Liaison in the Medical Intensive Care Unit: Effects on Attitudes and Beliefs of Trainees and Nurses Regarding Delirium. The Primary Care Companion for CNS Disorders 15,  DOI: 10.4088/PCC.12m01499

Objective: Despite high rates and increased risk of mortality, delirium remains underdiagnosed and a minimal focus of formal medical education. This is the first study to examine the educational impact of a psychiatric liaison on beliefs and knowledge about delirium among both nurses and residents.

Method: One psychiatrist spent 9 months rounding weekly in the medical intensive care unit, interacting with critical care nurses and internal medicine residents. Preintervention and postintervention surveys were distributed in July 2009 and June 2010, respectively, to staff (critical care nurses: n = 23 and n = 25, respectively; internal medicine residents: n = 31 and n = 23, respectively) and a comparison group (psychiatry residents: n = 29 and n = 23, respectively). Participants responded to 12 statements regarding delirium on a 5-point Likert scale.

Results: There were no statistically significant differences between the presurveys and postsurveys for any item when examining all respondents together, as well as psychiatry and internal medicine residents as individual groups. Critical care nurses showed a significant change between surveys for the statements, “Patients with new-onset anxiety or depression in the intensive care unit most commonly have delirium” (17.4% agree presurvey vs 56.0% agree postsurvey, χ2 = 7.62, P = .006) and “Delirium is diagnosed less often than it actually occurs” (100% agree presurvey vs 80% agree postsurvey, χ2 = 5.13, P = .023).

Conclusions: Though introduction of a psychiatric liaison was very well received by clinical staff, we did not meaningfully affect the attitudes and beliefs of trainees and nurses regarding delirium. Robust and lasting changes in attitudes regarding delirium may require more intensive efforts involving longer intervention periods, greater rounding frequency, or additional didactic teaching.

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