Thoughts On “Busyness” On The Psychiatry Consultation Service:

It’s been a while since my last post. That’s because the psychiatry consult service has been extra busy, partly because of the July Effect, a well-known phenomenon in academic medical centers.

Busyness is a way of life in this environment. In fact, I’ve been doing a little reading about Consultation-Liaison Psychiatry during the few free minutes I have in an effort to find ways to improve the way our own service works.

I found one article which mentioned a Likert scale for “Busyness” that somebody developed. Holmes and colleagues describe it as follows:

“In order to provide a measure of busyness, the director of each [sic] the C-L service [sic] was asked to rate the answer to the question ‘ how busy is your service on average? ’ on a 5-point scale anchored with ‘not busy at all’ to ‘extremely busy ’”–Holmes et al [1].

Hey, I developed my own Busyness Scale:

I think it’s tough to come up with an accurate number of FTE (called EFT in the Holmes’ paper) for a general hospital psychiatry consultation service. If I use their calculation for my hospital where a one man hit-and-run crisis-driven smokejumper model is used, it looks like we need a half dozen more faculty. That would be very difficult to sell to administration if they look at my RVUs and the average number of new consultation and follow-up consultation visits. The average is around 7 but it can go up to 10 or more on any given day. It doesn’t sound like much until you try to account for busyness.

Busyness includes a multitude of sins. It could include calling family and local doctors for collateral history and records. It could include multiple phone calls which always seem to be necessary to triage patients from general medicine or critical care units to inpatient psychiatric units. It sure includes time spent at the computer trying to make sense out of the electronic health record (EHR) algorithms, Best Practice Advisory (BPA) hard stops which interrupt documenting our consultation histories, lab data, assessments and recommendations. The BPAs prevent you from signing your note and billing until you’ve answered a question or addressed a concern, like “Has the patient peed in a cup today?”

Another factor contributing to busyness is the documenting of notes in EHR itself. Oh sure, every once in a great while someone gets excited about a newer version of voice recognition software but my experience with that has been disappointing because the error rate is so high. I’m still afraid I would have to use a disclaimer about the mistakes:

This note was created using Dragon Naturally Speaking, a voice recognition software that sometimes doesn’t recognize the difference between common little words like ‘in’, ‘or’, ‘and’, and so on. Every effort has been made to ensure the accuracy of this document, but because Dragon can make the most hilarious mistakes you ever saw in your lifetime, no guarantees about that can be made because we can do grammar and spelling checks until our eyes blur, but when we close the document, that is when the mysterious and disastrous mistakes seem to occur. It is only when our billing department, patients, supervisors, colleagues, and attorneys contact us, laughing so hard they pee their pants, and inform us that we are fired or under indictment, that we realize this award-winning voice recognition software has been manufactured and shipped from a distant galaxy by aliens bent on taking over our planet by destroying our communications networks. Thank you.

Referral rates or consultation requests are roughly 3%-6%. Some experts recommend proactive screening. Studies about that generally reveal that the prevalence of psychiatric illness in the general hospital runs between 20%-40%. Collaborative screening could raise referral rates to about 30% [2]. If you recommend proactive screening to a one man consult service, most of us would call that looking for trouble.

In my neck of the woods, it’s not so much that my colleagues are not referring. The most frequent reasons are for triage (for example, of patients who have attempted suicide or need specialized care in our medical-psychiatry unit), for assistance with diagnosing delirium and managing agitation from it, for assistance with decisional capacity assessment, and for suicide risk assessment not in the context of attempted suicide but because of clinician concerns about suicide ideation. The last one can mean making time to go to med-surg clinics, which can add to the inpatient psychiatric consultant’s list of things to do.

Busyness also includes crises involving patients who are violent or who may be just about to become violent anywhere in the hospital, clinics, and in the Emergency Room. Those can occur any time.

Speaking of the ER, I just received my copy of Dr. Paul Linde’s book, “Danger to Self: On the Front Line with an ER Psychiatrist.” I have had time to read only the preface so far, entitled “Nowhere to Hide.” The title is a pretty good description of what life is like on the psychiatry consultation service. Dr. Linde and I may not agree on the term “meatball psychiatry,”–but our jobs are very similar in many ways.

References:

1.Holmes, A., et al. (2011). “Service use in consultation-liaison psychiatry: guidelines for baseline staffing.” Australas Psychiatry 19(3): 254-258.Holmes, A., et al. (2011). “Service use in consultation-liaison psychiatry: guidelines for baseline staffing.” Australas Psychiatry 19(3): 254-258. OBJECTIVE: The aim of this study was to determine how referrals and clinical activity in consultation-liaison psychiatry (C-L) vary according to unit type and size, length of stay and psychiatric diagnosis, and to use these data to inform recommendations for the minimum levels of staffing required to conduct consultations in a general hospital. METHOD: Data were collected across three urban teaching hospitals over a 5-year period. The data included hospital admission data, referrals, psychiatric diagnosis, clinical contact time, clinical equivalent full time (EFT) and a measure of ‘busyness’. RESULTS: Mean clinical staffing was 0.84 EFT per 100 beds. Services received a mean of 2.4 referrals per 100 hospital admissions. On average, each referral generated 3.9 contacts and a total contact time of 2.6 hours. The contact time was greater in patients with multiple psychiatric diagnoses as compared with a single or no diagnosis. CONCLUSION: In order to provide a minimum level of service for consultations to the expected range of serious and immediate psychiatric disorders present in the general hospital, a C-L service requires about 1.0 clinical EFT per 100 beds. For services to be able to address more complex elements of illness behaviour, provide education, conduct research, contribute to comprehensive care in specialist areas and undertake other liaison activities, greater and more multi-disciplinary EFT is required.

2.Chen, K. Y., et al. (2016). “Why are hospital doctors not referring to Consultation-Liaison Psychiatry? – a systemic review.” BMC Psychiatry 16(1): 390.Chen, K. Y., et al. (2016). “Why are hospital doctors not referring to Consultation-Liaison Psychiatry? – a systemic review.” BMC Psychiatry 16(1): 390. BACKGROUND: Consultation-Liaison Psychiatry (CLP) is a subspecialty of psychiatry that provides care to inpatients under non-psychiatric care. Despite evidence of benefits of CLP for inpatients with psychiatric comorbidities, referral rates from hospital doctors remain low. This review aims to understand barriers to CLP inpatient referral as described in the literature. METHODS: We searched on Medline, PsychINFO, CINAHL and SCOPUS, using MESH and the following keywords: 1) Consultation-Liaison Psychiatry, Consultation Liaison Psychiatry, Consultation Psychiatry, Liaison Psychiatry, Hospital Psychiatry, Psychosomatic Medicine, the 2) Referral, Consultation, Consultancy and 3) Inpatient, Hospitalized patient, Hospitalized patient. We considered papers published between 1 Jan 1965 and 30 Sep 2015 and all articles written in English that contribute to understanding of barriers to CLP referral were included. RESULTS: Thirty-five eligible articles were found and they were grouped thematically into three categories: (1) Systemic factors; (2) Referrer factors; (3) Patient factors. Systemic factors that improves referrals include a dedicated CLP service, active CLP consultant and collaborative screening of patients. Referrer factors that increases referrals include doctors of internal medicine specialty and comfortable with CLP. Patients more likely to be referred tend to be young, has psychiatric history, live in an urban setting or has functional psychosis. CONCLUSION: This is the first systematic review that examines factors that influence CLP inpatient referrals. Although there is research in this area, it is of limited quality. Education could be provided to hospital doctors to better recognise mental illness. Collaborative screening of vulnerable groups could prevent inpatients from missing out on psychiatric care. CLP clinicians should use the knowledge gained in this review to provide quality engagement with referrers.

Advertisements

Comments

  1. Jim,

    Love the title “Nowhere To Hide”.

    That captures most of my career – handling problems that nobody else wanted to deal with.

    Went into work too many times thinking: “What the hell am I going to do about this?”

    You get that catastrophic bias when you keep getting impossible problems that take days to resolve and the administration converts all of that into meager RVUs and tells you to throw the patient out!

    George

    George Dawson, MD, DFAPA

    Liked by 1 person

%d bloggers like this: