The Effects of a Psychiatric Liaison Program on the Utilization of Psychiatric Consultations An Evaluation by Chart Audit Barry A. Kramer,

M.D.

Staff Psychiatrist, Long Island jewish-Hillside Medical Center, Glen Oaks, New York Assistant Professor of Psychiatry, State University of New York at Stony Brook

James Spikes, M.D. Assistant Clinical Professor of Psychiatry, Albert Einstein College of Medicine, Bronx, New York Acting Director, Liaison Service, Montefiore Hospital and Medical Center, Bronx, New York

James J. Strain, M.D. Director, Psychiatric Consultation Liaison Service, Mt. Sinai School of Medicine, New York, New York

Abstract: The effects of a psychiatric liaison program were studied by a chart audit examination of psychiatric consultations on a medical service. A comparison of the full liaison ward with the other wards revealed significant differences in the use of emergency consultation and psychiatric follow-up treatment. The results indicated improved psychologic management of medical patients on wards with intense liaison involvement but no measurable change in attitude toward the psychiatrist. Evaluation methodology and implications of the results are discussed.

Liaison psychiatry is the medical subspecialty concerned with the clinical relationship between psychiatry and all other areas of medicine-a traditionally difficult relationship, with both groups tending to promote isolation of the psychiatrist in the general hospital and primary care settings (l-3). As Cavanaugh and Flood (4) concluded after reviewing the literature: “The working relationship between physicians can influence consultation to a greater degree than the professional competence of the consultant. Furthermore, the psychological attitudes of the referring physician with regard to a patient, the patient’s illness, and psychiatry in general can influence the rate of referrals.” Because the future of psychologic medicine largely depends on 122 ISSN 0163-83931791020122-07602.25

the effectiveness of the liaison psychiatrist in promoting the working alliance with the other medical fields, it is difficult to comprehend the paucity of evaluation studies in this field. Eaton et al. (5) note that well-developed evaluation plans are rarely present in grant proposals for liaison programs submitted to the National Institute of Mental Health (NIMH). Greenhill (6) also points to the total lack of studies on the relative effectiveness of approaches to, and theoretical models of, consultation and comments that no studies exist on changes in patient care resulting from liaison psychiatry programs. The two most recent studies evaluating the effectiveness of liaison training programs concluded that approximately 40% of nurses (7) and house staff (8) were unable to use psychologic techniques effectively upon completion of training, despite different degrees of motivation and resistance in the two groups. Such a study has not been reported since. The inherent difficulties in mental health evaluation may bear some responsibility for this deficit. One major problem is to identify precisely what is actually being evaluated; another is to pursue consistently a limited number of identified goals which can then be selected for specific evaluation (7). In this paper the authors present a preliminary

General Hospital Psychiatry @ Elsevier North Holland, Inc., 1979

Utilization

attempt at evaluation of the effectiveness of liaison psychiatry on the six medical wards at Montefiore Hospital and Medical Center (MHMC). Because one of the primary tasks of a liaison program is to foster a change in attitude on the part of the medical house staff toward psychologic issues, the authors chose to examine these attitudes as reflected in two parameters: (a) the interest in the psychosocial aspects of the patient’s life as reflected by the presence of psychosocial information in the charts of patients referred for psychiatric consultation, and (b) the medical resident’s attitude toward psychiatry and the psychiatric consultation, as reflected by his notes on the chart after the consultation and his interest in following through on the psychiatrist’s recommendations. An attempt was made to evaluate the psychologic management of patients by examining delay in requesting the consultation, number of routine and emergency consultations, and the frequency of referral for further psychologic care upon discharge.

Methods The study took place on the general medical service

in a large teaching hospital in New York City (MHMC). A complete description of the organization of this liaison program has been given elsewhere (9) and is only briefly reviewed. The MHMC liaison program, gradually evolving since 1968, has had some success in developing a satisfactory alliance between psychiatry and medicine. The current primary purpose of this program is to attempt to effect a change in the attitudes of medical caregivers so that psychologic issues are more readily considered in their approach to patients. An anticipated consequence of this change should be more effective use of the psychiatric consultation. Over the past 5 years there has been significant variation in the amount of liaison contact that the six medical wards at MHMC have received. Although all the wards have had weekly conferences, chaired jointly by a medical attending (ombudsman) and a liaison psychiatrist, several have had a liaison psychiatrist assigned on year-long rotations (9,lO) who spends 10 hours or more per week doing consultations, goes on rounds with the house staff, and confers with nurses and social workers. Ward F had intense liaison contact during 4 out of the past 5 years (including the year of the study), consisting of a weekly ombudsman conference and the daily involvement of a liaison psychiatrist. The

of Psychiatric

Consultations

other wards had minimal liaison contact, consisting only of a weekly ombudsman conference during the year of the study. Although some wards (A, B, and C) have had liaison psychiatrists at some time in the past 5 years, two of the wards (D and E) have not. This disparity provided the opportunity for a comparative study of the way staff attitudes varied with the amount of liaison exposure. For an g-month period (September 1976 through April 1977), 143 consecutive psychiatric consultations from these wards were examined for the specific parameters discussed above by collecting data from the charts (Table 1). This period included four 2-month rotations of medical house staff. The first and last 2-month rotations of the year were excluded to eliminate any unrelated emotional influence from the impact of the beginning or ending of training. The authors examined all routine and emergency consultations requiring follow-up by consultants. Emergency consultations not requiring follow-up were not examined because of the built-in lack of ongoing collaboration that usually occurs after the immediate problem has been resolved. The total number of emergency consultations was recorded, however, for comparison between wards. The questionnaire (Table 1) was answered as completely as possible by chart audit; personal interviews with staff were avoided, since it was felt this would influence the results. Psychosocial information was recorded as having been noted in the chart if there was any mention of the patient’s family, work, social situation, or psychologic probTable 1. Data collected from hospital charts on patients with psychiatric consultations Demographic data (age, sex, marital status): Ward hospitalized on: ConsultantiConsultee: Routine or emergency consult: Chronology (dates patient admitted; problem noted, by doctor and nurses; consult requested; patient seen by consultant): Psychosocial information (family history, work history, social system): Drug or alcohol involvement: Diagnosis (medical and psychidtric): Recommendations of consultant (medications; laboratory tests; other consultations; environmental manipulation; actions taken by the consultee on recommendations by the consultant): Follow-up notes (by consultant and medical staff): Psychiatric referral made:

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8. A. Kramer et al.

Table 2. Demographic description of sample Patients Age (years) Below 20 20-29 30-39 4049 50-59 60-69 70+ Unknown Total

receiving

consultations

from general medical wards

Total No.

% of sample

Male

Female

Total No.

% of sample

Male

Female

18 19 16 25 26 39 143

12.59 13.29 11.19 17.48 18.18 27.27 -

8’ 11 6 11 7 10 53

10 8 10 14 19 29 90

18 236 228 368 599 895 1892 8 4244

0.42 5.56 5.37 8.67 14.11 21.09 44.58 0.19 -

9 108 117 178 304 432 821 2 1971

9 128 111 190 295 463 1071 6 2273

lems. The data were then coded and computerized for analysis. Statistical analysis was by Chi-square. Although the reviewers were aware of the varying intensity of liaison contact on the individual patient wards, the objective nature of the questionnaire would tend to minimize any bias the reviewers may have had.

Sample Of the 4244 patients admitted to the general medical service over the B-month period, 143 routine consultations and 146 emergency consultations not requiring follow-up were conducted. These 289 consults represent a rate of 6.81% of the medical patients on whom psychiatric consultations, routine or emergency, were requested. The demographic breakdown of the 143 patients receiving routine consultations (Table 2) and the distribution of the psychiatric and medical diagnoses of the sample (Table 3) are similar to those of other reported samples (U-13).

Results Except for ward F, where one liaison psychiatrist did all of the consultations, several psychiatrists were randomly distributed among the remaining wards. The six medical wards were compared according to the parameters listed above (Table 4). Wards E and F had more requests for routine consultation (45% of total) than the remainder of the wards. Ward E’s performance in this area is thought to be artificially high owing to the presence of one of the authors (J. Spikes) as the psychiatrist attending ombudsman rounds, since he frequently encour124

Total discharges

aged routine consultations to be requested on patients presented to him. Ward F had the lowest utilization of emergency consultations. When contrasted to the other floors, this difference is significant (X2 = 5.05, P = 0.02). An examination of the ratio of emergency consultations to routine consultations presents a more graphic presentation: Although emergency consultations will always be requested (e.g., for a patient who has attempted suicide admitted for medical care), a lower ratio implies that problems are seen before they develop into emergencies. Ward F has the lowest ratio, and Ward E, a service that has never had a liaison psychiatrist on a daily basis, had the highest ratio. Contrasting F with all floors except E, there were significantly more (X2 = 9.3, P = 0.05) patient referrals for follow-up psychologic care (e.g., transfer to inpatient psychiatric ward, outpatient psychiatric clinic, private psychiatrist, Alcoholics Anonymous and so forth). Although not as high as F, Ward E ranked higher than the other medical wards in frequency of referral for futher psychologic treatment. Again, the performance of this floor in this area is thought to rank artificially high owing to the presence of one of the authors (J. Spikes) at ombudsman rounds and his supervision of the consulting psychiatrist. In several instances, he took direct responsibility to ensure that patients were referred for follow-up care when it was clear that neither the medical resident nor the consulting psychiatrist was inclined to do this. For this reason, Ward E was omitted from this statistical calculation. Although the inclusion of psychosocial information in the physician’s notes in the chart and follow-up notes by consultant and/or consultee do not significantly differ between the floors, a trend

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Table 3. Psychiatric and medical diagnoses of pa-

tients receiving psychiatric consultation Total number

PRIMARY PSYCHIATRIC Organic brain syndrome Depression Character disorder Other (situational reaction and so forth) Schizophrenia Neurosis

DIAGNOSIS 52 33 26 18 7 2

% of sample

36.4 23.1 18.2 12.6 4.9 1.4

PRIMARY MEDICAL DIAGNOSIS (based on ICD-8) Diseases of circulatory 38 26.6 system 17 11.9 Neoplasms Diseases of the digestive 16 11.2 system Symptoms and ill9 defined conditions 6.3 Diseases of the genito8 5.6 urinary system Disease of the nervous system and sense 5.6 organs Endocrine, nutritional, and metabolic diseases 4.9 Accidents, poisoning, 4.9 and violence Mental disorders 4.9 Diseases of the respiratory system 4.2 Infective and parasitic diseases 4.2 Diseases of blood and blood-forming organs 3.5 Diseases of the musculoskeletal system and connective tissue 5 3.5 Diseases of the skin and 4 subcutaneous system 2.8

does exist in favor of F. The time lag in recognizing a psychologic problem and in having a consultant evaluate it does not differ between wards. When examining the frequency with which psychiatrist’s recommendations for medication, further laboratory tests, or consultations with other specialties were not followed through by the consultee, no significant differences between the wards were evident. The general trend, however, can be examined: Of 55 recommendations for psychotropic medications, 24 recommendations for other consultations, and 11 recommendations for labora-

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tory tests, ten (18.18%), seven (29.17%), and five (45.45%), respectively, were not followed. In addition, despite attempts at teaching the primary physician to recognize and treat the psychologic manifestations of the organic brain syndrome, it has remained the diagnostic category of those most frequently referred to the psychiatric consultants (Table 3).

Discussion Greenhill (7) has stated that in spite of over 40 years of liaison-consultation work, physicians in the acute inhospital setting do little about the emotional care of their patients, and that little change has occurred in liaison-consultation training over the past 10 years. Both factors indicate a lack of progress-not surprising when one considers the paucity of evaluation studies in the field. Various methods of evaluation have been enumerated elsewhere (14): videotaped interviews, knowledge examination, chart audit, attitude ratings, career follow-up questionnaires, live interview performance, conference presentation, and/or the production of a scientific paper. For this study, the authors chose the psychiatric consultation as a measure of liaison activity, examined its effects by chart audit, and evaluated only data that could easily be assessed objectively. Several major differences were evident when comparing the ward with intense liaison contact with the other wards. After exclusion of E for the reason noted above, Ward F emerged as having a greater number of consultations than the remaining wards, validating previous observations (14) that psychiatric consultations increase with more intense liaison contact. It may be that close contactwith the liaison psychiatrist serves to reduce the primary physician’s sense of stigmatizing the patient that psychiatric consultations may produce, and to demonstrate through observation the benefits of psychiatry for patient care. The decreased need for emergency consultation on Ward F is also significant. One possible explanation is that problems were identified and addressed before they developed into emergencies, either through more appropriate use of routine consultations, informal discussion with the liaison psychiatrist, or the staff’s increased awareness of psychosocial factors, which enabled them to deal with a problem without formal consultation. Other factors may also be involved. If staff anxiety about dealing with psychologic problems can 125

Total

A B C D E F

Ward

143

19 16 27 17 36 28

Total No. consults

-

3 2 2 3 10 11

No.

made

-

15.7 12.5 7.4 17.6 27.8 39.3

% of referrals

Referrals

95 (66.4%)

(63.2%) (75%) (48.2%) (70.6%) (66.7%) (78.6%)

Yes (36.8%) (25%) (51.8%) (29.4%) (33.3%) (21.4%)

48 (33.6%)

7 4 14 5 12 6

No (21.1%) (25%) (7.4%) (29.4%) (27.8%) (7.1%) 27 (18.9%)

4 4 2 5 10 2

Primary physician

Follow-up

(10.5%) (6.2%) (29.6%) (5.90/,) (13.9%) (10.7%) 20 (14.0%)

2 1 8 1 5 3

Consultant

consultations on several parameters Psychosocial information recorded?

12 12 13 12 24 22

Table 4. Comparison of psychiatic

(26.3%) (25%) (25.9%) (11.8%) (11.1%) (42.9%) 34 (23.8%)

5 4 7 2 4 12

Both

notes by:

(42.1%) (43.8%) (37.1%) (52.9%) (47.2%) (39.3%) 62 (43.4%)

8 7 10 9 17 11

Neither (no follow-up)

163

21 19 45 31 30 17

Total No.

-

12.9% 11.7% 27.6% 19.0% 18.4% 10.8%

Total % emergency consults

Emergency

1.14

1.11 1.19 1.67 1.82 0.83 0.61

Emergency/ routine ratio

consults

Utilization of Psychiatric Consultations

be lessened, many problems can be managed without overreaction and panic. The liaison psychiatrist can do much to lower the anxiety level by providing the staff an intellectual framework within which to examine and understand human behavior and by demonstrating to staff their ability to handle some potentially volatile situations. In addition, knowing that a reliable, helping person is available as part of the treatment team also tends to lower anxiety and, in turn, the need for emergency consultation. In the area of referrals for continuing psychologic care, Ward E is again atypical because of the major role of the psychiatrist attending ombudsman rounds in teaching, supervising, and thus directly influencing consultations. The greatest percentage of patients referred for further psychologic care was on Ward F, consistent with the staff’s greater involvement and concern with psychologic issues and a belief that the patient, and even the course of his medical illness, could benefit from further psychologic management. The increased number of referrals, the decreased frequency of emergency consultations, and the greater likelihood for psychologic follow-up reflected an enhanced facility with psychologic management of medical patients. Although an assumption may be made concerning improved attitudes in recognizing and dealing with psychologic issues, this cannot objectively be substantiated. Even on full liaison wards, however, suggestions are not always accepted, and many patients remain without psychosocial information recorded in their charts, adequate follow-up notes, or referrals for further psychologic care. The time lag in referring patients with psychologic problems does not differ between wards with intense and minimal liaison involvement. Although 20-50% of medical patients have been estimated to have psychologic problems, only 6.81% of all patients had psychiatric consultations, suggesting that a large number of patients with psychologic problems did not receive proper evaluation and care. Finally, little evidence exists that attempts to teach the recognition and management of the organic brain syndromes have been sufficiently effective. The three major areas in which differences were observed (number of routine consultations, emergency consultation, and referrals for further treatment) directly involve patient care and management, Patients were more likely to receive psychiatric consultation before an emergency arose and to be encouraged to obtain continued help upon discharge on floors with more intense liaison contact. In addition to their effect on patient care, the

issues of not including psychosocial information on the chart, the lack of follow-up notes after the consultation, and the reluctance to follow a large number of the psychiatrists’ recommendations also reflect an attitude toward the psychiatrist, which did not differ on intense or minimal liaison wards. Undoubtedly, a consultant in the fields of hematology, endocrinology, or cardiology would find data in the chart reflecting the problem upon which he was called to advise and would usually be granted, at minimum, the courtesy of a brief follow-up note acknowledging his recommendation. If the primary physician decided not to follow the consultant’s suggestion, he would most likely discuss this with him first. Why then is the consultation of the psychiatrist treated differently? What can be done to alter his denigrated status in the eyes of the primary physician? The liaison program must work to maintain its current value in patient care while attempting to resolve the problems in attitude that have not yet been affected. Two methodologic issues need comment. First, could the results be more indicative of varying degrees of staff psychologic mindedness? Although house staff, attendings, nurses, and aides on the various wards may have had some past psychiatric, liaison, or life experiences influencing performance, positively or negatively, personal differences between them would be expected to be randomly distributed throughout the different wards and, therefore, should not significantly bias the data. The second issue relates to the method of chart audit (15), which runs the risk of not assessing attitudes, knowledge, and skills that are present but not reflected in the medical records of the patient. Although a chart audit cannot measure unrecorded knowledge, skills, and attitudes, if indeed they do exist, it should raise an additional question: Why are psychologic issues relevant to the patient’s care not charted to the same extent as issues related to other medical specialties? The method of interviewing patients and/or staff, on the other hand, runs the opposite risk of measuring attitudes and knowledge that are influenced by the interview but not present in actual patient care.

References 1. Green MR, Haar E, Hyams L, Philpot JW: Physicians’ interests and needs for psychiatric resources. NY State JM 71:1549-1552, 1971 2. Lipowski ZJ: Review of consultation psychiatry and

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psychosomatic medicine: I. General principles. Psychosom Med 29:153-171, 1967 Lipowski ZJ: Review of consultation psychiatry and psychosomatic medicine: II. Clinical aspects. Psychosom Med 29:201-224, 1967 Cavanaugh JL, Flood J: Psychiatric consultation services in the large hospital: A review and a new report. Int J Psychiatry Med 7:193-207, 1976-77 Eaton JS, Goldberg R, Rosinski E, Allerton WS: The educational challenge of consultation-liaison psychiatry. Am J Psychiatry (Suppl) 134:20-23, 1977 Greenhill MH: The development of liaison programs (Chapter 4). In Usdin G (ed). Psychiatric Medicine. New York, BrunnerlMazel, 1977 Burnett FM, Greenhill MH: Some problems in the evaluation of an inservice training program in mental health. Am J Public Health 44:1546-1556, 1954 Greenhill MH, Kilgere SR: Principles of methodology in teaching the psychiatric approach to medicine house officers. Psychosom Med 12:3848, 1950 Strain JJ, Grossman S: Psychological Care of the Medically Ill: A Primer in Liaison Psychiatry. New York, Appleton-Century-Crofts, 1975 Strain JJ, Hamerman D: Ombudsmen (medicalpsychiatric) rounds: An approach to meeting patientstaff needs. Ann Intern Med 88:550-555, 1978

11. Kligerman MJ, McKegney FE’: Patterns of psychiatric consultation in two general hospitals. Int J Psychiatry Med 2:126-132, 1971 12. Shevitz SA, Silberfarb PM, Lipowski ZJ: Psychiatric consultation in a general hospital: A report on 1,000 referrals. Dis Nerv Sys 37:295-300, 1976 13. West, ND, Bastani JG: The pattern of psychiatric referrals in a teaching hospital. Neb Med J 15:438440, 1973 14. Torem M, Saravay SM, Steinberg H: Changes in referrals for psychiatric consultation on two medical wards as a result of intensive liaison work. Unpublished material, 1978 15. Reifler B, Eaton JS: The evaluation of teaching and learning by psychiatric consultation and liaison training programs. Psychosom Med 40:99-106, 1978

Direct reprint requests to: Barry A. Kramer, M.D. Department of Psychiatry Long Island Jewish-Hillside I’. 0. Box 38 Glen Oaks, NY 11004

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