Consultation–liaison psychiatry training and supervision results in fewer recommendations for constant observation

Consultation–Liaison Psychiatry Training and Supervision Results in Fewer Recommendations for Constant Observation Charles Jin, M.D., Sonia Novik, B.Sc., and Stephen Saravay, M.D. Abstract: In this study, we tested two hypotheses. First, that consultation-liaison (C–L)-trained psychiatry residents would order constant observation (CO) less frequently than psychiatry residents untrained in C–L. Second, we predicted that CO would be ordered less frequently under circumstances when experienced C–L psychiatry attending and fellows would be available to supervise psychiatry residents training in C–L. We reviewed a total of 138 consultations during a 6-month period. Constant observation was recommended in 31 cases (22.5%). Consultations were done by residents who had received training in C–L psychiatry (n⫽34) and by residents who were not trained in C–L (n⫽34). Residents not trained in C–L had a significantly higher percentage of CO orders (44.1%) compared to those trained in C–L (15.4%) (␹2⫽12.1, df⫽1, P⬍0.001). Because C–L-trained residents provided regular-hour and after-hour consults while residents without C–L training provided only after-hour consults, we also separately analyzed data from the 102 after-hour cases. We again found that residents with C–L training had a significantly lower rate of ordering CO (22.1%) than those who had not yet received C–L psychiatry training (44.1%) (␹2⫽5.31, df⫽1, P⬍0.05). We also found that C–L-trained residents ordered CO less frequently during regular hour consults (2.8%) when experienced staff are available in supervision compared to after hours (22.1%) (␹2⫽6.72, df⫽1, P⬍0.01). Our findings suggest that training in C–L psychiatry has a significant impact on the use of constant observation for patients in the general hospital

Current address of Charles Jin: Department of Psychiatry, the Hospital for Sick Children, University of Toronto, 555 University Avenue, Toronto, Ontario, Canada, M5G 1X8. Department of Consultation–Liaison Psychiatry, Long Island Jewish Medical Center of the North Shore–Long Island Jewish Health System, Albert Einstein College of Medicine, New Hyde Park, New York 11040. Address reprint requests to: S. Saravay, M.D., Department of Consultation–Liaison Psychiatry, Long Island Jewish Medical Center of the North Shore–Long Island Jewish Health System, Albert Einstein College of Medicine, New Hyde, NY 11040.

General Hospital Psychiatry 22, 359 –364, 2000 © 2000 Elsevier Science Inc. All rights reserved. 655 Avenue of the Americas, New York, NY 10010

thereby reducing the cost of care. Inc.

© 2000 Elsevier Science

Introduction Constant patient observation (CO) is a powerful but a costly measure to protect patients from harming themselves or others. A study by Goldberg [1] of 73 general hospitals in six New England states showed that 92% of the hospitals use CO. One study of psychiatric hospital [2] reported that 13% of psychiatric inpatients required the use of CO. The cost of CO care comprises as much as 20% of the total nursing budget in a psychiatric hospital and up to 10% in a long-term care facility or a general hospital [3]. The discrepancy of the costs between the hospitals is partially due to the fact that while nurses, nursing assistants, and mental health workers provide the majority of CO services in the psychiatric hospitals, “lay” persons often carry out the service in the general hospitals [3]. The actual annual dollar cost of CO may run between $232,000 and $581,000 annually, depending on the size of the hospital and the frequency of CO use [3]. Insurance companies rarely reimburse for CO, and the cost is often absorbed by the hospital [4]. Many financially strapped hospitals use laypeople and even patients’ relatives to provide these services despite the desirability of using well-trained personnel to maintain high standards of care and minimize the hospital’s legal liability [1,3,5]. Most hospitals allow a registered nurse to initiate CO, even though it is ultimately the treating physician’s responsibility to ensure his or her patients’ safety. Two major studies on CO agreed that psychiatric consultation decreases CO expenditure

359 ISSN 0163-8343/00/$–see front matter PII S0163-8343(00)00091-8

C. Jin et al.

[6,7]. However, a study of Goldberg in 1987 showed that only 37% of hospitals made psychiatric consultation mandatory for patients placed on CO [1]. This figure may have since been increased due to the increasing awareness of hospital legal liability by hospital administration. CO is used for patients with suicide attempts, agitated dementia or delirium, and severe depression or psychosis with a high risk of self-harm [8 –10]. Hospitals and the treating physicians have been sued or held liable for completed as well as unsuccessful suicides that have occurred in the hospital, heightening concerns about liability [3,11–14]. As a result, many hospitals make CO available without financial constraint, accountability, or documentation of reasoning in the patient’s chart [5]. Despite the clinical, legal, and economic issues represented by CO, studies on the subject have been scarce. Existing data relate primarily to clinical context and characteristics of patients placed on CO. Studies by Goldberg [6] and Talley et al. [5] divided their patient population according to either clinical diagnostic categories or clinical symptoms. In this study, we decided to look not only at patient characteristics but also at the relative experience of the physician, since in our institution, it is the physician who makes the final decision to place a patient on CO. Many factors may influence the physician’s decision, such as level of training, personal experience with potentially high risk patients in the general hospital, and time constraints, which impinge upon the establishment of a meaningful working alliance with the patient or limit the ability to comprehensively collect and analyze the information about risk factors. In this study, we examined two hypotheses. Our first hypothesis was that the physicians who had not yet received formal C–L psychiatry training would recommend more COs than those who have had C–L psychiatry training. This hypothesis is based on our clinical observation that psychiatry residents who have had C–L psychiatry training are generally more confident in their decision making capacities for complicated or potentially dangerous patients. We also hypothesized that when a psychiatric consultation is provided by a trainee without direct on-site access to a supervisor, the threshold of ordering CO will be lower compared to a situation in which fellows and senior psychiatrists are available for questioning and sharing the responsibility of the consulting physician’s decision.

360

Methods This study consists of a retrospective chart review of psychiatric consultations that occurred from July 1, 1997 to December 31, 1997 at the Long Island Jewish Medical Center of the North Shore– Long Island Jewish Health System in New York. The Long Island Jewish Medical Center is a 452-bed tertiary care general hospital providing comprehensive inpatient and outpatient care for adult patients in all major medical and surgical specialties. Adjacent to the main building is the medical center’s 223-bed psychiatric division. The hospital is affiliated with the Albert Einstein College of Medicine and has a fully accredited psychiatry residency program and offers fellowship training in C–L psychiatry. Post-graduate year 3 (PGY-3) psychiatry residents provide the major portion of psychiatric consultation services under the supervision of C–L psychiatry fellows and attending psychiatrists. The residents spend 40% of 6 months of their training time in C–L psychiatry. The class of third-year residents is divided without regard to clinical experience or academic performance into two groups. Six residents start their 6-month C–L psychiatry training at the beginning of their third-year residency training and the remaining five residents during the last 6 months. The residents who are not assigned to the C–L psychiatry rotation during the first half of the academic year spend an equivalent 40% of their training at a child psychiatry outpatient clinic instead. However, all third-year psychiatry residents have on-call duties after hours, which include the general hospital during the entire 12 months of the PGY-3 year. All consultations done by residents are seen and evaluated by an attending on the same day or the next working day. This training schedule provided an opportunity to compare the pattern of CO recommendation with the physicians’ level of training in C–L psychiatry. We reviewed all 153 initial consultations kept in the file of duplicate consults provided by third year psychiatry residents. We collected all the demographic data, medical and psychiatric diagnoses and reasons for request for consultation. In this study, 2 weeks of training in C–L psychiatry was arbitrarily defined as C–L psychiatry trained. Therefore, 15 consults done by residents who were on their first 2-week of C–L psychiatry rotation were excluded from the main analysis.

C-L Psychiatry Training

Table 1. Comparison of general demographics among the groups

All cases C–L PSY training A: Yes n (%)

B: No n (%)

After hours cases C–L PSY training

Regular hours cases C–L PSY training status

C: Yes n (%)

D: Yes n (%)

Gender Female 56 (53.8) 17 (50.0) 34 (50.0) 22 (61.1) Male 48 (46.2) 17 (50.0) 34 (50.0) 14 (38.9) Marital Status Single 33 (31.7) 6 (17.6) 25 (36.8) 8 (22.2) Married 32 (30.8) 11 (32.4) 16 (23.5) 16 (44.4) Divorced/separated 11 (10.6) 3 (8.8) 9 (13.2) 2 (5.6) Widowed 14 (13.5) 3 (8.8) 7 (10.3) 7 (19.4) Not Available 14 (13.5) 11 (32.4) 11 (16.2) 3 (8.3) Race Caucasian 80 (76.9) 19 (55.9) 54 (79.4) 26 (72.0) African-American 16 (15.4) 9 (26.5) 9 (13.2) 7 (19.4) Hispanic 2 (1.9) 1 (2.9) 0 (N/A) 2 (5.6) Others 5 (4.8) 5 (14.7) 5 (7.4) 0 (N/A) Not available 1 (1.0) 0 (N/A) 0 (N/A) 1 (2.8) Substance Use No 84 (80.8) 25 (85.3) 52 (76.5) 32 (88.9) Yes 20 (19.2) 9 (26.5) 16 (23.5) 4 (11.1) Age Mean (SD) Mean (SD) Mean (SD) Mean (SD) 55.5 (21.4) 57.8 (17.7) 52.7 (22.4) 61.0 (18.5)

Statistical Analyses The ␹2 analysis (two-sided) was used when variables of interest were nominal. The t test was used when variables were numerical continuous data, such as patient age.

Results Of the total of 138 cases, the residents who had received C–L psychiatry training provided psychiatric consultations in 104 (75.3%) cases. CO recommendations were made on 16 cases (15.4%). The residents who had not yet received C–L psychiatry training, provided consults for the remaining 34 (24.6%) cases, which were all after-hour cases (request of consultation received after regular working hours). Fifteen (44.1%) CO recommendations were made among the total of 34 cases. Of the 104 C–L psychiatry-trained resident cases, 68 (65.4%) were after-hour cases, of which 15 (22.1%) received CO recommendations. Thirty-six (26.1%) of the 138

Analysis

A vs B

B vs C

␹2

df

0.15

1

0.70 0.00

1 1.00 1.17

1 0.28

7.39

4

0.12 6.57

4 0.16 8.76

4 0.07

7.23

4

0.12 7.25

3 0.06 9.06

4 0.06

0.81

1

0.37 0.11

1 0.75 2.34

1 0.13

P

␹2

C vs D

df

P

␹2

df

P

t t t 0.57 136 0.57 1.18 100 0.24 1.91 102 0.06

cases were seen during regular hours. Overall, COs were recommended in 31 cases, which represented 22.5% of the total 138 cases. We made three comparisons. The first comparison was between all psychiatry consultations by C–L psychiatry-trained residents with the residents who had not yet received C–L psychiatry training (Group A vs Group B). Because the time of consult (regular hours vs after hours) could be a potential confound, we compared after-hours cases and regular hour cases provided by the C–L psychiatrytrained residents (Group C vs Group D). We then did a comparison of after-hours consults only, done by C–L psychiatry trained residents and those done by the residents who had not received C–L psychiatry training (Group B vs Group C). There was no significant difference in demographic data (including age, gender, marital status, race and substance abuse) among the groups (Table 1). Similar comparisons were made for psychiatric and medical factors among the groups (Table 2).

361

C. Jin et al.

Table 2. Comparison of medical and psychiatric characteristics among the groups

Total cases 138 (100%)

All cases C–L Training A: Yes n (%)

Reasons for consults Capacity evaluation Suicidality Affective symptoms Diagnostic evaluation Disturbance of conduct Evaluation of CO Change in mental status History of psychiatry disorder Psychotic symptoms Psychiatric diagnoses None Affective disorders Psychotic disorders Delirium Dementia Adj. Disorders PTSD Intermittent explosive disorder Panic disorder Medical conditions Medical illness Surgical illness Terminal illness CNS illness Overdose Undiagnosed

B: No n (%)

Afterhours C–L training

Regular C–L training

C: Yes n (%)

D: Yes n (%)

26 (25.0) 17 (16.3) 29 (27.9) 5 (4.8) 3 (2.9) 3 (2.9) 7 (6.7)

5 (14.7) 21 (30.9) 5 (13.9) 7 (20.6) 12 (17.6) 5 (13.9) 3 (8.8) 12 (17.6) 17 (47.2) 3 (8.8) 3 (4.4) 2 (5.6) 3 (8.8) 3 (4.4) 0 (N/A) 2 (5.9) 2 (2.9) 1 (2.8) 6 (17.6) 5 (7.4) 2 (5.6)

12 (11.5) 2 (1.9)

3 (8.8) 2 (5.8)

9 (8.7) 34 (32.7) 12 (11.5) 15 (14.4) 7 (6.7) 24 (23.1) 1 (1.0)

1 (2.9) 7 (10.3) 2 (5.6) 7 (20.6) 26 (38.2) 8 (22.2) 6 (17.6) 8 (11.8) 4 (11.1) 4 (11.8) 11 (10.2) 4 (11.1) 6 (17.6) 5 (7.4) 2 (5.6) 8 (23.5) 9 (13.2) 15 (41.7) 1 (2.9) 1 (1.5) 0 (N/A)

8 (11.8) 2 (2.9)

A vs B

␹2

df

13.62

8

10.93

4.33

C vs D df

P

␹2

df

P

0.09 12.14

8

0.11

8.54

8

0.38

8

0.21 11.98

7

0.10 11.03

8

0.20

5

0.50

5

0.13

5

0.44

P

␹2

B vs C

4 (11.1) 0 (N/A)

0 (N/A) 1 (2.9) 0 (N/A) 0 (N/A) 2 (1.9) 0 (N/A) 1 (1.5) 1 (2.8) 8.58

4.81

62 (59.6) 22 (64.7) 40 (58.8) 22 (61.1) 9 (8.7) 1 (2.9) 8 (11.8) 1 (2.8) 16 (15.4) 3 (8.8) 8 (11.8) 8 (22.2) 7 (6.7) 3 (8.8) 3 (4.4) 4 (11.1) 5 (4.8) 1 (2.9) 5 (7.4) 0 (N/A) 5 (4.8) 4 (11.8) 4 (5.9) 1 (2.8)

The groups did not differ significantly in regard to reason for requesting consultation, psychiatric diagnosis or medical condition responsible for hospitalization. In Table 3, we compared patterns of ordering constant observation among the groups. Residents who had not received C–L psychiatry training had a significantly higher rate of recommending CO than those who had C–L psychiatry training (A vs B). The rates were 44.1% and 15.4%, respectively (␹2⫽12.1, df⫽1, P⬍0.001). When we compared regular and after-hour consults just within the group of residents who had received C–L psychiatry training, we found that CO was recommended at a significantly higher rate in the after-hour cases. The rates were 22.1% and 2.8%, respectively (␹2⫽6.72, df⫽1, P⬍0.01).

362

Analysis

To control for this confounding variable, we separately analyzed data only from the after-hour cases. There were a total of 102 after-hour cases. The results are shown in the third comparison, group B vs group C. Again, we found that residents who had C–L psychiatry training had a significantly lower rate of recommending CO than those who had not. The rates were 22.1% and 44.1%, respectively (␹2⫽5.31, df⫽1, P⬍0.05). We also looked at change over time in both groups. The rate of ordering CO declined from the 1st to the 2nd half of the rotation in C–Ltrained residents, while there was no significant change in the group of residents not trained in C–L. In this analysis, previously excluded 15 cases were included and counted as being done

C-L Psychiatry Training

Table 3. Patterns of ordering constant observation by physicians

All cases C–L PSY training

Afterhours cases C–L PSY training

Regularhour cases C–L PSY training status

A: Yes B: No Dependent variable n (%) n (%) CO: No 88 (84.6) 19 (55.8) CO: Yes 16 (15.4) 15 (44.1) Total cases 104 34

C: Yes n (%) 53 (77.9) 15 (22.1) 68

D: Yes n (%) 35 (97.2) 1 (2.8) 36

by residents who had not yet received training in C–L psychiatry.

Discussion To our knowledge, this is the first study that looked at CO from the perspective of physician training. Our results suggest that training in C–L psychiatry may increase physicians’ clinical confidence in handling high-risk patients. We chose to examine initial orders of CO rather than the length of time patients remained on CO since the latter would more likely be influenced by the direct impact of the attending supervisor’s opinions. Physicians who had received C–L psychiatry training were less likely to order CO than those who had not yet received C–L psychiatry training. In two comparisons, one for all consults and one controlling for time of consult,

Analysis

A vs B

␹2 12.1

df 1

B vs C

P ⬍0.001

␹2 5.31

df 1

P ⬍0.05

C vs D

␹2 6.72

df 1

P ⬍0.01

physicians who had not yet received C–L psychiatry training had significantly higher rates of recommending CO than those who had C–L psychiatry training. In addition, the rate of ordering CO declined over time in the residents who were on their C–L rotation, but not in the group who did have C–L training. The higher CO rate in after-hour cases might have been due to greater time pressure on the residents, decreasing the ability to establish a working alliance. It might have been difficult to obtain data from relatives, primary care physicians, and other informants about potential risk factors. Also, senior psychiatrists and fellows are less accessible after hours. The lower CO rate by the C–L psychiatry-trained residents reflected data in the initial write-up in which the patient was seen by the psychiatry resi-

Figure 1. Time-dependent change of CO rates.

363

C. Jin et al.

dent before the attending or fellow reviewed the case. A separate analysis of only after-hour cases also indicated a lower CO rate in C–L psychiatry trained residents compared to those not training in C–L. The residents, whether they were rotating in C–L psychiatry or elsewhere, after hours, all received same amount of support from a senior 4thyear resident on-call, as from an attending psychiatrist on duty whom they could contact by phone when the senior resident on-call felt that further support was needed. It is worth mentioning that there were no major adverse outcomes in any of these 138 cases. However, due to a relatively small sample size and the infrequency of major adverse outcomes, such as suicides, a large scale outcome study would be needed for definitive conclusions about this issue since only about 0.5% of all suicides in the US occur in the general hospital [15]. Although we could not control for the potential variations of style or personality between two groups as a potential confounding variable, an analysis of CO over time showed a reduction in the rate for residents on the C–L rotation, but no change for the residents who had yet not been trained in C–L (Figure 1). While we arbitrarily defined at least 2 weeks of training in C–L psychiatry as “C–L-trained residents,” C–L psychiatry requires extensive, systematic training over time. The reduction in CO rates in the second half of the rotation for C–L residents is consistent with that position. It is also possible that the positive results in this study may be partially due to the non-specific effect upon the residents training in C–L psychiatry of feeling increasingly supported over time by C–L psychiatry fellows and attendings. With these caveats in mind, our findings suggest that C–L psychiatry training results in less use of CO with no corresponding increase in poor outcome. These findings should be considered tentative requiring further validation through future research.

364

References 1. Goldberg RJ: Use of constant observation with potentially suicidal patients in general hospital. Hosp Community Psychiatry 38:303–305, 1987 2. Shugar G, Rehaluk R: Continuous observation for psychiatric inpatients. Comprehensive Psychiatry 30: 48–55, 1990 3. Moore P, Berman K, Knight M, Devine J: Constant observation: implications for nursing practice. J Psychosoc Nurs Ment Health Serv 33:46–50, 1995 4. Hogerty SS, Rodaitis CM: A suicide precaution policy for the general hospital. Hosp Community Psychiatry 17:36–42, 1987 5. Talley S, Davis DS, Coicoechea N, Brown L, Barber LL: Effect of psychiatric liaison nurse specialist consultation on the care of medical–surgical patients with sitters. Arch Psychiatr Nurs 4:114–123, 1990 6. Goldberg RJ: The use of constant observation in general hospitals. Int J Psychiatry Med 19:193–201, 1989 7. Lamdan RM, Ramchandani D, Schindler B: Constant observation in a medical-surgical setting. The role of consultation-liaison psychiatry. Psychosomatics 37: 368–373, 1996 8. Williams M, Campbell E, Raynor W, Musholt M, Mlynarczyk S, Crane L: Predictors of acute confusional states in elderly patients. Res Nursing Health 8:31–40, 1985 9. Janken J, Reynolds B, Swiech K: Patient falls in the acute care setting: identifying risk factors. Nursing Res 35:215–219, 1986 10. Clark DC: Inpatients under constant observation for suicide risk. Crisis 18:50, 1997 11. Cooper TR Jr: Medical treatment facility liability for patient suicide and other self-injury. J Legal Med 3:20–29, 1975 12. Perr IN: Suicide litigation and risk management: a review of 32 cases. Bull Am Acad Psychiatry Law 13:209–219, 1985 13. Cheung P: Suicide precautions for psychiatric inpatients: a review. Aust NZ J Psychiatry. 26:592– 598, 1992 14. Fiesta J: Liability issues: patients with psychiatric problems. Nursing Management 22:14–17, 1991 15. Litman RE: Hospital suicides: lawsuits and standards. Suicide Life Threatening Behav 12:212–220, 1982