Psychiatric consultation to a general hospital medical evaluation service

Psychiatric Consultation to a General Hospital Medical Evaluation Service Ronald Gelfand,

M.D.

Assistant Professor of Psychiatry

William F. Kiely, M.D. Professor of Clinical Psychiatry University of Southern California

School of Medicine,

Los Angeles,

Abstract: Psychiatric consultation to a general hospital medical evaluation service was reviewed and compared with consultation patterns for general hospital inpatients and psychiatric emergency service patients. Results of a questionnaire survey indicated nearly 1 in 5 patients admitted to this acute medical service (24-hour maximum stay) required psychiatric consultation. A study of those patients seen by psychiatric consultants is reported. The prevalence of depressive illness as well as the psychiatric hospitalization referral rate was substantially greater than in general hospital inpatient or psychiatric emergency service evaluations. The implications of this relatively new area of consultation-haison for hospital staffing and medical education are discussed.

In 1975 the Los Angeles County-University of Southern California (LAC-USC) Medical Center opened a “Diagnostic and Evaluation” (D&E) service adjacent to the medical emergency room. The purpose of this service was to evaluate and treat acute medical problems likely to resolve in 24 hours or less and thereby avoid admission to the crowded medical services. Patients with such problems as an acute asthmatic attack or drug overdose were appropriate for the D&E. The LAC-USC Psychiatric Consultation-Liaison Service began providing psychiatric consultation and liaison to the new service when it opened. Now, four years later, roughly 41% of the total 6000 psychiatric evaluations provided each year by the Consultation-Liaison Service are to patients on this Diagnostic Service. The amount of consultation time spent working in this new area warranted a

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systematic review of this experience. Specifically, a comparison was made of psychiatric consultations with the separately located Psychiatric Emergency Service patients, and with patients evaluated on the medical and surgical inpatient services of the general hospital. A review of the literature revealed three types of comparable studies: patients attending primary psychiatric facilities such as 24-hour mental health clinics or emergency/walk-in areas of psychiatric hospitals; general hospitals without associated psychiatric departments; and general hospitals with psychiatric departments, usually teaching hospitals in urban areas. No report was found of psychiatric consultation to a general hospital medical evaluation service existing separately but adjacent to a 24-hour psychiatric emergency/walk-in service such as that at the LAC-USC Medical Center. Only patients admitted to the D&E with a presumed acute medical illness were evaluated by the psychiatric consultation service; patients clearly in need of specific psychiatric evaluation without acute medical problems were referred to the separately staffed Psychiatric Emergency Service. It is the psychiatric,consultation provided to this medical evaluation service which is reported here.

Method The LAC-USC Psychiatric Consultation-Liaison Service is staffed by five full-time residents on a

General Hospital Psychiatry 2, 56-60, 1930 @ Elsevier North Holland, Inc., 1980

Consultation to Medical Evaluation Service

four month rotation and by three full-time and three part-time staff psychiatrists. In addition, three medical social workers work full-time with the Service evaluating only patients who have attempted suicide. All requests for consultation are phoned in to the Consultation-Liaison office during weekdays or to the Psychiatric Hospital during evenings and weekends. If not emergent, patients are usually seen within 24 hours. For this survey a questionnaire was developed that noted demographic data as well as psychiatric diagnosis and recommendations. Questionnaires were completed by the physicians who did the consultations. The study ran for five months with each new consultation request accompanied by the questionnaire to be filled out and returned when the case was closed; there was an 89% return rate on the questionnaires. The completed questionnaires were key-punched and computer analyzed. Ninetyeight percent of the consultations were completed by third year psychiatric residents, the remainder by psychiatric staff and first year residents.

Results During the 5-month study 19.6% (n = 628) of all D&E admissions (n = 3206) were evaluated by the Psychiatric Consultation-Liaison Service. More specifically, 9.2% (n = 296) of D&E patients were evaluated by psychiatrists; the remaining 10.4% were seen by social work staff of the Suicide Evaluation Team. The population of D&E patients evaluated by psychiatrists constitute the basis for this report. The most common reason for psychiatric consultation in the D&E was to evaluate patients who had made suicide attempts. Sixty percent of all of our consultations to the D&E were for this reason. Other reasons for consultation are listed in Table 1. Table 1. Reason for consultation Reason Suicide attempt Bizarre behavior or uncooperative Placement/transfer Alcohol/drug abuse Psychosis Depression Emotional factor in medical problem Other Total

Number 178 (60.1%) 35 (11.8%) 26 (8.8%) 23 (7.8%) 11 (3.7%) 7 (2.4%) 7 (2.4%) 9 (3.0%) 296 (100%)

The majority of the non-suicide requests fell under the categories of bizarre or uncooperative behavior, placement and transfer assistance, and alcohol or drug abuse evaluations. The small number of re-

quests for evaluation of depression was due to the separate category for suicide attempt, the majority of whom were depressed. .Demographically, the mean age of patients was 34.9 years (range 16-93). Men comprised 49.5% of the group and women 51.5%. Ethnic breakdown showed Black 24.6%, Caucasian 62.5%, Spanish surname 10.2%, Asian 2.1%, and unknown 0.6%. This group was not substantially different in sex distribution or ethnicity from the 783 consultations done on the inpatient medical and surgical services during the same time; however, they were, on average, 7 years younger than medical inpatients evaluated whose mean age was 41.5 years. Diagnostically (using DSM II criteria), the majority of patients seen on this medical evaluation service were classified as situational disturbance (18.2%), personality disorder (15.9%), alcohol/drug abuse (14.5%), and depressive neurosis (14.2%). Almost 90% of patients with situational disturbances had a diagnosis of adjustment reaction with depressive features and suicide attempt. Twothirds of those with a primary diagnosis of personality disorder had a secondary depression with suicide attempt. When the diagnostic categories of affective psychosis-depressed, depressive neurosis, and alcohol/drug abuse with secondary depression-are added to the group, 54% of all patients seen in this medical evaluation service suffered from significant depressive illness. When compared with concurrent general hospital consultations and Psychiatric Emergency Service evaluations, the proportion of patients with depressive disorders, situational disturbances, alcohol and/or drug abuse, and personality disorders was highest in the Diagnostic and Evaluation Service. In diagnosing organic brain syndromes the D&E was midway between the Psychiatric Emergency Service (which saw proportionately fewer patients with this diagnosis) and the General Hospital consultation service (which saw proportionately more patients with this diagnosis). Diagnoses of psychosis (schizophreniform or schizophrenic) were made proportionately less often in the D&E than in General Hospital consultation or in the Psychiatric Emergency Service. Table 2 shows the comparative diagnostic breakdowns for these three areas. For study purposes only the primary diagnosis is recorded. In Table 2, organic brain syn57

R. Gelfand and W. F. Kiely

Table 2. Comparative

psychiatric

diagnoses

Diagnosis

D & E4

General Hospital

Organic brain syndrome Psychosis-schizophreniform or schizophrenic Personality disorder Psychosis-affective Depressive neurosis Other neurosis Situational disturbance AlcohoUdrug Psychophysiological reaction Other Unknown/deferred Total

32 (10.8%)

180 (23.0%)

37 47 19 42 4 54 43 2 13 3 296

(12.5%) (15.9%) (6.4%) (14.2%) (1.4%) (18.2%) (14.5%) (0.7%) (4.4%) (1.0%) (100%)

147 80 34 63 22 93 82 6 46 20 783

(18.8%) (10.2%) (4.3%) (8.0%) (2.8%) (11.9%) (10.5%) (0.8%) (5.9%) (3.8%) (100%)

Psych ERb 595

(5.0%)

3558 (29.9%) 809 (6.8%) 214 (1.8%) 1523 (12.8%) 1023 (8.6%) 976 (8.2%) 0 (0.0%) 3142 (26.4%)” 61 (0.5%) 11901 (100%)

RPatients seen by psychiatric consultants. bCounty of Los Angeles Mental Health Services, Program Development Bureau: Client and Service Statistics 1976-1977. Report No. 14, January, 1979. ‘Includes those with no mental illness and those with mental retardation.

drome includes both acute and chronic brain syndromes. The psychiatric consultants in the D&E referred 34.5% of patients to mental health clinics or private outpatient settings, assisted in placements (nursing homes, board and care facilities, and so on) for 6.1%, had no referral recommendations (evaluation only) for 39.2%, and hospitalized 34.8% in psychiatric facilities-virtually all of them involuntarily. This number was considerably higher than the psychiatric hospitalization percentage of patients seen in general hospital inpatient consultation (13.4%) and even higher than the percentage of patients hospitalized by the Psychiatric Emergency Service (22.5%). In absolute numbers the Psychiatric Emergency Service hospitalized more people than the D&E consultants because of the greater number of

Table 3. Comparative

Discussion There are several striking findings in this study. First, a large number of suicide attempters are seen

recommendations

Recommendations Evaluation only Psychiatric hospitalization Placement Outpatient referral Psychotropic medication Other (milieu, further evaluation, “Primary recommendation only.

58

patients seen there, but nonetheless, more than one out of every three patients evaluated in the D&E were hospitalized in a psychiatric facility. Table 3 shows the recommendations made for D&E patients, general hospital inpatient consultations, and the Psychiatric Emergency Service. The smaller number of D&E consultations with recommendations for psychotropic medications (7.1%) may be explained by the short patient stay and resultant lack of follow-up by psychiatric consultants in this area, and the large number of patients recovering from drug overdoses when evaluated.

etc.)

D&E (n = 296)

General hospital (n = 783)

Psych ER” (n = 11901)

116 (39.2%) 103 (34.8%) 18 (6.1%) 102 (34.5%)

239 (30.5%) 105 (13.4%) 68 (8.7%) 198 (25.3%)

4499 (37.8%) 2678 (22.5%) 143 (1.2%) 2213 (18.6%)

21 (7.1%) 37 (12.5%)

202 (25.8 %) 353 (45.1%)

not available 2368 (19.9%)

Consultation to Medical Evaluation Service

in the medical evaluation service. Sixty percent of all patients were evaluated because of suicide attempts. Although no comparable medical evaluation service was found in the literature, other studies of psychiatric consultation to general hospital emergency rooms reported 7.4-16% of patients were evaluated for suicide attempts (l-3). Another notable finding, not surprising in light of the number of suicide attempts, is the large number of patients with depressive disorders seen in the D&E-approximately 50% of patients evaluated. This surpasses the proportion of depressive illness diagnosed in general hospital and Psychiatric Emergency Service consultations. It is difficult to compare this finding with published reports of psychiatric consultation to general hospital emergency rooms, but the major difference seems to be in the area of situational disturbances. In three studies of psychiatric consultation in general hospital emergency rooms, situational disturbances were diagnosed in 3.0-9.7% of patients (1,4,5) compared with 18.2% in this study. Perhaps patients in this study, largely of low socioeconomic class, experience more stress and/or are more vulnerable to situational disturbances. The D&E psychiatric hospitalization referral percentage of 34.8% also deserves comment. This was more than twice the 13.4% of patients referred for psychiatric hospitalization following general hospital consultation. Several factors may contribute to this, especially the large number of seriously depressed suicidal patients seen who require hospitalization, usually involuntarily. In addition, the nature of the D&E service is such that only patients with presumed acute medical problems are admitted and, with a 24-hour time limit to make a disposition, there is great pressure on the psychiatric consultant to make a decision about hospitalization, often with little information regarding possible family support, friends, and past psychiatric history. Again, the literature reveals several studies of psychiatric consultation in general hospital emergency rooms with a hospitalization rate of ll-40%, (1,4-7) comparable to findings in this study. The figure of 19.6% of patients in the D&E receiving psychiatric consultation is substantially higher than that of general hospital emergency room psychiatric consultations reported in the literature. Most studies quote a figure of 2.7%-4.5% (2,3,6,8). Although it is possible that the medical Diagnostic and Evaluation Service sees more psychiatrically ill patients than do other hospitals in their emergency rooms, a more likely explanation for the higher rate

of psychiatric consultation is the increased availability of the consultant and a good liaison relationship with the Diagnostic and Evaluation Service staff. Each day one consultation-liaison psychiatric resident is assigned to the D&E and spends most of his working day there. In addition, a staff psychiatrist is assigned half-time to this area and maintains an office there. The range of acute psychopathology seen in the D&E provides an excellent service to teach medical students, medical interns and residents brief interviewing technique, the differential diagnosis of functional versus organic psychosis, and the evaluation of acutely depressed and suicidal patients. Medical students in psychiatric clerkships on the Consultation-Liaison Service and medical housestaff taking electives on the Service also do supervised evaluations of D&E patients. A good working relationship with the D&E medical staff facilitates direct participation in the education of medical residents, through bedside consultations in the presence of the medical residents, and by informal seminars on selected topics. Psychiatric consultation to a general hospital medical evaluation service, itself a relatively new concept, has been a logical extension of the major functions of a psychiatric consultation-liaison service. As described by Lipowski (9), these include: (a) aid in diagnosis and management of mental disorders among medical and surgical patients; (b) liaison with medical and nursing staff aimed at prevention and early detection of psychological disturbances; (c) bedside teaching of psychosocial aspects of medicine; (d) maintenance of interprofessional communication in matters of comprehensive care of the sick; and (e) interdisciplinary clinical research. As this survey has indicated, nearly 20% of all admissions to the medical evaluation service required psychiatric consultation for proper diagnosis and treatment. The implications of the survey for the staffing of large central city hospital emergency admitting services are clear. Furthermore, the high referral rate is a reflection of the excellent liaison relationship that exists between psychiatry and medicine in this area, the success of an interdisciplinary approach to patient evaluation, and an attitude of collaboration with medical staff that emphasizes education of house officers as well as patient care. It is evident that regular presence on the medical evaluation service helps cement the integral relationships between psychiatry and medicine in this medical center. 59

R. Gelfand

and W. F. Kiely

References 1. Bauer SF and Balter L: Emergency psychiatric patients in a municipal hospital-demographic, clinical and dispositional characteristics. Psychiatr Q 45:382-393, 1971 2. Spitz L: The evolution of a psychiatric emergency crisis intervention service in a medical emergency room setting. Compr Psychiatry 17:99-113, 1976 3. Watson GD: Utilization of emergency departments for psychiatric treatment. Can Psychiatr Assoc J 23:143148, 1978 4. Schwartz MD and Errera P: Psychiatric care in a general hospital emergency room. II. Diagnostic Features. Arch Gen Psychiatry 9:113-121, 1963 5. Zonana H, Henisz J, and Levine M: Psychiatric emergency services a decade later. Psych Med 4:273-290, 1973 6. Errera P, Wyshak G, Jarecki H: Psychiatric care in a

general hospital emergency room. Arch Gen Psychiatrv 9:305-112, 1963 Muller JJ, Chafetz ME, Blane HT: Acute psychiatric services in the general hospital. III. Statistical Survey. Am J Psychiatry (Suppl.) 124:46-56, 1967 Anstee BH: Psychiatry in the casualty department. Br J Psychiatry 120:625429, 1972 Lipowski ZJ: Consultation-liaison psychiatry: An overview. Am J Psychiatry 131:623-630, 1974 Direct

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