Residents’ Voices

Proactive consultation: A new model of care in consultation-liaison

Sahil Munjal, MD

uring my residency training, I was The BIT collaborates closely with the trained in the standard “reactive” medical team through formal and informal Dpsychiatric consultation model. In consultation; co-management of behavioral this system, I would see consults placed issues; education of medical, nursing, and by the primary team after they identified social work staff; and direct care of complex a behavioral issue in a patient. As a patients with behavioral disorders. The BIT trainee, I experienced frequent frustra- assists the medical team with transitions to tions working in this model: Consults that appropriate outpatient and inpatient psy- Dr. Munjal is Assistant Professor, Psychiatry and , are discharge-dependent (“Can you see chiatric care. The team also manages the Wake Forest School of Medicine, the patient before he is discharged this relationship with the insurer when a patient Winston-Salem, North Carolina. At the time he wrote this article, morning?”), consults for acute behavioral requires a stay in a psychiatric unit. he was a fellow, consultation- dysregulation (“The patient is near the This model has a critical financial benefit liaison psychiatry, Department of Psychiatry, Yale New Haven elevator, can you come see him ASAP?”), in reducing the length of stay, but it also has Hospital, New Haven, Connecticut. or consults for consequences of poor many other benefits. It focuses on early rec- Disclosure management of alcohol/benzodiazepine ognition and treatment, and helps mitigate The author reports no financial withdrawal (“The patient is confused and the effects of mental or substance use disor- relationships with any company whose products are mentioned in trying to leave”). ders on patients’ recovery. BIT members edu- this article, or with manufacturers of As a fellow in consultation-liaison cate their peers regarding management of a competing products. (C-L) psychiatry, I was introduced to the multitude of behavioral issues. This fosters “proactive” consultation model, which extensive informal collaboration (“curbside avoids some of these issues. In this article, consultation”), which helps patients who which is intended for residents who have did not receive a formal consult. The model not been exposed to this new approach, I distributes work more rationally among explain how the proactive model changes different professional specialists. It yields a our experience as C-L clinicians. relationship with medical teams that is not only more effective, but also more enjoy- able. In the BIT model, pick the The Behavioral Intervention Team cases where they feel they can have the most At Yale New Haven Hospital, the impact, and avoid the cases they feel they Behavioral Intervention Team (BIT) is a cannot have any.1-3 proactive, multidisciplinary psychiat- continued ric consultation service that serves the units at the hospital. LET YOUR VOICE BE HEARD The team consists of nurse practitioners, Current Psychiatry invites psychiatry residents nurse liaison specialists, social workers, to share their views on professional or clinical and psychiatrists. The team identifies and topics for publication in Residents’ Voices. E-mail [email protected] for author removes behavioral barriers in the care of guidelines. Current Psychiatry hospitalized mentally ill patients. Vol. 17, No. 10 e3 Residents’ Voices

Table Consultation-liaison psychiatry: Traditional vs proactive models Trait Traditional ‘reactive’ C-L model Proactive C-L model Delivery of service Reactive Proactive Personnel Single discipline: MD Multidisciplinary: MD, advance practice registered nurse, social worker Case identification Request by the primary team Screening based on records and nursing staff report Mode of intervention Advice to the primary team MD Collaboration with nurses, social workers, and clinicians with close follow-up Service goals Treatment recommendation, risk Prevention of behavioral barriers to care, reduction, and crisis management avoidance of crises, provider synergy Clinical Point Location Team spread over hospital Team embedded in assigned medicine units with co-located personnel The proactive Source: Reference 4 model yields a more C-L: consultation-liaison effective, more enjoyable relationship with medical teams CASE practitioner gives apt recommendations of A better approach to alcohol withdrawal evidence-based management, including a Mr. X, age 56, has a history of alcohol use benzodiazepine taper, high-dose thiamine, disorder, hypertension, and coronary artery and psychopharmacologic approaches to disease. He’s had multiple past admissions severe agitation. The nurse liaison special- for complicated alcohol withdrawal. He is ist on the service makes behavioral plans for transferred from a local community hospital, managing agitation, which she communi- where he had presented with chest pain. His cates to the nurses caring for Mr. X. last drink was 2 days prior to admission, and Because his withdrawal is managed more his blood alcohol level is <10 mg/dL. promptly, Mr. X’s length of stay is shorter and During Mr. X’s previous hospitalizations, he does not experience any medical com- psychiatric consults were performed in the plications. The BIT social worker helps find standard reactive model. The primary team appropriate aftercare options, including resi- initially prescribed an ineffective dosage of dential treatment and Alcoholics Anonymous benzodiazepines for his alcohol withdrawal. meetings, to which the patient agrees. This escalated his withdrawal into tremens, after which psychiatry was involved. Participating in this case was highly educa- Due to this early ineffective management, tional for me as a trainee. This case is but the patient had a prolonged medical ICU stay one example among many where proac- and overall stay, experienced increased med- tive consultation provided prompt care, ical complications, and required increased lowered the rate of complications, reduced staff resources because he was extremely length of stay, and resulted in greater pro- agitated. vider satisfaction. The Table4 contrasts the Discuss this article at During this hospitalization, Mr. X arrives proactive and reactive consultation models. www.facebook.com/ with similar medical complaints. The nurse The following 5 factors are critical in the MDedgePsychiatry practitioner on the BIT service, who screened proactive consultation model4,5: all admissions each day, examines the prior 1. Standardized and reliable procedure notes (she finds the team sign-outs to be par- screening of all admissions, involving a ticularly useful). She suggests a psychiatric professional, through record consult on Day 1 of the admission, which the review and staff contact. This screening Current Psychiatry e4 October 2018 primary medical team orders. The BIT nurse should identify patients with issues who Residents’ Voices

will benefit specifically from in-hospital discharge planning teams, psychological services, rather than just patients with any services, and access to specialized provid- psychiatric issue. An electronic medical ers, such as addiction teams, as well as tra- record is essential to efficient screening, ditional consultation with an experienced team communication, and progress moni- . toring. Truly integrated consultation would Research has shown the effectiveness be impossible with a paper chart. of proactive, embedded, multidisciplinary 2. Rapid intervention that anticipates approaches.1-3,5 It was a gratifying experi- impending problems before a cascade of ence to work in this model. I worked inti- complications starts. mately with medical clinicians, and shared 3. Collaborative engagement with the the burden of responsibilities leading to primary medical team, sharing the burden optimal patient outcomes. The proactive of caring for the complex inpatient, and consultation model truly re-emphasizes the Clinical Point transmitting critical behavioral manage- “liaison” component of C-L psychiatry, as it Proactive ment skills to all caregivers, including the was originally envisioned. skill of recognizing patients who can benefit consultation can from a psychiatric consultation. Acknowledgment provide prompt care, The author thanks Paul Desan, MD, PhD, for his valuable comments 4. Daily and close contact between during the preparation of this manuscript. lower the rate of behavioral and medical teams, ensuring complications, and that treatment recommendations are under- References 1. Sledge WH, Gueorguieva R, Desan P, et al. Multidisciplinary reduce length of stay stood, enacted, and reinforced, ineffective proactive psychiatric consultation service: impact on length treatments are discontinued, and new prob- of stay for medical inpatients. Psychother Psychosom. 2015;84(4):208-216. lems are addressed before complicating 2. Desan PH, Zimbrean PC, Weinstein AJ, et al. Proactive consequences arise. Dedicating specific per- psychiatric consultation services reduce length of stay for admissions to an inpatient medical team. Psychosomatics. sonnel to specific hospital units and placing 2011;52(6):513-520. 3. Sledge WH, Bozzo J, White-McCullum BA, et al. The cost- them in rounds simplifies communication benefit from the perspective of the hospital of a proactive and speeds intervention implementation. psychiatric consultation service on inpatient general medicine services. Health Econ Outcome Res Open Access. 2016;2(4):122. 5. A multidisciplinary consultation team, 4. Sledge WH, Lee HB. Proactive psychiatric consultation for offering a range of responses, including hospitalized patients, a plan for the future. Health Affairs. www.healthaffairs.org/do/10.1377/hblog20150528.048026/ informal curbside consultation, consulta- full/. Published May 28, 2015. Accessed September 12, 2018. tion with an advanced practice registered 5. Desan P, Lee H, Zimbrean P, et al. New models of psychiatric consultation in the general medical hospital: liaison psychiatry nurse, social work interventions, advice to is back. Psychiatr Ann. 2017;47:355-361.

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