Spotting “Trouble” Automated Case Finding to Support Psychiatric Consultation-Liaison Teams
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Mount Sinai Hospital in Toronto developed an automated daily report using electronic health record data to help psychiatric consultation teams identify high-risk patients needing assessment. The report flagged patients meeting criteria like aggression, transfers from psychiatric units, or Clozapine prescriptions. In the first 3 months, 173 patients were identified by the report, leading to 42 new psychiatric consults. The report improved early involvement of psychiatric teams and identification of at-risk patients, promoting both patient and staff safety. Ongoing refinements aim to optimize the report while maintaining identification of true cases needing care.
Spotting “Trouble” Automated Case Finding to Support Psychiatric Consultation-Liaison Teams
- 1. Spotting “Trouble” Automated Case Finding to Support Psychiatric Consultation-Liaison Teams Mavis Afriyie-Boateng Jocelyn Bennett Carla Loftus Lesley Wiesenfeld
- 2. Context • Mount Sinai Hospital, Toronto, Canada is a 472 bed academic tertiary care centre • Psychiatric consultation-liaison teams previously relied on the attending physician to refer patients needing psychiatric assessment and care • Consultation request lags and several near misses led to a 2012 policy that allows psychiatric consultation to be triggered based on the presence of several high-risk/ high-need criteria
- 3. Problem/Issue/Opportunity Which patients did we want to identify? Hospitalized for medical and surgical care + Comorbid mental illness leading to High Psychiatric Need Patient is: •Transferred from a psychiatric or behavioural inpatient unit AND/OR •Prescribed Clozapine (an antipsychotic medication used to treat severe mental illness and requiring monitoring via a Health Canada registry) Challenging Behaviours These behaviours include: •Aggression •Resistance-to-care •Wandering The presence of these behaviours •Compromises care delivery •Increase the risk of unintentional patient/staff physical harm
- 4. Intervention • Collaboration with Health Informatics to develop a computer-generated daily report of inpatients meeting outlined criteria, utilizing information documented in the electronic health record • Psychiatric advanced practice nurses review the daily report • If high-risk/high-need criteria are confirmed as present, then the appropriate psychiatric consultation-liaison team further assesses the patient High-Risk/High-Need Criteria that can be extracted from the electronic record: •Transfer from a psychiatric or behavioral unit •Restraint use for aggressive behaviour •Nursing documentation of aggressive behaviour •Clozapine prescription •Security alerts (initiated by hospital security based on previous interactions) •Pyschiatric high risk flags (added by team in case of readmission)
- 5. Measurement Criteria # Action # Restraints for aggression 5 Consult Already followed None (imminent discharge) 1 3 1 Nursing documentation of aggression 154 Consult Already following False positive (charting error) None (imminent discharge) 38 21 93 2 Clozapine prescription 3 Consult Already followed 1 2 Security alert 9 Consult Already following No psychiatric need 2 4 3 Psychiatry alert 2 Consult No psychiatric need 0 2 Transfer from Inpatient Psychiatry 1 False positive (charting error) 1 Transfer from Behavioral Unit 0 Profile of Patients appearing on the report (July to September 2014): In summary: 173 patients were identified 42 psychiatric consults were triggered 21 patients were already being followed
- 6. Contribution to Patient Safety Safe Patients/Safe StaffTM • The computer-generated daily report has both – Facilitated early involvement of the psychiatric consultation-liaison teams in the care of patients with high psychiatric need and/or with challenging behaviours, and – Has led to identification of patients who would have been missed by the traditional consultative model • For patients with high psychiatric need, the psychiatric consultation-liaison teams ensured that ongoing psychiatric care was maintained during the patient’s medical or surgical admission • For patients with challenging behaviours, the psychiatric consultation-liaison teams focused on ensuring the safe delivery of needed care, which promoted both patient and staff safety • We recommend that other teams consider using an automated report to aid with case-finding
- 7. Partnership • The psychiatric consultation-liaison teams were concerned that patients would feel stigmatized through being identified as meeting high-risk/high-need criteria • Thus, the teams explained the reason for their involvement in terms of the benefit to the patient and the majority of patients were receptive to working with the teams
- 8. Lessons Learned & Sustainability • Ongoing iterative changes are being made to the report to optimize the identification of patients – The false positive rate has been hard to decrease without missing true cases • Sustainability has been ensured through having dedicated staff to review the safety reports and involve the psychiatric consultation-liaison teams • With multiple early good catches, the value of the report was quickly recognized and through further use it has become a routine method of identifying patients requiring psychiatric care • Overall, the automated report has been successful case-finding strategy and other teams are advised to consider developing their own report For any questions or further information, please contact Carla Loftus at 416-586-4800 x7292, cloftus@mtsinai.on.ca