Discharge checklist for psychiatric patients?

Research
1

Hi @cposs,

I heard that you were interested in this topic, and I was wondering if we could start thinking within this thread about how we might go about this. What have you been thinking on this topic?

To tell you a bit about what’s going on in my head, I’ve been thinking of trying to standardize my general approach to psychiatric patients (especially mood disorder and suicidality). These are patients who seldom benefit from admission, but can be quite scary to properly assess.

The idea, then, would be to look at the literature with an eye to creating an evidence-based checklist that we can ask colleagues to fill to help with decision-making. I’ve started some very preliminary web searching over the past few months thinking about this (e.g., 1, 2).

The tools I’ve found, though, depend on the patient to be reliable and not be manipulative. Unfortunately, I think this is an unsafe bet in some of the populations we see, since there is significant secondary gain to admission. I have been mulling the idea of adding a few markers that indicate low suicidal risk, perhaps based on some literature.

I think of this as more of a brainstorming conversation, and I’m really looking forward to hearing your thoughts about it!

tarek : )

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I was just looking at this thread by Christine Richardson, which seems to have a bit to do with this topic, albeit from 2006. @crichardson, do you remember what came of your work on this? Is there anything useful for us that might help us with the above?

tarek : )

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Hey Tarek (and everyone else)

Mental health in the emergency department is one my my major interests, and I’m hoping to make contributions in this area here as time goes on.

For the last few months, Dawn Giffin and I have sat on a committee with players in psychiatry and internal medicine regarding the management of acute cognitive change in the elderly in the emergency department. As we have all seen working in the ER, sometimes these patients get referred to medicine and sometimes to psychiatry. The exact endpoint for each individual patient is not standardized, and depends on a combination of patient / provider / accepting service factors.

In discussions I’ve had with Dawn, our hope was, and still remains, to develop a standardized pathway for disposition of elderly patients with acute cognitive changes. The research project I completed during my EM year using data from LHSC found what I felt to be an unacceptably high rate of adverse medical outcomes in elderly patients referred to psychiatry from the ED, the majority of whom were “behaviour changes”……these are often referred to psychiatry as their behaviour issue is attributed to a psychiatric disorder, and not a delirium due to an undiscovered medical illness.

A roadblock we have run into in this committee is that medicine and psychiatry do not agree on which patients should end up in which service. We will continue to politely push them, as we feel strongly about standardizing these patient’s disposition. It would also make it much easier in the ER as we would not have to argue with residents defending why we feel a patient should be in psychiatry or medicine, the pathway would pre-determine that.

My gut feeling is that the safest place for elderly patients with acute cognitive changes is usually not the psychiatry ward, but the medicine ward. At least for a short observation period, to ensure that something sinister does not declare itself. Mental illness in the elderly can be a diagnosis of exclusion. That is just my two cents.

Regarding a discharge checklist for psychiatric patients, I have not done any work on this specific topic. I am always interested in improving patient flow and I would welcome an evidence-based approach to safely managing our patients with mental illness. A physician checklist is one way to go about this. I wonder about having a patient checklist, where patients may check off symptoms they are having and indicate risk factors that would portend a high risk situation (e.g. famhx suicide, access to lethal means, elderly, etc)………we could consider involving residents (both ER and psych) in developing this as well.

However, before I spend too much time developing checklists, I have heard through the grapevine that CEPS is planning on having one of their nurses in the front bubble on a fairly regular basis at some point in the near future - I don’t know the ER’s role in this, but this may impact throughput and help in our safe disposition planning. A worthwhile place to start may be engaging CEPS and our colleagues in psychiatry and utilizing their manpower to our, and our patient’s, advantage.

I am happy to reach out to them and see where we can help. Even starting a round table discussion with them would be beneficial.

Chris

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Hi Chris,

It sounds like you’re doing lots of work on this. I can’t find a summary of your research easily available - do you mind posting an abstract or your conclusions here for posterity? It sounds, however, that you’re doing work mostly on the medicine vs. psychiatry front for elder patients who present. That’s amazing, and I can’t wait to see what you guys decide.

In terms of my thoughts regarding this idea, they are more about us - as emerg docs - taking over decision-making on these patients from our psychiatry colleagues in a way that is mostly safe and makes sense.

I see the problem as breaking down like so:

  • There are many patients who announce suicidality each day
  • Almost none of these patients warrant admission to the psychiatry ward
  • A significant number of people announcing suicidality do so because of secondary gain - often, it is the mistaken impression they will get better care, faster care or housing/food
  • A disproportionate number of these patients will be admitted when consulted to psychiatry

I am using the assumptions above to build my thinking, so if any need challenging, feel free to challenge them. Using the assumptions above, the goals would be as follows:

  • Create a tool for standard assessment
  • Use this tool to prevent consultations to the psychiatry service
  • Partner the tool with a discharge pathway

To try to articulate this another way: We don’t consult cardiology every time a patient with chest pain comes in. Why are we consulting psychiatry every time a patient with suicidality comes in? In the former case, pathways help us decide the risks. In the latter case, we don’t really have a pathway.

Considering the high correlation of the population in London announcing suicidality with secondary gain, I would propose that the tool should be drawn as a clinician tool rather than a self-assessment tool. Otherwise, a survey like this one will be abused by the same patients who are currently using suicidality as a buzzword for secondary gain, which is not helpful.

tarek : )

5

Never did get this up and running.

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