Oldham Mark A, Lang Valerie J, Hopkin Justin L, Maeng Daniel D
Department of Psychiatry, University of Rochester Medical Center, Rochester, NY.
Department of Medicine, University of Rochester Medical Center, Rochester, NY.
J Acad Consult Liaison Psychiatry. 2021 Nov-Dec;62(6):606-616. doi: 10.1016/j.jaclp.2021.06.005. Epub 2021 Jul 3.
Proactive consultation-liaison (C-L) psychiatry has been shown to reduce hospital length of stay (LOS), increase psychiatric C-L consult rate, and improve hospital staff satisfaction. Nursing attrition has not been studied in relation to proactive C-L.
Our primary aim in evaluating the proactive C-L service called Proactive Integration of Mental Health Care in Medicine (PRIME Medicine) is to analyze change in LOS over 10 months using historical and contemporary comparison cohorts. As secondary aims, we assess change in psychiatric consultation rate, time to consultation, and change in nurse attrition.
PRIME Medicine was implemented on 3 hospital medicine units as a quality-improvement project. Team members systematically screened patients arriving to assigned units for psychiatric comorbidity. Identified patients were reviewed with hospitalist teams and nurses with the goal of early intervention.
Including historical and contemporary comparison cohorts, the mean sample age was 62.4 years (n = 8884). Absolute LOS was unchanged, but difference-in-difference analysis trended toward reduced LOS by 0.16 day (P = 0.08). Consultation rate increased from 1.6% (40 consults) to 7.4% (176 consults). Time to consultation was unchanged (4.0-3.8 d). Annual per-unit nursing turnover increased from 4.7 to 5.7 on PRIME units but from 8.5 to 12.0 on comparison units. Nurses citing "population" as the reason for leaving decreased from 2.7 to 1.7 on PRIME units but increased from 1.5 to 4.5 on comparison units. PRIME Medicine led to increased consultation rate, and our unit-wide outcomes provide a conservative estimate of effect. Factors that may have influenced effect size include our cohort's advanced age, considerable emergency department boarding times, increasing proportion of patients discharged to skilled nursing facilities, and concurrent LOS-reduction initiatives on all units. The favorable trends in nursing attrition on PRIME units may be explained in part by our prior finding that PRIME Medicine was associated with enhanced nursing satisfaction.
While PRIME Medicine had no more than a modest effect on LOS, it was associated with a markedly increased psychiatric consult rate and favorable trends in nursing retention. This analysis highlights important factors that should be considered when implementing and determining value metrics for a proactive C-L service.
前瞻性会诊-联络（C-L）精神病学已被证明可缩短住院时间（LOS）、提高精神科C-L会诊率并提高医院工作人员满意度。尚未对前瞻性C-L与护理人员流失的关系进行研究。
我们评估名为“医学中精神卫生保健的前瞻性整合”（PRIME Medicine）的前瞻性C-L服务的主要目的是，使用历史和当代比较队列分析10个月内住院时间的变化。作为次要目的，我们评估精神科会诊率的变化、会诊时间以及护士流失的变化。
PRIME Medicine作为一项质量改进项目在3个医院内科病房实施。团队成员系统地筛查入住指定病房的患者是否存在精神疾病合并症。对确诊患者与住院医师团队和护士进行会诊，目标是进行早期干预。
纳入历史和当代比较队列后，样本的平均年龄为62.4岁（n = 8884）。绝对住院时间没有变化，但差异分析显示住院时间有缩短0.16天的趋势（P = 0.08）。会诊率从1.6%（40次会诊）增至7.4%（176次会诊）。会诊时间没有变化（4.0 - 3.8天）。PRIME病房的年单位护理人员更替率从4.7增至5.7，而对照病房则从8.5增至12.0。将“患者群体”作为离职原因的护士在PRIME病房从2.7降至1.7，而在对照病房从1.5增至4.5。PRIME Medicine导致会诊率提高，我们的全病房结果对效果进行了保守估计。可能影响效应大小的因素包括我们队列中患者年龄较大、急诊科住院时间较长、出院至专业护理机构的患者比例增加，以及所有病房同时开展的缩短住院时间举措。PRIME病房护理人员流失的有利趋势部分原因可能是我们之前的发现，即PRIME Medicine与护理满意度提高相关。
虽然PRIME Medicine对住院时间的影响不大，但它与精神科会诊率显著提高以及护理人员留用的有利趋势相关。该分析突出了实施前瞻性C-L服务并确定价值指标时应考虑的重要因素。
