Liaison Psychiatry Service Research Articles

New models of care: a liaison psychiatry service for medically unexplained symptoms and frequent attenders in primary care.

Aims and method This paper describes the process of setting up and the early results from a new liaison psychiatry service in primary care for people identified as frequent general practice attenders with long-term conditions or medically unexplained symptoms. Using a rapid evidence synthesis, we identified existing service models, mechanisms to identify and refer patients, and outcomes for the service. Considering this evidence, with local contingencies we defined options and resources. We agreed a model to set up a service in three diverse general practices. An evaluation explored the feasibility of the service and of collecting data for clinical, service and economic outcomes.Results High levels of patient and staff satisfaction, and reductions in the utilisation of primary and secondary healthcare, with associated cost savings are reported.Clinical implications A multidisciplinary liaison psychiatry service integrated in primary care is feasible and may be evaluated using routinely collected data.

Familiar faces: sharing expertise to plan frequent users of emergency services

Background: The Hammersmith & Fulham Integrated Care Programme is a core group of healthcare organisations in Hammersmith and Fulham working in partnership to develop a better way of providing care. Together, we will re-shape the health and care system in Hammersmith and Fulham to respond to a range of health challenges within the borough and the rest of the country. For example, providing care for people living with one or more long term condition and system issues, such as overly fragmented care. We are working to: design a practical, 'accountable care' approach - collectively looking after the whole health needs of local people, from beginning to end of life, rather than providing less joined-up treatment when they are ill. identify and implement immediate improvements to 'join-up' care, primarily through two pilot projects, one focusing on patients who are frequent users of A&E services and a second looking at ways of boosting child health. build strong foundations for potentially forming or becoming part of a formal accountable care partnership with pooled resources and shared clinical and financial risk so that we can genuinely provide whatever care is best to meet individual needs. The programme will seek to work in partnership with commissioners, patients and the public wherever possible and ensure they are informed of plans as they develop. Report to Board on Progress in Familiar Faces Project This project was aimed at analysing the attendance of H&F GP registered patients at Emergency departments operated by Imperial, Chelsea and Westminster and other acute providers from April 2015 to January 2016. This analysis identified 71 patients from across 22 practices who attended A&E more than 10 times, of which 13 have attended more than 20 times and 1 attended over 100 times. After extensive information governance consultation, patients were approached by their general practitioners to be consented for full information sharing between providers for data to analyse their patterns of healthcare and define any unmet needs, or improvements that could be made in service efficiency and patient outcome. An experienced GP was involved in the consenting of these patients which resulted in 20 patient giving their explicit consent. A multidisciplinary review of all consented case records took place including clinicians from all partners. Summary Findings: The patients who were considered by in depth notes review, revealed that remarkable effort had been made both by staff in Emergency Departments but also in General Practice, in Outpatients and in Mental Health Care to meet the needs and co-ordinate the care of those individuals who frequently attended ED. That significant examples of duplication of effort were discovered especially for outpatient referral and communications being disrupted because of the separation of information systems and clinical data barriers, which we believe result in significant inefficiency and duplication of cost in the system. That, despite extensive searching for care plans, these did not appear to be visible in any of the systems and where attempts at this were found, duplication of care plans with no version control was highlighted as an issue. In clinical terms there appear to be three main clusters of patients. One group of patients in which alcohol and mental illness compounded physical conditions particularly arteriopathy and cardio respiratory problems as well as pain syndromes. Secondly patients with indwelling catheters sometimes who also had recent treatment for malignancy and or neuropathy. Thirdly, patients who had drug and alcohol problems which acted as barriers to further referral into mental health in the community and which patient was able to refuse, after yet another ED attendance, any further assistance from their General practitioner when the call was made under the avoidance of admission protocol. Outcomes: There was a major theme that the collaborative work being done in ED involving greater and more acute involvement of psychiatry from West London Mental Health Trust should be further developed across our accountable care partnership, building upon previous work undertaken by the Liaison Psychiatry Services. There was also further discussion that the patient voice should be heard regarding how they would perceive their needs to be met and a subsequent qualitiative piece of work undertaken to interview a subsample of patients. Opportunities for collaborative care planning are being explored to reduce the use of unscheduled care by these patients and to improve identification of these high impact users of emergency services routinely in future.

Extending the liaison psychiatry service in a large hospital in the UK: a before and after evaluation of the economic impact and patient care following ED attendances for self-harm

ObjectivesTo evaluate the impact of an expansion of liaison psychiatry services (LPS) on patient management, outcomes and treatment costs for emergency department (ED) attendances for self-harm.DesignRetrospective before and after cohort...

21 Liaison psychiatry for neuropsychiatrists: experience from the national hospital of neurology and neurosurgery

Objective To evaluate the liaison psychiatry service provided to neurological and neurosurgical patients by the Neuropsychiatry department in a quaternary National Health Service setting. We then sought to improve our liaison processes and to describe the referral characteristics in this population. Method We retrospectively reviewed the electronic referral database for one calendar year. Patient characteristics were recorded from the electronic patient record. This data was used to map referral patterns and re-design our referral system. Follow up data was collected to assess these changes. Results Two hundred and seventy-four patients were referred during the initial 12 month period, resulting in five hundred and four contacts. Most referrals were made by neurologists (78%); surgical referrers made up a very small number (2.5%) and tended to refer acute presentations. The most common diagnosis for non-acute referrals was depression (50%). Functional neurological disorders were the second largest diagnostic category (17%). Pre-operative epilepsy surgical evaluations accounted for 9% of non-acute referrals. Delirium and acute confusional state were the main finding in 35% of acute referrals but psychosis (29%) and agitation (23%) were also commonly represented. Conclusion The neuropsychiatrists at NHNN provide both a general in-patient psychiatric liaison service to a specialised neuroscience population and specialist neuropsychiatric input. Our preliminary results broadly reflect experience in other centres (1). However, we identified data gaps and used these to re-design our referral process. Evaluation of this project will be completed early in 2017 and ww will present this in our final poster. Neurology referrals to a liaison psychiatry service. Fitzgerald, P et al. Ir Med J. 2008

Predictive accuracy of risk scales following self-harm: multicentre, prospective cohort study.

BackgroundScales are widely used in psychiatric assessments following self-harm. Robust evidence for their diagnostic use is lacking.AimsTo evaluate the performance of risk scales (Manchester Self-Harm Rule, ReACT Self-Harm Rule, SAD PERSONS scale, Modified SAD PERSONS scale, Barratt Impulsiveness Scale); and patient and clinician estimates of risk in identifying patients who repeat self-harm within 6 months.MethodA multisite prospective cohort study was conducted of adults aged 18 years and over referred to liaison psychiatry services following self-harm. Scale a priori cut-offs were evaluated using diagnostic accuracy statistics. The area under the curve (AUC) was used to determine optimal cut-offs and compare global accuracy.ResultsIn total, 483 episodes of self-harm were included in the study. The episode-based 6-month repetition rate was 30% (n = 145). Sensitivity ranged from 1% (95% CI 0–5) for the SAD PERSONS scale, to 97% (95% CI 93–99) for the Manchester Self-Harm Rule. Positive predictive values ranged from 13% (95% CI 2–47) for the Modified SAD PERSONS Scale to 47% (95% CI 41–53) for the clinician assessment of risk. The AUC ranged from 0.55 (95% CI 0.50–0.61) for the SAD PERSONS scale to 0.74 (95% CI 0.69–0.79) for the clinician global scale. The remaining scales performed significantly worse than clinician and patient estimates of risk (P<0.001).ConclusionsRisk scales following self-harm have limited clinical utility and may waste valuable resources. Most scales performed no better than clinician or patient ratings of risk. Some performed considerably worse. Positive predictive values were modest. In line with national guidelines, risk scales should not be used to determine patient management or predict self-harm.

Psychopathology of adolescents with an intellectual disability who present to general hospital services.

Adolescents with intellectual disability have increased rates of psychopathology compared with their typically developing peers and present to hospital more frequently for ambulant conditions. The aim of this study is to describe the psychopathology and related characteristics of a sample of adolescents with intellectual disability who presented to general hospital services. We investigated a cohort of adolescents with intellectual disability in South East Queensland, Australia between January 2006 and June 2010. Demographic and clinical data were obtained via mailed questionnaires and from general practice notes. Psychopathology was measured with the Short Form of the Developmental Behaviour Checklist. Of 98 individuals presenting to hospital, 71 (72.5%) had significant levels of psychopathology. Unknown aetiology for the intellectual disability was associated with presence of problem behaviours. Adolescents with more severe intellectual disability were more likely to have major problem behaviours. Co-morbid physical health issues were not associated with psychopathology. Only 12 (12.1%) adolescents had undergone specialized mental health intervention. The general hospital environment may offer opportunities for liaison psychiatry services to screen and provide management expertise for adolescent individuals with intellectual disability presenting for physical health issues.

The age of accountability of consultation liaison, an example from a big referral hospital

CL is a subspecialty in psychiatry and provides a variety of consultation services including diagnosis, therapeutic and teaching efforts of a psychiatrist in none psychiatric units or hospitals.ObjectivesThis is a retrospective descriptive study that evaluated the consultation liaison (CL) psychiatry services in Imam Khomeini hospital, during two recent years.MethodsThe information has been obtained from reviews of medical profiles of patients who attended the hospital.ResultsA total of 681 patients (365 patients were male) received CL services during the study period. The most prevalent diagnosis groups were mood disorder (37.91%), delirium (13.6%) and anxiety (12.64%). Our study revealed that cardiovascular unit, infectious disease unit and general surgery units frequently requested for consultations among all hospital wards. Pediatrics unit had the lowest request rate for psychiatric consultation.ConclusionCL is on the rise in general hospitals, specifically in internal medicine and surgery units which alarm us to pay more attention to preventive strategies focused on the most referred problems including mood disorders, delirium and anxiety disorders in patients who attended general hospitals.Disclosure of interestThe authors have not supplied their declaration of competing interest.

Protecting the incapable–Interdiction of in-patients in centro hospitalar De São João in the last two years

IntroductionThe interdiction of citizens is embodied in the Portuguese civil code and is untouched since 1966 regardless of the profound changes in our society. In 2006, Centro Hospitalar de São João (CHSJ) created protective measures for inpatients that are incapable; the procedure encompasses multidisciplinary evaluation of patients and the elaboration of a final report by liaison psychiatrists.ObjectivesTo describe the interdiction proceedings initiated at CHSJ in the last two years, establishing parallels with our socio-demographical and epidemiological reality.MethodsRetrospective study of the internal requests for psychiatric consultation concerning interdiction proceedings made in the CHSJ from January 2015 to December 2016.ResultsDuring the study period, the liaison psychiatry service received 37 requests for evaluation of patients’ decision-making capacity through the internal consultation system. The typology of the patient targeted in the interdiction process is male, more than 70 years old, hospitalized due to infectious intercurrences whose dependency of others enables him to return to his residence. More than a half (51%) of the requests were performed by internal medicine services. Twenty-one reports declaring the patient's inability to govern his person and property were made. The most common pathology underlying this cognitive impairment was dementia (57%).ConclusionOur results reflect the aging of Portuguese population and the increased prevalence of dementia. The evaluation of the capacity for self-governance will be increasingly required in our clinical practice and demands a holistic approach to the patient while taking into account the preservation of his autonomy, dignity and rights.Disclosure of interestThe authors have not supplied their declaration of competing interest.

Capacity in vacuo: an audit of decision-making capacity assessments in a liaison psychiatry service.

Aims and method We aimed to audit the documentation of decision-making capacity (DMC) assessments by our liaison psychiatry service against the legal criteria set out in the Mental Capacity Act 2005. We audited 3 months split over a 2-year period occurring before, during and after an educational intervention to staff.Results There were 21 assessments of DMC in month 1 (6.9% of all referrals), 27 (9.7%) in month 16, and 24 (6.6%) in month 21. Only during the intervention (month 16) did any meet our gold-standard (n = 2). Severity of consequences of the decision (odds ratio (OR) 24.4) and not agreeing to the intervention (OR = 21.8) were highly likely to result in lacking DMC.Clinical implications Our audit demonstrated that DMC assessments were infrequent and poorly documented, with no effect of our legally focused educational intervention demonstrated. Our findings of factors associated with the outcome of the assessment of DMC confirm the anecdotal beliefs in this area. Clinicians and service leads need to carefully consider how to make the legal model of DMC more meaningful to clinicians when striving to improve documentation of DMC assessments.

Effectiveness of Antipsychotics on Delirium in Elderly Patients

Study background: Delirium is common in older adults, but the pharmacological treatment of delirium in the elderly has not been established. This study aimed to compare the efficacy of three atypical antipsychotics (amisulpride, quetiapine, and risperidone) for the treatment of delirium in patients aged >65 years. Methods: Psychiatrists examined subjects aged >65 years referred to the consultation–liaison psychiatry service for at baseline, day 3, and day 7. Totally, 129 subjects were enrolled and assigned to receive either amisulpride (n=44), quetiapine (n=44), risperidone (n=21), or not to receive any antipsychotic medications (n=20). We examined the efficacy of each medication using the Korean version of the Delirium Rating Scale-Revised-98, which investigates the severity of delirium episodes. We then evaluated the cognitive function of subjects using the Mini-Mental Status Examination. Results: At baseline, no significant differences were found among the four groups with regard to mean Korean version of the Delirium Rating Scale-Revised-98 or Mini-Mental Status Examination scores. In all groups, including the non-antipsychotic group, the Korean version of the Delirium Rating Scale-Revised-98 score decreased and Mini-Mental Status Examination score increased a week after the delirium diagnosis. There were no significant differences in improved Korean version of the Delirium Rating Scale-Revised-98 or Mini-Mental Status Examination scores among these four groups. Conclusion: Compared to subjects taking atypical antipsychotics, subjects not taking any antipsychotic medications equally improved their delirium symptoms and cognition. For hospitalized older adults with acute delirium, the data suggests that atypical antipsychotic treatment is ineffective for improving delirium outcomes.

Where patients on a ward can access Liaison Psychiatry, patients in a 'virtual ward' should too: the Ealing model of integrated care

No health without mental health: Around ½ of acute hospital inpatients suffer from depression, dementia or delirium. When unrecognised / untreated, mental health problems lead to poorer health outcomes and increased length of stay. Estimated cost per year to NHS £13.5bn on extra spending on physical health services.In response to this, NHS England has set an expectation all acute trusts will have in place liaison psychiatry services for all ages appropriate to the size, acuity and specialty of the hospital by 2020.In parallel with these developments, across the country acute care services are being reconfigured to support greater numbers of patients to be treated closer to home, with the development of intermediate care services operating a 'virtual ward', home treatment model.Ealing model of integrated mental health care: In Ealing, West London Mental Health NHS Trust, supported by local commissioners, piloted the integration of liaison psychiatry specialist nurses into intermediate care teams working alongside general nurses, physio and occupational therapists to support the identification, assessment and treatment of mental health comorbidities in patients in this sub-acute setting.Data from pilots in 2013-14 and 2014-15 led to the incorporation of an integrated mental health approach in a newly commissioned integrated intermediate care service, Home ward Ealing, provided by a consortium of health and social care providers, led by the mental health trust.In 2013-14 the mental health worker inputted into the care of 22% patients being seen in intermediate care, and 82% of patients seen said their *care improved* as a result of all HCPs enquiring about their emotional wellbeing. In 2015-16, mental health staff inputted into the care of *38% of all patients in the service*, and saw 18% for face to face intervention. Feedback from patients, carers and referrers was positive.Home ward Ealing: The new fully integrated model of care in the re-specified *Home ward Ealing* service is expected to abolish the exclusion of patients on the basis of mental illness or cognitive impairment and to ensure that patients in intermediate care _virtual_ ward settings have access to the same liaison psychiatry expertise as those in inpatient wards.

Opening the ‘black box’: liaison psychiatry services and what they actually do

Aims and method To develop a simple, pragmatic typology to characterise the nature of liaison interventions delivered by a liaison service in a National Health Service setting. We carried out a retrospective electronic case-note review of referrals to a ward-based liaison psychiatry service.Results Three hundred and forty-four patients were referred to the service over a 12-month period. Ten different types of liaison interventions were identified, with the most common interventions being diagnosis (112 patients, 32.6%), medication management (57 patients, 16.6%), risk assessment and treatment (56 patients, 16.3% each). Mental Health Act work accounted for the greatest number of contacts per patient (median 7).Clinical implications There are inherent limitations in any single-site observational study, as site-specific results cannot be generalised to other liaison services. The intervention categories we developed, however, are easy to use and will provide a way of comparing and benchmarking the range of interventions delivered by different liaison psychiatry services.

Designing services for frequent attenders to the emergency department: a characterisation of this population to inform service design

Frequent attendance to the emergency department (ED) is a growing public health concern. Designing services for frequent attenders poses challenges, given the heterogeneous nature of this group. This was a two-part observational study identifying frequent attenders from ED records. The first stage studied trends and developed personas with emphasis on differentiating moderate frequent attenders (attending between 5 and 20 times per year) and extreme frequent attenders (attending more than 20 times). Stage 2 included a case note review of 100 consecutive frequent attenders. Results showed an increase in frequent attendance from 2.59% to 4.12% over 8years. Moderate frequent attenders accounted for 97%. Of the 100 frequent attenders studied, 45% had medically unexplained symptoms (MUS), associated with younger age (p<0.001) but not with gender (p>0.05). In conclusion, the ED is a useful hub for identifying frequent attenders with MUS, particularly among moderate frequent attenders; service design for this group should consider a 'whole-systems approach' with integration between primary and secondary care, including specialist liaison psychiatry services where appropriate.

Mental Capacity Assessments Among Inpatients Referred to the Consultation-Liaison Psychiatry Unit at a University Hospital in Bangkok, Thailand.

Clinicians routinely assess patients' mental capacity on a daily basis, but a more thorough assessment may be needed in complex cases. We aimed to identify the characteristics of inpatients in a general hospital, who were referred to a liaison psychiatry service for mental capacity assessment, reasons for the referrals, and the factors associated with their mental capacity. A 6-year retrospective study (2008-2013) was conducted using data collected routinely (e.g., age, gender, diagnosis, Thai Mental State Examination score, reasons for the referral, and the outcome of capacity assessment) on referrals for mental capacity assessment to a Consultation-liaison Psychiatry Unit at a university hospital in Thailand. Among 6194 consecutive referrals to the liaison-psychiatry services, only 0.6% [n=37, mean age (SD), 59.83 (20.42)] were referred for capacity assessment, 43.24% of which lacked mental capacity. The most common requests from referring physicians were for assessment of testamentary capacity (15 assessed, 53.33% lacking capacity), financial management capacity (14 assessed, 50% lacking capacity), and capacity to consent to treatment (9 assessed, 22.22% lacking capacity). Delirium, rather than dementia or other mental disorders, was associated with mental incapacity (p<0.001) and being more dependent during the admission (p=0.048). There were no significant differences for mean age (p=0.257) or Thai Mental State Examination score (p=0.206). The main request from referring clinicians was to assess testamentary capacity. Delirium and being more dependent during the admission were associated with lack of mental capacity, whereas age and dementia were not.

Survey of psychiatric assessment rooms in UK emergency departments.

Aims and method We aimed to estimate the proportion of UK emergency departments with a psychiatric assessment room and to determine whether such rooms met criteria for conducting high-risk assessments. Liaison psychiatry services were asked whether their hospital had such a room, whether it met the criteria and whether respondents judged it to be sufficiently safe and private.Results Of the 60 emergency departments included in the survey, 23% had a psychiatric assessment room that met all the safety criteria and was judged to be safe and private. Barriers to the establishment of an appropriate facility included it being a low priority for hospital management, a room being used for other purposes, and balancing safety requirements with the creation of a calming environment.Clinical implications Mental illness is a common reason for presentation to emergency departments. Despite national recommendations, this survey indicates that many departments lack a sufficiently safe and private assessment room, which compromises the safety and privacy of patient care.

Comparison of consultation–liaison psychiatry services for inner-city, district or regional general hospitals using a common tool: Does one size fit all?

ObjectiveConsultation–liaison psychiatry (CLP) services vary in terms of structure, function and responsiveness. It is not known whether evaluation measurements can be meaningfully compared across different CLP services to assess value and efficiency. The aim was to develop and test a common tool for measuring process and outcome measures in CLP. MethodsA data collection tool was developed using the literature and consultation with CLP clinicians. The tool was used to prospectively gather referral data, response times, health utilisation data and functional outcomes for individuals referred over seven months to three different CLP teams, servicing inner city, district and regional areas. ResultsThe structure, staffing, liaison attachments and scope of practice varied between the services. The regional CLP service attended seven hospitals and had the highest referral rate and largest inpatient population pool. The three services received referrals for similar reasons and made similar diagnoses. Multimodal management was the norm, and CLP facilitated follow-up arrangements upon discharge. Only the district CLP service saw all emergency referrals within an hour. Age and need for an interpreter did not affect response times. ConclusionDespite local differences in geography, CLP roles, hospital and community mental health service pathways and patient populations, the CLP data collection tool was applicable across sites. Staff resourcing and referral demand are key determinants of CLP response times.

Current and Future Perspectives of Liaison Psychiatry Services: Relevance for Older People's Care.

A large number of people admitted to medical wards have co-morbid mental health problems, and these predominantly include depression, dementia and delirium. An additional one third of medically ill patients remain in hospitals with undetected and, therefore, undiagnosed mental health problems. The comorbidity of mental and physical illnesses leads to poor health outcomes, prolonged inpatient stays and use of inpatient resources, involvement of various affiliated health services, introduction of medications and discharge to long-term facilities, including residential and nursing 24-h care, increased both readmission rates and mortality. The establishment of Liaison psychiatry services to meet the needs for people with mental health problems admitted to medical wards is a priority for many acute health Trusts. This has an economical background in terms of cost-savings, especially in relation to the older adults, with decreasing readmission rates and quicker hospital discharges. In the current review, we address the latest policies regarding Liaison psychiatry services; especially those for older people with dementia and delirium, and discuss their future shaping.

General hospital inpatients with delirium: A cross-sectional pilot study of patients referred to a consultation liaison psychiatry service

Introduction A significant number of referrals to consultation-liaison psychiatry are for delirium, which is often mistaken for a primary psychiatric illness. Delirium is associated with poor outcomes, particularly when it is not recognised. Aims To identify the rate of missed delirium and the factors associated with it, so as to inform interventions aimed at reducing the proportion of patients whose delirium is missed. Objectives To perform a cross-sectional survey of inpatients referred to a consultation-liaison psychiatry service in a general hospital who have an eventual diagnosis of delirium, in order to determine the proportion of patients with missed delirium and characteristics of such patients. Methods Data was collected retrospectively for a sample of 30 inpatients with delirium who had been referred to a consultation liaison psychiatry service, and analysed for associations with missed delirium. Results Only a third of patients with delirium were accurately diagnosed before referral, and there was a mean delay of about 4 days between delirium onset and psychiatry consultation. Misdiagnosed patients were most commonly thought to have either dementia or a mood disorder. The factors most closely associated with missed delirium were: being of Chinese ethnicity, not having any history of psychiatric problems, not having fluctuations in the mental state, not having agitated behaviour, and being of younger age. None of these associations were statistically significant. Conclusion Two-thirds of patients with delirium in this sample were misdiagnosed before referral. Further study is needed to identify factors which may contribute to missed delirium.

Optimizing the assessment of suicidal behavior: The application of curtailment techniques

BackgroundGiven their length, commonly used scales to assess suicide risk, such as the Beck Scale for Suicide Ideation (SSI) are of limited use as screening tools. In the current study we tested whether deterministic and stochastic curtailment can be applied to shorten the 19-item SSI, without compromising its accuracy. MethodsData from 366 patients, who were seen by a liaison psychiatry service in a general hospital in Scotland after a suicide attempt, were used. Within 24h of admission, the SSI was administered; 15 months later, it was determined whether a patient was re-admitted to a hospital as the result of another suicide attempt. We fitted a Receiver Operating Characteristic curve to derive the best cut-off value of the SSI for predicting future suicidal behavior. Using this cut-off, both deterministic and stochastic curtailment were simulated on the item score patterns of the SSI. ResultsA cut-off value of SSI≥6 provided the best classification accuracy for future suicidal behavior. Using this cut-off, we found that both deterministic and stochastic curtailment reduce the length of the SSI, without reducing the accuracy of the final classification decision. With stochastic curtailment, on average, less than 8 items are needed to assess whether administration of the full-length test will result in an SSI score below or above the cut-off value of 6. LimitationsNew studies using other datasets should re-validate the optimal cut-off for risk of repeated suicidal behavior after being treated in a hospital following an attempt. ConclusionsCurtailment can be used to simplify the assessment of suicidal behavior, and should be considered as an alternative to the full scale.

Thoughts on the development of liaison psychiatry services in London.

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