Enhancing the value of psychiatric consultation

A study of a developing psychiatric consultation service found shortcomings in the amount of experience of those who performed the consultations, in the timing of the consultations (not prompt enough), and in the tone, legibility, and organization of the reports provided by the consultants, as well as in follow-up of patients. Steps to resolve these problems have resulted in increased use of the consultation service and an improvement in the quality of psychiatric referrals.     

Implementation of a psychiatric consultation service: a single-site observational study over a 1-year-period.

This study describes changes in consultation process variables and referral patterns after implementation of a psychiatric consultation service at a university hospital in Germany. Two hundred eighty consecutive medical-surgical inpatient referrals for psychiatric consultation during a 1-year period were documented prospectively with a structured database. Changes took place in referral patterns and in psychiatric interventions and recommendations but not in psychiatric diagnoses. In addition, information is given on psychiatric and psychosomatic consultation service delivery in Germany.     

某三级甲等综合医院住院患者精神科会诊3年资料分析

目的:了解某三级甲等综合医院精神/心理服务需求的特点。方法:汇总某三甲综合医院2006年7月1日-2009年6月30日期间所有经心理医学科会诊的患者共2082例次,分析会诊率、会诊科室、会诊原因、精神科诊断及随诊情况。结果:3年来会诊率由1.01%升至1.48%,随诊率为15.77%。重症监护病房会诊率最高(4.77%),特需科室随诊比例最高(27.04%)。占1%以上的邀请会诊原因有10类,其中"目前情绪症状"最多,占28.4%。精神科诊断以"神经症性、应激性障碍及焦虑状态"为主,占44.2%,诊断为躯体形式障碍及医学不能解释的症状(Medical Unexplained symptoms,MUS)的患者随诊比例最高,达26.6%。结论:综合医院对精神/心理服务的需求全面,精神专科应提供全面深入、特点突出的会诊联络服务。     

A randomised controlled trial of joint consultations with general practitioners and cardiologists in primary care.

BACKGROUND: Joint consultation sessions of a small group of general practitioners (GPs) and a specialist in orthopaedics proved to be an effective way of decreasing the referral rate of orthopaedic patients. Cardiac complaints comprise an important category of health problems with high referral rates. AIMS: To study the effects of joint consultation on the quality of care and referrals for patients with cardiac complaints. DESIGN OF STUDY: Randomised controlled trial. SETTING: Forty-nine GPs participated in 16 consultation groups, each with one of 13 cardiologists, in monthly joint consultations over a period of about 18 months. METHOD: The GPs selected patients about whom they were uncertain, and those needing urgent referral were excluded. Patients were randomly assigned to joint consultation or to usual care. After a follow-up period all patients had a joint consultation for outcome assessment. Referral data were provided by two regional health insurance companies and questionnaires were given to the patients, GPs, and cardiologists to gauge their opinion of the trial. RESULTS: One hundred and forty-eight patients in the intervention group and 158 patients in the control group fulfilled the whole protocol. The quality of care was similar in both groups. In the intervention group, 34% of the patients were referred, compared with 55% in the control group (P = 0.001), and fewer patients underwent further diagnostic procedures (7% compared with 16%, P = 0.013). Referrals to cardiology as a proportion of all referrals decreased in the practices of the participating GPs, compared with their reference districts (P = 0.024). CONCLUSION: Joint consultation is an effective method that provides a quality of care that at least equals usual care and that contributes to a better selection of patients who need specialist care.     

Characteristics of patients referred to psychiatrists for competency evaluations

Requests for inpatient psychiatric consultations at a general hospital over a three-year period were reviewed. Of 2,423 referrals, 79 (3.3%) were specifically for evaluation of competency, and 78.5% of those cases resulted in a diagnosis of an organic mental disorder. The proportion of referrals with organic mental disorder was significantly greater than it was in a control population of patients referred for consultation for any reason. Patients with organic mental disorder who were referred for competency evaluation had greater cognitive impairment than did control subjects.     

Outcome of general practitioner referrals to specialist outpatient clinics for back pain.

In 1983-84 general practitioners in the Oxford region kept records of their referrals to outpatient clinics over a period of six months. Five years later in 1988-89 the general practice notes of 182 patients referred for back pain were studied to determine the outcomes of their referral. The actions initiated in the outpatient clinics were compared with the general practitioners' main reason for referral recorded at the time of referral. Of the 182 patients 136 (74.7%) received specialist treatment following the outpatient referral despite the fact that general practitioners had given treatment as the main reason for referral in only 28.6% of cases. Patients' mean consultation rate for back pain declined from 4.2 consultations per annum to 0.9 (P less than 0.001) over the five year period, but there was a small but significant increase in consultations for other problems. Five years after the referral 33.3% of patients were still consulting their general practitioner for back pain. The referral system for patients with chronic back pain could be rationalized to reduce the need for re-referrals and multiple follow-up outpatient consultations. There is a need to improve communications between general practitioners, specialists and patients about the purpose of referral, the likely effects of treatment and the scope for prevention. A survey of the outcome of referrals for common conditions, such as back pain, is a useful first step in the development of referral guidelines.     

Inpatient consultation of allergy/immunology in a tertiary care setting.

BACKGROUND: Few studies examine the referral patterns for allergy/immunology (A/I) inpatient consultation. OBJECTIVE: The purpose of this study was to examine the primary reason and trends for A/I inpatient consultation to improve fellowship training. METHODS: We performed a retrospective chart review of all inpatient A/I consults from July 1, 1987 to June 30, 2001 to determine the primary reason for consultation. We also reviewed trends in the total admissions and the average daily patient load compared with A/I consultation. RESULTS: A total of 1,284 A/I inpatient consults were reviewed. Thirty-six percent (460 of 1,284) of inpatient consults were for evaluation of adverse drug reactions, 21% (270 of 1,284) asthma, 21% (272 of 1,284) miscellaneous reasons, 8% (109 of 1,284) possible immunodeficiency, 7% (93 of 1,284) angioedema/urticaria, and 6% (80 of 1,284) anaphylaxis. Our results demonstrated a fall in inpatient consults that correlated with a similar fall in total hospital admissions. The ratio of A/I inpatient consults to total admissions remained constant. Additionally, the ratio of A/I consults to average daily patient load increased over the study period. There was a decrease in asthma and adverse drug reaction consults, whereas immunodeficiency and anaphylaxis referrals remained stable. CONCLUSIONS: Identifying the most common reasons for inpatient consultation provides a guide for the education of A/I fellows and primary care residents. Inpatient consultation continues to play a crucial role in A/I training as it provides unique opportunities to evaluate serious life threatening diseases. An unchanged trend of consultation for immunodeficiency and anaphylaxis reaffirms the importance of the allergist/immunologist as a valuable resource for inpatient consultation.     

Rectal and postmenopausal bleeding: consultation and referral of patients with and without severe mental health problems

BACKGROUND: People with severe mental health problems receive less effective care for some physical conditions. There is concern that this could apply to rectal bleeding or postmenopausal bleeding. Published estimates of consultation rates and outcomes for these symptoms vary widely. AIM: To estimate rates of first-ever consultation for rectal bleeding and postmenopausal bleeding in general practice, together with subsequent referrals and outcomes. To identify inequalities for patients with severe mental health problems. DESIGN OF STUDY: Cohort study. SETTING: Primary care. METHOD: Patients with first-ever consultations for rectal or postmenopausal bleeding were identified among more than 3 million patients from 328 practices contributing routine data to the QRESEARCH database. Their records were followed for 2 years. RESULTS: There were 30 175 first consultations for rectal bleeding (2.6 per thousand patients per year at age 25-29 years, rising to 4.8 over age 85 years) and 10 142 for postmenopausal bleeding (highest at 7.4 per thousand per year aged 55-59 years). Overall, 2.2% of those with rectal bleeding and 1.7% of those with postmenopausal bleeding went on to have a relevant cancer diagnosis within 2 years. Cancer risk was strongly related to age, and was higher for males with rectal bleeding than females with rectal bleeding. Recorded referrals were at similar rates among patients with and without severe mental health problems. CONCLUSION: The rate of first consultations for rectal bleeding or postmenopausal bleeding is relatively low. Less than 2.5% overall have a relevant cancer diagnosis within 2 years. There is no evidence of inequality in referral for patients with severe mental health problems.     

Contribution of consultants to care of compromised pregnancies.

Obstetricians often seek consultative services of other specialists in the management of compromised pregnancies. However, the extent of such consultations and the contribution of these consultants have not been addressed in the literature. This study is addresses the contribution of consultants to the care of complicated pregnancies at a tertiary care center. During the 2 1/2 years of this retrospective study, 2263 antepartum admissions were made for pregnancy complications. One hundred sixty-six of those patients were hospitalized 176 times and were treated by one or more consulting physicians for a consultation rate of 7.8%. Eighteen specialties were consulted, including 54 (32%) consultations from maternal fetal medicine, 44 (24%) from internal medicine, 28 (16%) from general surgery, and 22 (12%) from endocrinology. Of the initial admission diagnoses, 87.9% were confirmed and 46 new diagnoses were made by the consultants. A significant positive correlation was noted between the number of consultants, maternal length of hospital stay, and maternal hospitalization cost.     

Impact of inpatient diabetes transitions of care consult on glycemic control

Objective(s)An evaluation of a diabetes consult service for hospitalized patients was completed to determine effect on glycemic control.MethodsThis medical record review was conducted to determine impact of a short-term program on patients with diabetes. The electronic medical record was used to identify patients diagnosed with diabetes mellitus and hospitalized from September 2016 to September 2017. A case-control design was utilized to compare patients with an inpatient order for the diabetes transitions of care service to those receiving usual care. The consultation service consisted of inpatient diabetes education and follow-up post discharge. The HbA1c reduction of adult inpatients those who completed a consult (n = 67) and those who received usual care (n = 67) were compared. Statistical analyses were conducted.ResultsFor the primary outcome of HbA1c reduction at 3 months, absolute difference from baseline to 3 months in the intervention was -2.9 % compared to 0.9 % in the control group (p < 0.001).ConclusionsParticipation in the service reduced HbA1c at 3 months and 6 months post-discharge, reduced 30-day all-cause readmissions, and increased percentage of patients with HbA1c <9.0 % at 6 months post-discharge.Practical implicationsA consult-based diabetes transitions of care service decreased HbA1c versus usual care.     

Barriers engaging families and GPs in childhood weight management strategies

Background

The rapid increase in the prevalence of childhood obesity in recent years has led to inconclusive debate about the most effective way to manage the condition and the most appropriate care setting. Primary care has been suggested as a key site to identify and treat obesity in children.

Aim

To identify children from general practice databases with a body mass index (BMI) categorised as ‘obese’, and invite them for a primary care consultation and possible referral to a specialist secondary care clinic.

Design and setting

Targeted screening of GP practice databases for obese children in 12 general practices in Bristol, UK.

Method

Participating GP practices searched databases for children''s BMIs which were then screened by the study team to identify obese children (≥98th centile). Practices invited families of obese children to consult their GP with the potential for referral to a specialist clinic. Follow-up data was recorded with respect to: consultations; consultations about child''s weight; and referrals to specialist clinic; and other referrals.

Results

A total of 285 letters inviting families to consult their GP were sent; 134 patients consulted their GP in the follow-up period (minimum 3 months), and 42 of these consultations discussed the child''s weight. Nineteen patients received a secondary care referral and six received an alternative weight-management referral.

Conclusion

The low take-up following the mail-out of an invitation to consult highlights the inherent difficulties of engaging families and their obese children in care pathways that facilitate long-term weight management.     

Telemedicine-a complement to traditional referrals in oral medicine

Abstract Introduction: Introducing telemedicine into clinical practice has not been without difficulties. Within the framework of the European Union project "Health Optimum," telemedicine consultations with specialists at the Department of Oral & Maxillofacial Surgery at Uppsala University Hospital (Uppsala, Sweden) have been offered to dentists in the public dental health service. The aim is to streamline the consultation process, improve/develop the skills of the participating dentists and dental hygienists, and save time and money for patients, healthcare authorities, and society. Subjects and Methods: Patient records are collected in a database for demonstration and discussion, and the system is also available for referrals. Both medical and dental photographs and x-rays are digitized in the same system. These can be viewed during telemedicine rounds and by the consultants at the hospital prior to a consultation. Secure, interactive conferencing software is used, which provides a quick, easy, and effective way to share video and data over the Internet. Both parties can demonstrate different parts of an image using a pointer or a drawing system. Conference phones are presently used for verbal communication. Results: Ten patients were discussed during telemedicine rounds (3 males and 7 females), all of whom would normally have been referred to a specialist. As a result of the telemedicine round, 2 were referred to a specialist, whereas diagnoses were made for the other 8, and treatment was suggested. The dental health clinic could thus provide treatment without the need for referral to a consultant. Conclusions: The telemedicine system described here allows patient care to be provided rapidly and more economically. Future plans include "live" rounds using a videocamera, providing the possibility to relay real-time information about the intraoral situation. A camera is being developed and should preferably be permanently installed chair side.     

Internet Consultations from a Remote Pacific Island: Impact of Digitized Radiologic Images on Referral Decisions

A study was carried out to determine whether digitized radiologic images added valuable information to Internet consultations from a remote Pacific Island. Chuuk State Hospital (Federated States of Micronesia) has limited film screen radiology, minimal ultrasound capability, and no radiologist. Providers initiate Web-based referrals for consultation or patient transfer. Digitized images (via low-cost digital camera or flatbed scanner) were uploaded to a Web site. Images were assessed for impact on referral decisions. A radiologist scored image quality and confidence (scale: 1–7). Of 97 referrals with images that were reviewed, 74 (76%) image sets were abnormal, 20 (20%) were normal, and 3 (4%) were indeterminate. Median scores were 4 for image quality and 5 for diagnostic confidence. In most cases with abnormal radiology (52/74, 70%), images were considered valuable. Radiologic images digitized with a low-cost camera or flatbed scanner provided valuable information for decision making in an Internet-based consultation and referral process from a remote, impoverished Pacific Island jurisdiction, despite relatively low image quality.The views expressed herein are those of the authors and do not reflect the official policy of the Department of the Army, Department of Defense, or the US Government.     

Pulmonary telemedicine--a model to access the subspecialist services in underserved rural areas

Background

To describe the use of videoconference telemedicine for providing outpatient pulmonary consultation to a remote, underserved clinic site.

Methods

Analysis of data from the Milwaukee Veteran Affairs Medical Center (VAMC) pulmonary telemedicine clinic. Pulmonary physicians at the Milwaukee VAMC provide outpatient consultations with the use of videoconference technology to patients located at the Iron Mountain VAMC in Iron Mountain, MI (346 km or 215 miles from Milwaukee). Data on demographics, referral patterns, access to care, consultation process, and outcomes are presented.

Results

A total of 314 patients (684 visits) received telemedicine consultations between January 1, 1998 and December 31, 2004. Common reasons for referral were abnormal radiology (38%), chronic obstructive pulmonary disease (COPD) (26%), and dyspnea (13%). Physical exam was performed by the telemedicine registered nurse or respiratory therapists in 90% of visits. Common diagnoses were COPD (29%), benign pulmonary nodule (11%), bronchial asthma (6%), and lung cancer (6%). Telemedicine consultation resulted in a change in management for 41% of patients. Only 8% of patients required an in-person clinic visit at Milwaukee VAMC following a telemedicine visit. Telemedicine saved patients 473,340 km or 294,120 miles of travel over the study period.

Conclusions

The provision of subspecialty services using telemedicine to a remote underserved rural population provides improved patient access to subspecialty care. Physicians are able to rely on medical history and radiology to manage patients across a broad spectrum of complex pulmonary conditions with the assistance of a non-physician health care provider at the remote site.     

Community consultation following a major air disaster

United Airlines flight 232 crashed at Sioux City, Iowa, on July 19, 1989. The primary rescue workers were the men and women from the 185th Air National Guard Group. Because of the many deaths and massive destruction caused by the crash, a psychiatric consultation team was requested by the U.S. Air Force Surgeon General to assist the Air National Guard personnel. The consultation had four goals: (1) provide consultation to the Air National Guard on the mental health of the community; (2) provide direct psychiatric services on an acute basis and referral for follow-up care, if necessary; (3) train mental health personnel as consultants following disasters; and (4) develop and implement a research plan that would address both the immediate and long-term health consequences of the rescue work. The consultation included community-oriented interventions directed toward reducing the effects of psychological stress on high-risk groups. This paper describes the consultations and the 1-year follow-up.     

How well do nurse-run telephone consultations and consultations in the surgery agree? Experience in Swedish primary health care.

The telephone consultation service is an important part of Swedish primary health care. However, few studies have compared telephone consultations managed by nurses with surgery consultations managed by both doctors and nurses in terms of information obtained from the patient regarding his or her symptoms, and the management decisions made. In this study, the information obtained from a patient during a telephone consultation with a health centre nurse and the management decisions made, were compared with those obtained at a subsequent surgery consultation with the same nurse, and then with a doctor. Of 200 telephone consultations at a health centre (50 in each of the following four categories as defined by the management decision of the nurse: acute case, semi-acute case, referral case and self-care case), 193 patients were included in the study. The information given to the nurse during the telephone consultation was recorded. The patient was then asked to come for a surgery consultation on the same day, first with the same nurse and then with a general practitioner. A comparison was made between the information obtained and the decisions taken in these three situations. In 185 of the 193 cases (96%) the information led to the same management decision by the nurse, in both the telephone consultation and later in the surgery consultation. In all cases the same history was recorded by the nurse during the telephone and surgery consultations as by the general practitioner. This indicates that in most cases little or no information is missed in a telephone consultation with a nurse as compared with a surgery consultation with a nurse or doctor.(ABSTRACT TRUNCATED AT 250 WORDS)     

The comparative impact of video-consultation on neurosurgical health services

This study evaluated the impact of telemedicine technology on the provision of neurosurgical health services. We focused on the differences between the use of real time audio-visual teleconferencing and teleradiology versus conventional telephone consultations in the referral of neurosurgical patients from a large district general hospital. All patients requiring emergency neurosurgical consultation were included for randomization into telephone consultation only (Mode A), teleradiology and telephone consultation (Mode B) and video-consultation (Mode C). Measures of effectiveness included diagnostic accuracy and adverse events during the transfer and Glasgow Outcome Score. In a 10-month period, 327 patients were recruited and randomized into the study: the male/female ratio was 2:1 and the number of patients required to be transferred to the neurosurgical unit was 125 (38%). There was a trend towards a more favourable outcome in the video-consultation mode (44%, Mode C), versus teleradiology (31%, Mode B), versus telephone consultation (38%, Mode A). The interim data of this prospective randomized trial suggests that video-consultation may have a favourable impact on emergency neurosurgical consultations.     

Racial Patterns in Liaison Psychiatry

A study of 362 consecutive psychiatric referals from the general medical and surgical wards of a university hospital serving a large nonwhite community revealed an association between provision of active liaison and a higher rate of referral for whites than nonwhites. Once referral was made, however, there was no evidence of substantial bias in the consultation process with regard to reason for referral, diagnosis, or recommendations. The findings suggest the need for more systematic studies of need and demand for psychiatric care among nonpsychiatric inpatients, with special emphasis on racial patterns.     

Comparing virtual consults to traditional consults using an electronic health record: an observational case¿control study

ABSTRACT: BACKGROUND: Patients have typically received health care through face-to-face encounters. However, expansion of electronic communication and electronic health records (EHRs) provide alternative means for patient and physicians to interact. Electronic consultations may complement regular healthcare by providing "better, faster, cheaper" processes for diagnosing, treating, and monitoring health conditions. Virtual consultation between physicians may provide a method of streamlining care, potentially saving patients the time and expense of added visits. The purpose of this study was to compare physician usage and patient satisfaction with virtual consultations (VCs) with traditional consultations (TCs) facilitated within an EHR. METHODS: We conducted an observational case-control survey study within Kaiser Permanente, Colorado. A sample of patients who had VC requests (N=270) were matched with patients who had TC requests (N=270) by patient age, gender, reason for the consult, and specialty department. These patients (VC and TC), were invited to participate in a satisfaction survey. In addition, 205 primary care physicians who submitted a VC or TC were surveyed. RESULTS: During the study period, 58,146 VC or TC were requested (TC = 96.3%). Patients who completed a satisfaction survey (268 out of 540 patients, 49.6% response rate) indicated they were satisfied with their care, irrespective of the kind of consult (mean 10-point Likert score of 8.5). 88 of 205 primary care physicians surveyed (42.9%) returned at least one survey; VC and TC survey response rates and consulted departments were comparable (p = 0.13). More TCs than VCs requested transfer of patient care (p=0.03), assistance with diagnosis (p = 0.04) or initiating treatment (p =0.04). Within 3 weeks of the consultation request, 72.1% of respondents reported receiving information from VCs, compared with 33.9% of the TCs (p < 0.001). Utility of information provided by consultants and satisfaction with consultations did not differ between VCs and TCs. CONCLUSIONS: Referring physicians received information from consultants more quickly from VCs compared with TCs, but the value and application of information from both types of consultations were similar. VCs may decrease the need for face-to-face specialty encounters without a decrease in the patient's perception of care.     

Inpatient dermatological consultations in a university hospital

INTRODUCTION:

Dermatology is primarily an outpatient specialty, but it also plays an important role in the care of inpatients.

METHODS:

We conducted a prospective study that recorded data from inpatient dermatology consultation request forms over a period of four months. The study evaluated 313 requests that led to 566 visits, 86 biopsies, 35 laboratory exams, 41 direct microscopic studies, 18 direct immunofluorescence analyses, 14 skin cultures and a few other exams.

RESULTS:

The most frequent requesting service was internal medicine (24%), followed by neurology (12%), cardiology (11%), infectious diseases and pediatrics (8% each) and psychiatry and general surgery (6% each). The most frequent diagnostic groups were infectious diseases (25%, divided into fungal infections (13%), bacterial infections (7%) and viral infections (5%)), eczemas (15%) and drug reactions (14%). To our knowledge, this is the first study to attempt to evaluate the impact of the consultations by asking multiple‐choice questions that were analyzed by the authors. In 31% of the cases, the consultation was considered extremely relevant because it aided in managing the disease that led to admission or treated a potentially severe dermatological disease. In 58% of the cases, the consultation was considered important because it facilitated diagnosis and/or treatment of a dermatological disease that was unrelated to the reason for admission.