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。     

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.     

General practitioner referral to specialist psychiatric services: a comparison of practices in north- and south-Verona

Specialist psychiatric services run by the Italian National Health Service are mainly hospital-based in North-Verona and community-based in South-Verona. Ninety-two GPs from both areas participated in a one-day survey of their provision of psychiatric care, and this paper focuses on socio-demographic and clinical variables associated with specialist psychiatric referral. The one-day prevalence figure for GP referral to specialist psychiatric services was 7.3% (17.6/10,000): the figures did not differ between the sexes or between the two areas. Whereas in North-Verona 49% of the patients referred were sent to the two local hospital-based public services and 51% to other agencies (mainly to private psychiatrists), in South-Verona 71% of referrals were to the community-based public service. Log-linear analysis showed that past psychiatric history, psychological presenting complaint, social problems and GPs' psychiatric diagnosis exerted positive joint main effects on GP referral to specialist psychiatric services, and that diagnosed organic illness had a negative effect in this regard. In the presence of a psychological complaint, a psychiatric diagnosis proved to be quite unimportant, so that those without a psychiatric diagnosis were just as likely to be referred as those with one. However, in the absence of a psychological complaint a GP diagnosis of depression greatly increased the risk of referral. Though the type of psychiatric service proved not to be an important determinant of GP referral to specialist psychiatric services it influenced the GPs' choice of referral agency.     

Misdiagnosed delirium in patient referrals to a university-based hospital psychiatry department

The authors examined the factors associated with referral errors in which the presence of delirium was ostensibly not recognized by medical staff personnel. Medical records of 541 university-hospital patients consecutively referred for psychiatric consultation were scrutinized for extant delirium. The data indicated that a greater likelihood of a missed diagnosis was associated with younger age; referrals outside of family practice service; orientation as to person, place, and time; and a history of bipolar affective disorder or psychosis. The ramifications of failure to diagnose existing delirium include increased morbidity and mortality, longer length of hospital stay, and increased healthcare costs.     

Community psychiatric nursing: a survey of patients and problems

The work of a community psychiatric nursing service for acute psychiatric conditions was reviewed for the period 1980-82. Five community psychiatric nurses operated in 10 health centres. General practitioners were the most frequent users of the service and a wide range of psychiatric problems were encountered. The age structure of all referrals was found to be significantly related to sex, with the proportion of females in all age groups at least twice that for males. The most frequent reason for referral was mood/affect disturbance; female patients referred for the first time were predominant. Over half of all problems resolved within three months of referral and a limited number of patients were sent for further psychiatric investigation.     

Characteristics of obstetrical inpatients referred to a consultation-liaison psychiatry service in a tertiary-level university hospital

A review of psychiatric consult notes of 96 obstetric inpatients referred to a Consultation-Liaison (C-L) psychiatry service in a tertiary-level university general hospital was carried out in order to compare the characteristics of such a service in a North American setting with similar services in other parts of the world. Data extracted from consult notes included: reason for referral, current diagnosis (DSM-IV-R), psychiatric history, obstetrical history, recommended treatment approaches, current psychotropic medications, current gestational age or number of days postpartum, patient age, and partnership status. In addition, obstetrical referrals were calculated as a percentage of hospital-wide referrals to C-L psychiatry. The most prominent findings include: (1) a high C-L psychiatry referral rate from obstetrics as a percentage of total C-L referrals within the study hospital; (2) past psychiatric history alone as a prevalent reason for referral; (3) adverse reproductive event (past and/or current) as a common reason for referral. These findings differ markedly in certain ways from comparable studies and may reflect both the hospital’s large high-risk pregnancy service that represents an at-risk group for mental health issues, and the focus on educational collaboration with obstetrical staff regarding risk factors for, and consequences of, perinatal mental illness. Inpatient perinatal C-L psychiatric services require creative approaches to the accurate identification and treatment of women at risk for antenatal and postpartum mental illness due to psychiatric history and/or reproductive crises.     

Survey of a Royal Air Force practice in Germany

Throughout 1974 records were kept of all patients seen by the medical staff at Royal Air Force Bruggen, an RAF Station in Germany. Full details of patients and diagnoses were recorded and an analysis was made of the patterns of consultation and morbidity. The method of storing and analysis the information on punched cards is discussed, and the results are compared with service and civilian general practice in the UK and abroad.     

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.     

Consultation/liaison psychiatry utilization patterns in different cultural groups.

This study examined the effect of cross-cultural factors on psychiatric consultations in a general hospital. Using a retrospective case review, 476 patients receiving a psychiatric consultation were contrasted with 14,620 who did not receive a psychiatric consultation. The rate of psychiatric referral was lower for Hispanics compared with Anglos, blacks, and Asians (p less than 0.001). The reason for requesting psychiatric consultation was also different across the ethnic groups. There were more requests for evaluation of depression and suicide in Hispanics and fewer such requests in blacks. More requests for evaluation of grossly abnormal mental status were found in blacks. The different cultural groups also had differences in psychiatric diagnosis. Hispanics were more frequently diagnosed with an adjustment disorder; blacks were more frequently diagnosed with a primary thought disorder and delirium; and Anglos were more frequently diagnosed with dementia.     

Geriatric psychiatry patients' care by primary care physicians

Primary care physicians were surveyed regarding their perceptions from recall of psychiatric disorders in, and their use of treatment approaches for, their geriatric patients. Affective disorders, organic mental syndrome, and generalized anxiety disorders were the three most common problems reported, and they were felt to be among the three most common problems by 89%, 56%, and 39% of the physicians, respectively. The three most common disorders for which they sought psychiatric consultation or referral were affective disorders, "psychosis," and organic mental syndrome, by 61%, 22%, and 18% of the respondents. The use of various psychiatric treatments and various sources of consultation and referral are analyzed and reported by age, primary care specialty, and practice setting of responding physicians.     

Cumulated need for psychiatric service as shown in a community psychiatric project

District psychiatric services often supplement intramural mental health programmes. They usually result in an increase in the number of referrals to the mental health facilities, which reflects a cumulative need for psychiatric examination and treatment in the population. A significant decrease in the annual first referral rates per 1000 inhabitants aged 15 years and above is apparent in an analysis of the trends in the Danish Sams? community psychiatric service from its inception in 1957 until 1982. The average annual rates were 19.4 in the first 5-year period, 10.0 in the second 5-year period, and 8.4 in the 'steady state period' from 1967 to 1982. The conclusion is, therefore, that the work load connected with the cumulative need for psychiatric examination and treatment should be terminated in approximately 10 years. A comparison of the two 5-year periods, 1957-61 and 1978-82, demonstrated a decrease in first referral rates in almost all diagnostic groups: this is significant among manic-depressive psychoses, neurotic states and unspecified mental disorders. The rates of no mental disorders and senile and arteriosclerotic psychoses were almost unchanged. In the 10-year age groups there was a decrease in first referral rates for all groups, except for the groups aged 75 years and above whose rates were unchanged. The concept of cumulative need for psychiatric examination and treatment is discussed in relation to the reports of various district psychiatric service programmes in different European countries.     

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.     

The mortality of delirium: An underappreciated problem?

The author reviewed 116 charts of medical-surgical inpatients evaluated by a university hospital psychiatric consultation service. Five of 15 consultation patients with delirium died within three months after the consultation, whereas only one of 43 depressed patients died. Neither consultees nor psychiatric consultants usually considered patient prognosis, according to chart notations. Mortality associated with delirium may be underappreciated in the assessment of delirious patients.     

Utilization of a consultation liaison psychiatry service in a general hospital

This retrospective study was conducted in response to a need to evaluate the overall utilization rates of the psychiatric consultation liaison service by nonpsychiatric units within Howard University Hospital, which deals almost exclusively with a black, inner-city population. The study covers a three-year period (July 1982 to July 1985). During this time only 815 patients (2 percent) were referred for psychiatric evaluation out of the total number of hospital admissions (40,000 patients).     

A prospective analysis of inpatient consultations to a gastroenterology service

The provision of a formal consultation service for inpatients between subspecialists is little studied. We prospectively surveyed the pattern of inpatient consultations from hospital-based generalists and surgeons to the gastroenterology (GI) service for inpatients in a large urban teaching hospital over a 5 month period. There are two GI consultants/attendings and five GI registrars/fellows on the service. A formal consultation is made by the requesting team to the GI service using the hospital computer network. All referrals over a 5 month period were prospectively analysed. 242 consecutive inpatient referrals were sent to the GI service over 5 months. Average age was 56 years, 48.8% males. 32 consultants/attendings from other disciplines sent referrals. Most patients were seen within one working day. Urgent referrals were seen without delay. The commonest reasons for referral were abdominal pain (15.8%), percutaneous endoscopic gastrostomy (PEG) tube insertion (13.6%), diarrhoea (12.8%), abnormal liver blood tests (10%), nausea and vomiting (8.2%), anaemia (6.2%), and melaena (4.9%). Iatrogenic diseases accounted for 6.2% of consultations. Ongoing patient care was assumed by the GI team in 9.5% of referrals. 15.3% required a second consultation visit before discharge. 22.7% of referrals were followed in the GI outpatients' clinic after discharge. 51.2% underwent an endoscopic procedure. 13.6% of referrals were for PEG tube insertion. A quarter of these were considered unsuitable for immediate PEG tube insertion. Subspecialty consultation provides an expert opinion, encourages discussion and learning, and improves patient care. In our experience, the provision of specialist advice and reassurance often speeded up a patient's work-up and expedited discharge. However, evaluating referral patients and subsequently providing ongoing inpatient and outpatient care and provision of endoscopy for these referrals contributes significantly to the workload of the GI service.     

Domiciliary consultation — who benefits?

A survey was conducted of the domiciliary consultation service provided in one health district in order to identify the pattern of referral by specialty, the reasons for the consultation and its outcome and to determine whether the service is realizing its original objectives.

The district domiciliary consultation service was used in the majority of cases as an initial means of assessment for elderly patients with chronic disease. The majority of patients were kept out of hospital but responsibility for their care was usually transferred to the consultant. The domiciliary consultation service was rarely used as a means for joint consultation between family doctor and hospital specialist. To facilitate the care of patients in the community, it is suggested that domiciliary visiting should be incorporated into a consultant's NHS contract and the present regulations abandoned.

     

Consultation-liaison: a patient-based overview.

As the consulting psychiatrist and his or her fellow physicians come to know each other better, their interaction when offering comprehensive patient care becomes increasingly effective. This report is an overview of consecutive psychiatric consultations in a busy general hospital. In addition, the authors speculate about the components of an effective consultation liaison service.     

Improving psychiatric consultation to nonpsychiatrist physicians

Nonpsychiatrist physicians were surveyed regarding problems that they had experienced when seeking a psychiatric consultation or treatment referral. They gave three main reasons for not referring more patients to psychiatrists: a belief that other mental health professionals could do as well at less cost, that psychiatrists were less available to discuss patients, and that greater stigma was attached to seeing a psychiatrist than seeing other mental health professionals. Psychiatrists might improve their consultation and referral networks by addressing the misperceptions of their nonpsychiatrist physician colleagues.     

The role of the nurse on a consultation-liaison team

The authors report on the role and functions of a nurse-consultant on an expanding psychiatric consultation-liaison service. One hundred consecutive requests for intervention by a nurse were compared with 100 consecutive requests for psychiatric intervention. Psychiatrists saw 3½ times as many patients on critical care units as did the nurse-consultant. Patient withdrawal and depression were the prime reasons stated for requesting consultation with the nurse, but 24% of the cases seen by the nurse focused on issues of death and dying or on the need for staff or family support, areas in which formal psychiatric intervention was not routinely requested.     

Factors affecting the relationship between the timing of psychiatric consultation and general hospital length of stay

The purpose of this study was to examine the factors affecting the timing of psychiatric consultations and length of stay in the current managed care era. It also assessed the relationships between the timing of consultations and demographic/clinical characteristics. Medical records of 541 consecutive psychiatric consultation patients at a university teaching hospital in 2001 were reviewed for demographic characteristics, lengths of stay, number of days from admission to consultation, specialty services requesting consultations, reasons for the referral given by the referring physicians, and all five axes of DSM-IV. Earlier consultations independently predicted shorter lengths of stay. Delayed consultations were seen more often in women; surgical patients; those seen with a request to assess depression; and those seen with a diagnosis of adjustment disorder, delirium, or no psychiatric disorder. Delay in psychiatric consultations continues to be associated with longer lengths of stay in the current managed care environment. It is now possible that early detection strategies for high-risk patients with behavioral health problems in the medical setting, such as use of the INTERMED, may lead to reduction in delayed psychiatric consultations and thus shorter lengths of stay.