Using clinical decision support through the electronic medical record to increase prescribing of high-dose parenteral thiamine in hospitalized patients with alcohol use disorder.

BACKGROUND: Patients with alcohol use disorder (AUD) are at an increased risk of developing Wernicke's encephalopathy (WE), a devastating and difficult diagnosis caused by thiamine deficiency. Even as AUD is present in up to 25% of hospitalized patients on medical floors, appropriate thiamine supplementation in the hospital setting remains inadequate. These patients are particularly susceptible to thiamine deficiency and subsequent WE due to both their alcohol use and active medical illnesses. The electronic medical record (EMR) has become ubiquitous in health care systems and can be used as a tool to improve the care of hospitalized patients. METHODS: As a quality improvement initiative, we implemented a medication order panel in the EMR with autopopulated orders for thiamine dosing to increase the appropriate use of high-dose parenteral thiamine (HPT) for hospitalized patients with AUD. We conducted a retrospective cohort study of all inpatients with AUD who received an Addiction Psychiatry Consult Service consult three months before and after the EMR change. We compared the proportion of patients receiving HPT prior to consultation (primary outcome) and the length of stay (secondary outcome) between the historical control group and the EMR intervention group. RESULTS: Patients in the EMR intervention group were significantly more likely to receive HPT than the historical control group (20.2% vs. 2.7%, p < 0.0001). This difference remained statistically significant when adjusted for potential confounders (OR: 9.89, 95% CI: [2.77, 35.34], p = 0.0004). There was a trend towards statistical significance that the intervention group had a higher likelihood of being prescribed any thiamine (76.6% vs. 64.6%, p = 0.06) and had a shorter length of stay (median (IQR): 3.8 (2.4, 7.0) vs. 4.6 (2.9, 7.8) days, p = 0.06). CONCLUSION: These results indicate that providing autopopulated thiamine order panels for patients with AUD can be an effective method for specialty services to increase appropriate care practices without additional education or training for providers. Further research should consider the clinical outcomes of increasing HPT for patients with AUD.

Evidence for Greater Forensic Education of all Psychiatry Residents.

Booth and his colleagues have made an important contribution to the emerging evidence base that shows education in forensic psychiatry topics can improve attitudes toward the field. Given the desinstitutionalization of those with severe mental illness from state psychiatric facilities and the incarceration of many individuals with severe mental illness in correctional facilities, the need to train many more psychiatrists with competence in correctional settings is clear. Simply training more forensic psychiatrists will not both meet the psychiatric needs of incarcerated patients and fulfill the essential roles forensic psychiatrists play in the justice system. Therefore, it is essential that all psychiatry residency programs include time allotted to forensic psychiatry just as time is allotted to the other major subspecialties, including child and adolescent psychiatry, addiction psychiatry, geriatric psychiatry, and psychosomatic medicine. It is likely that the only way to achieve this necessary outcome is through advocacy for the Accreditation Council for Graduate Medical Education (ACGME) to mandate a rotation in forensic psychiatry, for psychiatry residency programs to be accredited.

23 y/o female with dysphagia--Evaluation, intervention and resolution of symptoms in the Psychiatry consultation setting.

Dysphagia is a symptom shared by many medical and psychiatric conditions. A thorough Psychiatric evaluation could rule in a functional or psychological etiology. If a Psychological etiology is identified, a psychodynamic formulation could help the consultation psychiatrist clarify the origin of the symptom and provide a better explanation to the patient and medical team, resulting in improved care by prevention of unnecessary medical interventions, improvement of symptoms and individualization of the treatment.