Evidence of practice gaps in emergency psychiatric care for borderline personality disorder: how can this be explained?

BACKGROUND: Recent research has highlighted that patients with borderline personality disorder (BPD) could experience symptomatic remissions. This led to the production of guidelines concerning the most appropriate care. In addition, as BPD patients frequently present at an emergency department (ED), specific recommendations concerning how they should be cared for there have also been developed. The recommendations include the referral of patients to inpatient, outpatient or specific crisis care. However, an issue that has not been addressed is the capacity of ED services to apply the care recommendations. The objective of our study, therefore, was to identify the factors limiting their use in the ED of Toulouse University Hospital. METHODS: A panel of psychiatrists specializing in BPD care examined the medical files of 298 patients with a BPD diagnosis to determine which referrals were consistent or not, according to the care recommendations. A logistic regression was then performed to identify which sociodemographic, clinical, organizational or professional-training factors were associated with inconsistent referrals. RESULTS: 32% of patients experienced an inconsistent referral. Consultations performed during an on-call or day-off schedule were linked with inconsistent referrals, while an active follow-up was associated with the provision of consistent care. CONCLUSION: Changing how evaluations of BPD patients in the ED are organized during on-call and day-off schedules could improve the application of the care recommendations regarding the most appropriate referrals.

Developing and Testing a Local Expert-Based Reading Process for Use to Examine Discrepancies Between Guidelines and Current Clinical Practices.

The use of relevant guidelines is critical in psychiatric clinical practice to ensure the homogeneity of the global care provided. Consequently, it is important to identify whether they are utilized successfully and, if not, why. This would enable pragmatic solutions to be agreed to improve the organization of care and the removal of any barriers to the guidelines' implementation. The first step in this process, before any exploration of the limitations of the guidelines themselves, involves a determination of whether they are actually applied in clinical practice. We therefore evaluated discrepancies between the guidelines relating to patients with borderline personality disorder and current practices in the psychiatric Emergency Department at Toulouse University Hospital. This was achieved using a reading process involving a panel of eight local experts who analyzed relevant medical files extracted from a database. They were guided by, and instructed to answer, six standardized questions in relation to each file to determine the method's feasibility. A total of 333 files were analyzed to determine whether, in the local experts' judgment, the care provided reflected current guidance. This reading process revealed substantial agreement (0.85%; Fleiss Kappa -0.69), which is a promising outcome and suggests that such methods could be used in future protocols. Moreover, the process is practical and reliable and requires very few materials.