Multidisciplinary Proactive Psychiatric Consultation Service: Impact on Length of Stay for Medical Inpatients.

BACKGROUND: Mental illness correlates with an increased length of stay (LOS) for patients hospitalized for medical conditions. While psychiatric consultations help manage mental illness among those hospitalized for medical conditions, consultations initiated by nonpsychiatric mental disease may lack maximum effectiveness. METHODS: In a before-and-after design, in 2 contiguous years LOS for internist-initiated, conventional consultation (CC) as usual treatment was compared to LOS of a proactive, mental health professional-initiated, multidisciplinary intervention delivered by the behavioral intervention team (BIT) on the same units. The patient populations included general medical patients with a variety of illnesses. Patients were treated in 3 different inpatient settings with a total capacity of 92 beds serving 15,858 patient visits over 3 comparison years. BIT comprised a psychiatrist, a nurse, and a social worker, each of whom performed the specific tasks of their professional discipline, while collaborating among themselves and their health-care colleagues. BIT provided timely, appropriate, and effective patient care alongside consultative advice and education to their corresponding professional peers. BIT was compared to CC on the outcome of LOS. RESULTS: There was a statistically significant reduction of LOS favoring BIT over CC for patients with an LOS of <31 days which persisted while controlling for multiple co-morbid factors. Also, a statistically significant spillover effect was suggested by the overall improvement of LOS on units implementing BIT. CONCLUSION: BIT is a promising means of lowering LOS on general medical units while providing a high level of care and staff support.

Association of inpatient and outpatient glucose management with inpatient mortality among patients with and without diabetes at a major academic medical center.

BACKGROUND: Hospitalized patients with diabetes have experienced a disproportionate reduction in mortality over the past decade. OBJECTIVE: To examine whether this differential decrease affected all patients with diabetes, and to identify explanatory factors. DESIGN: Serial, cross-sectional observational study. SETTING: Academic medical center. PATIENTS: All adult, nonobstetric patients with an inpatient discharge between January 1, 2000 and December 31, 2010. MEASUREMENT: We assessed in-hospital mortality; inpatient glycemic control (percentage of hospital days with glucose below 70, above 299, and between 70 and 179 mg/dL, and standard deviation of glucose measurements), and outpatient glycemic control (hemoglobin A1c). RESULTS: We analyzed 322,938 admissions, including 76,758 (23.8%) with diabetes. Among 54,645 intensive care unit (ICU) admissions, there was a 7.8% relative reduction in the odds of mortality in each successive year for patients with diabetes, adjusted for age, race, payer, length of stay, discharge diagnosis, comorbidities, and service (odds ratio [OR]: 0.923, 95% confidence interval [CI]: 0.906-0.940). This was significantly greater than the 2.6% yearly reduction for those without diabetes (OR: 0.974, 95% CI: 0.963-0.985; P < 0.001 for interaction). In contrast, the greater decrease in mortality among non-ICU patients with diabetes did not reach significance. Results were similar among medical and surgical patients. Among ICU patients with diabetes, the significant decline in mortality persisted after adjustment for inpatient and outpatient glucose control (OR: 0.953, 95% CI: 0.914-0.994). CONCLUSIONS: Patients with diabetes in the ICU have experienced a disproportionate reduction in mortality that is not explained by glucose control. Potential explanations include improved cardiovascular risk management or advances in therapies for diseases commonly affecting patients with diabetes.

Using the glucometrics website to benchmark ICU glucose control before and after the NICE-SUGAR study.

Prior to 2009, intensive glycemic control was the standard in main intensive care units (ICUs). Glucose targets have been recalibrated after publication of the NICE-SUGAR study in that year, followed by updated guidelines that endorsed more moderated control. We sought to determine if the prevalence of hyperglycemia in US ICUs had increased after the NICE-SUGAR study's results were reported. We used data from hospitals submitted to the Yale Glucometrics™ website to assess mean blood glucose values, percentage of blood glucose within various ranges, and the prevalence of hypo- and hyperglycemic excursions, based on the patient-day method, comparing the pre- to post-NICE-SUGAR time period. Among more than a total of 2 million blood glucose determinations, comprising 408 790 patient-days, median patient-day blood glucose decreased from 144 mg/dL to 141 mg/dL (P < .001) in the pre- versus post-NICE-SUGAR time period. The percentage of patient days with a mean blood glucose of 110-179 mg/dl increased from 58.3 to 63.6%. The percentage of patient-days with either hypoglycemia (<70 mg/dl) or severe hyperglycemia (≥300 mg/dl) decreased during this time. Our results suggest that glycemic control in US ICUs has improved when comparing time periods before versus after publication of the NICE-SUGAR study. We found no evidence that fewer hypoglycemic events were achieved at the expense of more hyperglycemia.

Proactive psychiatric consultation services reduce length of stay for admissions to an inpatient medical team.

BACKGROUND: Some studies suggest intensive psychiatric consultation services facilitate medical care and reduce length of stay (LOS) in general hospitals. OBJECTIVE: To compare LOS between a consultation-as-usual model and a proactive consultation model involving review of all admissions, rapid consultation, and close follow-up. METHODS: LOS was compared in an ABA design between a 33-day intervention period and 10 similar control periods, 5 before and 5 after the intervention, on an internal medical unit. During the intervention period, a staff psychiatrist met with the medical team each weekday, reviewed all admissions, provided immediate consultation as needed, and followed all cases throughout their hospital stay. RESULTS: Time required for initial case review was brief, 2.9 ± 2.2 minutes per patient (mean ± S.D.). Over 50% of admissions had mental health needs: 20.3% were estimated to require specialist consultation to avoid potential delay of discharge. The consultation rate for the intervention sample was 22.6%, significantly greater than in the control sample, 10.7%. Mean LOS was significantly shorter in the intervention sample, 2.90 ± 2.12 versus 3.82 ± 3.30 days, and the fraction of cases with LOS > 4 days was significantly lower, 14.5% versus 27.9%. A rough cost benefit analysis was favorable with at least a 4.2 ratio of financial benefit to cost. CONCLUSIONS: Psychiatric review of all admissions is feasible, indicates a high incidence of mental health barriers to discharge, identifies more necessary consultations than typically requested, and results in earlier consultation. A proactive consultation model can reduce hospital LOS.

Evaluating inpatient glycemic management: the Quality Hyperglycemia Score.

BACKGROUND: Inpatient hyperglycemia has become a major focus at many hospitals. However, although several professional organizations have pushed for improved inpatient glucose management, glycemic control at many institutions remains suboptimal. There is a general consensus that improved quality of care is needed, but objective assessment of care quality remains a challenge. Lack of clear, effective performance feedback to clinicians is one element that may derail efforts to improve practice. METHODS: We developed a simplified grading system, the Quality Hyperglycemia Score (QHS), to allow clinicians and managers to easily review and compare glycemic management on adult medical-surgical and intensive care units over the prior 3 months and to more fully engage patient care teams in quality improvement. RESULTS: The QHS represents a single value from 0 to 100, incorporating elements of glycemic management influenced by all team members. The scoring system rewards the maintenance of blood glucose levels in or near the normal range and adherence to the hospital policy on the use of bedside glucose meters, but penalizes frequent hypoglycemic episodes and severe hyperglycemic excursions. Each element is weighted independently and summed to produce the QHS. Scores then correspond to a color code highlighting each unit's performance level. CONCLUSIONS: To date, the QHS reflects the spectrum of blood glucose management at our hospital. While refinement and internal and external validation with clinical outcomes are planned, we propose the QHS as a standardized, objective measure of the quality of inpatient glycemic management.

"Glucometrics"--assessing the quality of inpatient glucose management.

BACKGROUND: For patients with diabetes, the quality of outpatient glycemic control is readily assessed by hemoglobin A1c. In contrast, standardized measures for assessing the quality of blood glucose (BG) management in hospitalized patients are lacking. Because of recent studies demonstrating the benefits of strict glycemic control in critically ill patients, hospitals nationwide are dedicating resources to address this important issue. To facilitate advances in this nascent field, standardized metrics for inpatient glycemic control should be developed and validated. METHODS: We used 1 month of fingerstick BG levels from a general hospital ward to develop and test three analytic models, based on three units of inpatient BG analysis: population (i.e., ward), patient-day, and patient. To assess the effect of the source of blood samples, we repeated these analyses after adding venous plasma glucose levels. Finally, we employed an idealized intensive care unit data set to establish "gold standard" metrics for inpatient glycemic control. RESULTS: Mean and median BG levels and the proportion of BG levels within an "optimal" range (80-139 mg/dL) were similar among the three models, whereas hypoglycemic and hyperglycemic event rates varied considerably. Inclusion of venous glucose levels did not substantially affect the results. Of the three models tested, the patient-day model appears to most faithfully reflect the quality of inpatient glycemic control. Achieving 85% of BG levels within optimal range may be considered gold standard. CONCLUSIONS: If validated elsewhere, these "glucometrics" would permit objective comparisons of inpatient glycemic control among hospitals and patient care units, and would allow institutions to gauge the success of their quality improvement initiatives.