Time from Medical Clearance to Psychiatric Transfer Orders: A Quality Indicator and Source of Value for Inpatient C-L Services

Background: Consultation-liaison (C-L) psychiatry is in the early stages of defining quality indicators that are valid, feasible to collect, and help demonstrate the full value of its services to all stakeholders (Trigwelll, 2016). Published reports suggest length of stay, readmission rates, and consultee satisfaction among potential metrics to explore (Lavakumar, 2013). Here, we present our C-L service’s experience with a novel quality indicator: time from medical clearance to psychiatric transfer orders for medical inpatients requiring psychiatric hospitalization.

Methods: The sample included all patients for whom psychiatric hospitalization was recommended by our C-L service from June 2017 through December 2020. A transfer nurse recorded when each patient was medically cleared for transfer by the primary medical team and when psychiatric admission orders were placed by the C-L psychiatrist. Reason for delayed transfer orders was also collected, if applicable. This data was characterized using descriptive statistics. Potential cost savings were estimated at $3,990 per day awaiting psychiatric transfer using the daily room rate published by our institution.

Results: 1604 of 1813 records of patients transferred to our institution’s stand-alone psychiatric hospital contained both date of medical clearance and date of psychiatric transfer orders and were included in the analysis. Psychiatric transfer orders were placed on the date of medical clearance in 76.0% of cases. In 15.3% of cases, transfer was delayed by a reason outside the control of the C-L service such as lack of available beds at our psychiatric hospital (60.7% of explained delays), unsuccessful bed search to other facilities at patient preference before the patient was ultimately transferred to our psychiatric hospital (23.6%), and insurance issues (9.5%). In 8.7% of cases, a reason for delayed transfer was not identified. Eliminating these unexplained delays would save approximately $156,000 in avoidable costs annually.

Discussion & Conclusion: Time from medical clearance to psychiatric transfer orders has several strengths as a quality indicator. This metric is easily collected as part of routine workflow, at least partly within the control of the C-L service, and relevant to both the consulting service and patient as a source of delays in care. Efficient patient transfer to the appropriate level of care is also directly tied to cost savings for the hospital and represents a quantifiable source of value for C-L services beyond billing revenues. Time from medical clearance to psychiatric transfer should be considered as a quality indicator for C-L psychiatry.

References:
1. Trigwell P, Kustow J: A multidimensional framework for routine outcome measurement in Liaison Psychiatry (FROM-LP). BJPsych Bulletin 2016; 40(4): 192–4.
2. Lavakumar M, Gastelum ED, Hussain F, et al: How do you know your consult service is doing a good job? Generating performance measures for C-L service effectiveness. Psychosomatics 2013; 54: 567–574.