(PO-169) (PO-169) Curbside Appeal: Navigating the Informal Consult on an Inpatient Consultation-Liaison Psychiatry Service

Background: Indirect care, sometimes known as “curbside” consultation, is used in outpatient integrated care to broaden access to psychiatric treatment.¹ Inpatient consultation-liaison (CL) psychiatry services also use indirect care to triage consultations. However, recommendations in indirect consultation can differ from those derived after formal, direct consultation² for a variety of reasons, including accuracy of background information and provider experience.³ There is limited research to help CL psychiatrists identify clinical questions suitable for indirect consultation. The goal of this study is to identify factors associated with discrepancies between recommendations generated from indirect versus formal consultation on inpatient CL psychiatry services.

Methods: This study was approved by the Institutional Review Board. Data were collected from the inpatient CL psychiatry service at a large safety-net hospital. Hypothetical “curbside” recommendations were formulated prior to conducting formal consultations. "Curbside" recommendations were compared to formal recommendations by two independent psychiatrists. In cases of disagreement, a third psychiatrist served as a blinded referee. Recommendations were assessed for differences in primary diagnosis, target symptom identification, need for involuntary detention, and pharmacologic treatment. Cases were categorized by the type of consult question. Data were evaluated for question types associated with recommendation discrepancies.

Results: A total of 56 cases were evaluated over three months. Consult questions were divided into five categories and accuracy was determined by dividing the number of recommendations that were the same by the total number of cases in each question category. Hypothetical “curbside” recommendations were most accurate when psychiatric symptoms were interfering with care (57.14%, n=7), then in cases evaluating the need for a psychiatric hold (48.14%, n=27), then when providing psychiatric medication recommendations (36.36%, n=11), then in unexplained altered mental status (30%, n=10), and least accurate when evaluating for psychiatric clearance for placement (0%, n=1).

Discussion: Accuracy of hypothetical "curbside" recommendations varied widely, likely due to multiple factors. Evaluated cases were limited to consultation questions already complex enough to warrant formal evaluation and legally mandated formal evaluations, which likely skewed prediction accuracy. Conducting the reverse of this study (i.e., formally evaluating commonly “curbsided” consultations) may partially address this challenge. Also, many consultations asked multifactorial questions, which complicated data interpretation. 

Future studies could identify patient-specific factors (e.g., comorbidities, length of stay, age, polypharmacy) and provider-specific factors (e.g., experience, specialty) that could inform triage decisions. Conducting this study in a private population may make results more generalizable.

Conclusion: Indirect consultation can facilitate stepped-care approaches, thus expanding access to psychiatric care in general hospital settings. This approach may be particularly beneficial in systems with resource limitations precluding development of proactive CL psychiatry services. This study design can facilitate development of evidence-based guidelines, enabling inpatient CL psychiatrists to better allocate resources to increase capacity and enhance quality of care.

References:

1. Unützer J et al.: Collaborative care management of late-life depression in the primary care setting: A randomized controlled trial. JAMA 2002; 288:2836-2845.


2. Burden M et al.: Prospective comparison of curbside versus formal consultations. J Hosp Med 2013; 8:31-35.


3. Raney LE: Integrated primary care and behavioral health: The role of the psychiatrist in the collaborative care model. Am J Psychiatry 2015; 172:721-728.