Ethnoracial disparities in care on a consultation-liaison service at an academic hospital.

BACKGROUND: There is currently an increasing recognition of and focus on structural and institutional racism and its impacts on health disparities. In psychiatry and mental health, research has focused on racial and ethnic disparities in the availability and utilization of mental health services, care in emergency departments, and inpatient psychiatric services. Little is known about disparities in care on general hospital psychiatry consultation-liaison (CL) services. METHODS: In this exploratory study, we conducted a retrospective chart review using electronic health record (EHR) data of all adults (≥ 18 years of age) admitted to inpatient medical or surgical floors at an urban academic medical center for whom a psychiatric consultation was requested during the study period. We examined differences by race and ethnicity in: rates of consultation requests; use of legal holds, constant observation, restraints; follow-up by the CL service; and ultimate disposition. RESULTS: The service received 310 unique consults during the study period. Compared to hospital-wide numbers, Black-identifying patients were over-represented in our sample (11.9% vs 6.6%), while Latinx patients were underrepresented (6.1% vs 9.8%). Of the clinical and outcome variables collected, there were higher odds of being placed on a legal hold both prior to (OR 2.6) and after the consult question (OR 2.98) and in the odds of having a one-to-one observer prior to (OR 2.47) and after (OR 2.9) the initial consult visit for Black-identifying patients, when adjusting for confounders. There were no other measurable differences in care or outcomes by racial or ethnic categories. CONCLUSION: Black-identifying patients may be more likely to receive psychiatric consultation and be placed on legal holds because of a combination of chronic adverse social determinants of health and race-based bias. Conversely, Latinx patients may be less likely to receive psychiatric consultation because of language barriers among other factors. The lack of disparities identified in other domains may be encouraging, but larger studies are needed. Further research is also needed to identify causality and interventions that could help close the gap in care and outcomes for racial and ethnic minorities.

Trends in suicidal ideation in an emergency department during COVID-19.

OBJECTIVE: This study aims to detail changes in presentations at a United States Emergency Department for suicidality before and after the outbreak of COVID-19. METHODS: A retrospective chart review was conducted of all adult patients who presented to an ED with suicidality and underwent psychiatric consultation during the study period. The cohorts consisted of patients who presented between December 2018 - May 2019 and December 2019 - May 2020. Information was collected on demographics, characteristics of suicidality, reasons for suicidality and disposition. The first wave from March - May 2020 was examined, using a difference-in-differences design to control for factors other than COVID-19 that may have influenced the outcomes' trend. RESULTS: Immediately following the pandemic outbreak there was a statistically significant increase in the proportion of undomiciled patients represented in visits for suicidality (40.7% vs. 57.4%; p-value <0.001). In addition, the proportion of patient visits attributed to social (18.0% vs. 29.2%; p-value 0.003) and structural (14.2% vs. 26.4%; p value <0.001) reasons for suicidality increased. Conversely, the proportion of visits due to psychiatric symptoms (70.5% vs 50.0%; p-value <0.001) decreased. Furthermore, patient visits were more likely to result in a medical admission (2.1% vs. 8.3%; p-value 0.002) and less likely to result in a psychiatric admission (68.4% vs 48.6%; p-value <0.001) during the initial phase of the pandemic. CONCLUSIONS: COVID-19 was associated with increased ED presentations for suicidality among undomiciled patients, as well as greater likelihood of social and structural reasons driving suicidality among all visits.

Evaluating the association between COVID-19 and psychiatric presentations, suicidal ideation in an emergency department.

OBJECTIVE: To estimate the association between COVID-19 and Emergency Department (ED) psychiatric presentations, including suicidal ideation. METHODS: Using an interrupted time series design, we analyzed psychiatric presentations using electronic health record data in an academic medical center ED between 2018 and 2020. We used regression models to assess the association between the onset of the COVID-19 outbreak and certain psychiatric presentations. The period February 26-March 6, 2020 was used to define patterns in psychiatric presentations before and after the coronavirus outbreak. RESULTS: We found a 36.2% decrease (unadjusted) in ED psychiatric consults following the coronavirus outbreak, as compared to the previous year. After accounting for underlying trends, our results estimate significant differential change associated with suicidal ideation and substance use disorder (SUD) presentations following the outbreak. Specifically, we noted a significant differential increase in presentations with suicidal ideation six weeks after the outbreak (36.4 percentage points change; 95% CI: 5.3, 67.6). For presentations with SUD, we found a differential increase in the COVID-19 time series relative to the comparison time series at all post-outbreak time points and this differential increase was significant three weeks (32.8 percentage points; 95% CI: 4.0, 61.6) following the outbreak. Our results estimate no differential changes significant at the P value < 0.05 level associated with affective disorder or psychotic disorder presentations in the COVID-19 time series relative to the comparator time series. CONCLUSIONS: The COVID-19 outbreak in Boston was associated with significant differential increases in ED presentations with suicidal ideation and SUD.

Case report: domperidone use as a galactagogue resulting in withdrawal symptoms upon discontinuation.

We present a case of domperidone withdrawal in a woman using the medication as a galactagogue. Our primary goal is to increase the literature available to providers who work with women who are breastfeeding. We evaluated a woman presenting to our reproductive psychiatry clinic for consultation regarding anxiety and agitation in the context of domperidone discontinuation. We evaluated the available literature regarding domperidone as a galactagogue, as well as the literature regarding adverse effects. The patient presented with withdrawal symptoms after gradual taper and discontinuation of domperidone. After restarting the medication, her symptoms resolved. She was able to successfully discontinue domperidone with a slow, gradual taper. Domperidone is occasionally used as a galactagogue in women with inadequate milk supply. We report a case in which a woman experienced withdrawal symptoms after domperidone discontinuation.

Awakenings? Patient and Hospital Staff Perceptions of Nighttime Disruptions and Their Effect on Patient Sleep.

STUDY OBJECTIVES: Although important to recovery, sleeping in the hospital is difficult because of disruptions. Understanding how patients, hospital physicians, and nurses perceive sleep disruptions and identifying which disruptions are associated with objective sleep loss can help target improvement initiatives. METHODS: Patients and hospital staff completed the Potential Hospital Sleep Disruptions and Noises Questionnaire (PHSDNQ). Cutoff points were defined based on means, and responses were dichotomized. Perceived percent disrupted for each item was calculated, and responses were compared across groups using chi-square tests. Objective sleep time of patients was measured using wrist actigraphy. The association between patient-reported disruptions and objective sleep time was assessed using a multivariable linear regression model controlling for subject random effects. RESULTS: Twenty-eight physicians (78%), 37 nurses (88%), and 166 of their patients completed the PHSDNQ. Patients, physicians, and nurses agreed that pain, vital signs and tests were the top three disrupters to patient sleep. Significant differences among the groups' perceptions existed for alarms [24% (patients) vs. 46% (physicians) vs. 27% (nurses), p < 0.040], room temperature (15% vs. 0% vs. 5%, p < 0.031) and anxiety (18% vs. 21% vs. 38%, p < 0.031). Using survey and actigraphy data from 645 nights and 379 patients, the presence of pain was the only disruption associated with lower objective sleep duration (minutes) [-38.1 (95% confidence interval -63.2, -12.9) p < 0.003]. CONCLUSION: Hospital staff and patients agreed that pain, vital signs and tests were top sleep disrupters. However, pain was associated with the greatest objective sleep loss, highlighting the need for proactive screening and management of patient pain to improve sleep in hospitals.

Effect of modest pay-for-performance financial incentive on time-to-discharge summary dictation among medical residents.

OBJECTIVE: Evaluate the effect of a modest financial incentive on time-to-discharge summary dictation among medicine residents. BACKGROUND: Pay-for-performance incentives are used in a number of health care settings. Studies are lacking on their use with medical residents and other trainees. Timely completion of discharge summaries is necessary for effective follow-up after hospitalization, and residents perform the majority of discharge summary dictations in academic medical centers. METHODS: Medicine residents with the lowest average discharge-to-dictation time during their 1-month inpatient medicine ward rotation were rewarded with a $50 gift card. Discharge data were captured using an autopopulating electronic database. RESULTS: The average discharge-to-dictation time was reduced from 7.44 to 1.84 days, representing a 75.3% decrease. Almost 90% of discharge summary dictations were performed on the day of discharge. CONCLUSION: A modest financial incentive resulted in a marked improvement in the time-to-discharge summary dictation by medicine residents. Pay-for-performance programs may be an effective strategy for improving the quality and efficiency of patient care in academic medical centers.

A tutorial on activity-based costing of electronic health records.

As the American Recovery and Restoration Act of 2009 allocates $19 billion to health information technology, it will be useful for health care managers to project the true cost of implementing an electronic health record (EHR). This study presents a step-by-step guide for using activity-based costing (ABC) to estimate the cost of an EHR. ABC is a cost accounting method with a "top-down" approach for estimating the cost of a project or service within an organization. The total cost to implement an EHR includes obvious costs, such as licensing fees, and hidden costs, such as impact on productivity. Unlike other methods, ABC includes all of the organization's expenditures and is less likely to miss hidden costs. Although ABC is used considerably in manufacturing and other industries, it is a relatively new phenomenon in health care. ABC is a comprehensive approach that the health care field can use to analyze the cost-effectiveness of implementing EHRs. In this article, ABC is applied to a health clinic that recently implemented an EHR, and the clinic is found to be more productive after EHR implementation. This methodology can help health care administrators assess the impact of a stimulus investment on organizational performance.