Best practices: an intervention to promote evidence-based prescribing at a large psychiatric hospital.

An intervention to affect prescribing behavior was implemented at a large psychiatric hospital. Articles providing support for appropriate dosing of quetiapine were distributed to physicians, and peer discussions about prescribing practices were held. From April 2005 through December 2006, low-dose quetiapine prescriptions (

When is antipsychotic polypharmacy supported by research evidence? Implications for QI.

BACKGROUND: Concurrent use of multiple standing antipsychotics (antipsychotic polypharmacy) is increasingly common among both inpatients and outpatients. Although this has often been cited as a potential quality-of-care problem, reviews of research evidence on antipsychotic polypharmacy have not distinguished between appropriate versus inappropriate use. METHODS: A MEDLINE search from 1966 to December 2007 was completed to identify studies comparing changes in symptoms, functioning, and/or side effects between patients treated with multiple antipsychotics and patients treated with a single antipsychotic. The studies were reviewed in two groups on the basis of whether prescribing was concordant with guideline recommendations for multiple-antipsychotic use. RESULTS: A review of the literature, including three randomized controlled trials, found no support for the use of antipsychotic polypharmacy in patients without an established history of treatment resistance to multiple trials of monotherapy. In patients with a history of treatment resistance to multiple monotherapy trials, limited data support antipsychotic polypharmacy, but positive outcomes were primarily found in studies of clozapine augmented with a second-generation antipsychotic. DISCUSSION: Research evidence is consistent with the goal of avoiding antipsychotic polypharmacy in patients who lack guideline-recommended indications for its use. The Joint Commission is implementing a core measure set for Hospital-Based Inpatient Psychiatric Services. Two of the measures address antipsychotic polypharmacy. The first measure assesses the overall rate. The second measure determines whether clinically appropriate justification has been documented supporting the use of more than one antipsychotic medication.

Of treatment systems and depression: an overview of quality-improvement opportunities in hospital-based psychiatric care.

A clinical perspective on depression tends to focus on therapy and on medications or psychological interventions that may be helpful to individual patients. A broader view on the treatment enterprise, however, suggests that there are other dimensions to treatment and that opportunities for improving the quality of care and patient outcomes are not limited to innovation in therapeutics. This article examines several of the nonclinical facets of inpatient care, using the frame of a conceptual pyramid to explore the relationships between therapy and its professional, organizational, care-management, and economic concomitants. By drawing on a conceptual pyramid that elucidates several nonclinical dimensions of inpatient treatment for depression, we describe the potential for corresponding quality improvement activities among psychiatric providers. The pyramid suggests that there are multiple opportunities for future interventions to promote quality in inpatient psychiatric care, that those opportunities are considerably more varied than a purely clinical perspective might recognize, and that interventions in nonclinical aspects of the treatment system have the potential to cascade "downward" to affect clinical outcomes over time.

Short-term outcome of psychiatric inpatients with anorexia nervosa in the current care environment.

OBJECTIVE: The current study describes the short-term outcome of 61 inpatients with anorexia nervosa (AN), utilizing a standardized protocol that could be completed by most patients within the typical length of stay (LOS) in an academic medical center in our geographic area. METHOD: Patients were placed on disorder-specific and medication clinical pathways and completed questionnaires at admission and discharge. Diagnostic, historical, demographic, and treatment-related information was obtained. RESULTS: Treatment was sufficient to resolve acute medical problems, initiate refeeding, and interrupt compensatory behaviors, but continued intensive treatment will be critical to full recovery. Patients were discharged at an average of 85% of ideal body weight (IBW). Twenty patients were discharged against medical advice (AMA). Clinical and demographic variables poorly predicted AMA status. DISCUSSION: Attainable inpatient treatment goals in our care environment appear to be > or = 80% IBW at discharge, resolution of acute medical problems, and interruption of compensatory behaviors. Future research should examine whether shorter LOS increases readmission rates or long-term costs.