Benefits of using the Psychiatric Risk Assessment Checklist (PRE-CL) to assess risk in general hospital inpatients

The high prevalence (up to 60%) and severity of psychiatric and behavioral disorders among inpatients in general hospitals¹ have prompted the search for different models of mental health care.² Ideally, these models would address the identification of high-risk situations, such as undetected psychiatric diagnosis, inadequate treatment, and disruptive or self-harmful behavior,³ and enable adequate care, focusing on the current reality for hospitals: limited budgets, short lengths of stay, and safety concerns. Within these parameters, we developed the Psychiatric Risk Assessment Checklist (PRE-CL), an 11-item screening tool to be routinely applied by nurses upon patient admission and every 48 hours thereafter or in case of emergency, at any time during a hospital stay.² Risk-positive screening forms are systematically notified to the hospital psychiatrist and, via case discussion and chart review, an intervention plan is proposed.² In a 6-month period, 21,007 screening forms were completed at admission. Of these, 2,820 (13.4%) indicated the presence of risk, 2,420 of which were evaluated by a psychiatrist, who confirmed risk in 2,396 forms (99.0%). The categorization of interventions and the descriptive results are shown in Table 1.

Table 1
Risk intervention categories

	n	%
Case management guidance	2,285	95.4
To the nursing team; to the attending physician; to the hospital leadership
Medication-related prevention measures	1,163	48.6
Examples: To reinforce the need to address the patient’s use of psychiatric medications on admission in order to prevent relapses and/or abstinence through reconciliation; prevention of patient’s self-medication; optimizing the use of psychiatric medications through discussion and guidance of nursing team and medical staff
Calling for safety measures during hospitalization	4,83	20.2
Examples: Ensure patient has family member or caregiver as chaperone; remove medications or psychoactive substances from the room; room arrangements, such as keeping windows locked; recommending safety measures for when the patient needs to leave the room
Referral for mental health consultations	233	9.7
Examples: Referral to mental health care during hospitalization; referral to psychiatric care upon discharge
Presumptive diagnosis	180	7.5
When a diagnostic hypothesis is presumed through the risk discussion:- Hypothesis of the presence of a diagnosis that had not been previously reported- Hypothesis of a second diagnosis- Hypothesis of a diagnosis other than that originally reported
Most common presumptive diagnoses:	n=180	100
Organic disorders	45	25
Depression	29	16.1
Personality disorders	25	13.8
Alcohol, drug, or medicine abuse	24	13.3
Adjustment disorder	19	10.5
Anxiety disorder	16	8.9
Bipolar disorder	11	6.1
Others	11	6.1
Suicide prevention measures	34	1.4
Examples: Referral to mental health care during hospitalization; referral to mental health follow-up after discharge; calling for safety measures on admission for patients at risk

The results highlight that important interventions can be accomplished by using this new model of care, in addition to referrals for further mental health care. The high percentage of “case management guidance” (95.4%) confirms the importance of the specialist’s support to the healthcare team, mainly to nurses, who oversee patient care around the clock. This support is also expressed in the number of cases that required medication-related interventions and, moreover, guidance on safety measures. Interestingly, the need for guidance was much higher than the need to trigger mental health interventions, suggesting that, with proper advice, the healthcare team can at times successfully manage mild psychiatric/behavioral conditions and safety issues in general hospitals, thereby optimizing costs and resources.

Nevertheless, the psychiatrist did trigger a mental healthcare consultation in 9.7% of notifications. This raises the question of whether these patients would have been correctly treated otherwise, as patients who are referred for psychiatric consultation by the healthcare team are often not those who truly need psychiatric care, while those in need are not always referred.⁴ These results suggest that case discussion with a specialist can help identify which patients can be managed by the healthcare team and which actually need specialist care.

Interestingly, the psychiatrist was able, through case discussions, to question the accuracy of previously established psychiatric diagnoses or suggest a second hypothesis that could be addressed by the healthcare team. Notably, the most prevalent presumed diagnostic hypothesis represents a major issue of concern in general hospitals: organic disorders, which, left undiagnosed, can lead to death; depression, which affects disease prognosis; and personality disorders, which may cause adverse events.⁵ Further studies should address the consistency of the hypothesis achieved through risk discussion, thereby clarifying its contribution to quality of care.

In conclusion, the PRE-CL can be an important tool to address mental health situations in general hospitals.

References

• ¹
  Lipowski ZJ. Current trends in consultation-liaison psychiatry. Can J Psychiatry. 1983;28:329-38.
• ²
  Camargo AL, Maluf Neto A, Colman FT, Citero Vde A. Development of psychiatric risk evaluation checklist and routine for nurses in a general hospital: ethnographic qualitative study. São Paulo Med J. 2019;133:350-7.
• ³
  Briner M, Manser T. Clinical risk management in mental health: a qualitative study of main risks and related organizational management practices. BMC Health Serv Res. 2013;13:44.
• ⁴
  Seltzer A. Prevalence, detection and referral of psychiatric morbidity in general medical patients. J R Soc Med. 1989;82:410-2.
• ⁵
  Carr VJ, Lewin TJ, Walton JM, Faehrmann C, Reid A. Consultation-liaison psychiatry in general practice. Aust N Z J Psychiatry. 1997;31:85-94.

Publication Dates

• Publication in this collection
  Jan-Feb 2019

History

• Received
  19 Dec 2017
• Accepted
  21 Apr 2018