Proactive psychiatric consultation services for the general hospital of the future

Psychiatric consultation services in general medical hospitals typically operate on a consultation-as-requested basis: medical teams determine that a patient requires a consultation, place an order for a consultation, and the patient is then seen by a psychiatrist for a standard consultation. This system may fail to detect patients who could benefit from consultation or may detect such patients after a delay, and conversely may generate consult requests for patients who will not benefit from inpatient consultation. We argue that psychiatric consultation services must become proactive, organized to seek out cases that require and will benefit from consultation, and to provide the services actually needed in each case. We argue that such services can improve health care and decrease length of stay (LOS). LOS has been widely studied as an indicator of the timely delivery of appropriate care. Studies used many different models and research designs. We analyze the characteristics of the few studies that had a significant effect on LOS. There are ten studies of increased psychiatric consultation, with four showing a significant improvement in LOS. Twelve studies have analyzed the effects of increased geriatric consultation, with three showing significant improvement in LOS. Three studies have focused on delirium in geriatric patients without showing LOS benefit, but one study in geriatric trauma patients did demonstrate a notable trend towards LOS improvement. Eight studies have investigated increased geriatric consultation for elderly patients with hip fracture, two with statistically significant benefit, and an additional four with trend towards improvement. Additionally, we note that three studies on clinical pathways including comprehensive geriatric consultation all show clear evidence of LOS benefit, as do six studies with dedicated ortho-geriatric unit care. Finally, we describe two models of proactive psychiatric consultation implemented in our hospital that have demonstrated reductions in LOS. Successful studies do share certain elements in common: screening for and selection of appropriate target population who can benefit, focus on improving LOS, and close integration of consult care into medical team operation. We argue that the data thus far show that simply doing more consultations is not efficient, but that appropriately targeted and integrated care does provide timely services and reduce LOS. We conclude with suggestions about the design of successful proactive psychiatric consultation services, and with suggestions about appropriate research designs for further work in the field.