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Critical Care Psychiatry: Scope of Practice for Psychiatric Consultation in the Intensive Care Unit

Alyssa Rautenberg, MD – Psychiatry Resident, Cambridge Health Alliance

Clare Herickhoff, MD – Psychiatry Resident, Harvard Longwood Psychiatry Residency Training Program

David Gitlin, MD, FACLP, DFAPA – Vice Chair for Clinical Programs, Brigham Health, Brigham and Women's Hospital

Nomi Levy-Carrick, MD, MPhil – Psychiatrist, Division of Medical Psychiatry, Dept of Psychiatry, Brigham and Women's Hospital

Abstract:

Background: Psychiatrists are minimally utilized in intensive care units (ICUs) despite high levels of psychiatric comorbidity, increasing awareness of post-ICU syndromes (PICS) (Huggins, 2016) and demonstrated benefit of a unique proactive psychiatric consultation model in the ICU, including decreased length of hospital stay (Bui, 2018). The ACGME Program Requirements for Graduate Medical Education in Consultation-Liaison (CL) Psychiatry do not currently include an ICU-specific curriculum. The scope of practice of critical care psychiatry has not been clearly defined, and doing so would support optimized training for and utilization of critical care psychiatric consultation.

Method: Descriptive statistical analyses were conducted on an IRB-approved retrospective chart review of 124 patients who had a proactive psychiatric consultation during hospital admission at a metropolitan tertiary care center that included ICU level of care. The proactive model includes an attending CL psychiatrist embedded on ICU rounds who decided together with the ICU team whether psychiatric consultation was indicated. Our primary outcome is recommendations made by a CL psychiatrist. Secondary outcomes include patient demographics and history, consultation indication, psychiatric diagnoses made by the CL psychiatrist, and continuity of care. 

Results: The majority of patients (62.9%) had pre-existing psychiatric diagnoses. The majority of patients had respiratory failure (56.4%) and patients are often mechanically ventilated at the time of consultation (33.1%). The majority of patients also have delirium (69.4%). The psychiatrist made recommendations addressing sedatives and opioid analgesics (28.2%), as well as regarding further neurologic workup of altered mental status (20.2%). The psychiatrist served a liaison role with the ICU medical team, as well as with patients and families (13.7%). After delirium, the most common diagnoses made by the psychiatrist were Adjustment Disorders (20.2%), Depressive disorders (20.2%), and Substance-related disorders (20.2%).  Psychiatry followed nearly half (49.2%) of patients when transferred to the medical ward. Recommendations were made for follow-up psychiatric and neuropsychiatric care (33.8%) for patients who did not have mental health providers prior to admission. 

Discussion: Our findings illustrate the scope of practice of a proactive psychiatric consultation model in critical care. We propose that 3 domains, which emerge from these findings, may represent important elements of critical care psychiatry as a subspecialty field. These include the uniqueness of consultations in the critical care environment (including frequent mechanical ventilation, co-management of opioids and analgesics, high rates of delirium, and recommendations regarding neurologic workup of altered mental status). Additionally, critical care psychiatrists serve as liaisons with critically ill patients and their families, and are uniquely positioned to identify and intervene for patients and families at risk for PICS and PICS-F. We propose curricular elements for subspecialty psychiatric training which address these components of critical care psychiatry. 

Conclusions: The emergence of critical care psychiatry as a subspecialty field reflects growing recognition of the potential optimization of outcomes through early psychiatric intervention in the ICU. This study describes a scope of practice which contains unique elements (including management of mechanically ventilated patients, high rates of delirium, and co-management of opioids and sedatives), and illustrates an important liaison role with the critical care team, patients and their families. Critical care psychiatrists are also uniquely positioned to identify and potentially intervene for patients and families at risk for PICS and PICS-F. This scope of practice has implications for further psychiatric curricular development which could bolster the utilization and effectiveness of psychiatry in this setting. Further research is needed to assess generalizability of these findings, and the role of critical care psychiatry in the management of post-intensive care syndromes.

Huggins EL, Bloom SL, et al. A Clinic Model: Post-Intensive Care Syndrome and Post-Intensive Care Syndrome. AACN Adv Crit Care.2016;27(2):204-211

Bui M, Thom RP, Hurwitz S, et al. Hospital Length of Stay With a Proactive Psychiatric Consultation Model in the Medical Intensive Care Unit: A Prospective Cohort Analysis. Psychosomatics 2018;S0033-3182(18)30413-4


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