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(151) Changing Practices for Psychiatric Assessment and Post-discharge Follow up Among Post-cardiac Arrest Patients


Authors:

Rafael Tamargo, MD MBA – Resident Physician, UPMC - Western Psychiatric Hospital

John Saunders, MD – Assistant Professor, Baylor College of Medicine

Darcy Moschenross, MD, PhD – Assistant Professor of Psychiatry, University of Pittsburgh Medical Center/Western Psychiatric Hospital

Pierre Azzam, MD, FACLP – CL Psychiatry Fellowship Program Director, University of Pittsburgh Medical Center

Morgan Faeder, MD, PhD – Assistant Professor of Psychiatry, University of Pittsburgh School of Medicine

Priya Gopalan, MD – Assistant Professor of Psychiatry, University of Pittsburgh Medical Center, Western Psychiatric Hospital


Co-Authors:

Presenting Author: Rafael Tamargo, MD, University of Pittsburgh Medical Center Western Psychiatric Hospital
Co-Author: John Saunders, MD, Baylor College of Medicine
Co-Author: Darcy Moschenross, MD, PhD, University of Pittsburgh Medical Center/Western Psychiatric Hospital
Co-Author: Pierre Azzam, MD, FACLP, University of Pittsburgh Medical Center
Co-Author: Morgan Faeder, MD, PhD, University of Pittsburgh School of Medicine
Co-Author: Priya Gopalan, MD, University of Pittsburgh Medical Center, Western Psychiatric Hospital

Abstract:

Background: Cardiac arrest is associated with elevated rates of depression, PTSD, cognitive impairment, and other psychiatric sequelae. Over 40% of post-arrest patients experience psychiatric sequelae and approximately 20% report worsened quality of life as a result (Naber, 2018). Only recently has the incidence of these conditions been elucidated, resulting in increasing attention to the psychiatric needs of post-arrest patients both in the hospital and after discharge, but further characterization of associated diagnoses and successful treatment strategies are needed. 

Methods: A manually-collected database of 3,281 psychiatric consults at UPMC facilities in 2013 was queried to identify patients for whom psychiatric consults were placed following cardiac arrest. 27 such cases were identified. For comparison over time, a second case series was identified by isolating psychiatric consults from 2016-2018 in which diagnostic codes related to cardiac arrest were used, resulting in 82 cases. Descriptive statistics on consulting service, medical comorbidities, psychiatric diagnoses, and post-discharge psychiatric trajectory, including further diagnoses and outpatient follow up, were collected.


Results: 
Twenty-eight post-cardiac arrest patients were evaluated by the Psychiatric Consult-Liaison service in 2013. Average patient age was 48.6 years old. The mean number of medical comorbidities was 7.2. Average length of stay was 22.4 days, with average time to psychiatric consult 10.1 days and average time to discharge after psychiatric consult 12.3 days. Among these, 36% of consults originated from the Cardiology service, 32% from Internal Medicine, 11% from General Surgery, and the remaining 21% coming from Transplant, Cardiothoracic Surgery, Pulmonology, Otolaryngology, and Physical Medicine and Rehab services. The most common psychiatric diagnoses after consult were depression and delirium, comprising 20% of diagnoses each. Anxiety disorders, non-alcohol substance use disorders, and cognitive impairment accounted for 18%, 14%, and 12% of diagnoses, respectively. Patients averaged two diagnoses each. Only one patient in this group was diagnosed with PTSD. Five patients (19%) died before hospital discharge. Among those who survived to discharge, six (27%) attended outpatient psychiatric follow up within six months and 16 (73%) did not. 

By comparison, in the 2016-2018 cohort of 82 patients, average patient age was 56.1 years old. Average length of stay was 26.6 days, with average time to psychiatric consult 13.7 days and average time to discharge after psychiatric consult 13.2 days. General Surgery and Cardiology accounted for the largest proportion of consults, at 16% each. The most common psychiatric diagnoses after consult were again depression and delirium. Anxiety disorders followed at 18%. Five patients (4%) were diagnosed with PTSD or trauma-related disorders. Twenty patients (24%) died before hospital discharge. Among those who survived to discharge, 8 (13%) attended outpatient psychiatric follow up within six months and 54 (87%) did not.

Discussion: Cardiac arrest is associated with increased rates of psychiatric sequelae, but post-discharge psychiatric treatment is limited. We investigate psychiatric trajectory of these patients after discharge and changes in practice with increasing awareness of these risks. A broader range of consulting services engaged the Psychiatry CL service in the care of post-arrest patients. Substance use disorders and major neurocognitive disorders were diagnosed less in the later cohort, while bipolar disorder and trauma-related disorders represented a larger portion of the later cohort. Six-month outpatient psychiatric follow up rate among survivors of cardiac arrest decreased by half over the period studied. There is a significant need for a more robust referral process. Further investigation will seek to characterize reasons for or against consulting Psychiatry CL, appropriate screening tools and timing, and predictors of outpatient follow up. 

Reference:
Naber, D., & Bullinger, M. (2018). Psychiatric sequelae of cardiac arrest. Dialogues in clinical neuroscience, 20(1), 73–77.

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