Revista Brasileira de Psiquiatria ISSN print 1516-4446
ISSN on-line 1809-452X
JCR IF 2017: 2.093
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Braz J Psychiatry 2019; 1: Volume 41; 90-91


LETTERS TO THE EDITORS

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

Ana L.L.S. Camargo1; Jair J. Mari1; Elisa A.A. Reis2; Vanessa A. Citero1

1. Universidade Federal de São Paulo - Escola Paulista de Medicina (UNIFESP-EPM), São Paulo, SP, Brazil; https://orcid.org/0000-0001-7070-8432
2. Hospital Israelita Albert Einstein, São Paulo, SP, Brazil; https://orcid.org/0000-0002-5403-0112

Submitted Dec 19 2017
Accepted Apr 21 2018

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.




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.


DISCLOSURE

The authors report no conflicts of interest.


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.