Faculty Bibliography

Background: Data that demonstrates productivity, value or quality in clinical practice are high priority in healthcare systems but are less developed for the field of C-L Psychiatry. Recent work has focused on qualitative metrics (Kovacs et al., 2021) and service effectiveness (Wood, et al., 2014) but there is no consensus on what operational or safety metrics CL teams should track. Without reliable metrics, it can be challenging to illustrate daily CL service operations or provide quantitative support to justify expansion of staffing to hospital leadership. In response to an administrative need, our service started an ongoing collaboration with departmental leadership, administrative support staff, and medical center information technology to develop CL operational and safety metrics.
Method(s): We developed 17 monthly and 9 daily metrics to describe our operations. These metrics cluster into the following groups: clinical volume and encounters; behavioral emergency response activations (BERTs) and bedside safety huddles for patients with recent violence; length of stay; proactive Addiction CL service; behavioral acuity highlights (ex: 1:1s for suicide risk); and "CL Dwell Time" which is the time from medical clearance to discharge to inpatient psychiatry (if applicable). From this data, we selected key metrics to display on a quarterly basis to senior hospital leadership in the form of a "metrics card" to parallel our medicine and surgical colleagues who present High Reliability Organization score cards.
Result(s): Our service demonstrated increases in consultation requests, completed consultations, total clinical encounters and activation of BERTs. We compared trends for total length of stay by ultimate discharge destination, such as psychiatric admission vs acute rehabilitation vs home. The data allowed for deeper dives into concerning trends, such as the problem of escalating violence in the general medical hospital as evidenced by the increasing BERTs per month over several years. We examined the number of unique patients with BERTs, BERTs per patient, BERTs per patient by psychiatric diagnoses, and BERT total per medical unit or service. The data has allowed for the development of interventions to reduce BERTs for specific populations and medical units.
Discussion(s): The creation of comprehensive CL service operational metrics has provided our team with the ability to analyze clinical, acuity, and safety trends over the past 2 years. This ability has led to improved advocacy for service needs (i.e. expansion of FTE and fellowship lines), data-informed communication with hospital leadership, and identification of clinical care gaps needing quality improvement. References: 1. Kovacs Z, Asztalos M, et al. Quality assessment of a consultation-liaison psychiatry service. BMC Psychiatry. 2021 Jun 1;21(1):281. 2. Wood R, Wand AP. The effectiveness of consultation-liaison psychiatry in the general hospital setting: a systematic review. J Psychosom Res. 2014 Mar;76(3):175-92.
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Background/Significance: During the COVID-19 pandemic, people with substance use disorders have experienced increased rates of overdose, decreased access to substance use disorder treatment, and increased risk for adverse COVID outcomes (NIDA, 2020). Throughout the pandemic, NYU Langone Health has continued using the Tobacco, Alcohol, and Prescription Substance (TAPS) screening tool for all inpatient admissions in order to identify and provide proactive consultation to hospitalized patients at risk for substance use disorders.
Method(s): We conducted a retrospective review of adult inpatient medical and surgical admissions to NYU Langone Health, using data collected from a pre-defined Epic report based on TAPS documentation. We compared groups pre-COVID-19 pandemic (defined as 9/2018-9/2019) and during COVID-19 pandemic (defined as 3/2020-3/2021) for the following outcomes: (1) nursing compliance rate with TAPS administration, (2) prevalence of patients with substance use disorders as measured by positive TAPS screen, and (3) severity of alcohol use disorder among patients with TAPS positive for alcohol.
Result(s): During the pre-COVID-19 period, 24,057 patients were screened with a compliance rate of 90% and a positivity rate of 6% (N=1673). ICU compliance was 84%. Prevalence of patients at risk for various substance use disorders was as follows: 4.3% (N=1027) alcohol, 1.5% (N=357) cannabis, 0.32% (N=78) heroin, 0.24% (N=57) opiates, 0.15% (N=35) sedatives, 0.48% (N=116) stimulants, and 0.01% (N=3) prescription stimulants. Of positive alcohol screens, 26.7% (274/1027) represented the highest severity of use (Alcohol Score 4). During the COVID-19 period, 17,931 patients were screened with a compliance rate of 82% and positivity rate of 6% (N=1374). ICU compliance was 74%. Prevalence of patients at risk for various substance use disorders was as follows: 4.3% (N=772) alcohol, 1.5% (N=272) cannabis, 0.60% (N=108) heroin, 0.26% (N=46) opiates, 0.20% (N=35) sedatives, 0.69% (N=124) stimulants, and 0.04% (N=7) prescription stimulants. Of positive alcohol screens, 41.2% (318/772) were highest severity. We were unable to meaningfully test for significant given limitations of Epic datasets and variability in unit composition and staffing throughout COVID-19 period.
Discussion(s): There was decreased compliance with TAPS administration during COVID-19 as compared to pre-COVID-19, as well as overall low compliance in ICUs during both time periods. There were similar rates of positive screens for all substance use disorders pre-COVID-19 and during COVID-19, with an increase in positive heroin and other opiate screens during COVID-19. Among patients with positive alcohol screens, there was increased severity of alcohol scores during COVID-19 relative to pre-COVID-19. Conclusion/Implications: These results suggest a change in patterns of substance use during the COVID-19 pandemic, consistent with findings from prior studies of increased opioid overdoses (Slavova 2020, Georgia Department of Public Health 2020) and severity of substance use (NIDA 2020). Poor ICU compliance suggests increased barriers to TAPS administration in patients with critical illness and/or altered mental status, which may lead to decreased identification and treatment of patients at increased risk for substance use disorders. These results may inform clinical practice and future studies regarding utilization of TAPS screen and proactive addiction psychiatry consultation service in acute care settings. References: 1. NIDA. 2020, September 14. Addressing the Unique Challenges of COVID-19 for People in Recovery. Retrieved from https://www.drugabuse.gov/about-nida/noras-blog/2020/09/addressing-u nique-challenges-covid-19-people-in-recovery on 2021, March 15 2. Slavova, S., Rock, P., Bush, H. M., Quesinberry, D., & Walsh, S. L. (2020). Signal of increased opioid overdose during COVID-19 from emergency medical services data. Drug and alcohol dependence, 214, 108176. 3. Georgia Department of Public Health. 2020, June 19. Suspected Drug Overdose Increases in Georgia Amid COVID-19. Retrieved from https://www.drugabuse.gov/sites/default/files/suspected_drug_overdos e_increases_in_georgia_amid_covid-19_1.pdf
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BACKGROUND:New York City's first case of SARS-associated coronavirus (SARS-CoV-2) disease 2019 (COVID-19) was identified on 1 March 2020, prompting rapid restructuring of hospital-based services to accommodate the increasing numbers of medical admissions. Non-essential services were eliminated but in-patient treatment of psychiatric illnesses was necessarily maintained. AIMS/OBJECTIVE:To detail the response of the NYU Langone Health in-patient psychiatric services to the COVID-19 outbreak from 1 March to 1 May 2020. METHOD/METHODS:Process improvement/quality improvement study. RESULTS:Over this time period, our two in-patient psychiatric units (57 total beds) treated 238 patients, including COVID-19-positive and -negative individuals. Testing for COVID-19 was initially limited to symptomatic patients but expanded over the 62-day time frame. In total, 122 SARS-CoV-2 polymerase chain reaction (PCR) tests were performed in 98 patients. We observed an overall rate of COVID-19 infection of 15.6% in the patients who were tested, with an asymptomatic positive rate of 13.7%. Although phased roll-out of testing impaired the ability to fully track on-unit transmission of COVID-19, 3% of cases were clearly identified as results of on-unit transmission. CONCLUSIONS:Our experience indicates that, with appropriate precautions, patients in need of in-patient psychiatric admission who have COVID-19 can be safely managed. We provide suggested guidelines for COVID-19 management on in-patient psychiatric units which incorporate our own experiences as well as published recommendations.

The following is a report of two patients who developed reversible facial myoclonus in association with use of topiramate. The first patient was a 28-year-old man with posttraumatic frontal lobe epilepsy who was switched to topiramate monotherapy after failure on phenytoin. Topiramate was initiated at 25 mg/day, then increased by 25 mg every week. The second patient was a 49-year-old woman who presented with new-onset complex partial seizures. In both patients described above, facial myoclonus appears to be a dose-related adverse event associated with topiramate.

A 37-year-old woman with an eating disorder and major depressive disorder, initially presented in 2005 to the University of New Mexico Mental Health Center when she was forced into treatment by her probation officer after a routine urine drug screen was positive for methamphetamine. The patient adamantly denied having ever used methamphetamine but did acknowledge a 20-year history of abusing over-the-counter medications to maintain her weight. Subsequent hair analysis confirmed the presence of ephedrine but not methamphetamine. The patient had limited insight into the problems associated with her ephedrine dependence. She refused to consider the risk of cardiac complications that could result from excessive ephedrine intake. Moreover, she continued to use ephedrine despite having to spend 3 nights in the county jail after a second urine drug screen was positive for methamphetamine. Subsequent hair analysis demonstrated this to be a false positive.

Over the past 2 decades, serotonin reuptake inhibitors (SRIs) have become mainstays in the pharmacologic treatment of depression and anxiety disorders. Surprisingly given their widespread use around the world, few studies have been conducted to evaluate the impact of SRIs on male fertility. The following is a report of two men treated at a high-volume male infertility practice at New York Hospital-Cornell Medical Center in New York City who presented with a clear temporal association between selective serotonin reuptake inhibitor (SSRI) use and impairment in sperm motility and/or sperm transport (emission). Both men subsequently showed improvement in sperm counts and motility after discontinuation of their SSRIs, with one of the men also showing a similar association with the norepinephrine-dopamine reuptake inhibitor (NDRI) bupropion.

The July 2007 'Psychopharmacology Reviews' discussed a report of second-degree, type 2 sinoatrial block that resulted from toxic lithium levels Other possible electrocardiogram (ECG) manifestations of lithium toxicity include prolonged QT interval, T-wave flattening and inversion, first-degree atrioventricular conduction delay, and, rarely, ventricular tachycardia and ventricular fibrillation resulting in death.

This is a report of a patient with an acute schizoaffective episode who developed severe cervical dystonia while being treated with a combination of quetiapine and valproic acid. A 60-year-old woman with schizoaffective disorder was admitted to the inpatient psychiatry unit at the University Hospital in Basel, Switzerland due to symptoms of mania and psychosis. She had recently been discharged from the hospital on quetiapine monotherapy 500 mg/day, which led her to remission and had been well tolerated. During that last hospitalization, she suffered two generalized seizures. She discontinued the quetiapine on her own, resulting in a rapid return of psychotic symptoms. She developed paranoia about being poisoned, as manifested by her persistent refusal of food and fluid intake. Upon readmission to the hospital, quetiapine was rapidly increased to 800 mg/day. The cervical dystonia improved with biperiden and resolved totally after reduction of both quetiapine and valproic acid. The patient was discharged on a combination of olanzapine and valproic acid.

A side effect reported in association with olanzapine is metabolic dysregulation, which includes weight gain, hyperinsulinemia, and lipid abnormalities. The following a report of olanzapine induced chylomicronemia resulting in acute pancreatitis. A 36-year-old Libyan man presented with a 3-day history of epigastric pain. While there have been several prior reports describing the association of olanzapine with acute pancreatitis, the exact mechanism remains unclear. Based on the case described here, it appears that chylomicronemia may underlie the association between olanzapine and acute pancreatitis. Regular monitoring of serum lipids is essential not only for general cardiovascular health, but to prevent this potential life-threatening condition.