Faculty Bibliography

Background: Consultation-Liaison (CL) psychiatrists frequently provide consultation for patients prescribed psychotropic medications who have complex cardiopulmonary disease, including prolonged QTc interval and risk for fatal ventricular arrhythmias, like torsades de pointes (TdP). CL Psychiatrists routinely utilize QTc measurements, along other risk factors, to inform risk-benefit analysis when recommending psychotropic medications known to prolong QTc. In order to assess the risk of certain psychotropic medications, the literature suggests relying on EKG parameters not routinely available on automated EKG interpretations. For example, in conditions where a ventricular conduction delay results in a widening of the QRS interval, different methods of correcting the QT interval are required. However, the methods most supported by the literature require complex calculations, limiting their clinical utility especially during behavioral emergencies, as there were no application based or online calculators that offer these formulas. (Funk et al, 2021) Method: Using the Calconic online interactive calculator platform, we created an online calculator that provides the CL psychiatrist with a point-of-care assessment of the QTc interval. This calculator includes the Hodges formula for correcting QTc; Hodges is thought to provide more accurate rate correction than the more commonly available Bazett formula which can overestimate QTc in tachycardic patients. (Beach et al, 2018). In addition, the calculator identifies prolonged QRS intervals and offers four methods for correction: the Bogossian formula with Hodges correction for QTc, the Rautaharju formula for QTc, corrected JT interval (JTc) and the JT prolongation index (JTi). The calculator is optimized for mobile devices, but can be accessed by any web browser (tinyurl.com/QTcCal). We present three cases derived from our clinical experiences to demonstrate the utility of the calculator. Cases: #1: Patient taking methadone and QTc -Bazett prolongation in setting of elevated heart rate. The online calculator recalculates the QTc interval using the Hodges correction supports a recommendation to continue methadone. #2: Patient on aripiprazole and QTc-Bazett prolongation in setting of widened QRS interval. The online calculator corrects for heart rate and widened QRS interval with multiple formulas, the results which support a recommendation to continue aripiprazole. #3: Acute agitation and QTc-Bazett prolongation in an elderly patient. The online calculator corrects for heart rate and widened QRS; however, with these corrections, the risk of TdP remained elevated and the clinician recommends using intravenous valproate for agitation instead of antipsychotics.
Conclusion(s): The interactive online calculator is an effective, point-of-care tool to assist CL psychiatrists in assessing the arrhythmia risk of QTc prolonging medication, including antipsychotics in medically ill patients. References: Beach SR, Celano CM, Sugrue AM, et al. QT Prolongation, Torsades de Pointes, and Psychotropic Medications: A 5-Year Update. Psychosomatics. 2018;59(2):105-122. Funk MC, Beach SR, Bostwick JR, et al. QTc Prolongation and Psychotropic Medications. Am J Psychiatry. 2020;177(3):273-274.
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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: Recent papers have argued that establishing a Behavioral Emergency Response Team (BERT) in the general medical setting can lead to more equitable care for patients (Parker et al., 2020). An unpublished study by our own service on BERT outcomes found that restraints were used to deescalate 3% of patients (n = 29). Of those included in the study sample, Black patients were overrepresented. This was also a pattern in a 2021 study of Emergency Department visits (Wong et al, 2021). The purpose of this planned study is to examine possible racial, ethnic, gender, or language bias patterns in the use of 4-point restraints for behavioral control in the general medical setting when the BERT was activated versus during usual care (no BERT). We intend to use the data to find actionable targets for programmatic and / or institutional quality improvements.
Method(s): This IRB approved study will utilize secondary analysis of an existing clinical dataset combined with retrospective chart review. We will examine all episodes of 4-point restraint use occurring in adult inpatients admitted to any medical or surgical unit from Feb 2017 - December 2021. The following variables will be collected: demographics (race, ethnicity, gender, language, age, height & weight), restraint use (indication, duration), and BERT / psychiatric variables (Psychiatry CL consulted Y/N, BERT involved Y/N, diagnosis). The new combined dataset will be analyzed using simple descriptive statistics. The pattern of restraint use in two subgroups (BERT involved versus BERT not involved) will be compared to investigate whether or not involvement of the BERT influences bias.
Result(s): Our study has been IRB approved. Fifty-seven unique patients have been identified for study inclusion, including 29 patients with restraints documented during a BERT activation and 28 patients with restraints without BERT activation. Preliminary chart review shows variability in documentation on events of restraint use. Data collection is ongoing.
Discussion(s): Preliminary data suggests there may be an important opportunity to improve clinical care by standardizing ordering requirements and documentation of restraint use. Given the ongoing harm that racism poses for both patients and staff, understanding how it influences restraint utilization and BERT activation will guide local programmatic and institutional change, and may help inform future research into bias in mental health care. This project is part of a long-term quality improvement project to examine racial bias in the management of behavioral emergencies throughout our hospital. References: Parker CB, Calhoun A, Wong AH, Davidson L, Dike C. A Call for Behavioral Emergency Response Teams in Inpatient Hospital Settings. AMA J Ethics. Nov 1 2020;22(11):E956-964. Wong AH, Whitfill T, Ohuabunwa EC, et al. Association of Race/Ethnicity and Other Demographic Characteristics With Use of Physical Restraints in the Emergency Department. JAMA Netw Open. 2021;4(1):e2035241.
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Background: CL psychiatrists are uniquely positioned to combat structural racism in medicine Currently, there are no published papers examining racial bias in the management of psychiatric emergencies in the general medical hospital. Given the potential for restrictive clinical interventions that directly challenge a patient's autonomy (including intramuscular injections and restraints), our group embarked on a long-term, quality improvement project to detect and address racial bias affecting the clinical management of these psychiatric emergencies.
Method(s): Our institution has a multidisciplinary behavioral code team known as the Behavioral Emergency Response Team (BERT) that responds to behavioral emergencies throughout the medical hospital. Secondary BERT event data occurring from 2017 to 2020 was combined with demographic data from the electronic medical record. Race and ethnic data were collapsed into unique, phenotypic categories. BERT events were coded based on the most restrictive intervention utilized. Descriptive statistics were used to describe the sample and examine whether race / ethnicity correlated with BERT intervention utilized, diagnostic impression, reason for BERT activation, or recurrent BERTs.
Result(s): Our sample included 1532 BERT events representing N = 902 unique patients. The main interaction of BERT intervention by Race / Ethnic category reached statistical significance (p=0.04). Though most BERTs only required verbal de-escalation (n=419, 46.45%), 3% of BERTs (n = 29) escalated to 4-pt restraints (most restrictive intervention). Though reaching level 5 was rare, Black patients had a statistically significant higher likelihood of receiving this intervention compared with White patients (6% v 2%, p=0.027) and compared with all other non-Black patients (6% v 2%, p=0.040). Although the overall comparison for Race/Ethnicity and the diagnostic impression "Psychosis" did not reach significance (p=0.086), targeted analysis showed that Black patients were significantly more likely to have "Psychosis" listed as a contributing factor compared with White patients (p=0.009) and all other non-Black patients (p=0.016). Several other comparisons with Race / Ethnic category reached statistical significance: Age (p=0.048), and need for interpreter yes/no (p<0.001). Closer examination of the interaction of Race/Ethnicity x Need for Interpreter revealed that half of events involving Asian patients (n=22, 53.66%) and a third of events involving Hispanic patients (n=29, 30.53%) required interpreter services.
Discussion(s): This study demonstrates the feasibility of investigating racial bias in behavioral emergency management. The results of this preliminary analysis suggest multiple areas for enhanced education, self-awareness development, and programmatic improvement to target systemic racism, decrease racial bias, and improve patient care. These areas include bias in restraints use, the role of language in behavioral emergencies, and the influence of race on perception of underlying diagnosis.
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Objective: To review issues with ECT and fire safety. Background: Regulatory agencies are increasing concerned with fire safety in procedural areas. While surgical lasers and electrocautery are more common culprits, ECT may come to the attention of internal and external agencies. ECT providers will need to respond to inquiries about fire safety and demonstrate safety protocols. Design/Methods: We reviewed the literature on fire safety and ECT as well as the Food and Drug Administration's Manufacturer and User Facility Device Experience for adverse events regarding ECT, fire or burns. We developed a fire-safety protocol based on our findings. Results: There are no reports of fire in the FDA database with either of the two commercially available machines in the United States. We discovered only two reported cases of fires related to ECT from the time period of 1992-2015, and none in the last ten years. In the both reported cases, the presence of 100% oxygen has been implicated as an important factor. There are roughly 26 cases of burns or suspected burns reported to the FDA between 1992-2015. Many of these burns appear to be related to improper use of adhesive electrodes or improper preparation of the treatment site. Fire safety in procedural areas focuses on reducing the three components required for ignition: spark, fuel source and oxygen. We adapted these concepts in creating a fire-safety protocol for ECT. Conclusions: Fires and burns are an extremely rare complication in ECT. A reasonable fire-safety protocol can reduce this risk even further

We report a case of a 33-year-old woman with depression and suicidal ideation, treated successfully with electroconvulsive therapy (ECT) in the past. Since her previous course of ECT, she underwent gastric banding, a bariatric surgical procedure associated with increased risk of gastric regurgitation. Despite increasingly stringent measures to minimize the risk of regurgitation and aspiration during ECT, she had several episodes of regurgitation, the last of which precipitated an acute illness consistent with aspiration pneumonitis. We took additional precautions after each event, until she had no further episodes of regurgitation. We discuss the risk posed by the gastric band, the measures we implemented to minimize that risk, and our recommendations for assessment and management of post-gastric banding patients who present for ECT.