Screening and Early Intervention for pSychiatric Management In Critical care (SEISMIC): Clinical outcomes associated with proactive psychiatric consultation for delirium.

BACKGROUND

Previous research has demonstrated that embedded psychiatric consultation in the intensive care unit (ICU) reduces hospital length of stay (LOS) among patients with respiratory failure. However, the financial impact of proactive psychiatric consultation for delirium in the ICU has not been established.

OBJECTIVE

To evaluate the financial and clinical impacts of proactive psychiatric consultation for delirium compared with usual care in a medical ICU.

METHODS

Two medical respiratory ICU (MRICU) teams were quasi-randomized to receive proactive psychiatric consultation for delirium or usual care (UC). Proactive consultation involved screening all patients on the proactive MRICU team for evidence of delirium and performing psychiatric consultations for those meeting predetermined criteria. The UC MRICU requested psychiatric consultations at their discretion. A prospective cohort analysis compared groups using a generalized linear model for mean cost and a negative binomial for LOS. The entire cohort of MRICU patients with documented delirium was analyzed regardless of whether consultation occurred. The primary outcome was average total cost per discharge. Secondary outcomes included hospital and MRICU LOS, and 30-day hospital readmission rates. A subgroup analysis was performed for patients ≥70 years old.

RESULTS

Over a 20-month study period, 693 patients were included (n=331 proactive consultation, n=362 UC). Cohorts were comparable with respect to age, gender, race, insurance, and high-risk clinical variables. The proactive cohort showed a trend toward reduced variable costs ($7,406 lower mean variable cost, p = 0.08). In the ≥70-year-old cohort (n=227; n=108 proactive, n=119 UC), the proactive cohort demonstrated statistically significant reductions in total hospital cost ($12,103 lower mean total cost, p = 0.04) and hospital LOS (3.24 mean fewer days, p = 0.02). The ≥70-year-old cohorts significantly differed in respiratory failure rates and racial composition. An actual return on investment (ROI) calculation ranged from 5.96-12.05.

CONCLUSIONS

Proactive psychiatric consultation for delirium in the ICU yields clinical and financial benefits, including significant reductions in total cost and hospital LOS among patients ≥70-years-old. These findings support the value of proactive psychiatric consultation as a financially and clinically effective strategy for older critically ill patients with delirium.