Mount Sinai Hospital in Toronto developed an automated daily report using electronic health record data to help psychiatric consultation teams identify high-risk patients needing assessment. The report flagged patients meeting criteria like aggression, transfers from psychiatric units, or Clozapine prescriptions. In the first 3 months, 173 patients were identified by the report, leading to 42 new psychiatric consults. The report improved early involvement of psychiatric teams and identification of at-risk patients, promoting both patient and staff safety. Ongoing refinements aim to optimize the report while maintaining identification of true cases needing care.

1. Spotting “Trouble”
Automated Case Finding to Support
Psychiatric Consultation-Liaison Teams
Mavis Afriyie-Boateng
Jocelyn Bennett
Carla Loftus
Lesley Wiesenfeld

2. Context
• Mount Sinai Hospital, Toronto, Canada is a
472 bed academic tertiary care centre
• Psychiatric consultation-liaison teams
previously relied on the attending
physician to refer patients needing
psychiatric assessment and care
• Consultation request lags and several near
misses led to a 2012 policy that allows
psychiatric consultation to be triggered
based on the presence of several high-risk/
high-need criteria

3. Problem/Issue/Opportunity
Which patients did we want to identify?
Hospitalized for medical and surgical care
+
Comorbid mental illness leading to
High Psychiatric Need
Patient is:
•Transferred from a psychiatric or
behavioural inpatient unit
AND/OR
•Prescribed Clozapine (an
antipsychotic medication used to treat
severe mental illness and requiring
monitoring via a Health Canada registry)
Challenging Behaviours
These behaviours include:
•Aggression
•Resistance-to-care
•Wandering
The presence of these behaviours
•Compromises care delivery
•Increase the risk of unintentional
patient/staff physical harm

4. Intervention
• Collaboration with Health
Informatics to develop a
computer-generated daily report
of inpatients meeting outlined
criteria, utilizing information
documented in the electronic
health record
• Psychiatric advanced practice
nurses review the daily report
• If high-risk/high-need criteria are
confirmed as present, then the
appropriate psychiatric
consultation-liaison team further
assesses the patient
High-Risk/High-Need Criteria
that can be extracted from
the electronic record:
•Transfer from a psychiatric or
behavioral unit
•Restraint use for aggressive
behaviour
•Nursing documentation of
aggressive behaviour
•Clozapine prescription
•Security alerts (initiated by
hospital security based on
previous interactions)
•Pyschiatric high risk flags
(added by team in case of
readmission)

5. Measurement
Criteria # Action #
Restraints for aggression 5 Consult
Already followed
None (imminent discharge)
1
3
1
Nursing documentation
of aggression
154 Consult
Already following
False positive (charting error)
None (imminent discharge)
38
21
93
2
Clozapine prescription 3 Consult
Already followed
1
2
Security alert 9 Consult
Already following
No psychiatric need
2
4
3
Psychiatry alert 2 Consult
No psychiatric need
0
2
Transfer from Inpatient
Psychiatry
1 False positive (charting error) 1
Transfer from Behavioral
Unit
0
Profile of Patients
appearing on the
report (July to
September 2014):
In summary:
173 patients were
identified
42 psychiatric
consults were
triggered
21 patients were
already being
followed

6. Contribution to Patient Safety
Safe Patients/Safe StaffTM
• The computer-generated daily report has both
– Facilitated early involvement of the psychiatric consultation-liaison teams in the care of
patients with high psychiatric need and/or with challenging behaviours, and
– Has led to identification of patients who would have been missed by the traditional
consultative model
• For patients with high psychiatric need, the psychiatric consultation-liaison
teams ensured that ongoing psychiatric care was maintained
during the patient’s medical or surgical admission
• For patients with challenging behaviours, the psychiatric consultation-liaison
teams focused on ensuring the safe delivery of needed care, which
promoted both patient and staff safety
• We recommend that other teams consider using an automated report to
aid with case-finding

7. Partnership
• The psychiatric consultation-liaison teams were
concerned that patients would feel stigmatized
through being identified as meeting high-risk/high-need
criteria
• Thus, the teams explained the reason for their
involvement in terms of the benefit to the patient
and the majority of patients were receptive to
working with the teams

8. Lessons Learned &
Sustainability
• Ongoing iterative changes are being made to the report to optimize the
identification of patients
– The false positive rate has been hard to decrease without missing true cases
• Sustainability has been ensured through having dedicated staff to review
the safety reports and involve the psychiatric consultation-liaison teams
• With multiple early good catches, the value of the report was quickly
recognized and through further use it has become a routine method of
identifying patients requiring psychiatric care
• Overall, the automated report has been successful case-finding strategy
and other teams are advised to consider developing their own report
For any questions or further information, please contact Carla Loftus
at 416-586-4800 x7292, cloftus@mtsinai.on.ca