more appropriate in centers in which treatment plans for Medicaid clients or for clients of particular programs are handled by different individuals. The Cumberland County CM HC periodically creates this listing for several months preceding the current month. This procedure allows the medical records administrator to verify that no past-due treatment plans go unattended. Since the listing includes the type of payment and the number of the responsible therapist, it simplifies the distribution of the record to the appropriate staff member for correction. ADVANTAGES
OF
THE
SYSTEM
This package of computer programs is intended as a model of an information storage and retrieval system that meets specific organizational and logistical needs of the record-reviewing process. Since these are simple programs that merely store data and then retrieve selected portions, similar programs can be easily written for other machine models. This cjnd of retrieval approach can even be simulated at small centers through a series of card index systems. It is not necessary to have computer hardware inhouse. The programs can be processed in computer centers in the comrpinity or in the computer facilities of the state department of mental health. The keypunching and actuJ pomputer run-time depend on the size of the c!ient load, but they ar reduced and become reasonably constant once the basic disk file is established. Confidentiality of a client’s records is protected by ensuring that only individuals who are employed or contracted by the CM HC have access to the data. The computer cards and the disks can b stored at the center for additional security. There are a number of administrative and clinica’ advantages to using such an automated information storage and retrieval package. The programs provide administrators with data that can be analyzed to determine such information as the distribution of caseload among programs and among clinical personnel, the duration of treatment for all clients and for clients by payment type or by program, the average number of clinical staff and of programs that provide services to each client, and monthly trends in client activity for different programs. Clients also benefit from an automated storage and retrieval approach because the clinical staff can more efficiently comply with the documentation requirements and thereby devote more of their time to direct care and treatment. The system itself, by way of regular updated print-outs, encourages clinical staff to maintain current treatment plans for each client. Such staff cooperation in turn allows the utilization review committee to proceed beyond their initial responsibility for proper and accountable record documentation to the clinical task of monitoring quality control in treatment services.#{149}
Psychiatric Peer Review: A Working Model
M. GERALD Berkeley,
HOSPITAL
& COMMUNITY
PSYCHIATRY
M.D.
The author describes a system for psychiatric peer review developed by a peer review committee in a general hospital. At the heart of the system is aform called the peer review check sheet, which requires the physician to specify diagnosis, reasons for hospitalization, and major symptom complexes, as well as laboratory work and treatment and discharge plans. Minimal criteria have been established to verify the diagnoses and to justify the need for hospitalization. Each month the check sheets are removed from the charts of patients who have been discharged and sent to committee members for evaluation. Those that are incomplete or unsatisfactory signal the need to examine the patient’s chart. #{149} Herrick Memorial Hospital in Berkeley, California, has been using a psychiatric peer review system for more than two years. Our results are sufficiently encouraging to make us feel the system is worth describing to others; deficiencies are sufficiently apparent to let us hope that others may offer thoughts for improving it. We believe that peers can and should review the work of one another, and that if the methods used are appropriate, benefits will accrue to both patients and staff. Our system functions in a 241-bed general hospital, with 62 of the beds in three psychiatric wards; two are open, one is closed. We average 130 psychiatric admissions per month, with the average length of stay 12 Dr.
Edelstien’s
94704.
656
EDELSTIEN,
California
address
is 2486
Shattuck
Avenue,
Berkeley,
California
days. Medi-Cal and Medicare fund 70 per cent of our admissions. There are 140 psychiatrists on our staff; approximately a third of them admit patients to the hospital. Because members of our staff use a diversity of therapeutic approaches, ranging from almost purely somatic to primarily insight-oriented, we have attempted to set broad but reasonable criteria for acceptable care. When the six-member peer review committee was first organized, there was a long and painful process of trying to determine not only what we were attempting to evaluate, but how to set standards for that evaluation. It became apparent to us, as it had to others before us, that a specific diagnosis has little relationship to whether or not a patient requires hospitalization. Schizophrenics, for example, are hospitalized not because they are schizophrenics, but because they have certain deficiencies in specific areas of functioning that make their staying in the open community painful, disruptive, or dangerous. We therefore decided that reasons for hospitalization should be based primarily on the severity of dysfunction in those specific areas. We further realized that lengths of stay should not be determined by the patient’s diagnosis and his age, because those factors did not seem nearly as relevant as the severity of his illness and the effectiveness of his treatment. The effectiveness of his treatment, in turn, seemed most related to two factors: the availability of specific therapeutic modalities, and the intelligent application of those modalities. For any case under review, therefore, we wished to know the following: In what ways i the patient disabled? Do his areas of disability cpnform to the ex-
FIGURE HMH
1
Peer Review
DEPARTMENT
Chart
OF
Check
List
PSYCHIATRY
Peer
Ag.S.z_Admltt.d
No.
A
Diajnos..
B
R.ason. for Ho.pttali.atioo I Danger to .1f; 2 Dang.r faA; S Sp.c*.fic tr..gnt.nt vol. Level. Brief eiatloo
pected pattern for his stated diagnosis? Are they sufficiently severe to justify his initial hospitalization, and have they remained sufficiently severe to warrant his continued hospitalization? Is the treatment being rendered appropriate to the disease? Because obtaining that information from the hospital chart would require tedious digging through tracts of terrible handwriting, a form called the Peer Review Check Sheet was devised to present us with the necessary data in a clear, concise manner (see Figure 1). The check sheet can be filled out initially by the attending physician in four to five minutes, and he can update it at the specified intervals in one to three mmutes. It is removed from the chart at the time of the patient’s discharge, and becomes available only to members of the committee, thus permitting physicians to be more specific than they might otherwise choose to be if the sheet were a permanent part of the chart and potentially available to third parties. We established minimal criteria to verify the diagnoses that together represent more than 90 per cent of the admissions to our service (see Table 1). Minimal criteria such as these must be appalling to anyone who is a purist about diagnoses, and they are no source of joy to us either, yet they serve a useful functiop. Frankly, I doubt that any member of the committee uses these criteria exclusively, but augments them with his own clinical judgment-a process that must be appalling to anyone who is a purist about forms and minimal criteria. We see no purpose in having clinicians on the committee, however, if their experience and judgment are not to be used. We established criteria that would justify an admis-
R.vt.w
Cb.ck
Sh..t
D
Tr.atm..t
(Circle appropriate number and comm.ntf to other.; 3 Graoeiy disabl.d; 4 #{163}notro.tment r.qul.tog ho.pttaiioation; 6 Other.
Symptom to .hox’
Reality (C)
ta.tthg
hallucination.
2 3
linpul.e control Object r.lation.: cl .adi.tic,
4
Thought gored,
S
(a) . .
.lgitO.
earea#{149} of trouble at ume pre.,. t, 1.2, mild, 3.4,
of unreality. .ound,
(b) touch,
delo.iona, .mell,
: )e)
of admi..ton moderate, Day 1
(o)do,.ftooot...oio..__________________________________
3
and 5-6. lay 3
us. cevxrc.
lay 7
sy 14
b.c. lay 21
7
8 9
10 11
(.&o..
do.sg,
.
SOth. Mojo
tinch. 1Mg
Choog..
Ploo
I,
-
(oho,g.
dot.
o1oaal.l___________________________
F
(.)________________________
(a) retardation, night of Idea.,
)b) blocking, (f) ctrcum.tantial.
cl
-1DS.
pr...
ng.ntia1, (h) incoherent, (1) Thcugbtco.,t.ct )n)grxndlo.tty, )b) Idea. (Cl persecution. dl self. accua hon. (.1 bypochondriasl.. (1) .elf-d..tructlce. )g) ctol.nc. tox’ard other., )h) ob.... stone, (I) phobia., ) hop.l . )k)__________________ L.r.l of conoctou #{149} (a) fugue state, (b( confu.ton, (c( delirium, (d) .tupor. (e) coma. fl__________________ Int.ll.ctun.l functions a) judgment )b( orl.ntation____________________ (C) Intellect _______________________________ )d)memory Affect: (xl xuphoria. )b( depre..ion. cl anxiety. (dl anger. I.) flat. (1) inapproprlat.. )g( labile. )b(_________________ Acticlty: (a) by perac tire. )b) hypoactire. (C) dy.functional. (d, calatonic. (e) repetitice. fl automatic. (g( compulnios. (b) muti.m. (I) .tereotropl.m. il lice. (hI_________________ Drug aba.. l..t drug._______________________________ Pby.ical (.p.clfy) _____________________________________ (4)
6
M.dios2oo.
(d)______
(.pectIy)_______________________________ (a) t.olated. (b) dep.nd.nt.clingtng, ma.ochi.ttc.
(4)
proc ...es (4) loo.e.
(Ctrcl 0, not
e.e.c
(a) goal.
ECT
.
Complex Iecer1,y
P.y,h.tI....py (b)ft.qooooyof....loa.
too .tre..-
4
Mejor code.
dtr.ctton.
I 2
C
Plan
1
Sp.cifio
Di.charg.d__________
E,op,lab*:k
b.food
C
H
Ro.olt.
Dincttargo 1
D .$o...
2
D *.po.ili
00
(1) 1i.*og (2) aft
asog.m.o (I) UI)
in#{149}titotloo
(Ill) th.apt.’ (3) .o.dlcatlo
VOLUME
27
NUMBER
dt.p.tt..d
foam..
app’.
otsdo.................PRN
do.ago)
9 SEPTEMBER
1976
657
TABLE
Minimal
1
criteria
for acceptable
diagnosis
TABLE
Required
symptom
All charts must have: Treatment plan
complex1
3
Check
Treatment Organic
brain
syndrome
6 or two
Schizophrenia Manic-depressive Psychotic
psychosis depression
Depressive
neurosis
Alcoholism
or other
I
Refer
to peer
review
1 or4
or5
4 or 8
and
4 or 8 and drugs check
5 or 8
and
2 and
10
items
in 7
sheet
2
Minimal
nursing
One-to-one
orders
therapy
9 9
Psychotic
9
depressive
depressions (including involutional illness): ECT and/or Antidepressants (see table for recommended
criteria
for
symptom
Danger Danger
to self
1 or 2 or 5 or 7
to others
1 or 2 or 5
Gravely
disabled
6 or two
Treatment
The
items
Parnate,
tion,
(see
reason
to peer
review
for recommended
dosage)
for recommended
dosage)
phase:
(see
table
ECT
and/or
checks tests
must ECT,
Nardil,
drug
structured
lithium. If lithium is used, there must be twice-weekly of lithium levels until level stabilizes; thyroid (T3, T4, or PB!); and BUN
plan
to use
Manic-depressive,
lithium, detoxifica-
environment,
high
depressed
phase:
Antidepressants
(see
for
and/or and/or
If
table
recommended
dosage)
ECT
lithium.
lithium
is used,
see above
requirements
of tranquilizers
Committee check
table
manic
tranquilizer
Alcoholism
review
with
Medication Refer
dosage)
in 7
physician
the following:
doses
Major and/or
complex1
9 or 6 or 7
1 and
Diagnosis
I
manic-
hospitalization Manic-depressive,
other
and
sheet
Required
Any
review
goals
Specific
Acute schizophrenia: Major tranquilizer
TABLE
for treatment
sheet
Librium,
orders
vulsive
vitamins
or
paraldehyde
must
call
for
I
and
precautions,
sleep SMA
DTs:
include
Valium,
Nursing
sion for each of the more common reasons for admission (see Table 2).These work out rather well. If a patient is admitted for some reasons other than those listed, the chart will he pulled, but to date we have always found the admission justifiable in those cases thus examined. Table 3 presents the minimal requirements for ade-
impending
must
18
time (electrolytes
Internal
and
medicine
Interview
patient’s
either
frequent 0,
observation,
vital
liver
signs,
functions) per
consultation
with
Posthospital
and
(60
con-
and
cent
of
cases)
family
plans
treatment of each of the most common diagnoses. This area is most in need of further development as far as the committee is concerned. It is obvious from these criteria that we became specific only about physical therapies, hut this in no way indicates that we are minimizing the importance of interactional and insightoriented therapies; rather, it is an indication of our inability to specifically state what would be appropriate for such therapies. Here, more than elsewhere, clinical judgment becomes a necessary part of the evaluation. Data to make those evaluations are available from the treatment plan. For instance, for an overtly psychotic patient, it might be considered appropriate if the talking part of the therapy were devoted to establishing a therapeutic allegiance, stressing the need for continued use of medication and outpatient therapy, and planning an adequate posthospital placement. For the neurotic patient, however, we would probably expect evidence of attention to the dynamic issues involved in the case.
Organic
IMPLEMENTING
were given permission for a three-month trial period. Cooperation in filling out the check sheets was quite poor initially, so at the end of the first three months, we requested that we be given another three-month trial period and that filling out the sheets be made a departI
(Plate
THE
Having established plans for utilizing the departmental
our them, staff
658
HOSPITAL
REVIEW
PROCESS
criteria, and having worked we requested permission to try out our procedure.
& COMMUNITY
out from We
PSYCHIATRY
brain
Known
syndrome:
origin
or
Recommended (This
daily
level
unless
extensive
should
there
dosage
be
are
search
it
for antidepressants:
reached
clear
for
by
signs
of
the
end
of
the second
improvement
with
week lower
doses.) 30 150
mg.
for Nardil,
mg.
for
Parnate,
Aventyl,
Pertofrane,
Vivactil
Deprol,
Presamine,
Elavil,
Sinequan,
Etrafon,
Tofranil,
Recommended daily dosage for tranquilizers: (This level should be reached by the end unless
there
are
clear
signs
of
improvement
Norpramin,
Triavil
of the
first week with
lower
doses.)
Haldol
10
mg.
Serentil
Mellaril
600
mg.
Stelazine
30
Navane
30
mg.
Taractan
200
Thorazine
600
mg. mg. mg. mg.
24
mg.
8 mg.
Prolixin
Quide
120
mg.
Trilafon
400
mental requirement. Those requests were also granted. To be certain that each member of the department fully understood how the forms were to be completed, instructions were mailed out, and they are also given to each new member of the department. Our program is running smoothly at this point; there is no specific time limit on our functioning, and with only a few exceptions cooperation from the staff is quite good. These are the procedures we have established: I Each month all check sheets are removed from the charts of patients who were discharged that month. They are sent to the committee, and there they are divided evenly among the members for evaluation. We have found that we can evaluate a check sheet, after a little practice, in one or two minutes. S The evaluation divides the check sheets into three categories: Complete and meeting minimal requirements. No further action is taken. Incomplete. These sheets are returned to the attending physician for completion, and are then reviewed again. Complete, but not meeting minimal requirements or otherwise indicating the chart should be reviewed. It should be stressed that the check sheets are never used to determine that care is substandard. They merely signal possible trouble, and at that point the chart itself is examined. . Each member reviews four to five charts a month. If there are not that many that have been signaled out by the check sheet, he reviews a few good’ ones, to help assure us that our screening method is still working adequately. . If review of the chart leaves important questions still unanswered, or answered unsatisfactorily, one of three actions will be taken: A letter of information will be sent to the physician. For instance, if he failed to note an abnormal laboratory finding, we will call it to his attention. Or if he started a patient on lithium and did not order thyroid and renal function tests, we will state that most authorities believe these preliminary tests should be done. A letter requesting further information from him will be sent, so that we might better understand an issue that was not adequately explained on the chart. The physician will be invited to attend a committee meeting and discuss his case. That is done primarily if we have multiple questions about the case, or any time there has been a death on the ward. . We attempt to emphasize the fact that our function is primarily educational. To this end we send letters of information to individual physicians, submit monthly reports to the staff, and inform the contmnuing-education committee of problem areas in order to facilitate programs covering those areas. . We maintain records of check sheets evaluated, charts reviewed, deficiencies found, and actions taken. ‘ ‘
‘
The results of our activities are not spectacular, are they statistically significant. We have found most of the cases reviewed have been handled well,
that there are not statistically significant areas of deficiency to be improved in statistically significant ways. We believe, however, that our efforts have been useful, and can offer the following “soft” data as evidence. Of the first 12 charts examined, three had no physicals recorded, and two had no histories. Letters were sent to the attending physicians, and a notice was sent to the staff. In the past year, only one physician has repeated that omission. Abnormal CBCs and urines went unnoted several times a month on the charts reviewed until we started oalling that fact to the attention of the staff; such occurrences are now rare. Gross polypharmacy seems to be reduced, although a number of doctors still use a combination of two major tranquilizers at a time. Numerous other deficiencies have occurred, but each with such infrequency that the only comment we are able to make is that we have tried to call each of these to the attention of the attending physician. From time to time members of our staff have expressed appreciation for our letters of information. The few who have attended a meeting to discuss a case have generally felt that the discussion was more like a friendly consultation than like an inquisition. Ward nurses often find that the check sheet gives them more information about the patient than they get from the doctor in any other manner, and thus it enables them to formulate better treatment plans. Finally, information on the check sheet is an excellent source of necessary data for the utilization review coordinator. The check sheet, which is the heart of our program, has proven to be a reliable screening device. If it signals out a chart, we find deficiencies in that chart 40 to 70 per cent of the time. The worst deficiency we have yet found in a chart that passes the screening test was failure to note an abnormal urinalysis. On random checks of charts that passed the screen, we have always found that the data on the check sheet correspond well with the data in the chart-relieving early apprehensions that the check sheet might be filled out fraudulently to sneak questionable cases past the committee. In summary, we have a reasonably satisfactory method of doing psychiatric peer review. Our system enables us to do a screening evaluation of all of the cases admitted to our service, to do a detailed review of approximately 20 per cent of our cases, and to have in that group the cases most apt to show deficiencies. Additionally, it enables us to enhance the continuingeducation program at our hospital. All of this involves considerable work, but we feel it is worth it.U
nor that and
VOLUME
27
NUMBER
9 SEPTEMBER
1976
659
OF
THE
SYSTEM
This package of computer programs is intended as a model of an information storage and retrieval system that meets specific organizational and logistical needs of the record-reviewing process. Since these are simple programs that merely store data and then retrieve selected portions, similar programs can be easily written for other machine models. This cjnd of retrieval approach can even be simulated at small centers through a series of card index systems. It is not necessary to have computer hardware inhouse. The programs can be processed in computer centers in the comrpinity or in the computer facilities of the state department of mental health. The keypunching and actuJ pomputer run-time depend on the size of the c!ient load, but they ar reduced and become reasonably constant once the basic disk file is established. Confidentiality of a client’s records is protected by ensuring that only individuals who are employed or contracted by the CM HC have access to the data. The computer cards and the disks can b stored at the center for additional security. There are a number of administrative and clinica’ advantages to using such an automated information storage and retrieval package. The programs provide administrators with data that can be analyzed to determine such information as the distribution of caseload among programs and among clinical personnel, the duration of treatment for all clients and for clients by payment type or by program, the average number of clinical staff and of programs that provide services to each client, and monthly trends in client activity for different programs. Clients also benefit from an automated storage and retrieval approach because the clinical staff can more efficiently comply with the documentation requirements and thereby devote more of their time to direct care and treatment. The system itself, by way of regular updated print-outs, encourages clinical staff to maintain current treatment plans for each client. Such staff cooperation in turn allows the utilization review committee to proceed beyond their initial responsibility for proper and accountable record documentation to the clinical task of monitoring quality control in treatment services.#{149}
Psychiatric Peer Review: A Working Model
M. GERALD Berkeley,
HOSPITAL
& COMMUNITY
PSYCHIATRY
M.D.
The author describes a system for psychiatric peer review developed by a peer review committee in a general hospital. At the heart of the system is aform called the peer review check sheet, which requires the physician to specify diagnosis, reasons for hospitalization, and major symptom complexes, as well as laboratory work and treatment and discharge plans. Minimal criteria have been established to verify the diagnoses and to justify the need for hospitalization. Each month the check sheets are removed from the charts of patients who have been discharged and sent to committee members for evaluation. Those that are incomplete or unsatisfactory signal the need to examine the patient’s chart. #{149} Herrick Memorial Hospital in Berkeley, California, has been using a psychiatric peer review system for more than two years. Our results are sufficiently encouraging to make us feel the system is worth describing to others; deficiencies are sufficiently apparent to let us hope that others may offer thoughts for improving it. We believe that peers can and should review the work of one another, and that if the methods used are appropriate, benefits will accrue to both patients and staff. Our system functions in a 241-bed general hospital, with 62 of the beds in three psychiatric wards; two are open, one is closed. We average 130 psychiatric admissions per month, with the average length of stay 12 Dr.
Edelstien’s
94704.
656
EDELSTIEN,
California
address
is 2486
Shattuck
Avenue,
Berkeley,
California
days. Medi-Cal and Medicare fund 70 per cent of our admissions. There are 140 psychiatrists on our staff; approximately a third of them admit patients to the hospital. Because members of our staff use a diversity of therapeutic approaches, ranging from almost purely somatic to primarily insight-oriented, we have attempted to set broad but reasonable criteria for acceptable care. When the six-member peer review committee was first organized, there was a long and painful process of trying to determine not only what we were attempting to evaluate, but how to set standards for that evaluation. It became apparent to us, as it had to others before us, that a specific diagnosis has little relationship to whether or not a patient requires hospitalization. Schizophrenics, for example, are hospitalized not because they are schizophrenics, but because they have certain deficiencies in specific areas of functioning that make their staying in the open community painful, disruptive, or dangerous. We therefore decided that reasons for hospitalization should be based primarily on the severity of dysfunction in those specific areas. We further realized that lengths of stay should not be determined by the patient’s diagnosis and his age, because those factors did not seem nearly as relevant as the severity of his illness and the effectiveness of his treatment. The effectiveness of his treatment, in turn, seemed most related to two factors: the availability of specific therapeutic modalities, and the intelligent application of those modalities. For any case under review, therefore, we wished to know the following: In what ways i the patient disabled? Do his areas of disability cpnform to the ex-
FIGURE HMH
1
Peer Review
DEPARTMENT
Chart
OF
Check
List
PSYCHIATRY
Peer
Ag.S.z_Admltt.d
No.
A
Diajnos..
B
R.ason. for Ho.pttali.atioo I Danger to .1f; 2 Dang.r faA; S Sp.c*.fic tr..gnt.nt vol. Level. Brief eiatloo
pected pattern for his stated diagnosis? Are they sufficiently severe to justify his initial hospitalization, and have they remained sufficiently severe to warrant his continued hospitalization? Is the treatment being rendered appropriate to the disease? Because obtaining that information from the hospital chart would require tedious digging through tracts of terrible handwriting, a form called the Peer Review Check Sheet was devised to present us with the necessary data in a clear, concise manner (see Figure 1). The check sheet can be filled out initially by the attending physician in four to five minutes, and he can update it at the specified intervals in one to three mmutes. It is removed from the chart at the time of the patient’s discharge, and becomes available only to members of the committee, thus permitting physicians to be more specific than they might otherwise choose to be if the sheet were a permanent part of the chart and potentially available to third parties. We established minimal criteria to verify the diagnoses that together represent more than 90 per cent of the admissions to our service (see Table 1). Minimal criteria such as these must be appalling to anyone who is a purist about diagnoses, and they are no source of joy to us either, yet they serve a useful functiop. Frankly, I doubt that any member of the committee uses these criteria exclusively, but augments them with his own clinical judgment-a process that must be appalling to anyone who is a purist about forms and minimal criteria. We see no purpose in having clinicians on the committee, however, if their experience and judgment are not to be used. We established criteria that would justify an admis-
R.vt.w
Cb.ck
Sh..t
D
Tr.atm..t
(Circle appropriate number and comm.ntf to other.; 3 Graoeiy disabl.d; 4 #{163}notro.tment r.qul.tog ho.pttaiioation; 6 Other.
Symptom to .hox’
Reality (C)
ta.tthg
hallucination.
2 3
linpul.e control Object r.lation.: cl .adi.tic,
4
Thought gored,
S
(a) . .
.lgitO.
earea#{149} of trouble at ume pre.,. t, 1.2, mild, 3.4,
of unreality. .ound,
(b) touch,
delo.iona, .mell,
: )e)
of admi..ton moderate, Day 1
(o)do,.ftooot...oio..__________________________________
3
and 5-6. lay 3
us. cevxrc.
lay 7
sy 14
b.c. lay 21
7
8 9
10 11
(.&o..
do.sg,
.
SOth. Mojo
tinch. 1Mg
Choog..
Ploo
I,
-
(oho,g.
dot.
o1oaal.l___________________________
F
(.)________________________
(a) retardation, night of Idea.,
)b) blocking, (f) ctrcum.tantial.
cl
-1DS.
pr...
ng.ntia1, (h) incoherent, (1) Thcugbtco.,t.ct )n)grxndlo.tty, )b) Idea. (Cl persecution. dl self. accua hon. (.1 bypochondriasl.. (1) .elf-d..tructlce. )g) ctol.nc. tox’ard other., )h) ob.... stone, (I) phobia., ) hop.l . )k)__________________ L.r.l of conoctou #{149} (a) fugue state, (b( confu.ton, (c( delirium, (d) .tupor. (e) coma. fl__________________ Int.ll.ctun.l functions a) judgment )b( orl.ntation____________________ (C) Intellect _______________________________ )d)memory Affect: (xl xuphoria. )b( depre..ion. cl anxiety. (dl anger. I.) flat. (1) inapproprlat.. )g( labile. )b(_________________ Acticlty: (a) by perac tire. )b) hypoactire. (C) dy.functional. (d, calatonic. (e) repetitice. fl automatic. (g( compulnios. (b) muti.m. (I) .tereotropl.m. il lice. (hI_________________ Drug aba.. l..t drug._______________________________ Pby.ical (.p.clfy) _____________________________________ (4)
6
M.dios2oo.
(d)______
(.pectIy)_______________________________ (a) t.olated. (b) dep.nd.nt.clingtng, ma.ochi.ttc.
(4)
proc ...es (4) loo.e.
(Ctrcl 0, not
e.e.c
(a) goal.
ECT
.
Complex Iecer1,y
P.y,h.tI....py (b)ft.qooooyof....loa.
too .tre..-
4
Mejor code.
dtr.ctton.
I 2
C
Plan
1
Sp.cifio
Di.charg.d__________
E,op,lab*:k
b.food
C
H
Ro.olt.
Dincttargo 1
D .$o...
2
D *.po.ili
00
(1) 1i.*og (2) aft
asog.m.o (I) UI)
in#{149}titotloo
(Ill) th.apt.’ (3) .o.dlcatlo
VOLUME
27
NUMBER
dt.p.tt..d
foam..
app’.
otsdo.................PRN
do.ago)
9 SEPTEMBER
1976
657
TABLE
Minimal
1
criteria
for acceptable
diagnosis
TABLE
Required
symptom
All charts must have: Treatment plan
complex1
3
Check
Treatment Organic
brain
syndrome
6 or two
Schizophrenia Manic-depressive Psychotic
psychosis depression
Depressive
neurosis
Alcoholism
or other
I
Refer
to peer
review
1 or4
or5
4 or 8
and
4 or 8 and drugs check
5 or 8
and
2 and
10
items
in 7
sheet
2
Minimal
nursing
One-to-one
orders
therapy
9 9
Psychotic
9
depressive
depressions (including involutional illness): ECT and/or Antidepressants (see table for recommended
criteria
for
symptom
Danger Danger
to self
1 or 2 or 5 or 7
to others
1 or 2 or 5
Gravely
disabled
6 or two
Treatment
The
items
Parnate,
tion,
(see
reason
to peer
review
for recommended
dosage)
for recommended
dosage)
phase:
(see
table
ECT
and/or
checks tests
must ECT,
Nardil,
drug
structured
lithium. If lithium is used, there must be twice-weekly of lithium levels until level stabilizes; thyroid (T3, T4, or PB!); and BUN
plan
to use
Manic-depressive,
lithium, detoxifica-
environment,
high
depressed
phase:
Antidepressants
(see
for
and/or and/or
If
table
recommended
dosage)
ECT
lithium.
lithium
is used,
see above
requirements
of tranquilizers
Committee check
table
manic
tranquilizer
Alcoholism
review
with
Medication Refer
dosage)
in 7
physician
the following:
doses
Major and/or
complex1
9 or 6 or 7
1 and
Diagnosis
I
manic-
hospitalization Manic-depressive,
other
and
sheet
Required
Any
review
goals
Specific
Acute schizophrenia: Major tranquilizer
TABLE
for treatment
sheet
Librium,
orders
vulsive
vitamins
or
paraldehyde
must
call
for
I
and
precautions,
sleep SMA
DTs:
include
Valium,
Nursing
sion for each of the more common reasons for admission (see Table 2).These work out rather well. If a patient is admitted for some reasons other than those listed, the chart will he pulled, but to date we have always found the admission justifiable in those cases thus examined. Table 3 presents the minimal requirements for ade-
impending
must
18
time (electrolytes
Internal
and
medicine
Interview
patient’s
either
frequent 0,
observation,
vital
liver
signs,
functions) per
consultation
with
Posthospital
and
(60
con-
and
cent
of
cases)
family
plans
treatment of each of the most common diagnoses. This area is most in need of further development as far as the committee is concerned. It is obvious from these criteria that we became specific only about physical therapies, hut this in no way indicates that we are minimizing the importance of interactional and insightoriented therapies; rather, it is an indication of our inability to specifically state what would be appropriate for such therapies. Here, more than elsewhere, clinical judgment becomes a necessary part of the evaluation. Data to make those evaluations are available from the treatment plan. For instance, for an overtly psychotic patient, it might be considered appropriate if the talking part of the therapy were devoted to establishing a therapeutic allegiance, stressing the need for continued use of medication and outpatient therapy, and planning an adequate posthospital placement. For the neurotic patient, however, we would probably expect evidence of attention to the dynamic issues involved in the case.
Organic
IMPLEMENTING
were given permission for a three-month trial period. Cooperation in filling out the check sheets was quite poor initially, so at the end of the first three months, we requested that we be given another three-month trial period and that filling out the sheets be made a departI
(Plate
THE
Having established plans for utilizing the departmental
our them, staff
658
HOSPITAL
REVIEW
PROCESS
criteria, and having worked we requested permission to try out our procedure.
& COMMUNITY
out from We
PSYCHIATRY
brain
Known
syndrome:
origin
or
Recommended (This
daily
level
unless
extensive
should
there
dosage
be
are
search
it
for antidepressants:
reached
clear
for
by
signs
of
the
end
of
the second
improvement
with
week lower
doses.) 30 150
mg.
for Nardil,
mg.
for
Parnate,
Aventyl,
Pertofrane,
Vivactil
Deprol,
Presamine,
Elavil,
Sinequan,
Etrafon,
Tofranil,
Recommended daily dosage for tranquilizers: (This level should be reached by the end unless
there
are
clear
signs
of
improvement
Norpramin,
Triavil
of the
first week with
lower
doses.)
Haldol
10
mg.
Serentil
Mellaril
600
mg.
Stelazine
30
Navane
30
mg.
Taractan
200
Thorazine
600
mg. mg. mg. mg.
24
mg.
8 mg.
Prolixin
Quide
120
mg.
Trilafon
400
mental requirement. Those requests were also granted. To be certain that each member of the department fully understood how the forms were to be completed, instructions were mailed out, and they are also given to each new member of the department. Our program is running smoothly at this point; there is no specific time limit on our functioning, and with only a few exceptions cooperation from the staff is quite good. These are the procedures we have established: I Each month all check sheets are removed from the charts of patients who were discharged that month. They are sent to the committee, and there they are divided evenly among the members for evaluation. We have found that we can evaluate a check sheet, after a little practice, in one or two minutes. S The evaluation divides the check sheets into three categories: Complete and meeting minimal requirements. No further action is taken. Incomplete. These sheets are returned to the attending physician for completion, and are then reviewed again. Complete, but not meeting minimal requirements or otherwise indicating the chart should be reviewed. It should be stressed that the check sheets are never used to determine that care is substandard. They merely signal possible trouble, and at that point the chart itself is examined. . Each member reviews four to five charts a month. If there are not that many that have been signaled out by the check sheet, he reviews a few good’ ones, to help assure us that our screening method is still working adequately. . If review of the chart leaves important questions still unanswered, or answered unsatisfactorily, one of three actions will be taken: A letter of information will be sent to the physician. For instance, if he failed to note an abnormal laboratory finding, we will call it to his attention. Or if he started a patient on lithium and did not order thyroid and renal function tests, we will state that most authorities believe these preliminary tests should be done. A letter requesting further information from him will be sent, so that we might better understand an issue that was not adequately explained on the chart. The physician will be invited to attend a committee meeting and discuss his case. That is done primarily if we have multiple questions about the case, or any time there has been a death on the ward. . We attempt to emphasize the fact that our function is primarily educational. To this end we send letters of information to individual physicians, submit monthly reports to the staff, and inform the contmnuing-education committee of problem areas in order to facilitate programs covering those areas. . We maintain records of check sheets evaluated, charts reviewed, deficiencies found, and actions taken. ‘ ‘
‘
The results of our activities are not spectacular, are they statistically significant. We have found most of the cases reviewed have been handled well,
that there are not statistically significant areas of deficiency to be improved in statistically significant ways. We believe, however, that our efforts have been useful, and can offer the following “soft” data as evidence. Of the first 12 charts examined, three had no physicals recorded, and two had no histories. Letters were sent to the attending physicians, and a notice was sent to the staff. In the past year, only one physician has repeated that omission. Abnormal CBCs and urines went unnoted several times a month on the charts reviewed until we started oalling that fact to the attention of the staff; such occurrences are now rare. Gross polypharmacy seems to be reduced, although a number of doctors still use a combination of two major tranquilizers at a time. Numerous other deficiencies have occurred, but each with such infrequency that the only comment we are able to make is that we have tried to call each of these to the attention of the attending physician. From time to time members of our staff have expressed appreciation for our letters of information. The few who have attended a meeting to discuss a case have generally felt that the discussion was more like a friendly consultation than like an inquisition. Ward nurses often find that the check sheet gives them more information about the patient than they get from the doctor in any other manner, and thus it enables them to formulate better treatment plans. Finally, information on the check sheet is an excellent source of necessary data for the utilization review coordinator. The check sheet, which is the heart of our program, has proven to be a reliable screening device. If it signals out a chart, we find deficiencies in that chart 40 to 70 per cent of the time. The worst deficiency we have yet found in a chart that passes the screening test was failure to note an abnormal urinalysis. On random checks of charts that passed the screen, we have always found that the data on the check sheet correspond well with the data in the chart-relieving early apprehensions that the check sheet might be filled out fraudulently to sneak questionable cases past the committee. In summary, we have a reasonably satisfactory method of doing psychiatric peer review. Our system enables us to do a screening evaluation of all of the cases admitted to our service, to do a detailed review of approximately 20 per cent of our cases, and to have in that group the cases most apt to show deficiencies. Additionally, it enables us to enhance the continuingeducation program at our hospital. All of this involves considerable work, but we feel it is worth it.U
nor that and
VOLUME
27
NUMBER
9 SEPTEMBER
1976
659
