C.E.R.E.B.R.O. 1 C.E.R.E.B.R.O. Central EPIC Requisition of Emotional & Behavioral Responses Organizer Franklin Gregory Quider Jr. College of Nursing, Michigan State University NUR-997- Doctor of Nursing Practice Project III Dr. Dawn Goldstein April 30, 2023 C.E.R.E.B.R.O. 2 Table of Contents Abstract ................................................................................................................................ 4 C.E.R.E.B.R.O. ..................................................................................................................... 6 Background........................................................................................................................... 7 Delirium ........................................................................................................................................8 PICS ..............................................................................................................................................8 Significance ...................................................................................................................................9 Problem Statement ....................................................................................................................... 10 Organizational Assessment “Gap Analysis” of Project Site ............................................................ 10 Purpose of Project ........................................................................................................................ 13 Evidence-Based Quality Improvement Model ................................................................................ 13 Review of the Literature....................................................................................................... 14 Literature Processing ................................................................................................................... 15 Exclusionary Articles ................................................................................................................... 16 Synthesis of the Evidence ............................................................................................................. 17 Goals and Expected Outcomes ............................................................................................. 22 Methods .............................................................................................................................. 25 Design and Methodology .............................................................................................................. 25 Project Site and Population .......................................................................................................... 27 Ethical Considerations ................................................................................................................. 27 Setting Facilitators and Barriers (Gap analysis) ............................................................................ 29 The Intervention and Data Collection Procedure .......................................................................... 29 Pre-Implementation ..................................................................................................................... 30 Implementation ............................................................................................................................ 30 Post Implementation .................................................................................................................... 30 Measurement Instruments ............................................................................................................ 30 Analysis .............................................................................................................................. 31 Sustainability Plan .............................................................................................................. 32 Discussion ........................................................................................................................... 33 Limitations .......................................................................................................................... 34 Implications for Nursing ..................................................................................................... 34 C.E.R.E.B.R.O. 3 Conclusion .......................................................................................................................... 35 References........................................................................................................................... 37 Appendix A: Introduction .................................................................................................... 43 Appendix B: Literature Review ............................................................................................. 47 Appendix C: Literature Review ............................................................................................. 49 Appendix D: Johns Hopkins Nursing Evidence-Based Practice Guide ...................................... 69 Appendix E: Projected Timeline ............................................................................................ 74 Appendix F: ICU Staff Initial/Progress Survey .................................................................... 75 Appendix G: EPIC .............................................................................................................. 76 Appendix H: Prevalence Data .............................................................................................. 78 Appendix I: Approvals ......................................................................................................... 82 Faculty/Student Feedback Table .......................................................................................... 87 C.E.R.E.B.R.O. 4 Abstract Nature and scope of the project: Patients admitted into the intensive care unit (ICU) anticipate critical medical/surgical issues to be addressed. However, it may not be the primary focus of ICU hospitalization; patients’ mental health needs must be addressed to be successfully discharged from the ICU and/or the hospital. Evidence-based studies have shown interventions and tools to assist with the physical aspects of Post ICU Care Syndrome (PICS). PICS collectively have produced a prevalence of complications for the patients and families after stays in the ICU. Cognitive impairments occur in 30-80% of those leaving the ICU. Concerns of anxiety, depression, and PTSD account for 8-57% of the cases, where the effects can last for years afterward. The average length of stay increases by 40% due to psychological stress. Psychiatry is consulted only in extreme cases where a patient has committed acts of suicide or is currently suicidal, or the clinical judgment of the ICU staff requires a psychiatric provider to assist in the care planning. Synthesis and analysis of literature: Overall, 2164 articles were found in three databases. Of the articles, 18 were found to describe psychiatric providers consulted in the ICU. The six themes from these articles included: an embedded behavioral health provider/team, utilizing the EHR, taking a proactive approach, past psychiatric/substance-use history, past trauma history, and psychotropic prescriptions (future, present or past). Reviewing with the team, the embedded team member(s) have the financial barrier, whereas the remaining five themes utilize the existing EHR. Project implementation: The project will utilize the existing EHR with a revised triggering methodology to initiate consultations in the ICU. In addition, a new dashboard called C.E.R.E.B.R.O. 5 C.E.R.E.B.R.O. will provide healthcare providers with snapshots to encourage consultations that are not automatically triggered, including EHR themes. Outcomes: The project evaluates three aspects of a dashboard in the ICU: increased psychiatric consultations, improved healthcare provider satisfaction, and decreased average LOS for patients. In 2022, 33.53% of patients in the ICU had a DSM-5 diagnosis. There were 18 consults counting for 0.2% of the total patients. The leading diagnosis groups were anxiety/stress disorders, mood, and substance use. For admitted patients, 36.8% had a DSM-5 diagnosis with the leading diagnosis groups being anxiety/stress, mood, substance use, and neurocognitive disorders. Recommendations: The dashboard C.E.R.E.B.R.O. will guide practice allowing for a more proactive approach to care. It will require extensive time with the Information & Technology Services to implement. In the future, psychiatric services will become an embedded member of the ICU. Further work and studies with C.E.R.E.B.R.O. could increase the rate of EHR triggers and process automation. C.E.R.E.B.R.O. 6 C.E.R.E.B.R.O. Whether planned or unplanned, admission to the Intensive Care Unit (ICU) can lead to increasing multifocal stress, including physical, mental, spiritual, and other facets. The stress is linked to the patient's vulnerability upon entry or shortly after that, contributing to post-ICU stress that increases the risk of mortality for the patient based on the length of stay (Brown et al., 2019). This can be presented in hemodynamics or other confounding physiological factors such as hyperglycemia, hypermetabolic, hypercortisolism, higher risk for infection, and sleep disturbances (Inoue et al., 2019). Most studies conducted in a meta-analysis concluded that medical-psychiatric comorbidity resulted in overwhelming readmission based on the duality alone (Jansen et al., 2018). Mental health and psychiatric symptoms come up in the forms of anxiety, depression, delirium, psychosis, or exacerbate initial mental health conditions established before admission (Stein et al., Lastly, the ICU places strain on the personal and spiritual connections of the patient, often forming hopelessness, loneliness, and other forms of psycho/spiritual disconnect (Smith & Rahman, 2022). The ICU medical providers govern the prescriptive authority, while the ICU nurses govern the care jurisdiction. The ICU providers and nurses complement each other to bring comprehensive care to the patient during this traumatic time. For the patients whose time is brief, the likelihood of residual effects is typically minimal. For those unable to have a brief encounter with the ICU, there may be residual effects on their psychosocial being (Lone, 2016). With patients entering the critical care realm with disorders in the Diagnostic and Statistical Manual of Mental Disorders (5th edition) (DSM-5), the path out of the ICU may need the help of psychiatric providers who seldom walk the hallways. Unless a consultation is placed by the ICU team or the social worker from a specialized assessment, psychiatric providers will not likely be involved in the patient’s care (Jackson & Jutte, 2016). C.E.R.E.B.R.O. 7 In essence, the project aims to target missed opportunities of having the psychiatric provider assist with the patient's care before a hallmark event, such as suicidal ideations, demands a consult. Many patients come into the care of the ICU with current psychiatric disorders and or substance use disorders (SUD). The exact number of these occurrences runs high even though computerized systems, EPIC, in this case, centralize the patient’s problem for the current visit along with the past and even the planned future visits. To measure the success of the psychiatric team involvement, the average length of stay in the ICU will be measured along with the number of consults within the same time. Background Current ICU practice guidelines identify the need for holistic approaches in the highly acute medical setting. Nevertheless, the needs addressed in the realms of the patient are bundled in care algorithms that address mental health superficially only after discontinuity of progress in the patient healthcare worker paradigm. Treatments could include psychopharmacology; however, the ICU team does the prescribing through anecdotal knowledge before a psychiatric provider may, sometimes not, be brought on board. The severity increases when the patient has further barriers (inability to talk, move, express, or articulate) to blur the connection to the care team leading to disparities in care, increased length of stays, increased risk for harm, and increased risk for infection. The current protocol to help address the needs of ICU patients is the evidence-based practice ABCDEF Bundle. This bundle addresses the patient's needs, each letter addressing different needs along the intensive care journey. A stand for Assessment and management of Pain. B indicates the need for Both spontaneous awakening trials and spontaneous breathing trials. C is the Choice of analgesia and sedation. D is for Delirium: assess, prevent, and manage. E is for Early mobility and Exercise. F is for Family engagement and empowerment. See C.E.R.E.B.R.O. 8 Appendix A.1 (Smith & Rahman, 2022). The responsible parties in the ABCDEF Bundle are the medical providers, nurses, pharmacists, respiratory therapists, and physical therapists, with additional support from the unit secretary and nursing assistants. These outcomes have been proven to reduce pain, agitation, and delirium through this interdisciplinary approach. It reduces the length of stay, decreases ventilator days, decreases long-term acute care hospital transfers, increases mobility, increases pain control, and increases the quality-of-life post ICU discharge (Ely, 2017). Delirium Delirium is a psychiatric DSM5 diagnosis and represents a decompensation of cerebral function in response to one or more pathophysiological stressors (European Delirium Association, & American Delirium Society, 2014). This syndrome is well covered through diagnostic tools specific to this interim condition. It does not reflect the longer duration mental health array that can be simply remedied by removing stressor(s). Delirium precipitates from psychosocial, medical, and environmental factors. Some examples include infection, medication side effects, sleep deprivation, inadequate day/night distinctions such as light or noise, and many other factors found in the EBP articles about delirium. Further studies have been conducted providing evidence-based interventions for the diagnosis of delirium. Delirium in the studies has been majorly proven manageable by ICU providers (Wei et al., 2008). One study did conclude that the providers appreciated psychiatry’s input and support; however, this was based on the grouping of psychiatric disorders, with delirium included (Sharma B. et al., 2014). PICS The sequelae of signs and symptoms related to the ICU stay have been dubbed Post Intensive Care Syndrome or PICS for short. PICS is best described as the impairments of cognitive, mental health, and physical attributes that are either an effect of what brought them to C.E.R.E.B.R.O. 9 the ICU or a condition of recovering from the initial onslaught. The syndrome contributes to the mortality of the patients, the length of stay, and the holistic integrity. One campaign of PICS describes the result of the physiological effects of COVID-19, one of the many reasons for admission to the ICU, resulting in PICS with symptoms of cognitive impairments, mental health problems, and physical impairments (Nakanishi et al., 2021). See Appendix A.2. Another of the campaigns describing PICS documented in the journal CHEST described PICS in a single evaluation diagram (CHEST, 2021). See Appendix A.3. The infographic explains well, in brief, the various domains affected by PICS with pointers on the risk factors, prevention interventions, and recovery programs. Unfortunately, the people described in this dilemma as multidisciplinary teams that could help the patients with all three domains are those with a psychiatric background. Especially with the patient population coming into the ICU with prior diagnoses in mental health, the psychiatric professional will be paramount to recovering the patients of the ICU from getting home with as few setbacks as possible. One of the articles in the AJCC in 2008, “Monitoring psychological outcomes for ICU patients may be as important as their physical recovery.” (Wallen et al., 2008). Significance The prevalence of PICS collectively has produced an array of complications for the patients and families after their stays in the ICU (Jensen et al., 2015). Cognitive impairments occur in 30-80% of those leaving the ICU. Concerns of anxiety, depression, and PTSD account for 8-57% of the cases where the effects can last for years afterward (Colbenson, 2019). The exact number of costs, length of stay, and lasting effects are currently being studied with the increased interest of critical care groups combating this phenomenon attached to the stay in critical care units (Lone, 2015). C.E.R.E.B.R.O. 10 The average length of stay of all ICU patients is five days, with the total cost amounting to $13,443, with the cost per day averaging $2,902 reported in 2020 (Tucker, 2022). This equates to the patient in terms of substantial healthcare costs, lost wages, possible loss of employment, and social network restructuring beyond what would be imaginable. Patients have an increased likelihood of not returning to work post-discharge. In addition to this load burdened by the patient, the collective surrounding the patient (family, friends, etc.) has reported the loss of earnings with the potential of loss of employment. Problem Statement Patients are not receiving psychiatric consult services in the ICU of a level 1 trauma hospital in the Detroit metropolitan area. The psychiatric consultation rate for the year 2022 at this facility was 0.20%. Those resulted either in acute psychiatric emergencies, a breakdown in progress due to physical and mental complications, or progress to failure to thrive. Many with past mental health and psychiatric disorders are admitted without consultation despite alterations in treatment. For this project, the clinical question is, in ICU patients, is an electronic health record dashboard highlighting past psychiatric diagnoses to include substance use disorders, history of trauma, and psychotropic medication trials compared to critical care treatment as usual effective in increasing the psychiatric consultations for patients in the ICU? Organizational Assessment “Gap Analysis” of Project Site In the initial evaluation, two processes were utilized to begin the assessment of the gap analysis of the site. With the first evaluation, the “5 Whys” (also known as 5Y) was used because it is a Six Sigma intervention as part of their DMAIC methodology to find the root of a problem (iSixSigma-Editorial, 2022). The root of the problem of delayed psychiatric evaluations resulted in themes of positive suicidal ideations, severe psychiatric symptoms (anxiety, depression, C.E.R.E.B.R.O. 11 mania, hallucinations, delusions, etc.), relapse addiction, increased length of stay (LOS) not originating in physical nature, or clinical judgment. This is sometimes, but not always, coinciding with previous psychiatric diagnoses that may or may not be managed. (See Appendix A.4 for 5Y) In the second evaluation, a further gap analysis was conducted using the “Strength/Weakness/Opportunity/Threat” tool, also known as SWOT analysis (Peterdy, 2022). This is a strategy to take a deeper look into the hospital’s culture to look at the project for goals and challenges in a concise document to encapsulate the organizational pluses and deltas. This matrix combines internal and external forces to allow for strategic planning to propel this project toward a beneficial trajectory. The SWOT analysis for this EBP/QI project demonstrated several strengths while outlining a few potential threats affecting the nursing staff, licensed independent practitioners, and the workload placed on the system. (See Appendix A.5 for SWOT Analysis). In terms of the analysis, the hospital strongly desires to do what is suitable for the patients, and there is vital stakeholder buy-in because of this patient-centered focus. This is conducted by utilizing the Patient Health Questionaire-9 (PHQ-9) and Columbia Suicide Screen Index (CSSI) upon admission to the ICU. The hospital has used EPIC for several years, allowing access to the patient's records at several different facilities, specifically psychiatric history, psychotropic medication history, substance use history, and trauma history. This particular hospital houses its psychiatric unit allowing for continuity of care under the same roof. Several psychiatrists in the consult service allow multiple providers to care for the patients in the ICU, step-down, and other medical/surgical units. Unfortunately, the PHQ-9 and CSSI are not required per policy to be done after the admission intake. The staff is being pulled in several directions, and recalling the psychiatric assessments adds to a long list of requirements being taxed on the staff. For patients with past C.E.R.E.B.R.O. 12 psychiatric, substance use, trauma, and psychotropic medication histories, this does not automatically trigger a consult for psychiatry to review the patients’ cases. The social workers at this facility are focused on a more case management level due to their numbers across the hospital platform. Lastly, no therapy can be conducted for the patients in the medical units because there are no therapists, and the psychiatric providers are covering other responsibilities. In contrast, there are many opportunities for growth in the hospital for psychiatric assistance in managing the patients in the medical hospital. With the consult psychiatrists, providing automatic consults for past psychiatric/substance-use/trauma/psychotropic medications would be a practical use of the electronic health record (EHR). For assisting the nursing staff, providing nurse-driven consults would allow the nurses to utilize clinical experience to direct psychiatric consults. There are even opportunities to embed a psychiatric provider in multiple teams in the hospital, like the ICU, to give patients a more considerable holistic care experience. In processing these strengths, weaknesses, and opportunities, it would be appropriate to discuss the threats in implementing increased psychiatric provider support to the various teams in the hospital. This could overload the current consult psychiatrists and require increased staffing to maintain these increased needs. In certain areas, non-psychiatric providers currently prescribe psychotropic medications without a psychiatric provider consulted. This practice may need to be addressed to some degree to assist in the prevalence of psychiatry without overloading the consults. Currently, there are no protocols for non-psychiatric providers to use as guides, thereby providing inconsistency and unrepeatable outcomes. Through the final initial gap analysis, the program Slicer Dicer was used to dive into the macroscopic level of the data. The program utilizes the current EHR, EPIC, for the overall data pool of all the patient encounters with their multifaceted data components. The first run of data was to see how many encounters occurred in the critical care realm for the hospital in 2022. C.E.R.E.B.R.O. 13 There were 9,667 admission encounters within this hospital, and this represents 1.5% of the overall admissions. Of these 9,667 encounters, the next algorithm was to measure the number of patients admitted to the critical care realm with DSM diagnoses. The result was that 33.53% of the patients carried a mental health diagnosis. The final prevalence algorithm was to measure how many psychiatric consultations occurred in the critical care units in 2022. From 2022, there were listed 18 consultations for the team of psychiatrists, measuring to be 0.20% of encounters with diagnoses in mental health and 0.12% of the overall critical care encounters. Purpose of Project This EBP/QI project aims to optimize patient outcomes by implementing a psychiatric consultation project, which is a change in the current process to initiate a psychiatric consultation. The psychiatric consultation project would trigger for those patients with a past psychiatric history, past substance-use history, past trauma history, and past psychotropic medication history to be admitted to the ICU. For the patients without a prior history, the physical, emotional, and mental health progress would be evaluated by psychiatric consultants to decrease the length of ICU stay. This project would increase automation through the EHR or dashboard evaluation. Evidence-Based Quality Improvement Model The choice of utilizing the Johns Hopkins Change model is based on the incredible multidisciplinary approach and extensive feedback from clinical and academic end users. The model focuses on evidence-based practice as an activity for nursing practice combining the efforts of the disciplinaries involved for a common goal. The approach has three phases: practice question, evidence, and translation seen in Appendix B1 (Johns Hopkins Medicine, 2022). The practice question comes from the experiences seen at the bedside. The query is developed into forming the team to move forward in defining the problem. As a collective, the C.E.R.E.B.R.O. 14 team hones the question by determining the importance and stakeholders through the project. The project concludes with the PICO question. The evidence phase focuses on utilizing the literary evidence that is most recent and relevant to shape the problem better, along with shaping the translational phase. The evidence is collected, sifted by its appraisal, and presented. The presentation summarizes the evidentiary project to demonstrate the lineage of question formation to what the evidence suggests in response to the question. See Appendix D. Lastly, the transition is putting the latest and greatest evidence into practice. This project is structured to analyze the process within a structured time limit. The stakeholders are evaluated before and after the project period. The phase ends with the dissemination of the project for future studies. Review of the Literature A comprehensive literature review was completed to determine prior assessments, evaluations, tests, or tools in the intensive care unit (ICU) or critical care for psychiatric, mental health, or substance use disorder needs. The databases used for the literature review were CINAHL, Psych INFO, and PubMed in a systematic approach. The search was conducted in these databases using natural language and controlled terms. Terms for the target location of implementation were spelled out as “Intensive Care Unit,” “ICU,” and “Critical Care.” Search terms for psychosocial distress were described in the parameters as "mental health," "mental illness," "mental disorder," "psychiatric illness," “psych*,” or “substance use.” Inclusion criteria were articles within the last five years and the adult population of 18 years and over. Exclusion criteria developed from the start and evolved over the literature review process. Neonatal, pediatric (paediatric for international journals), and adolescent populations (all under the age of 18) were excluded from the criteria with disparities in cognitive C.E.R.E.B.R.O. 15 development. Delirium was excluded from the literature search based on the studies and evidence placed on this well-studied condition managed by the ICU providers. The mental health-related articles about the end of life and hospice care were excluded from the criteria because the myriad of signs and symptoms are native to death and dying rather than psychiatry and the DSM 5. Studies that looked at narratives, experiences, and phenomena were excluded from the approach of the studies that identified the psychiatric need already and did not use a system to decipher psychosocial distress. With the growing popularity of “Psych ICUs,” they were excluded since they are a new subsection of the psychiatric care model and fundamentally different from the medical/surgical care models. Lastly, approaches to evaluating nurse, provider, or caretaker distress were excluded from the criteria based on the decentralization from the patient in the ICU bed. Literature Processing The searches from CINAHL, Psych INFO, and PubMed produced 4,684 articles to be reviewed. These searches were imported into a program called Covidence (Cochrane Community, 2022) for data management, duplicate management, and screening for alignment of the project's scope. There 2,597 duplicates were removed to allow 2,164 articles for the initial screening process. The first pass in Covidence was screening through abstracts followed by full- text screening if relevant to the EBP/QI project. If there was ambiguity in the abstract's relevancy, the article was put forward to full-text screening to avoid missed-bodied text relevant to this project. In this initial screen, 1,837 articles were determined irrelevant based on the inclusion/exclusion parameters. There were 250 articles left to be read in full for the second round of literary assessment. The articles were read with common themes found in the excluded materials. The most prominent exclusionary theme was 113 pieces where psychiatric tools were C.E.R.E.B.R.O. 16 implemented in the ICU setting. However, there was no mention of a psychiatric consult in any shape or form. Following this, 62 articles had the wrong indication for this review of literature, 47 pieces were framed in the wrong clinical setting, ten articles were not related to utilizing psychiatric services, nine articles with the incorrect study format desired for the literary review, one piece with the wrong outcome of consulting psychiatry, and one essay not comparing with psychiatric services. This left 18 articles meeting the literature search criteria to be analyzed and abstract data forming themes. See Appendix B.2. Exclusionary Articles The 113 articles from the full-text review were excluded from the literature search and were labeled for utilizing psychiatric tools in the ICU. These articles did not reference the usage of psychiatric providers, and thereby, these articles were excluded. One thing should be brought up with this collection of articles that is important to delineate tangentially to this project. Each article decided on one or more evidence-based scales or tools to assist in evaluating the documented intervention. Through these articles, there was no decision on “best” or “more accurate” regarding the ICU population. The tools chosen reported good internal consistency in the related studies. In one article, the team led by Kusi-Appiah published a systemic review in Australian Critical Care that covered the use of assessment of psychiatric distress in critical care. Evaluating research articles from 1946 to April 9, 2020, revealed several critical understandings of the ICU population looking to be studied (Kusi-Appiah et al., 2020). There is a lack of consistency among the ICU population, who can speak and communicate effectively between the various tools to evaluate psychiatric distress. There is no study to evaluate the tools for patients unable to speak and therefore required to be observed. The ICU population has a diverse level of severity of illness where in certain studies, the severe cases were excluded based on the complexity C.E.R.E.B.R.O. 17 present. Kudi-Appiah’s team questioned whether the sickest patients would be the most likely subgroup to experience psychiatric distress and benefit most from psychiatric interventions. The gaps found in their study run parallel in this project as the paradigm of distress in critical care is not well understood and requires more attention and tools specific to this clinical setting and would benefit from the psychiatric provider to assist in the multifaceted, complex patient load. Synthesis of the Evidence The evidence concluded with the presence of themes being expressed through the 18 remaining articles seen in Appendix C1. Twelve articles contained the theme of an embedded psychiatric provider in the structure of the overarching care team. Eleven articles described the usage of an EHR in the formation of identification of patients. Eleven articles described identifying patients by their psychiatric and or SUD history. Eleven articles described identifying patients by their trauma history. Nine articles described identifying patients by their psychotropic medication usage. The themes in relation to the 18 articles are seen in Appendix C2. Theme 1: Embedded psychiatric provider. The evidence provided compelling results for utilizing this strategy for the theme of embedded psychiatric providers. The study by Dr. Bui saw a fourfold increase in consultations, decreased time to consult, an 11% decrease in length of stay overall, and a 30% decrease in respiratory failure patients specifically (Bui et al., 2019). Dr. Camus’s study reported more consultations through the embedded provider, from 4% to 32%. However, there was no significant decrease in LOS. One thing to conclude from the Camus study, there was no difference in medical cost between the embedded provider and the traditional psychiatrist (Camus et al., 2003). Okoronkwo’s report stated a nearly 50% reduction in readmissions since implementing the embedded psychiatric provider, along with a 27% reduction in LOS. Furthermore, the report documented significant cost savings of $179,800 per 100 patients based on the decreased LOS. C.E.R.E.B.R.O. 18 This report was written to help describe the effects of the introduction of the clinical liaison psychiatry provider. It also described the staff members' perceptions of the introduction of this embedded team member (Okoronkwo, 2019). Weisser’s study focused on the staff satisfaction of the embedded psychiatric provider. Compared to before, the staff rated the service above average compared to before the implementation. Staff satisfaction was poor, which led to the intervention (Weisser, 2019). Peris’ study revealed a reduction in anxiety, depression, and PTSD by nearly half of patients without a comorbid psychiatric diagnosis. Peris did note that twelve months post- admission, though, there was a 50% increase in psychiatric medications amongst the intervention group (Peris, 2011). The study by Hosey (2019) utilized an embedded psychiatric provider; however, the utilization was not like the other studies with a proactive approach. The providers utilized an observational approach which led to the discovery of prolonged ICU stays correlated with the necessity of a psychiatric consult for discharge. The work provided by these psychiatric providers could provide expedited services when the consult was placed (Hosey, 2019). The survey conducted by Bieber (2022) did not result from implementing this intervention; yet the perceived impression by the stakeholders of the ICU overwhelmingly felt (82.5% in total) that the presence of the embedded provider would enhance the prevention of PICS. The stakeholders also endorsed (84.6%) that the presence would decrease family psychiatric distress through education and interventions at the bedside (Bieber, 2022). Dr. Kovac’s study approached the staff's view regarding having an embedded psychiatric provider. The staff reported high levels (median report of agreement above average) of content with the application of the embedded psychiatric provider (Kovac et al., 2021). The systematic review conducted by Roberts et al., (2018) revealed multiple studies concluded PTSD is prevalent in the survivors of the ICU, and the earliest interventions, citing a C.E.R.E.B.R.O. 19 possible embedded provider even in the ICU, produced a reduction of PTSD symptoms compared to a delayed post-ICU discharge (Roberts et al., 2018). In the review by Dr. Wade, the argument stood for the sensitivity the psychiatric provider brings to the table in the ICU in terms of the psychosocial realm. The ICU providers do not always have the expertise or time to get involved. The psychiatric provider can practice psychological therapies in addition to pharmacology for the holistic patient, meaning the family. The role is ever expanding with more integration, and with more studies conducted with the integration, more opportunities exist to bring the psychiatric provider into the fold of the ICU (Wade & Howell, 2016). Four other studies noted the embedded provider, yet they did not record any significant numbers related to the ICU population. Theme 2: Use of Electronic Health Records. In the evidence supporting the use of EHR, despite the lack of service in the ICU with the studies by Desan (2011) and Sledge (2015), their data propelled the studies that did focus on the ICU unanimously. Desan (2011) focused on the preemptive usage of the psychiatric provider in the medical areas with the utilization of the EHR to expertly navigate the indicators charted in the patient’s medical record. Desan (2011) noted a 22% increase in psychiatric consults and a 32% reduction in LOS. Unique to his research was an embedded psychiatric provider; however, the provider conducted screening in addition to the consultations being ordered to generate more consultations through this proactive approach (Desan, 2011). Sledge’s study continued the work performed by Desan. It amplified the intervention to include a dedicated clinical nurse specialist (CNS) and dedicated social worker in what was dubbed the Behavioral Intervention Team (BIT). The LOS was reduced by .64 on average (generally a 10% decrease), with 92.3% of the BIT consults versus regular consultations (Sledge, 2015). Shdaifat (2022) evaluated seven hospitals in Jordan to evaluate the anxiety and depression scores in 108 patients in this prevalence-based cross-sectional study. Without the use C.E.R.E.B.R.O. 20 of the EHR, Shdaifat’s (2022) research would not have been able to be executed in the time frame of the study done in 2019, evaluated, and published with the limited team involved (Shdaifat & Al Qadir, 2022). Theme 3: Identity by psychiatric history, Theme 4: Identity by trauma history, & Theme 5: Identity by psychotropic medication history. These three themes focused on using health records to identify patients based on their histories' attributes to a more significant extent. This can also come up in verbal discourse, even though this was not explicitly brought up in the articles. Articles specifically discussing the identification process only focused on the target components in methods discussed in the individual articles. In discussing trauma, Findley’s study focused on the comorbidities of trauma and psychiatric diagnoses in the critical care population. One of the findings from this study showed that despite having a pre-existing psychiatric diagnosis 68% of the time, the providers would only consult psychiatry in 12% of the cases (Findley et al., 2003). Warnack’s study focused on the duality of trauma and past psychiatric diagnoses and measured the service needs of prior psychiatric diagnoses versus those of not. Patients with primary psychiatric diagnoses were three times more likely to present with penetrating trauma, 33% longer LOS, 70% more like to require ICU level of care, and 80% less likely to be discharged back home after their admission compared to those without a diagnosis (Warnack et al., 2018). In contrast, Kishi’s study looked at the health record for identifying psychiatric diagnoses in its retrospective study. The patients who had this going into their hospitalization were more likely not to get the assistance they needed from a psychiatric provider and not discharge in the time frame resulting in complications. The recommendation from this study was to form an early detection system to highlight these at-risk patients to get more services early than delayed (Kishi et al., 2004). Similar findings were found in the Bourgois retrospective study C.E.R.E.B.R.O. 21 published at a similar time. The similar sentiment of early interventions would help reduce the LOS of the patients with increased likelihood, like adjustment disorders (Bourgois, 2005). Chen’s systematic literature review looked into the literature to see if there was any current lack of identification of patients with psychiatric disorders. The review pointed out that with advancements in technology, in this case, the EHR, patients are more accessible to identify than ever. The summation of the review focused on the education of the medical providers to enlist the psychiatric provider in earlier interventions to improve the outcomes for patients with pre- existing psychiatric disorders with acute medical problems (Chen et al., 2016). With the progress discussed in the study by Desan to the study by Sledge with the promotion of a proactive embedded system, the study by Sledge discussed this unique system identifying patients by the medications as another way the health record can help exemplify the identifying and treatment processes (Desan, 2014). Surprisingly, the other studies listed did not discuss the medication component found in these two studies. Desan provided examples of a single-person team identifying the patients through routine screening. However, Sledge developed a more robust approach with a team approach to looking at the many facets covering patient needs (Sledge et al., 2015). Theme 6: Proactive psychiatric approach. The underlying theme, which was either presented as part of the intervention or was indicated in the discussion of the respective articles, is that a proactive approach made the biggest impact. There are different levels of proactivity put into the design of the research articles. Consult Liaison is one level of having an embedded psychiatric provider and have a proactive approach. Consult Liaison (CL) is the diagnosis and management of comorbid psychiatric and medical/surgical conditions in the hospital setting. The CL, unlike a psychiatry consultation as it has been traditionally done, is a seven-day-a-week position in the hospital seeing patients with their dichotomous specialty ensuring medical C.E.R.E.B.R.O. 22 stabilization is done in conjunction with psychiatric interventions (Bourgeois & Sharpe, 2020). Consultation as usual would mean the psychiatric provider only comes to the hospital if the consult is placed for diagnosis and care planning. The remainder of the care is left to the primary care team unless they call the psychiatric provider back for further treatment. Desan’s research took the CL role to another level by allowing the psychiatrist screen patients without the consult in place by using the HER to scrub the admissions daily for patients coming in with psychiatric disorders, trauma histories, and psychotropic medications (Desan et al., 2011). Bui’s research took the work of Desan and implemented it for a brief session in the ICU to work for the prone distressed patients to receive care before jeopardizing their health and their trajectory to home (Bui et al, 2019). The progress of Desan’s research continued with Sledge’s work, where the psychiatric provider became a psychiatric team, the Behavioral Intervention Team (BIT). The BIT would work the same proactive way as described by Desan, except the team consisting of a psychiatrist, advanced practicing nurses, and social workers were able to provide a more robust level of psychiatric care to the interdisciplinary team. Goals and Expected Outcomes The project aims to increase the number of psychiatric consults for ICU patients through quicker evaluation of psychosocial needs. The desired treatment is left out of the equation as the psychiatric provider will use clinical skills to prescribe medications, treatments, and therapies as warranted on the specific and individual case-by-case process. This individualized care will not be comparable with the multitude and clusters of diagnoses being treated. The expected outcome is that the number of psychiatric consultations will increase upon initiation of the project. The data collected will come from aggregate data derived from the electronic health record system, EPIC, in terms of number of consults from psychiatry. This would be through a submission process by IT where the sensitive information, which is not required for this project, C.E.R.E.B.R.O. 23 is removed from the reports. The information is then placed in approved file systems and would be released for the purposes of this project with their permission. Any publications and conferences would also require their permission to disseminate the information. In the first part of the project, the information from the previous year would need to be evaluated for the total effect of the missed opportunities of solely relying on critical care clinical judgement before consulting psychiatry. This would be using themes 3, 4, & 5 to isolate cases who have gone through the ICU with these preexisting conditions. The number of consultations would need to be evaluated for the number of encounters without preexisting conditions who also received a psychiatric consultation. This would be processed to see the finalized prevalence of consultations in the ICU, consultations with preexisting conditions, and overall prevalence of missed opportunities. After the data is able to be evaluated for the prior year, evaluated, and compiled, there will be a meeting with the psychiatry team, the ICU manager, and the ICU providers (APRNs and attendings) to see what would be the satisfactory level of consultations with the implementation of C.E.R.E.B.R.O. Currently, there is an assumption many opportunities are missed due to the fact of psychiatry not being consulted to the floor for months on end from bedside nurses and APRNs. The data of success of the consult service in critical care and the overall medical hospital has not ever been done. This project would be the first of this kind in this healthcare association’s history. Sequentially, the intervention of instituting C.E.R.E.B.R.O., the information obtained from the charting system is aimed at the improved number of consultations, especially with the presence of preexisting conditions. Using Information & Technology Services (ITS) reports through the approved file system for storage and evaluation. C.E.R.E.B.R.O. 24 In addition to the goal and measuring of the consultations in the ICU, the staff of the research council will need to evaluate the implementation of C.E.R.E.B.R.O. before, during, and after the project period. The survey ultimately is accepted by the research council, and an example of the initial and follow-up survey is available in Appendix F to be later approved. The intention of the survey will be to include the nursing staff (bedside nurses, assistant managers, and nurse manager) of the ICU, the nurse practitioners of the ICU staff, and the associated ICU doctors who will be consistent for the pre and post evaluation of the dashboard. This could include interns and residents along with the attendings provided the timing works out for the intervention and their respective rotations. Regardless of the health care professional, the eliciting of survey feedback will be on a voluntary basis. The research council monitors the project of all scholarly endeavors through the data collection, the survey, and the dissemination of the evidence collected. Each individual step requires check-ins with council liaisons or the council before the sequential steps can commence. The liaison will be checking in on the auditing for compliance purposes of the investigator on a weekly basis. In summary, the following objectives will guide this project: • The goal is to increase the number of psychiatric consultations in a level I ICU unit. For the study period, the goal is to achieve a 20% rate of psychiatric consultations in this ICU unit. • The goal is to measure the education of the ICU staff before and after through a survey. The goal is to have an 80% understanding from the education sessions. • The expected outcomes of the project will be measured by ordered psychiatric consultations in Epic in the study period. C.E.R.E.B.R.O. 25 Methods Design and Methodology The plan for the implementation of the project is outlined in a proposed Gantt chart illustrated in Appendix E. The beginning is with Michigan State University Internal Review Board (IRB) for the first stage of approval. After MSU IRB approves the plan (See Appendix I), the next stage is to apply for the hospital’s IRB approval through their nursing research committee. This review occurs partially at the individual hospital level, then it proceeds through the system level. With the approval process going on, the intention is to begin working on the dashboard in Epic with the Information Technology (IT) staff. This would depend on the approval process within the hospital to allow the project to commence. With this project starting, the process of onboarding the unit staff can begin. By having ITS and the unit staff working at the same time, the potential for quality improvements noted by either side can be addressed faster than in a linear progression. An example of a dashboard designed in Epic is illustrated in Appendix G.1. The major criteria to be built into C.E.R.E.B.R.O. is past psychiatric history, i.e., depression, suicide attempt, alcohol use, trauma, etc.; psychotropic medication, i.e., quetiapine, trazodone, mirtazapine, etc., and past psychological/psychiatric notes, i.e., therapists, psychologists, psychiatrists, etc. After the dashboard is created, the unit staff would be surveyed prior to initiation of the dashboard. The dashboard goes live with the staff ordering consultations, as evident by the dashboard displays of general patient conditions, medications, past psychiatric history, etc. Every week for the beginning period, there will be check-ins to assess any improvements in the project. After a few weeks, the check-ins become less frequent as per the needs of the unit. At the end of C.E.R.E.B.R.O. 26 the intervention period, there would be a final check-in with the unit staff before compiling the data with the statistician. Data Management. Neither patients nor the staff will be personally identified in any data collected, or in reports or publications as a result of this project. Staff survey results will be deidentified. Any notes taken from meetings with staff, survey data, any aggregate data from Epic, and data sources will be stored in a locked cabinet in the DNP student’s home office. Any electronic reports displaying aggregate data will be secured using a password-protected file on a password protected computer. With the finalized data, the plan moves to dissemination of the data from the local level to the larger levels as permitted by time and committees. The first audience would be the unit staff to see the implications of the work performed with the interventions of the dashboard. The next grouping would be the nursing research council, and based on that discussion, it would be open to their annual conference. The macro level planned then would be the MNRS Conference to reveal the findings to the Midwest region. Design Schematic: The proposed plan –The first approval required for the project is the MSU IRB approval. Afterward, the research committee approvals and their IRB will follow. Setting – Timeline November – Applying for the approvals to MSU December – Applying for hospital approvals January – Epic build-out pending approval. Initiate beginning surveys for staff and providers while teaching about the dashboard intervention. February – Intervention Period C.E.R.E.B.R.O. 27 March – Compiling data and formatting for dissemination. April – Disseminate data to the hospital, MSU, & MNRS Resources – User guide leading to interventions and how to for dashboards Cost – No additional costs in terms of items or personnel. Time spent on the creation of the dashboard by ITS Barriers – Teaching access to the dashboard, system limitations on referrals, referral protocols, and adaptations in epic for continued upgrade and utilization. Sustainability plan – The plan depends on reassessment of the healthcare team's needs and patients' needs and making changes appropriate for continued promotion and automation. Project Site and Population The project site is a level one trauma hospital for adults and level two trauma for pediatrics located in the greater Detroit metropolitan area of Michigan. This 1,100+ bed hospital is a significant academic and referral center for the metro area with specialties in women’s health, pediatrics, transplants, heart and vascular, orthopedics, surgical services, urology, digestive health, and ophthalmology. There is an onsite adult psychiatric emergency room and inpatient unit. The hospital is part of a more extensive network of mental health care in age and diagnosis needs. Currently, 10-12 psychiatric providers work in this hospital's medical inpatient (consult service). Ethical Considerations Ethical considerations that need to be considered for this EBP/QI project can be broken up into six broad areas: Voluntary participation, informed consent, confidentiality, anonymity, the potential for harm, communication results, and issues not otherwise specified (Polonsky, C.E.R.E.B.R.O. 28 2019). Voluntary participation is based on the involvement of the hospital and the unit staff. The intervention of the project is increasing psychiatric consults in the ICU. The patients could refuse the consultation without jeopardizing the project if they desire to restrict it. Informed consent is based on the participants in this EBP/QI project. Since the project is based on initiating more psychiatric consultations through automation or her providers, the healthcare team is the primary participant in this project. In terms of confidentiality and anonymity, the project will be able to provide this to the patients as the sole intent is to initiate consultations in the ICU. The data collected from the health care providers will be through a coding system for surveys pre- and post-initiation. The potential for harm is low since the studied project is the initiation of extra providers into the care of the patients. This additional team member will utilize the centralized computer system with its safeguarding systems to ensure that prescriptive authority is monitored. Communication of the results will be brought through a stepped approval first round of the results will be disclosed to the ICU and the psychiatric team involved. The second round will be with the hospital administration and education team. The third round will be for the systemwide research event scheduled for the next possible Fall conference. Lastly, the result dissemination would encourage communication through publications and professional conferences. Since either can be predicted, it will be left to be determined. Specific ethical concerns not categorized as the above would be the considerations of presenting the dashboard to the company responsible for the implementation of the dashboard. The above ethical considerations would remain in play for this sixth challenge, which could help the dispersal of the dashboard to many other sites outside this healthcare system regardless of the publication and presentation status. C.E.R.E.B.R.O. 29 Setting Facilitators and Barriers (Gap analysis) The final gap analysis will be conducted once the hospital IRB process concludes, and project approval has been received. At this point, the SWAT analysis is based on observations, and the data behind the gap will be revealed once access to EPIC is granted and reports are allowed to be processed. A barrier being highlighted at this time is the long lead times being highlighted by ITS and Epic departments. Currently, there are numerous high-level demands from the ITS department, which will translate into time constraints for projects like the dashboard, which are a lower priority in comparison. This may even be present with collecting data for the final gap analysis. Currently, one unit implementing an electronic dashboard within the EHR system and promoting increased psychiatric consults will not be problematic for psychiatric providers. If additional units adopt this dashboard data system, this could translate into a burden for the current providers to maintain efficient consultations. There would need to be more providers in proportion to the units utilizing the C.E.R.E.B.R.O. dashboard. From comparing Desan's study of 2011 to Sledge's study of 2015, providing an analysis of the same hospital, the team's evolution proportionately grew to respond to the units onboarded for their behavioral health team. This would need to be considered in future planning at this large healthcare organization. The Intervention and Data Collection Procedure The dashboard C.E.R.E.B.R.O. is a tool for the ICU staff to utilize and process consultations. The data collection would be through EPIC throughout the intervention period. While the dashboard is being developed, data collection will be simultaneously done to evaluate the true gap analysis of the hospital. This project will lend itself to the data collected by implementing C.E.R.E.B.R.O. to reduce possible processing variability occurring after the C.E.R.E.B.R.O. 30 project commences. The two metrics that will be measured through Epic are the prevalence of patients with prior psychiatric and mental health histories and the number of patients receiving psychiatric consultations. This would be derived from ITS and Epic data collection from charts. Pre-Implementation Pre-implementation would be creating C.E.R.E.B.R.O. into EPIC. During this design phase, education sessions are to be conducted with the staff. The ICU staff (nurses, APRNs, intensivists) will be surveyed through this pre-implementation phase to assess the perceived healthcare worker readiness for C.E.R.E.B.R.O. The hospital research committee will validate an approved survey model for the execution of research projects once the project has been approved at their institution. Implementation The dashboard goes live with the ICU staff utilizing this data for screening for potential consultations for psychiatry to supply interventions. Staff will be continued to be surveyed during the implementation and assessed for project bugs to be worked out. The management will meet on a biweekly basis to review issues, and if there is need, full unit meetings to follow up on issues through implementation. Post Implementation The implementation concludes with staff giving final input to the overall project. The data is processed for statistical information. Once the data is processed, the project is presented to the unit, system, and possibly outside conferences for the purposes of micro to macro dissemination of the findings. Measurement Instruments The primary instrument is the EHR EPIC and the tool C.E.R.E.B.R.O. Each plays a vital component in the project's success. The design of the C.E.R.E.B.R.O. dashboard will be worked C.E.R.E.B.R.O. 31 on after the approval processes are completed. Per hospital’s policy, no permissions into the EHR will be granted until all approvals are submitted and satisfactory. The data collected will be prevalent numbers taken from the organization’s Epic EHR derived through the ITS department. The data will de-identify the patient's identifiable factors. This would be compared to the overall number of patients admitted to the ICU, a quality metric void of patient-specific data, and the overall number of psychiatric consultations, another quality metric void of patient-specific data. These metrics will also be compared to the ICU staff satisfaction scores to make relevant the prevalence changes. Analysis Ideally, the dashboard would be created in a matter of weeks, granting permission to the healthcare employees of the implementation group. The implementation employees would be educated about the process and surveyed before implementation. The data would be compiled on the utilization of psychiatric consultation services. The data collected from utilizing the data analysis tool in EPIC, Slicer Dicer, allowed for some preliminary data giving insight into the potential C.E.R.E.B.R.O. has for the practice of working with ICU patients with the potential for PICS. The data described for this comes from the data sets of 2022 at the target hospital. One defining component to the data that creates some potential skewing of the data is the presence of COVID-19 still prevalent in the region and impacting the patient populations. In looking at the encounters as a whole, admission and transfers alike, there was an overall prevalence of one-third of the patients in the ICU service line. This can be seen in Appendix H.1 showing this overall prevalence broken down over the year by months. The patients with a mental health history are drilled down by International Classification of Diseases C.E.R.E.B.R.O. 32 (ICD) codes differentiating the encounters by common mental health groups. The three major groups for the overall encounters are anxiety and stress codes (F40-F48), mood codes (F30-F39), and substance-use codes (F10-F19) in descending prevalence. The remaining classification groups occur in a tighter precision occurrence where there is a closer heterogeneous mixture with a significantly less prevalence than anxiety, mood, and substance-use. Appendix H.2 demonstrates this dyad of higher prevalence and the lower prevalence groups. Sequentially, looking into the admissions directly admitted into the ICU service line, the data demonstrates some other findings that are similar and different. The patients admitted to the ICU directly was slightly higher in having a mental health history at 37%. Appendix H.3 demonstrates the admission binary over the course of 2022 month by month. Again, the patients with histories were drilled down by the same ICD code brackets. The variation was similar to the overall encounters with anxiety, mood, and substance-use being the leading codes. However, the admission patients had a 4th group that was added in the higher prevalence dyad being neurocognitive disorders such as dementia or delirium or neurocognitive changes by known physiological issues such as a stroke. Appendix H.4 demonstrates this admission dyad of mental health prevalence. Sustainability Plan The plan for C.E.R.E.B.R.O. is based on recent meetings and projections that it may take longer for one investigator to conduct. The healthcare organization merged with another large healthcare system resulting in the IT department focusing its primary attention on the merger. This results in the dashboard lag time estimated to be six months to a year to create. It has created a dynamic not originally planned through this project's design and implementation phases, which works into its sustainability. Instead of this being a capsulated project with a sole investigator, there would be a shift to capture a subdivided legacy of the project. C.E.R.E.B.R.O. 33 For the initial and immediate component, the staff is educated on the piece of the dashboard that would be done in an analog method. The ICU performs rounds daily, and the concept brought on by the ICU manager was the ask the questions dashboard would be digitally performed during the rounds. This might be redundant in terms of asking the questions performed daily, however, the staff would be able to bring up current information if it was discovered. In essence, this would reduce the lost consultations the dashboard would highlight. This would be combined with educating the staff about the importance of psychiatric consultations of the patient’s hospitalization, and the process of consulting psychiatrists in the ICU. The development of the dashboard, when it becomes available to be designed and deployed, will be something resting on the shoulders of another investigator, such as a fellow doctoral student. This could be the ongoing theme with the concept C.E.RE.B.R.O. as it could be the analogy for the net being cast out into the medical areas. Each new investigator can cast a larger net to ensure more people are captured in a holistic mental health approach resulting in fewer and fewer people missing. Discussion The EBP/QI project was not able to be implemented due to unforeseen organizational restructuring, inhibiting the process for the proposed study period. The ITS department projected wait times escalated to over one year for non-necessary restructuring projects. This project fell into that latter category without proposed chances of prioritizing for the foreseeable future. The project was deemed to be interesting by the research committee for potential projects when ITS is not overwhelmed. C.E.R.E.B.R.O. 34 During the discovery period of this emerging happenstance, several circumstantial facets compounded the propulsion of the project’s trajectory. The intended unit for the implementation had increased staff turnover drastically reducing the superusers in the nursing pool as well as in the provider pool of staff. Lastly, the merging of systems created drastic uncertainty in the process of development and implementation of projects. On several occasions, there was misinformation presented due to conflicted policies, procedures, and ideologies dispersing at the same time. This resorted into excessive clarification that normally would not be presented in a research focused organization. Limitations The greatest limitation that occurred during this EBP/QI project was the time available for the primary investigator. If this was a project designed to be carried out by a staff member as the primary investigator, the limitation of time would not be as heavy as a factor in terms of longevity of the current projection of the project given the long lead times estimated at the current time. There are numerous minor limitations that can be defined withing the scope of the project, however, the time limitation is the extreme leading outlier. Implications for Nursing The project, had it been able to implement, would have been an easy and clear example of how informatics can be used in the care of patients. The diagnoses of mental health were found within the chart, albeit may not have been at the forefront of sections providing a clear give away to the healthcare workers. The achievement goals were also lowered despite the fact there is a patient with a known history of mental health conditions coming into the ICU. There is an expected level of clinical judgement that needs to be expressed when considering firing off the orders for consultation. One example that occurs very often in the ICU realm are the patients C.E.R.E.B.R.O. 35 coming in for a prescribed twenty-four-hour post procedure observation. If conditions are then going as planned, their medications are being continued as previously prescribed, and the progress is matching the planned conditions, then there is no need to pull the trigger. PICS occurs because expectations of the ICU stay are well underestimated, traumatizing, or exacerbated by predictable complications. In addition to the immediate informatic implications, the dashboard has potential beyond identifying the condition into predicting the possible. PICS occurs indiscriminately to those with histories or not of mental health problems. The population of people with and without histories versus the population of people with PICS are not well defined since the emergence of the definition of the disorder. Predicting factors have yet to be discovered, and the data the dashboard could funnel can help expand this knowledge by testing hypotheses of various contributing factors. Examples could include, but are not limited to, endurance time of physical therapy, respirations, flowsheet assessment data such as anxiety, and patient reportable mood. Conclusion Informatics has a lot to offer in the realms of psychiatry, critical care, and the prevention of PICS. The charts of patients in the EMR can be a transcendental source of information, and difficult for the lone provider to dig for every array of diagnostic criteria, however, this delegation could be directed to the computer to summarize the information in dashboards, such as C.E.R.E.B.R.O., to cross reference patients of multiplying vulnerability. One of the wonderful features of the EPIC EMR is the best practice advisories (BPAs) that are generated from the programmed delegations by informatic specialists to bring critical information to the healthcare professionals working in the program. One good example of this BPA is one proposed for this project in Appendix G, figure G.2. 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Nordic Journal of Psychiatry, 73(1), 9–15. https://doi.org/10.1080/08039488.2018.1525426 C.E.R.E.B.R.O. 43 Appendix A: Introduction Figure A.1 ABCDEF Bundle Figure A.2 PICS C.E.R.E.B.R.O. 44 Figure A.3 PICS C.E.R.E.B.R.O. 45 Figure A.4 5 Whys C.E.R.E.B.R.O. 46 Figure A.5 SWOT Analysis Strengths Weaknesses • Stakeholders buy-in • Staff overworked. • Nurse-driven assessment (PHQ-9) on • No screenings admission • No routine consults for those with PPH • Columbia Suicide Screen Index on • No therapists admission • Few Social Workers available • Past Psychiatric History (PPH) • Social Workers’ primary focus is case documentation management • EPIC documentation shared across • Limited adaptability for psychiatric team multiple providers and specialties. • Primary care team prescribing • Multiple psychiatrists employed in the psychotherapies without psych provider hospital for overall consult services collaboration • The psychiatric hospital attached to the hospital Opportunities Threats • Increase educational competencies. • Lack of staff engagement/motivation • Consults were given for admission with • Increased consultations may overload the Past Psychiatric History system • Nurse driven consults. • ITS/Epic • Cognitive/behavioral/psychiatric tracking C.E.R.E.B.R.O. 47 Appendix B: Literature Review Figure B.1 Johns Hopkins Change Model C.E.R.E.B.R.O. 48 Figure B.2 Prisma Chart C.E.R.E.B.R.O. 49 Appendix C: Literature Review C.1 Literature Synthesis-Critique Table Article Design/Purpose Setting Results Level of Strengths/ Relevance to Evidence Weaknesses Problem (see Appendix D) Bieber et al. A web-based survey -Several -Psychiatry’s primary current III -Qualitative research -Embedded (2022) obtained ICU role was seen as assistance with -Academic facility psych provider perspectives from settings management of mental health -One concern included-Proactive 373 critical care -Mayo issues (38%) and suicide risk potential conflict psychiatric healthcare provider Clinic assessments (23%). among providers approach practice providers. Minnesota -46% wished for psychiatry’s regarding treatment. -Staff enjoyed Descriptive increased involvement in the -Perceived benefits of recurrent information and ICU. psychological presence content analysis of -An additional perceived support -Assisted in qualitative data benefit included reduction in -Identifying care of patient provided provider burnout through psychiatric factors and patient information on processing difficult situations impacting treatment, family C.E.R.E.B.R.O. 50 stakeholder and decreasing family -Patient family perspectives. psychological distress. education of the pt.’s mental state/delirium -Worried about stigma of mental health Bourgeois et Analysis of LOS -Inpatient at -Patients with psychiatric III -Cross sectional -Proactive al. (2005) based on DSM IV large disorders represented 33%– retrospective study psychiatric diagnoses in medical -University 35% of total cases. from 1999-2001 approach setting of -Substance use (9,824 cases), -Academic Facility -Embedded California, mood disorders (2,524 cases), -Some cases might psych provider Davis and cognitive disorders (2,362 reflect the Medical cases) were the most common development of Center. -Patients with substance use psychiatric illness disorders or no psychiatric because of excessive diagnosis had the shortest time in the hospital. LOS. C.E.R.E.B.R.O. 51 -Adjustment disorders (N 147) -No ICU specific were the longest. cases noted -Other psychiatric patient’s -Nonpsychiatric LOS were in between. physicians over diagnosed psychiatric illness - substance use disorders, including legal substances, such as nicotine and caffeine, are included. C.E.R.E.B.R.O. 52 Bui et al. To compare -Medical -A total of 429 patients were I -Randomized -Proactive (2016) outcomes between a ICU admitted to the proactive controlled trial psychiatric conventional -Brigham consultation MICU; 393 -Academic facility approach consultation model and patients were admitted to the -Proactive psychiatric -Embedded and a proactive Women’s conventional consultation consultations psychiatric psychiatric Hospital, MICU. services in ICUs provider on consultation model. Boston -The consultation rate for the -Improved LOS staff MA intervention group overall -Utilized EHR was 24.2% vs 6.1% in the -No change in MICU identification of control group. LOS patients -Time to psychiatric -Faster consults consultation was shorter in the intervention group. -Median hospital LOS was 6.92 days in the intervention group vs 7.69 days in the control group. C.E.R.E.B.R.O. 53 - Respiratory failure LOS was 9.46 intervention vs control 12.29 median days) Camus et Compare pre and -Five Swiss -515 patients admitted to the II -Observational Study -Proactive al. (2003) post CL university internal medicine. -No change of LOS psychiatric implementation vs general -176 were included in the -No change in cost approach traditional hospitals. study; 81 in control group & 95 -No change in pt. -Embedded psychiatrist consult in intervention group. perception of psychiatric psychiatry provider on staff C.E.R.E.B.R.O. 54 Chen et al. This review aims to N/A Thirty-five eligible articles I -Systemic Review -Proactive (2016) understand barriers were found and they were -Younger patients psychiatric to CL inpatient grouped thematically into three more likely get psych approach referral as described categories: consults -Embedded in the literature. (1) Systemic factors -Diagnosed pts. more psychiatric (2) Referrer factors likely get consult Provider (3) Patient factors. verse undiagnosed -When provider unavailable, RN could assist -Provider specialties can be barriers to consults Desan et al. Compare LOS -Inpatient -Intervention group consisted I -Quasi-experimental -Proactive (2011) between a units of 62 admissions and the Study psychiatric consultation-as- control group consisted of 531 -Academic facility approach usual model and a admissions (257 admitted -No ICU patients C.E.R.E.B.R.O. 55 proactive -Yale New in the pre-control period, and -Cost figured for -Embedded consultation model Haven 274 in the post-control period). embedded psychiatrist psychiatric Hospital -LOS for control 3.88 vs 2.90 by savings of LOS provider on intervention. -Daily rounded staff increased -Use of EHR effectiveness -Identified -Psychiatry provider trauma, psych, spent 38.7 hrs. to and by meds. review all cases per week -proactive model is feasible and effective. -Medical team appreciate CL service C.E.R.E.B.R.O. 56 Findley et al. Comparing -Trauma -Intervention group, 28 I -Quantitative -Proactive (2000) proactive vs Service patients. Research psychiatric retrospective -Mass -Control group, 18 patients. -Some ICU, not approach consults General -68% prevalence of specific -Embedded Hospital psychopathy -Psychiatry not psychiatric -12% prevalence based on required everyday provider on trauma service -Having psychiatry staff -75% discharged without assisted other staff to -Use of EHR mental health support by be more sensitive -Identified trauma service -Psychiatric support trauma patients -100% after psychiatry doubled without -Identified onboard psychiatrist being psychiatric pts. there (off shift) Hosey et al. To characterize -MICU N (79) patient consultations: II -Retrospective Cohort -Use of EHR (2019) psychology -Johns -Emotional distress 56% Study -Identified consultation patterns Hopkins -Engagement in rehab 24% -All ICU patients psychiatric pts. Hospital -Family support 13% -Academic facility C.E.R.E.B.R.O. 57 within a medical -Delirium/cognition 4% -No other patient ICU -Nonpharmacological pain 4% populations 21 pts. with PMH preexisting: -Suggested more 41% Depressive disorder psychiatry involved in 30% Anxiety disorder ICU based on needs 11% Severe mental illness and preexisting 3% Dementia conditions -Demonstrated 1:3 patients had a psych diagnosis going into ICU -Demonstrated 1:4 needed for engagement in rehab Kishi et al. To examine factors -Multiple N (541) pts by CL Service: I -Cohort Study -Use of EHR (2003) affecting timing of areas Suicidal ideation 11.5% -Academic facility -Identified Depression 35.4% psychiatric pts. C.E.R.E.B.R.O. 58 psychiatric -University Psychosis 6.1% -Had ICU as a -Identified consultations of Chemical dependency 27.5% specialty unit psychotropic Minnesota – Evaluation 7.6% -Oversaw multiple medications University Competence 2.4% specialties -Identified Medical Behavioral problems 3.7% -Study showed trauma pts. Center Agitation 1.8% consistency of psych Anxiety 5.9% consultations Confusion, delirium 8.1% -Demonstrated Somatic complaints 3.9% reasons for delayed Other 2.2% consults - Delayed psych. consult -Demonstrated associated with a longer LOS reasons for expedited -Women, surgical patients, and consultations pts. perceived as depressed had -Large cohort number delayed consults -SI and chemical addictions had fast consults. C.E.R.E.B.R.O. 59 Kovacs et al. Examine health -Multiple - 152 responses III -Qualitative Research - Proactive (2021) workers perceptions areas -high level of satisfaction 99% - 16 general hospital psychiatric of -Aalborg units (11 medical, 3 approach University surgical and 3 ICU -Embedded Hospital wards) psychiatric -Academic facility provider on -Had ICU as a part of staff the study -Use of EHR -CL service helped with pts, families, and with staff development Okoronkwo CL service -Multiple - total of 2246 referrals, 1267 III - Cross sectional - Proactive (2019) evaluated by cost on areas before and 979 after study psychiatric system, - Health -readmission rates 33% and -Academic facility approach effectiveness, and Sciences 24% for the pre and post -ICU was part of it -Embedded staff satisfaction North, periods -cost effective psychiatric C.E.R.E.B.R.O. 60 Ontario, -10% decrease in the number of -Improved staff provider on Canada hospitalizations post CL satisfaction staff service -Assisted with LOS -Use of EHR -LOS before/after 9.24 days vs. and readmission -Identified 7.25 days. -still has room for psych pts. -staff satisfaction was high improvement with -Identified Reasons for consultations: staff and psychiatry medications medication review 22.5% psychiatric diagnosis 24.04% suicide risk assessment 18% Pt care management 26.3% Peris et al. Observational study -ICU - 86 patients in control period, II - Cross sectional - Proactive (2011) comparing - Careggi - anxiety 8.9% control vs. study psychiatric contemporary psych Teaching 17.4% intervention -Academic facility approach services vs CL Hospital, - depression 6.5% control vs. -All ICU level -Embedded service Italy 12.8% intervention patients psychiatric C.E.R.E.B.R.O. 61 - PTSD diagnosis 21.1% -Assessed only provider on intervention vs.57% control anxiety, depression, staff - patients who needed and PTSD symptoms -Use of EHR anxiolytic and/or antidepressant -Did not evaluate -Identified therapy post discharge 41.7% other areas of psych pts. control vs. 8.1% intervention psychiatry -Identified -Quality of life evaluations -Promising results for trauma patients higher in intervention vs post ICU and post -Identified control hospital stay in terms medications of assistance required Roberts et al. The review -ICU -17 studies included I -Systemic Review -Proactive (2018) comparing aims of - Cooper -12 studies called for proactive -Academic facility psychiatric preventing PTSD in University approaches -All ICU level approach the ICU Hospital, -1:5 retroactive approach studies -Use of EHR studies had good results -Identified psych pts C.E.R.E.B.R.O. 62 -Identified trauma pts -Identified medications Shdaifat et al. To identify the -ICU -Female 56.5% I -Cross sectional -Use of EHR (2022) prevalence of -7 hospitals , -mean age 44.6 years study -Identified anxiety and in Jordan -84.3% had anxiety symptoms -Evaluation of several psych pts depression among -79.6% had depression hospitals patients admitted to symptoms -All ICU level intensive care units patients in Jordan and their -Assessed only correlation with symptoms quality of life -no psychiatry evaluation occurred -Encouraged more proactive interventions C.E.R.E.B.R.O. 63 Sledge et al. Measuring LOS and Multiple -Control 535, Intervention 509 I -Randomized control -Proactive (2015) staff satisfaction of areas -LOS 7.29 control vs 6.65 study psychiatric proactive CL service -Yale New intervention -Academic facility approach vs psych consults as Haven -85% of staff rated the service -Included ICU -Embedded usual. Hospital satisfactory or above. -Assessed proactively psychiatric -estimated the cost of saving -Staff largely provider on days equaled the cost for the supportive of the CL staff intervention team efforts -Use of EHR -Identified psych pts. -Identified trauma patients -Identified medications Wade et al. Review of literature -University Offered services: II -Systemic Review -Proactive (2016) supporting College Psychological support 9% -Little evaluation of psychiatric Hospital Psychological welfare 10% psychiatry in the ICU approach C.E.R.E.B.R.O. 64 psychiatry in the London, Staff training 7% -Evidence available -Embedded ICU UK Provide pts. assessment 3% shows positive psychiatric Psychological follow-up 13% correlation for further provider Provide staff support 10% studies -Employing more integration of psychiatry to ICU team Warnack et Evaluation of trauma-Trauma N (119) trauma and psych pts. I -Retrospective Cohort -Use of EHR al. (2018) patients with - Bellevue -Psych pts. 3x more likely to Study -Identified psychiatric Hospital have penetrating injuries -Identified high psych pts comorbidities Center, -39% self-inflicted injuries prevalence in trauma -Identified NYC -64.7% require psychotropic patients trauma pts medication (17.6% -high connection to -Identified by noncompliant) psych and trauma pts. medications -7.6% had outpatient psych -Medications often provider required C.E.R.E.B.R.O. 65 -24.4% have SUD -SUD patients 1:4 of patients Weisser et al. Evaluation of -Multiple -45% of referrals were logical III -Qualitative research -Proactive (2019) proactive CL service areas consults study psychiatric in the hospital -Oslo -20% were not reasonable -Academic facility approach University -Staff overwhelmingly positive -Included ICU -Embedded Hospital, for CL service -Assessed proactively psychiatric Norway -Reason for consults: -Staff largely provider 1. Suicidal behavior supportive of the CL -Use of EHR 2. Anxiety and depression efforts -Identified 3. Crisis following admit -Evaluated top needs psych pts. 4. Substance use by CL service -Identified 5. Psychosis Coping -Evaluated efficacy of trauma patients 6. Psychosocial stress consults -Identified 7. Indeterminate conditions medications 8. Other C.E.R.E.B.R.O. 66 C2. Literature Synthesis-Intervention Table Article Theme 1: Theme 2: Theme 3: Theme 4: Identify Theme 5: Theme 6: Embedded Use of EHR Identify by by trauma history Identify by Proactive psychiatric psychiatric psychotropic psychiatric provider history medication history approach Bieber et al. (2022) x x Bourgeois et al. x x (2005) Bui et al. (2016) x x x x x x Camus et x x al. (2003) Chen et al. (2016) x x Desan et al. (2011) x x x x x x C.E.R.E.B.R.O. 67 Findley et al. x x x x (2000) Hosey et al. (2019) x x Kishi et al. (2003) x x x x Kovacs et al. x x x (2021) Okoronkwo (2019) x x x x x Peris et al. (2011) x x x x x x Roberts et al. x x x x x (2018) Shdaifat et al. x x (2022) Sledge et al. (2015) x x x x x x Wade et al. (2016) x x x x Warnack et al. x x x x (2018) C.E.R.E.B.R.O. 68 Weisser et al. x x x x x x (2019) Total 12 14 13 9 9 14 C.E.R.E.B.R.O. 69 Appendix D: Johns Hopkins Nursing Evidence-Based Practice Guide D: Evidence Level and Quality Guide Evidence Levels Quality Guides Level I A: High quality: Consistent, generalizable results; sufficient Experimental study, randomized controlled trial (RCT) sample size for the study design; adequate control; definitive Systematic review of RCTs, with or without meta-analysis conclusions; consistent recommendations based on Level II comprehensive literature review that includes thorough reference Quasi-experimental study to scientific evidence Systematic review of a combination of RCTs and quasi- experimental, or quasi-experimental studies only, with or without B: Good quality: Reasonably consistent results; sufficient sample meta-analysis size for the study Level III design; some control, fairly definitive conclusions; reasonably Non-experimental study Systematic review of a combination of consistent recommendations based on fairly comprehensive RCTs, quasi-experimental and non-experimental studies, or non- literature review that includes one reference to scientific experimental studies only, with or without meta-analysis evidence Qualitative study or systematic review with or without a meta synthesis C.E.R.E.B.R.O. 70 C: Low quality or major flaws: Little evidence with inconsistent results; insufficient sample size for the study design; conclusions cannot be drawn. Evidence Levels Quality Guides Level IV A: High quality: Material officially sponsored by a professional, Opinion of respected authorities and/or nationally recognized public, private organization, or government agency; expert committees/consensus panels based on scientific evidence documentation of a systematic literature search strategy; consistent results with sufficient numbers of well-designed Includes: studies; criteria-based evaluation of overall scientific strength • Clinical practice guidelines and quality of included studies and definitive conclusions; • Consensus panels national expertise is clearly evident; developed or revised within the last 5 years B: Good quality: Material officially sponsored by a professional, public, private organization, or government agency; reasonably thorough and appropriate systematic literature search strategy; reasonably consistent results, sufficient numbers of well- C.E.R.E.B.R.O. 71 designed studies; evaluation of strengths and limitations of included studies with fairly definitive conclusions; national expertise is clearly evident; developed or revised within the last 5 years C: Low quality or major flaws: Material not sponsored by an official organization or agency; undefined, poorly defined, or limited literature search strategy; no evaluation of strengths and limitations of included studies, insufficient evidence with inconsistent results, conclusions cannot be drawn; not revised within the last 5 years. Level V Organizational Experience: Based on experiential and non-research evidence A: High quality: Clear aims and objectives; consistent results Includes: across multiple settings; formal quality improvement, financial • Literature reviews or program evaluation methods used; definitive conclusions; C.E.R.E.B.R.O. 72 • Quality improvement, program, or financial evaluation consistent recommendations with thorough reference to scientific • Case reports evidence • Opinion of nationally recognized experts(s) based on experiential evidence B: Good quality: Clear aims and objectives; consistent results in a single setting; formal quality improvement or financial or program evaluation methods used; reasonably consistent recommendations with some reference to scientific evidence C: Low quality or major flaws: Unclear or missing aims and objectives; inconsistent results; poorly defined quality improvement, financial or program evaluation methods; recommendations cannot be made Literature Review, Expert Opinion, Case Report, Community Standard, Clinician Experience, Consumer Preference: C.E.R.E.B.R.O. 73 A: High quality: Expertise is clearly evident; draws definitive conclusions; provides scientific rationale; thought leader(s) in the field B: Good quality: Expertise appears to be credible; draws fairly definitive conclusions; provides logical argument for opinions C: Low quality or major flaws: Expertise is not discernable or is dubious; conclusions cannot be drawn. C.E.R.E.B.R.O. 74 Appendix E: Projected Timeline E: Gantt Chart Example C.E.R.E.B.R.O. 75 Appendix F: ICU Staff Initial/Progress Survey Thank you all for participating in the DNP project C.E.R.E.B.R.O. through MSU College of Nursing. In an effort to gauge the effectiveness of the project, please give us feedback on the implementation of the C.E.R.E.B.R.O. dashboard in the Epic EHR. 1. On a scale of 1-10, 1 being the worst and 10 being the best, how easy is it getting the psychiatric and mental health needs of the patients in the ICU? 2. On a scale of 1-10, 1 being the slowest and 10 being the fastest, how fast is the consultation take to get placed? 3. On a scale of 1-10, 1 being the slowest and 10 being the fastest, how quick is the response from the psychiatric providers? 4. On a scale of 1-10, 1 being the worst and 10 being the best, how happy are you with the response from the psychiatric providers? 5. On a scale of 1-10, 1 being unlikely and 10 being very likely, what is the likelihood of utilizing psychiatric providers for the next case? 6. Have you identified a patient who should be consulted by psychiatry on past psychiatric history, trauma history, or medication history? 7. If the patient did not meet past criteria, does the patient meet current criteria (depressed/traumatized/anxious/requiring psychotropic mediation/etc.) 8. What detail do you consider helping get ICU patients the mental health care they need? 9. Are there any outside factors identified coming in between psychiatry and the bedside? 10. What would you like to see from psychiatry? C.E.R.E.B.R.O. 76 Appendix G: EPIC Figure G.1 Example of Epic Dashboard C.E.R.E.B.R.O. 77 Figure G.2 Example of proposed Epic BPA C.E.R.E.B.R.O. 78 Appendix H: Prevalence Data Chart H.1: Overall prevalence of ICU patients with and without Psychiatric Histories C.E.R.E.B.R.O. 79 Chart H.2: Admission prevalence of ICU patients with and without Psychiatric Histories C.E.R.E.B.R.O. 80 Chart H.3: Overall prevalence of ICU patients with Psychiatric Histories differentiated by ICD Codes C.E.R.E.B.R.O. 81 Chart H.4: Admission prevalence of ICU patients with Psychiatric Histories differentiated by ICD Codes C.E.R.E.B.R.O. 82 Appendix I: Approvals C.E.R.E.B.R.O. 83 Chart I.1: Internal Review Board Approval C.E.R.E.B.R.O. 84 C.E.R.E.B.R.O. 85 Chart I.2: Psychiatric Provider Agreement Approval C.E.R.E.B.R.O. 86 C.E.R.E.B.R.O. 87 Appendix ** Faculty/Student Feedback Table Faculty Comments Student Re-Submission Need a paragraph or two describing what the Information and data added problem is at the specific site. Add a sentence summarizing the problem Clinical problem clarified then have your PICOT question. Also need to clarify the exact problem. Add appendices A-D from the project Added appendices handbook Spell out COVID-19 the first time it is used Change made Change the wording so assume is not used Reviewed and made changes related to the increase in FTR events Reword the last sentence in the significance Reviewed and made changes section about the role bedside nurses play in identifying deterioration and intervening Make PRISMA diagram an appendix Moved to appendices Use feedback table Feedback table updated Add more information to background Reviewed and made changes Literature synthesis themes all need to have Reviewed and will make changes more information added APA corrections Reviewed and made changes Faculty advisor meeting with change in Numerous changes made to reflect change focus of paper in focus