Integrated healthcare in the ICU

By Norman M. Shulman, Ed.D.
July 20, 2019



Intensive Care Unit and mental health integrationI have previously stressed the importance of fully integrating a mental health professional in the critical and intensive care units (ICUs) of general hospitals. In this article, I will outline a suggested model to make systemic changes to improve overall patient care in these settings.

What follows is a detailed description of day-to-day functioning of psycho-medical integration with specific suggestions regarding how a mental health professional should operate along with a description of ways the role of these professionals may be expanded for even greater clinical effectiveness.

Initial contact and follow-ups

To begin, it is necessary to reconsider the definition of psychotherapy. It is clear that the traditional definition of a therapist sitting down with a patient in a private space is not applicable on ICUs. Yet it can be argued that brief daily supportive interventions are in fact therapeutic.

These relatively short interventions are necessitated by medical conditions and treatment considerations in ICUs. However, they can still have lasting positive preventive and postventive impact on patients subject to psychopathological symptom development.

Consistent – daily if possible – interventions can create positive clinical outcomes due to their cumulative effect. Initial contact, when introductions are made and purpose expressed, starts building a rapport that often becomes essential in resolving later developing problems during intensive care.

The first visit should convey openness, genuineness, honesty, trust and confidence, which are not a given presentation for any professional to project. This opening gambit is especially important when family members or friends are present at first contact.

A properly conducted initial session provides a brief overview of the potential symptoms of adjustment issues, depression, anxiety and PTSD that can be a direct result of the incurred trauma. A checklist which delineates relevant symptoms is provided to patients and significant others. Immediate awareness of what to identify considerably enhances diagnostic potential.

For example, patients often manifest symptoms while asleep or under the influence of anesthesia or pain medication, which may not come to consciousness. In these cases, having reliable witnesses around the patient is invaluable.

Follow-up interventions provide opportunities to reinforce confidence in the mental health professional. In the event that questionable symptoms emerge, a patient and/or family member are much more likely to report any changes in the loved one’s mental status.

The medical team’s treatment is a priority, of course, and must be worked around, but a daily appearance should be attempted. These visits mean a lot to most patients, especially those who have limited or no support. Showing up with positive words of encouragement says that the patient matters in spite of the circumstances.

When therapy issues do present themselves, they can be addressed during these interventions until the patient advances to a level conducive to a traditional model of psychotherapy.

Brief interactions provide sufficient time to establish a workable diagnosis and differentiation between pre-existing and post-morbid symptomology. Ideally, the mental health professional who makes the initial assessment will be the same one who works with the patient (and family) throughout the stay. This may include lesser levels of care until discharge.

Beyond discharge it is clinically optimal for the same therapist to continue to see the patient, if indicated, as an outpatient. Such a system has been established at the Texas Tech University Medical Center in Lubbock, Texas, where the above-described intervention model is in place and is readily available to trauma patients throughout treatment.

Coordination with psychiatry

At our facility the role of psychiatry in this system has been limited to medication evaluations and maintenance. All supportive psychotherapeutic interventions are left to the mental health professional. As a result there is no confusion for the patient and family as to how the two disciplines interface.

The increasing confidence that the trauma team gained from extensive exposure to psycho-medical interventions has made team members less dependent on psychiatric consultations. Therefore, the team’s interventions have become even more efficient.

For example, a PTSD medication protocol is in place to implement as soon as it is warranted. This saves time between when a psychiatric order is written and recommendations are made, which could take as long as a few days.

Interdisciplinary coordination

The regularly scheduled interdisciplinary staffing is an especially useful mechanism to maximize communication among treating modalities. At these meetings attending physicians, resident surgeons, nurses, therapists, nutritionists and pharmacists provide a comprehensive picture of the patient’s condition. This is also a teaching opportunity, in that each professional can learn something from other fields that may be relevant to overall patient care.

Valuable information becomes available and utilized across disciplines. Psychological symptoms identification and rehabilitation compliance are two of many areas where this cross-learning occurs. In addition, knowledge of relative interdisciplinary duties increases cooperation during the majority of clinical time spent on the floor as opposed to in-person meetings.

Burnout prevention

The integrated mental health professional is uniquely situated to assist colleagues who struggle with the stress of working in an ICU. It is not uncommon for a team member to approach or be referred to the mental health professional about the emotional impact of traumatic events endemic to trauma settings.

Sometimes a brief intervention is all that is necessary to help a team member get back on track. At other times more extensive psycho- and pharmacotherapeutic interventions are necessary.
In either case the already known and trusted interdisciplinary mental health professional is the logical resource for a stressed colleague to utilize in times of need.

In sum, the integrated mental health professional offers multiple means of improving the functioning of critical care units. While these expanded roles exist outside the purview of traditional psychology and counseling, they are a logical extension of patient care.

More evidence-based research is needed to measure the relative efficacy of such interventions as opposed to other models or no model at all.

This type of evidence-based research project is being planned at Texas Tech University. Because of the nature of the psychological problems that develop in ICUs there has never been a better time to embrace and study the proposed innovative psycho-medical integration model by individual practitioners and health systems alike.

References available from author

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Norman M. Shulman, Ed.D., is a clinical psychologist in Lubbock, Texas. His email is: psychmang@yahoo.com.

 

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