Lack of Guideline-Supported Protocols


Joe Avelino, RN, BSN, MHSA, CPHQ, defines a hospital versus an institution; and Rahn Bailey, MD, DFAPA, and Henry Nasrallah, MD, discuss the lack of guideline-supported protocols for patients

Peter Salgo, MD: There are protocols for patients transitioning from a hospital to an institutional setting. What is the difference between a hospital setting and an institutional setting? Joe, can you lay that out for us?

Joe Avelino, RN, BSN, MHSA, CPHQ: From a hospital perspective—like in our ER [emergency department] in our earlier conversation regarding protocols—there isn’t a protocol, but we do have order sets from our psychiatrists in the ER working with the ER doctors because they do not want to be called; they do not want to be bothered. Through the order sets, we also have our EMR [electronic medical record] through Cerner Corp, which follows through order sets so that when the patient is admitted to the unit from a hospital acute care setting, they can follow these order sets. According to our medical staff bylaws, they have to see the patient within 24 hours of admission, and if necessary, they would need to modify these so-called order sets.

Peter Salgo, MD: That is 1 set of guidelines in your hospital. But I am getting the sense that these guidelines are not universal. I want to go back to stroke or heart attack. If somebody is having chest pain, the mantra is what? One hour from ER to catheterization laboratory, period, for MI [myocardial infarction]. It is similar for a stroke. You want to get the CT done. You want to get the CTA [CT angiography] done and then give therapy. Why is not this a national set of guidelines so that it does not matter where you go—Columbia, Duke, UCLA, anywhere—this is what we do. You come in with these symptoms; you have got 24 hours; do it. Why isn’t that in place?

Rahn Bailey, MD, DFAPA: You ask what I consider a parenthetical question, and I will give you an answer that has some historical context, but it is a challenging 1 because we can do better. We can attribute some of these difficulties, and they certainly are well stated, to our historical legacy of treatment in psychiatry. Some were analysts. They did not wear a white coat, they did not use medications, and they believed in the ethical approach or unethical approach and are biologically based in our approach. When I was in training, interviewing for residency 30 years ago, that was a discussion: What kind of training would you get? But you bring up a very good point. Training should be based on what’s best in class. That should be evidence based and empirically oriented. Once you get a better answer, everybody should move along that line whether we like the term algorithms or not.

Peter Salgo, MD: I happen to like it, by the way.

Rahn Bailey, MD, DFAPA: We hold on much longer than we should, and that’s why this discussion that we’re having about why many doctors in a way don’t choose LAIs [long-acting injectables] despite the evidence that they are practically better for many of your patients for a lot of reasons, speaks to the other opinion. We must educate not only the majority of our young students and trainees but also our midcareer doctors who think that or will continue to do it the old way. 

I’ll give you an example. Early in my career I spent quite a bit of time discussing—somebody mentioned earlier—the issue of metabolics in our business. We all thought that metabolics are bad and, Henry even referred to it today, some people in the past thought the medications caused the endocrinopathies if you will, rather than appreciating that we’ve had data going back to the 1920s—that if you have diabetes or chronic mental illness, you’re more likely to have endocrine problem such as diabetes and hyperglycemia. 

Back then, Pfizer did the 054 study, and it showed that although docs thought Mellaril was safe, and we’re all looking to see whether ziprasidone was the cause of the problem. Instead, it was all the atypicals, ziprasidone, risperidone, Zyprexa, and others that were similar. But Mellaril was the outlier. I was always shocked at how many psychiatrists fought against that. The majority fought against having a visceral response that was negative to the data. It’s spoken well over the course of my career and how we have to find ways to communicate new messaging when we have empirical data in psychiatry. We need to have discipline when we very quickly move toward best in class. Your question is right: We don’t do that regularly, and unfortunately at times it’s to our patients’ detriment.

Peter Salgo, MD: Early in my career you would say to somebody on the psychiatric service with an inpatient, “Have you checked his blood sugar? Have you done this? Have you checked his thyroid hormone?” And they say, “We don’t want to do that because we think it’s counterproductive, and it interferes with the therapeutic relationship.” That seems to be similar to what I’m hearing. We have drugs, these drugs work, and they work better when hey are given LAIs than they do when they’re given orally, yet I am hearing you tell me there’s pushback. “Oh, no, I don’t like my white coat. I don’t want to be thinking this way. I want to do it the old way because I think it’s better for the patient.” Am I missing something here, Henry?

Henry Nasrallah, MD: The psychodynamic era of psychiatry hurt us for a long time. It is much better now, but when I was training, some of my faculty regarded giving an injection to a patient as equivalent to rape. “You’re penetrating them,” they would say, and they objected to touching patients, which makes it very hard. How can you not touch the patient and test for EPSs [extrapyramidal symptoms]. That is ridiculous because touching was taboo in psychoanalytic circles. It does not help psychiatry at all. We need to touch our patient, we need to draw labs, we need to examine them just as a neurologist does. 

Every patient with psychiatric disorder has a brain disorder and deserves a full neurological work-up before you give them a medication. Here is an example why this is important: There are numerous studies, like 15, showing that at first episode, before you give any antipsychotic, about 30% of the patients have Parkinson disease symptoms, another percentage has akathisia, and another percentage has dystonia before you touch them with any antipsychotic. If you do not do a good motor exam before you give the antipsychotic, you blame all the motor abnormality on the antipsychotic. That is an example of poor medical care.

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Transcript Edited for Clarity

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