Journal of Behavioral and Brain Science, 2011, 1, 17-22
doi:10.4236/jbbs.2011.12004 Published Online May 2011 (
Copyright © 2011 SciRes. JBBS
In-House Implications of a 1-Year Retrospective Analysis
of the Psychiatric Co nsu lt ati on-Service
in a German University Hospital
Maximilian Gahr, Markus Schmid, Roland W. Freudenmann, Carlos Schönfeldt-Lecuona
Department of Psychiatry and Psychotherapy III, Ulm University, Ulm, Germany
E-mail: {maximilian.gahr, markus.schmid, roland.freudenmann, carlos.schoenfeldt}
Received February 11, 2011; revised March 12 , 20 1 1; acc epted March 14, 2011
Objective: Due to major differences in patient populations, consultants and hospital settings of single-centres
structured analyses of the psychiatric consultation-service (PCS) might be considered as an internal statistical
appraisal for quality and efficacy improvements of the focused PCS. Method: The patient population given
by the original documentation schedules of psychiatric consultations performed in the University hospital of
Ulm in the year 2008 were analysed for the following variables: sex, age, requesting department, based
problem or consultation query, allocated psychiatric diagnosis, therapeutic suggestion, occurrence and num-
ber of psychiatric consultations within the same case, acuteness level, diagnosis according to ICD-10 F and
therapeutic recommendation. Results: In a total of n = 656 consultations most frequent questions were for:
“medication”, “diagnostic suggestions” and “no specific question”, whereupon “no question” was given in
19%. A statement concerning the urgency-level of the consultation was present in 10.5%. Organic mental
disorders, mood disorders, neurotic, stress-related and somatoform disorders formed 72% of all diagnoses.
Pharmacotherapy was most frequently recommended. The detected shortcomings were mostly the result of
heterogenous documentation. Conclusions: Frequent absence of relevant information throughout the consul-
tation process gives reason for interdisciplinary arrangements to create a rational algorithm for PCS. Based
on our findings standardization of our consultation reports was established by means of a standard form and
a pocket-booklet which provides diagnostic guidelines and therapeutic recommendations.
Keywords: Consultation- and Liaison-Psychiatry, Standardization, Quality Control
1. Introduction
Mental and behavioural disorders have been reported to
be present among approximately one third of general
hospital inpatients [1-4]. Therefore, PCS plays a pre-
ponderant role in the multidisciplinary treatment ap-
proach when dealing with multimorbid patients, which
suffer secondarily psychiatric symptoms as a conse-
quence of a somatic disease or have a genuine comorbid
psychiatric disorder. An improvement in diagnostic and
therapeutic accuracy of comorbid psychiatric disorders
would be desirable since psychiatric comorbidity has
been described to be associated with poor clinical out-
come, extended hospitalization and increased mortality
in medically ill patients [5-8]. A small number of studies
have been conducted in the last decades to picture the
PCS in single centres [7,9-12]. As a result of major dif-
ferences in patient populations, consultants and hospital
settings the findings rendered by these studies are het-
erogeneous and primarily only valid for the particular
institution. In this light, single-centre data are not gener-
alisable and not appropriate to make comparisons among
other centres in order to retrieve general insights in con-
sultation psychiatry. Structured analyses of the PCS
might primarily be considered as an internal appraisal
that offers the statistical foundation for quality and effi-
cacy improvement of the focused consultation-service.
Considering that clinical outcome and hospitalization
time in medically ill patients with psychiatric comorbid-
ity is deeply related with the accomplishment of the
consultation-liaison psychiatry service, we aimed to as-
sess the performance of our department. With the ulti-
mate aim of optimizing our PCS in the matter of adj usted
standardization and quality control a retrospective cross-
sectional analysis of all psychiatric consultations at the
University Hospital Ulm (Ulm, Germany) was carried
out observing a 1-year period. Therefore, an in-house
inventory was developed to gain data (see methods) from
the documentation schedules for further analysis. Based
on shortcomings in documentation, that should be identi-
fied in our analysis, we first intended to create a standard
form with particular items according to detected idiosyn-
cracies that should replace the former blank documenta-
tion schedules. In addition, composing a pocket-booklet
with useful information for the consulting psychiatrist
was proposed. This pocket-booklet should contain in-
formation regarding diagnostic criteria, differential di-
agnosis and treatment guidelines of the most frequent
diseases within our PCR to render an improved and more
homogenous outcome possible.
2. Materials and Methods
Data used for further analysis was obtained from the
original documentation schedules of psychiatric consul-
tations performed by physicians belonging to the De-
partment of Psychiatry and Psychotherapy III of the
University hospital Ulm. We collected data from all
psychiatric consultations of the year 2008 (between the
1st of January and the 31th of December) performed by
our consultants in other medical departments of the Uni-
versity Hospital in Ulm. Selected data (patient and case
related data) from these documents was retrieved and
assembled in a separate chart review assessing different
issues (see below). For data analysis two perspectives
were regarded: 1) The information standing on the re-
quest schedule (requesting department) and 2) the psy-
chiatric evaluation and recommendation documented.
2.1. Data Assessment from the Request Schedule
Following aspects were assessed from the request sched-
ule: “Gender” and “age” of the patient, “requesting de-
partment”, “based problem or consultation query”, “al-
located psychiatric diagnosis”, “therapeutic suggestion”,
“occurrence and number of psychiatric consultations
within the same case”, and existence of a statement indi-
cating the “acuteness level” and accordingly the “number
of affirmated emergency consultations”. In this context,
documentation schedules were scrutinized for the exis-
tence of explicit declarations of urgency, respective
emergency and whether this indication (e.g. emergency:
yes/no) could be confirmed by the consulted psychiatrist
of our department. In order to identify and accurately
quantify the most frequently formulated questions by the
colleagues of other disciplines requesting a psychiatric
consultation in the documentation schedules we decided
to build subcategories. Those were created having regard
to frequently articulated pro blems that were standing out
within a first view of th e data and in consid eration of our
clinical experience. Here we focused on explicit verbal
formulations that displayed distinct questions or that
were denoted with a question mark. Recurring reasons
for a psychiatric consultation were as followed: “no
question documented”, “medication procedure?”, “diag-
nostic procedure?”, “diagnosis?”, “suicidal tendencies or
risk?”, “forensic reason?” (in a broader sense, e.g. pa-
tient’s capacity to give informed consent to a medical
procedure or the necessity of installation a legal repre-
sentative), “indication for transferring the patient to the
psychiatry department?” and questions that contained
combinations of the above explained subcategories: “di-
agnostic and medication procedure”, “forensic reason
and therapy procedure”, “forensic reason and diagnosis”.
2.2. Data Assessment from the Psychiatric
Evaluation and Recommendation
Following issues were assessed from the psychiatric
evaluation and recommendations: “Diagnoses”; those
were registered according to international classification
of disorders (ICD-10), chapter F from the world health
organization [13]. Therapeutic recommendations docu-
mented were also distributed to a set of subcategories:
“no specific recommendation”, “medication”, “indication
for transferring the patient to the psychiatric department”,
“forensic reason”, “diagnostic procedure (e.g. MRI scan
of the brain, cerebrospinal fluid)”, “medication and psy-
chotherapy”, “psychotherapy”.
3. Results
Between the 1st of January and the 31th of December
2008 a total of 656 psychiatric consultations were per-
formed by our department.
1) Assessed Data gained from the request schedule,
independent of the psychiatric evaluation and recom-
mendation, showed following results:
Sex and age: Fifty nine percent of the patients were
female (n = 390) and 41% (n = 266) were male. Regard-
ing the different age-groups, 2% of the patients (n = 15)
were older than 90 years, 14% (n = 90) showed an age
between 80 and 89, 16% (n = 107) between 70 and 79,
18% (n = 119) betw een 60 and 69, 14 % (n = 94 ) betw een
50 and 59, 15% (n = 99) between 40 and 49, 10% (n = 66)
between 30 and 39, 10% (n = 63) between 20 and 29 and
1% (n = 3) were younger than 20 years (see Figure 1).
More than half of the patients (50.5%, n = 331) were 60
years or older on time of individual consultation.
Copyright © 2011 SciRes. JBBS
Requesting department: Considering the requesting
department, 79% of all consultations were performed in
four departments: internal medicine (n = 230 / 35%),
surgery (n = 173 / 26%), geriatrics (n = 64 / 10%) and
neurology (n = 54 / 8%). Details can be seen in Table 1.
Consultation query: The majority of questions stated
on the request schedule (84%, n = 552) could be allo-
cated to four subcategories: “medication” (27%, n = 180),
“diagnostic suggestions” (20%, n = 129), “no specific
question” (19%, n = 124) and “suicidal tendency or risk”
(18%, n = 119). For details see Table 2.
2) Assessed Data gained from the documented psychi-
atric evaluation and recommendation, showed following
Diagnostic codes: Three ICD-10 F diagnostic code-
groups covered 72% of all diagnoses: Organic, including
symptomatic, mental disorders (ICD-10 F00-F09) were n
= 193 (30%), mood (affective) disorders (ICD-10 F30-
F39) had n = 192 (29%), neurotic, stress-related and
somatoform disorders (ICD-10 F40-F48) n = 88 (13%).
No psychiatric diagnosis was given in 12% of the cases
(n = 78). Details are listed in Table 2.
Therapeutic recommendations: Pharmacotherapy was
the therapeutic recommendation in 59% (n = 384),
whereas a non classifiable recommendation respectively
no specific psychiatric recommendation was articulated
in 16% (n = 103). Transfer to the department of psychia-
try for continuative inpatient treatment (independent of
diagnosis) was rec om mended in 7% (n = 44).
Forensic recommendation: In 6% (n = 40) of all con-
sultations a forensic recommendation in the broader
sense was documented (e.g. a statement concerning pa-
tient’s capacity to give informed consent to a medical
procedure or the necessity of installation a legal repre-
sentative). Details can be seen in Table 3.
Consultation frequency: Regarding the consultation
frequency per case, 7% of all patients (n = 48) have been
consulted twice, whereas 2% (n = 14) r eceived a psychi-
atric consultation three times, and 1% (n = 7) had four
psychiatric consultations. In only 0.5% of the cases (n =
3) had to come across the psychiatrist more than four
Emergency consultation: Consultation request texts
were also analysed for the existence of specific declara-
tions according to the urgency of the psychiatric consul-
tation, respectively to a possible emergency situation.
Existing designations of this kind were inspected
whether the psychiatrist had acknowledged the particular
labelling or not. A statement ind icating the priority o f th e
inquired consultation as urgent or emergency was found
in n = 69 (10.5%) with n = 40 (6%) of declared and sub-
sequent acknowledged emergencies and n = 29 (4.5%) of
so declared but later on not confirmed emergencies.
Table 1. Requesting departement in a total of n = 656 con-
sultations [female n = 390 (59%); male n = 266 (41%)].
Requesting departement n / %
Internal medicine 230 / 35%
Surgery 173 / 26%
Geriatrics 64/ 10%
Neurology 54 / 8%
Otorhinolaryngology 26 / 4%
Gynecology 22 / 3%
Urology 19 / 3%
Dermatology 14 / 2%
Anesthesia 14 / 2%
Orthopedics 13 / 2%
Nuclear medicine 11 / 2%
Neurosurgery 8 / 1%
Ophtalmology 6 / 1%
Child-and adolesce n t p sychiatry 2 / 1 %
Table 2. Question categories and psychiatric diagnoses.
Question category: n / % Diagnosis
(ICD-10 F): n / %
Medication 180 / 27% ICD-10 F 0 193 / 30%
Diagnostic 129 / 20% ICD-10 F 1 37 / 6%
None 124 / 19% ICD-10 F 2 35 / 5%
Suicidal tendency 119 / 18% ICD-10 F 3 192 / 29%
Forensic 47 / 7% ICD-10 F 4 88 / 13%
Diagnostic +
medication 33 / 5% ICD-10 F 5 4 / 1%
Transfer to psychiatry 18 / 3% ICD-10 F 6 28 / 4%
Forensic and therapy 3 / 0.5% ICD-10 F 7 0 / 0%
Forensic and diagnosis3 / 0.5% ICD-10 F 8 1 / 0%
ICD-10 F 9 0 / 0%
No psychi-
atric diag-
nosis 78 / 12%
Table 3. Therapeutical recommendations.
Category of therapeutical
recommendation n / %
Medication 384 / 59%
No specific 103 / 16%
Transfer to psychiatry 44 / 7%
Forensic 40 / 6%
Further diagnostic pro c e d ures 37 / 5%
Medication and psychotherapy 33 / 5%
Psychotherapy 15 / 2%
Further diagnostical procedures, recommended in addition to any of the
above mentioned recommendations at n = 84 (13%) consultations; Addi-
tional recommendation with psychosocial or forensic character at n = 38
4. Discussion
Several studies have reported an association between
psychiatric comorbidity and poor clinical outcome, ex-
tended hospitalization and increased mortality in medi-
cally ill patients. Thus, improvement in diagnostic and
Copyright © 2011 SciRes. JBBS
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Figure 1. Age structure o f the total population on time of individual consultation (n = 656).
therapeutic accuracy of comorbid psychiatric disorders
would be essential to ameliorate the actual scenery. En-
hancing the expertise of PCS is the key issue of being
more efficient in the treatment of multimorbid patients
that present psychiatric co-morbidity. The accurate
analysis of our work has to be conceived as quality con-
trol, and should be used to better characterize the needs
of system implementation.
Regarding our data, the department of internal medi-
cine accounted for the majority of psychiatric consulta-
tions (35%), followed by the surgery department (26%);
this is in line with o ther published studies [9,14-17]. The
analysis of the consultation query showed that the major-
ity of questions documented on the request schedule
could be allocated to four subcategories ranging from
“pharmacotherapy” (27%), followed by “diagnostic sug-
gestions” (20%), “no specific question” (19%), and “sui-
cidal tendency or risk” in 18% of the cases. On the other
hand, the analysis of the data gained from the docu-
mented psychiatric evaluation and recommendation
showed that organic mental disorders (including symp-
tomatic and substance induced disorders ICD-10 F00-
F09) were the most frequently diagnosed (30%), fol-
lowed by mood (ICD-10 F30-F39 = 29%) and neurotic,
stress-related and somatoform disorders (ICD-10 F40-
F48 = 13%). Pharmacotherapy was the most frequently
therapeutic recommendation in 59%, similarly to previ-
ously reported investigations [10,14,17]. Transfer to the
department of psychiatry for continuative inpatient
treatment (independent of diagnosis) was recommended
only in 7% of the consultations. Forensic recommenda-
tions as are e.g. a statement concerning patient’s capacity
to give informed consent to a medical procedure or the
necessity of installation of a legal representative, was in
6% of all consultations. 7% of all patients received a
psychiatric consultation twice; whereas 2% received it
three times (1.5% had four psychiatric consultations).
10.5% of requested consultations were declared as
emergency consultations by the requesting department;
in only the half of them the consultation could be con-
firmed as emergency.
All in all, the shortcomings of our PCS that were de-
tected in our analysis seemed to be the consequence of
lacking standardization. The request schedule plays a
very important role when considering the efficiency of
the PCS, since the psychiatric consultant has to orient his
work to the question stated on the requesting schedule. A
consultation schedule without precise question (“no spe-
cific question” in our study was provided 19% of the
cases) could trigger at least two extreme positions: the
consultant rejects the evaluation and demands a new
schedule or he has to evaluate all anamnestical, medical
and psychopathological aspects of the case. A third pos-
sibility is contacting the requesting department and try-
ing to find out the reason for the consultation; all three
positions resulting in an unfeasible waist of resources
and time. In consideration of unspecific or even missing
consultation questions an interdisciplinary arrangement
to create a rational algorithm for reasonable processing
of psychiatric consultation seems reasonable from a
quality and economical point of view. Predominantly
clear indication of an acuteness level (emergency: yes/no)
was not provided by the requesting physician but should
be part of the regularly communicated information. The
particularly absence of this information makes it difficult
to perform a reasonable coordination of the consultation
service and to set adequate preferences. On the other
hand, the arbitrary completion of the consultation letters
by the consultants could decrease the treatment quality
by means of missing standardization that possibly results
in reduced capability of the psychiatric treatment. For
those circumstances and based on these findings we
conducted and established a standard form for the con-
sulting psychiatrist that replaced the former blank docu-
ments that were the primary object of this inquiry and, as
we noticed during the process of data accumulation, had
been completed mostly arbitrarily. Exhibiting distinct
items (basic patient data, requesting department, consul-
tation query, anamnesis, diagnostic findings, diagnosis
and therapeutic suggestions) this standard from quickly
provides information to the requesting physician. Having
the possibility to mark frequently neccessary statements
(e.g. suidial tendency: yes/no, capacity to give informed
consent: yes/no, suggested further treatment context:
inpatient/outpatient) with a cross the form also reduces
the psychiatrist’s documentation effort. By means of this
standardization the probability of occurrence of gross
faults, as e.g. a missing statement towards suicidal ten-
dency with depressive patients, can be minimized.
Within the frame of acquiring more homogeneity in the
outcome of our consultation psychiatry department, in a
second step, a pocket-booklet regarding the most fre-
quent mental and behavioural disorders within psychiat-
ric consultations in our clinic as detected by our analysis
was created. This pocket-booklet provided valuable in-
formation in the field of diagnostic criteria, differential
diagnosis and treatment guidelines of frequently faced
psychiatric comorbid disorders, and resulted in a signifi-
cant relieve of consultants work, as reported in the feed
Organic mental disorders (e.g. dementia, delirium, in-
cluding substance induced disorders) and affective dis-
orders were the most frequently diagnosed, pointing that
consultation psychiatrists should preponderantly be spe-
cialised in mentioned conditions and more over in the
differential diagnostic considerations and acute interven-
tion that makes the management of the case in an internal
medicine or surgical department possible. On the other
hand “no psychiatric diagnosis” was given in 12% of the
cases, even though the requesting department was re-
quiring psychiatric advice. The interpretation of this data
is rather speculative, but one may postulate, that some-
times patients in somatic departments report emotional
complaints that do not reach the degree of a mental dis-
To achieve an increase of the efficiency of their PCS
periodic investigations of PCS in terms of internal qual-
ity control are indispensable for every psychiatric de-
partment. Insights retrieved by those appraisals allow
detecting weak points and providing basic data to create
algorithms for further optimization. The necessity of
quality and efficiency improvements of PCS is also re-
flected by the foundation of associations for consulta-
tion- and liaison-psychiatry in several countries (e.g.
EACLPP: European Association of Consultation-Liaison
Psychiatry and Psychosomatics, SSCLP: Association for
consultation psychiatry in Switzerland, Academy of
Psychosomatic Medicine: Association for consultation
psychiatry in the US, Section for consultation- and liai-
son-psychiatry of the DGPPN: German Association for
Psychiatry, Psychotherapy and Neuroscience). Those
institutions offer further education and set the scientific
frame for the consultation- and liaison-psychiatry in par-
ticular countries. Not least, efficiency issues implicate
economic aspects as well what gives reason to account
for the economic character of the relationship between
the department of psychiatry as the care provider and the
particular requesting department as the recipient of bene-
fits. Thus, both sides should be interested in smooth
transfer of relevant information to guarantee optimal
outcome and cost-effectiveness. For that purpose we
suggest an electronic request system managing the dis-
tribution of incoming consultations requests as most ef-
fective. Thereby, the requesting physician should be in
charge of providing contact information to allow the
psychiatrist elimination of unclarities before the consul-
tation visit. A common problem is the evaluation of the
clinical results of the psychiatric intervention in the con-
text of PCS due to the usual single-contact setting with
its difficulty to retrieve data of the patient’s development
after the psychiatric consultation. The electronic data
system could easily been modified to allow the request-
ing physician to state how the patients developed and
whether the psychiatric consultation was realised at all
and, if so, was felt to be helpful or not.
There were some relevant limitations in our study.
First, a large amount of data of the documentation was
predominantly represented in metric variables and
nominal scaled variables. This fact made the attribution
of single cases to certain data impossible. The absence of
systematically interdependence between the measured
variables did not allow to target on e.g. the frequency of
certain diagnoses regarding to special departments or sex
or age related accents. Secondly, identification of diag-
noses was based on ICD-10 diagnoses without specifica-
tion of subgroups what made it impossible to distinguish
between e.g. delirium and dementia in the F0 group.
Least, other variables of interest as types of recom-
mended medications, and preexisting psychiatric history
have not been investigated.
5. Conclusions
Our retrospective analyses of the PCS displayed a useful
data set to identify unfavourable idiosyncrasies of docu-
mentation on both sides of the consultation process, the
psychiatrist as the care provider as well as the requesting
physician, and furthermore provided basic statistical data
concerning the spectrum of frequent diseases, patient
Copyright © 2011 SciRes. JBBS
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population, frequently asked questions, etc. Lacking
standardization seemed to be the main culprit in the
genesis of inadequateness of our PCS. The high fre-
quency of unspecific or even missing consultation ques-
tions judge an interdisciplinary arrangement as expedient
for creating a rational algorithm for reasonable process-
ing of the PCS. Intending rational improvement of our
PCS we established standardization of our consultation
reports with a standard form that was created based on
our findings. In addition we created a mandatory pocket-
booklet for our consultants providing useful information
according to the most frequent psychiatric diseases in our
clinic to generate more homogeneity in the treatment
outcome. Though no prospective study concerning the
outcome of these two interventions had been performed
first feedbacks of our consultants were promising.
Therefore, we suggest meticulous and structured
analysis of the PCS of particular hospitals as valuable for
quality improvements based on the retrieved data by
means of standardization. Implementation of standard-
ized consultation sheets and a pocket-booklet with bind-
ing information together with a specific interdisciplinary
arrangement to optimize communication could be ele-
ments of a possible first strategy for improvements of
PCS. However, effects of interventions of that kind re-
main to be examined in prospective studies.
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