Desenvolvimento e avaliação de um instrumento para identificação de risco psiquiátrico no hospital geral
Data
2018-03-01
Autores
Camargo, Ana Luiza Lourenco Simoes 
Orientadores
Citero, Vanessa de Albuquerque
Tipo
Tese de doutorado
Título da Revista
ISSN da Revista
Título de Volume
Resumo
Objetivo: Desenvolver e avaliar o instrumento “Avaliação de Risco Psiquiátrico”
(ARP), para identificação de riscos psiquiátricos e sua gravidade no hospital geral.
Método: Dois estudos foram efetuados num hospital geral terciário em São Paulo,
Brasil. A ARP foi desenvolvida através do estudo qualitativo etnográfico dos relatos
de 300 enfermeiros de unidades de internação clínico-cirúrgicas, obtidos através de
grupos abertos, conduzidos por enfermeira treinada, durante 2 meses, nas
passagens de plantão. Foram utilizadas duas questões: “Vocês considerariam útil
discutir com um psiquiatra situações da prática diária? Quais situações?”. A análise
etnográfica dos relatos foi utilizada na elaboração do instrumento. A aplicabilidade
da ARP foi medida através de um estudo quantitativo, transversal, no qual todas as
21.007 admissões hospitalares que ocorreram em um período de 6 meses foram
submetidas ao rastreio pela ARP, e os riscos identificados pelos enfermeiros
discutidos com os psiquiatras institucionais. Avaliou-se a concordância entre
enfermeiros e psiquiatras quanto à presença do risco, itens do instrumento e
gravidade do risco psiquiátrico, categorizada como leve-moderada-grave, através do
coeficiente Kappa, valores preditivos e acurácia diagnóstica. Por fim, foram descritas
as intervenções desencadeadas pelos psiquiatras para os riscos notificados.
Resultados: A análise etnográfica dos relatos mostrou que os enfermeiros
observavam e consideravam útil a discussão com o psiquiatra de situações relativas
a riscos psiquiátricos. Através da linguagem descritiva destas situações
desenvolveu-se um instrumento com 11 itens, a ARP, inserida na Avaliação de
Riscos Global do Paciente, efetuada pelos enfermeiros na admissão e a cada 48
horas durante a internação. Os riscos identificados foram compulsoriamente
notificados ao psiquiatra institucional e, através da discussão de caso, um plano de
intervenção deflagrado. A avaliação da aplicabilidade do instrumento mostrou que os
enfermeiros identificaram 2.820 riscos psiquiátricos, correspondendo a 13,4% de
todas as admissões. Foram excluídas notificações com dados demográficos
incompletos (n=36) e notificações não discutidas com o psiquiatra (n=364), sendo a
alta prévia a razão mais frequente para a não discussão do risco. Das restantes
2.420 notificações, os psiquiatras consideraram o risco presente em 2.396 casos
(99%). Quanto aos itens da ARP, houve uma concordância de 83,7% entre
enfermeiros e psiquiatras em pelo menos um item. A avaliação da gravidade do risco mostrou uma concordância de 92,9% para casos leves, 42,9% para casos
moderados, e 4,2% para casos graves. Melhor acurácia (89%), valor preditivo
negativo (95%) e valor preditivo positivo (43%) foram obtidos utilizando uma
categoria dicotômica: risco leve vs risco não leve. As ações desencadeadas pela
discussão com os psiquiatras contemplaram predominantemente a orientação à
equipe de saúde no manejo dos casos de risco (95,4%), intervenções relacionadas a
medicações (48,6%) e orientação sobre medidas de segurança (20,2%). O
encaminhamento a interconsulta ocorreu em 9,7% dos riscos, e em 7,5% das
discussões o psiquiatra pode sugerir uma hipótese diagnóstica diversa ou adicional
à anteriormente referida em prontuário.
Conclusão: Foi possível desenvolver um instrumento de avaliação de risco baseado
nas observações e linguagem descritiva da população que o utiliza, os enfermeiros.
A ARP mostrou ser uma ferramenta útil para a identificação de riscos psiquiátricos e
sua gravidade, propiciando intervenções através da discussão de casos com o
especialista, sugerindo assim um novo modelo, simples e pragmático, de atenção
em saúde mental no hospital geral.
Objectives: To develop and study the use of a screening instrument, the Psychiatric Risk Evaluation Checklist (PRE-CL), to identify psychiatric risk and risk severity in a general hospital. Methods: The studies were conducted in a tertiary care center in São Paulo, Brazil. The PRE-CL was developed through an ethnographic qualitative study of the reports of 300 general-unit nurses, collected through open groups conducted by a trained nurse at shift changes for two months. There were two questions asked: “Would you consider it helpful to discuss daily practice situations with a psychiatrist? Which situations?” The reports were analyzed through an ethnographic approach to develop a user-friendly screening instrument. The applicability of the PRE-CL was assessed through a cross-sectional study: all of the hospital admissions (21,007) in a six-month period were submitted for screening, and the risks identified by the nurses were discussed with the hospital psychiatrist, thus leading to the development of a potential intervention plan. The data were assessed in terms of the agreement between nurses and the specialist regarding risk presence, the PRE-CL items and risk severity (categorized as mild, moderate and severe), using kappa coefficients and psychometric properties. The interventions triggered by the psychiatrist were also described. Results: The ethnographic analyses of the reports showed that nurses considered it useful to discuss daily practice situations related to psychiatric risks with a psychiatrist. Acknowledging their descriptive accounts, it was possible to develop an 11-item tool, the PRE-CL, to be used as part of the hospital’s global risk assessment, performed by nurses in the first 24 hours of a patient’s admission and every 48 hours throughout a patient’s hospital stay. The study of the applicability of the instrument showed that, from a total of 21,007 admissions, nurses identified 2,820 risks (13.4% of all admissions), and 2,396 were assessed and confirmed by the psychiatrist. The following notifications were excluded: incomplete demographic or admission data (n = 36) and notifications that were not discussed with a psychiatrist (n = 364). In the latter case, the most common reason for the lack of assessment was a prior discharge. A psychiatric risk was confirmed to be present by a psychiatrist in 2,396 (99%) of the 2,420 notifications. For the PRE-CL items, there was 83.7% agreement on at least one item. The results of the severity rating showed 92.9% agreement in mild cases, 42.9% in moderate cases, and 4.2% in severe cases. Enhanced accuracy (89%), negative predictive value (95%) and positive predictive value (43%) were achieved by dichotomizing severity categories (mild risk vs. non-mild risk). The interventions’ descriptive results showed a wide percentage of case management guidance (95.4%), medication-related interventions (48.6%) and guidance on safety measures (20.2%). A mental healthcare consultation was triggered in 9.7% of notifications. In 7.5% of risk situations, the psychiatrist was able to question the accuracy of the patient’s previously referred psychiatric diagnosis or suggest a second hypothesis. Conclusion: It was possible to develop a screening instrument to be used by nurses, considering their reports about psychiatric risk situations. The PRE-CL was shown to be a useful instrument to identify psychiatric risks, to measure risk severity and to trigger pertinent risk interventions, thus possibly providing a new model to address hazardous mental health situations in general hospitals.
Objectives: To develop and study the use of a screening instrument, the Psychiatric Risk Evaluation Checklist (PRE-CL), to identify psychiatric risk and risk severity in a general hospital. Methods: The studies were conducted in a tertiary care center in São Paulo, Brazil. The PRE-CL was developed through an ethnographic qualitative study of the reports of 300 general-unit nurses, collected through open groups conducted by a trained nurse at shift changes for two months. There were two questions asked: “Would you consider it helpful to discuss daily practice situations with a psychiatrist? Which situations?” The reports were analyzed through an ethnographic approach to develop a user-friendly screening instrument. The applicability of the PRE-CL was assessed through a cross-sectional study: all of the hospital admissions (21,007) in a six-month period were submitted for screening, and the risks identified by the nurses were discussed with the hospital psychiatrist, thus leading to the development of a potential intervention plan. The data were assessed in terms of the agreement between nurses and the specialist regarding risk presence, the PRE-CL items and risk severity (categorized as mild, moderate and severe), using kappa coefficients and psychometric properties. The interventions triggered by the psychiatrist were also described. Results: The ethnographic analyses of the reports showed that nurses considered it useful to discuss daily practice situations related to psychiatric risks with a psychiatrist. Acknowledging their descriptive accounts, it was possible to develop an 11-item tool, the PRE-CL, to be used as part of the hospital’s global risk assessment, performed by nurses in the first 24 hours of a patient’s admission and every 48 hours throughout a patient’s hospital stay. The study of the applicability of the instrument showed that, from a total of 21,007 admissions, nurses identified 2,820 risks (13.4% of all admissions), and 2,396 were assessed and confirmed by the psychiatrist. The following notifications were excluded: incomplete demographic or admission data (n = 36) and notifications that were not discussed with a psychiatrist (n = 364). In the latter case, the most common reason for the lack of assessment was a prior discharge. A psychiatric risk was confirmed to be present by a psychiatrist in 2,396 (99%) of the 2,420 notifications. For the PRE-CL items, there was 83.7% agreement on at least one item. The results of the severity rating showed 92.9% agreement in mild cases, 42.9% in moderate cases, and 4.2% in severe cases. Enhanced accuracy (89%), negative predictive value (95%) and positive predictive value (43%) were achieved by dichotomizing severity categories (mild risk vs. non-mild risk). The interventions’ descriptive results showed a wide percentage of case management guidance (95.4%), medication-related interventions (48.6%) and guidance on safety measures (20.2%). A mental healthcare consultation was triggered in 9.7% of notifications. In 7.5% of risk situations, the psychiatrist was able to question the accuracy of the patient’s previously referred psychiatric diagnosis or suggest a second hypothesis. Conclusion: It was possible to develop a screening instrument to be used by nurses, considering their reports about psychiatric risk situations. The PRE-CL was shown to be a useful instrument to identify psychiatric risks, to measure risk severity and to trigger pertinent risk interventions, thus possibly providing a new model to address hazardous mental health situations in general hospitals.
Descrição
Citação
CAMARGO, Ana Luiza Lourenço Simões. Desenvolvimento e avaliação de um instrumento para identificação de risco psiquiátrico no hospital geral. 2018. 109 f. Tese (Doutorado em Psiquiatria e Psicologia Médica) - Escola Paulista de Medicina, Universidade Federal de São Paulo, São Paulo, 2018.