NURSING AT McLEAN

New study by Deborah Mindnich re-evaluates patient evaluation

By Jenna Brown

In October, Deborah Mindnich, MS, RN/PC, of the Clinical Evaluation Center (CEC), attended the 25th annual APNA conference to give present the findings of a recent study, which she conducted in conjunction with Beth Murphy, MD, PhD, assistant director of the Clinical Evaluation center. The chart-based research study examined the correlation between patients’ self-reporting of suicidal ideation and clinical assessments of patients’ suicidal thoughts in a hospital setting.

The focus of Midnich’s research was guided by her extensive experience in conducting patient assessments in the CEC, where accurately assessing suicidality is a standard step in the intake process, and critical for reducing occurrences of self-injury and death.

“When a patient arrives in the CEC, their suicide risk is determined through a self-report questionnaire called the BASIS-24 and a clinician interview, but I noticed that there seems to be little information out there on how self-report ratings correlate with clinicians’ ratings,” said Mindnich. “I thought that by looking at the factors that contribute to the agreement or disagreement of these ratings we may uncover information that could be useful in improving the assessment process.”

Mindnich and Murphy focused on 100 patients who were admitted to McLean Hospital between  March 2010 and September 2010 with a primary diagnosis of anxiety and mood disorder. Patients with psychosis and those who were unable to complete the self-assessment were not included. The study examined factors relating to depression and suicide, and was based upon data collected from patient charts, including clinical admission notes, risk assessment forms completed by clinicians, and the patient-completed BASIS-24 questionnaire.

Mindnich compared patient and physician scores relating to suicide and divided subjects into high and low depression categories. In evaluating levels of depression, there was found to be patient and clinician agreement in 75 percent of the cases. Of the incidences of disagreement, 21 percent showed a higher clinician rating and just four percent showed a higher patient rating.

This method was repeated for scores relating to suicide risk, but with a more surprising outcome. Patient and clinician agreement was significantly lower in the assessment of levels of suicide risk, with just 42 percent of assessments reflecting agreement. When ratings showed disagreement, it was almost four times more common for the clinician to indicate a greater level of concern than the patient.

“The 58 percent majority of disagreement was significant enough for us to begin to delve into factors that may have contributed to the discrepancy between clinician and self-evaluations,” said Mindnich. “As we researched further it became clear that one of the most significant factors was the diagnosis of a co-morbid personality disorder, which existed in 31 percent of the study population. Of that 31 percent, more than three-quarters were diagnosed with Borderline Personality Disorder (BPD) or traits thereof.”

Armed with the knowledge that patients with personality disorder, and particularly those with BPD, are less likely to express concern about suicide in self-evaluations, clinicians can make more accurate assessments of suicide risk and adjust treatment plans accordingly.

“This study confirms what I have observed as a clinician in the thousands of assessments I have performed over the years,” said Mindnich. “And while the results may not be surprising, I believe that it validates the need for us, as clinicians, to make a push to be more more evidence-based in our assessments and to approach our evaluations with an awareness that we need to assess more than just this one incident, or this one moment in time - we need to assess each patient’s ongoing state of mind.”

01.2012