Racing Toward the Fire: Proactive Consultation-Liaison Psychiatry in Critical Care

CATEGORY 1 CME

Premiere Date: March 20, 2026 

Expiration Date: September 20, 2027

This activity offers CE credits for: 

1. Physicians (CME) 

2. Other

All other clinicians either will receive a CME Attendance Certificate or may choose any of the types of CE credit being offered.

ACTIVITY GOAL

To highlight the clinical, operational, and value-based impact of proactive consultation-liaison psychiatry in the intensive care unit (ICU), and to demonstrate how early, integrated psychiatric engagement can improve outcomes for critically ill patients, support ICU teams, advance health equity, and align psychiatry with value-based care principles.

LEARNING OBJECTIVES

1. Describe the clinical, operational, and value-based rationale for proactive consultation-liaison psychiatry in the ICU, including its alignment with the Institute for Healthcare Improvement Quintuple Aim.

2. Apply principles of proactive critical care psychiatry to identify high-risk ICU populations and deploy targeted psychiatric interventions that may improve delirium outcomes, length of stay, readmissions, and patient and clinician experience.

TARGET AUDIENCE

This accredited continuing education (CE) activity is intended for psychiatrists, psychologists, primary care physicians, physician assistants, nurse practitioners, and other health care professionals who seek to improve their care for patients with mental health disorders.

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Physicians’ Education Resource, LLC designates this enduring material for a maximum of 1.5 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

This activity is funded entirely by Physicians’ Education Resource, LLC. No commercial support was received.

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The intensive care unit (ICU) represents one of health care’s most complex and demanding environments. Yet the very factors that make it daunting also place the ICU squarely within psychiatry’s familiar clinical terrain. Step into any ICU, and you will encounter liberal use of antipsychotics and anxiolytics. Review a single patient’s medical record, and symptoms of anxiety, agitation, insomnia, or delirium appear with striking frequency. Approach the bedside of a patient who has mechanical ventilation, and the consequences of impaired communication become immediately apparent, limiting self-expression and amplifying distress. These are our patients, and we possess the specialized tools to help them navigate the physical, emotional, and neurocognitive burdens of life-threatening critical illness. A growing body of evidence now supports the value of proactive psychiatric integration directly in the ICU to simultaneously improve patient outcomes, support clinical teams, and strengthen health systems, reflecting the fundamental values of the Institute for Healthcare Improvement (IHI)’s Quintuple Aim for value-based care.

At the heart of the IHI’s Quintuple Aim lies the health of populations, a guiding principle from which improved outcomes, cost containment, clinician well-being, and equitable care flow (Table).¹ This framework aligns seamlessly with evidence from proactive consultation-liaison (C-L) psychiatry, which prioritizes population-level screening, equitable and strategic patient selection, and early psychiatric intervention. Proactive models have repeatedly demonstrated measurable gains across 1 or more domains of the Quintuple Aim and are increasingly recognized as exemplars of value-based care.^2-5

By systematically targeting populations with high psychiatric burden, proactive C-L psychiatry delivers early, tailored expertise that addresses barriers to recovery before crises arise. These proactive interventions complement conventional, reactive C-L strategies, which remain essential for real-time support in complex or unpredictable scenarios. Together, this synergistic approach creates a true economy of efficiency that health systems value, optimizing outcomes, preserving resources, and ensuring that psychiatric expertise is deployed precisely when and where it is needed for maximal patient and system benefit.

As a clinical environment, the ICU provides innumerable opportunities for proactive psychiatric engagement. Psychiatric comorbidity is common among patients with critical illness; approximately 1 in 3 individuals admitted to the ICU carries a preexisting psychiatric diagnosis, and more than 1 in 4 meets criteria for a substance use disorder.^6,7 These figures likely underestimate the true burden, as psychiatric conditions are frequently underrecognized in the setting of acute critical illness. In addition, neuropsychiatric syndromes frequently emerge during ICU hospitalization: Delirium develops in roughly 36% of all patients who are in an ICU and in as many as 80% of those requiring mechanical ventilation.^8,9 Other severe and often underappreciated syndromes are also prevalent, including catatonia, which has been identified in one-third of patients with critical illness, and delusional memories, reported by more than two-thirds of survivors requiring mechanical ventilation.^10,11 Collectively, these conditions represent not only markers of illness severity but also potentially modifiable contributors to both short- and long-term morbidity and quality of life.

Evidence increasingly shows that proactive C-L psychiatry delivers meaningful clinical and financial benefits in the ICU. Findings from a prior study examining integrated psychiatric care in a medical ICU (MICU) demonstrated significant clinical and financial benefits among a high-risk subpopulation of patients with respiratory failure.^12-14 Compared with conventional consultation, an embedded model of critical care psychiatry (CCP) was associated with a statistically significant reduction in median hospital length of stay among patients with respiratory failure (median of 9.46 days [IQR, 4.95-17.56] in the embedded ICU vs 12.29 days [IQR, 6.58-21.10] in usual care; P = .011).¹² More recently, an expanded analysis of the same MICU model of care demonstrated a statistically significant reduction in 30-day hospital readmission rates among patients with respiratory failure who required mechanical ventilation (8.12% vs 14.19%; P = .017).¹³ A financial analysis of the original data set projected a return on investment of 26.7% among patients with respiratory failure.¹⁴ Taken together, these findings affirm that psychiatry has a significant role to play in optimizing the care and costs of patients with critical illness, particularly when delivered in an early and integrated way.

Despite its promise, proactive consultation in the ICU presents several challenges to implementation. Psychiatrists who enter the critical care environment must develop nuanced and adaptable communication strategies in order to navigate significant restrictions that limit patient assessment and intervention. Logistical constraints, including ICU workflows, competing clinical priorities, and staffing limitations, can further complicate the model’s design and implementation. C-L psychiatrists must integrate into highly structured, fast-paced environments where medical instability, fluctuating patient acuity, and time-sensitive decision-making may all restrict the psychiatric assessment. Variability in staffing models, both among ICU teams and also C-L services, may further limit when and where proactive consultations can occur. Successful implementation of proactive psychiatric consultation requires a close partnership between a supportive ICU team and a C-L service with sufficient staffing to ensure that proactive models do not compromise psychiatric availability among other clinical environments. Taken together, these contextual and system-level factors make it neither feasible nor desirable to prescribe a single, rigid model of proactive psychiatric care for critical care settings.

Fortunately, the strength of proactive C-L psychiatry lies in its inherent adaptability. Rather than functioning as a fixed protocol, proactive consultation exists along a continuum of engagement, allowing services to scale up or down in response to local constraints.¹⁵ This flexibility enables CCP teams to anticipate predictable psychiatric risks and selectively deploy evidence-based interventions that promote more stabilizing trajectories for patients with clinical instability. For example, by utilizing the ICU Liberation (ABCDEF) Bundle, the critical care psychiatrist may recognize how a patient’s agitated delirium (element D) is interfering with successful liberation from the ventilator (element B), leading to polypharmacy via uptitration of opiates and sedative drips (elements A and C).¹⁶ In response, the CCP team may deploy careful antipsychotic stewardship to ensure strategic pharmacologic interventions to optimize calming during the periextubation window, facilitating ventilator liberation and promoting patient recovery. Similarly, through strategic alignment with the patient’s family (element F), proactive C-L teams can extend the reach of nonpharmacologic care by actively engaging families as partners in recovery. As a result, families are empowered to reinforce evidence-based practices throughout the day, sustain these interventions over the course of weeks, and speak on behalf of their loved ones during periods of frightening silence and uncertainty.

For clinicians who seek to investigate the impact of these models, careful study design is critical. The proactive psychiatric consultant must carefully select their population, screening criteria, and study objectives, aligning their work with realistic outcomes. Delirium is a highly desirable target for patient screening and intervention, providing valuable secondary prevention measures that mitigate downstream negative effects. Although primary prevention strategies for delirium have been demonstrated through the coordinated efforts of the Hospital Elder Life Program among hospitalized patients and the ABCDEF bundle within critical care, proactive psychiatric consultation has not yet demonstrated a measurable impact as a primary prevention strategy for delirium within the ICU.^16-18 Existing studies focus primarily on single-center investigations of patients with respiratory failure; however, expanding this work into other ICU populations offers an opportunity to validate and refine proactive CCP across diverse clinical contexts. In addition, postintensive care syndrome represents a highly promising longitudinal target for proactive psychiatric integration, as early, multidisciplinary interventions in the ICU have the potential to greatly enhance long-term cognitive, emotional, and functional outcomes.¹⁹

As a direct result of proactive C-L’s potential to improve the health of populations, it stands to reason that colocalizing neuropsychiatric expertise within critical care environments has significant potential to translate into enormous gains for health care’s sickest patients. Critical care psychiatry has already demonstrated a positive impact on critical care medicine by improving clinical outcomes, reducing costs to health systems, and enhancing health equity. Even modest improvements in ICU outcomes are rapidly compounded to generate disproportionate downstream benefits. The model’s gains naturally appeal to health system leaders, who seek to develop and expand value-based models of care.

Given recent developments in the creation of CCP as a new subspecialty within C-L psychiatry, a sea change appears to be brewing in which proactive CCP stands front and center, holding space for patients with critical illness as they endure their most difficult life-and-death battles.²⁰ Within this context of predictable vulnerability and disproportionate risk, the ICU becomes an ideal setting for proactive psychiatric engagement, delivering timely interventions that can positively affect the long arc of recovery. It is here that our field can push new frontiers, serving as a force multiplier wherein small, well-timed interventions yield downstream benefits across multiple orders of magnitude.

By racing toward the fire, proactive CCP exemplifies psychiatry’s dual mission: to address the fundamental human needs of individual patients while advancing the delivery of psychiatric care itself. In championing proactive critical care psychiatry, we have the opportunity to transform the ICU’s greatest challenges into a call to action, and in doing so, we position our field at the forefront of value-based care.

Dr Bui is an associate professor of psychiatry at Virginia Commonwealth University.

References

1. Nundy S, Cooper LA, Mate KS. The Quintuple Aim for health care improvement: a new imperative to advance health equity. JAMA. 2022;327(6):521-522.

2. Oldham MA, Chahal K, Lee HB. A systematic review of proactive psychiatric consultation on hospital length of stay. Gen Hosp Psychiatry. 2019;60:120-126.

3. Bronson BD, Alam A, Calabrese T, et al. An economic evaluation of a proactive consultation-liaison psychiatry pilot as compared to usual psychiatric consultation on demand for hospital medicine. J Acad Consult Liaison Psychiatry. 2022;63(4):363-371.

4. Oldham MA, Lang VJ, Hopkin JL, Maeng DD. Proactive integration of mental health care in hospital medicine: PRIME medicine. J Acad Consult Liaison Psychiatry. 2021;62(6):606-616.

5. Triplett PT, Prince E, Bienvenu OJ, et al. An observational study of proactive and on-request psychiatry consultation services: evidence for differing roles and outcomes. J Acad Consult Liaison Psychiatry. 2024;65(4):338-346.

6. Pilowsky JK, Elliott R, Roche MA. Association between preexisting mental health disorders and adverse outcomes in adult intensive care patients: a data linkage study. Crit Care Med. 2023;51(4):513-524.

7. Westerhausen D, Perkins AJ, Conley J, et al. Burden of substance abuse-related admissions to the medical ICU. Chest. 2020;157(1):61-66.

8. Leong AY, Edginton S, Lee LA, et al. Prevalence and incidence of ICU delirium and pain: a systematic review and meta-analysis. Intensive Care Med. 2025;51(11):2093-2103.

9. Ely EW, Inouye SK, Bernard GR, et al. Delirium in mechanically ventilated patients: validity and reliability of the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU). JAMA. 2001;286(21):2703-2710.

10. Wilson JE, Carlson R, Duggan MC, et al; Delirium and Catatonia (DeCat) Prospective Cohort Investigation. Delirium and catatonia in critically ill patients: the Delirium and Catatonia Prospective Cohort Investigation. Crit Care Med. 2017;45(11):1837-1844.

11. Yoshino Y, Unoki T, Sakuramoto H, et al. Association between intensive care unit delirium and delusional memory after critical care in mechanically ventilated patients. Nurs Open. 2021;8(3):1436-1443.

12. Bui M, Thom RP, Hurwitz S, et al. Hospital length of stay with a proactive psychiatric consultation model in the medical intensive care unit: a prospective cohort analysis. Psychosomatics. 2019;60(3):263-270.

13. Dietrich E, Cassady M, Barnes-Scott Z, et al. Proactive psychiatric consultation in the medical intensive care setting: a retrospective review of the financial and clinical impact of this model of care. J Acad Consult Liaison Psychiatry. 2025;66(suppl):S14.

14. Bui MP. Critical care psychiatry. Chest. 2025;167(2):571-572.

15. Dietrich EA, Bui MP, Triplett P, Oldham MA. Consultation-liaison case conference: proactive consultation-liaison psychiatry in critical care. J Acad Consult Liaison Psychiatry. Published online December 13, 2025.

16. Pun BT, Balas MC, Barnes-Daly MA, et al. Caring for critically ill patients with the ABCDEF bundle: results of the ICU Liberation Collaborative in over 15,000 adults. Crit Care Med. 2019;47(1):3-14.

17. Hshieh TT, Yang T, Gartaganis SL, et al. Hospital Elder Life Program: systematic review and meta-analysis of effectiveness. Am J Geriatr Psychiatry. 2018;26(10):1015-1033.

18. Choi KJ, Tan M, Jones K, et al. The impact of rounds with a psychiatry team in the intensive care unit: a prospective observational pilot study evaluating the effects on delirium incidence and outcomes. J Psychiatr Res. 2023;160:64-70.

19. Leonard KM, Mart MF, Ely EW. Preventing PICS with the ABCDEF bundle. In: Haines KJ, McPeake J, Sevin CM, eds. Improving Critical Care Survivorship. Springer; 2021.

20. Dragonetti JD, Bui MP, Rueve ME, Bourgeois JA. Critical care psychiatry: the value of psychiatrists in the ICU. Psychiatric Times. May 31, 2024. https://www.psychiatrictimes.com/view/critical-care-psychiatry-the-value-of-psychiatrists-in-the-icu