The Nordic comparative study on sectorized psychiatry: characteristics of repeat users of emergency outpatient services in two Nordic psychiatric services. A 1-year follow-up study

To characterise frequent use of psychiatric emergency outpatients services, this paper reports results from a prospective investigation of use of psychiatric services by new patients in two Nordic psychiatric services, Frederiksberg in Denmark and Oulu in Finland. One year treated incidence cohorts were used. Total number of patients included was 1,055. The repeat user was defined as a patient having at least three emergency outpatient contacts during a 1-year follow-up. The repeat users constituted 15.8% of the sample and 70.8% of all the emergency contacts in Frederiksberg. In Oulu the respective figures were 9.3% and 33.8%. The number of planned outpatient contacts or the number of hospital admissions of the repeat users did not differ from the non-repeaters. Repeaters in Frederiksberg were more likely to be self-referrals, male, divorced or unmarried, living with their parents, without their own housing, unemployed, aged between 25 and 44 years, and to have a diagnosis of dependency or personality disorder. In Oulu they did not differ from the other patients with regard to sociodemographic or diagnostic characteristics.

The impact of racism and discrimination on mental health of refugees and asylum seekers

With the strong focus on terrorism in recent years, there is an increasing concern that the fundamental rights of refugees and asylum seekers may be violated in the interest to combat acts of terrorism. It may also lead to increasing racism and discrimination towards these populations.

Racism and discrimination encompass the negative stereotypes and prejudicial beliefs that people may hold, as well as inequitable practices that may result hereof.

Knowledge about the mental health consequences of racism and discrimination is of clear clinical relevance for psychiatrists worldwide, as a significant proportion of psychiatric patients will have a background as refugees and asylum seekers. Many of them have experiences of war, strife, persecution and torture that further ads to their mental distress.

The paper will outline the psychiatric symptomatology related to racism as well as ethical dilemmas and educational needs for the psychiatric profession.

Further the role of national psychiatric associations in combating racism and discrimination by e.g. defining best practices and revising medical training curricula will be outlined.

http://www.mariannekastrup.dk/

Disclosure of interest

The authors have not supplied their declaration of competing interest.

Ethical challenges in the use of coercion

The use of coercive measures remains one of the great challenges in psychiatry.

Increased focus on patient rights and autonomy, concern from user and relatives organizations as well as from human rights organizations all have contributed to that the use of all kinds of coercion is high on the agenda. And yet, we are still faced with that a number of psychiatric patients will experience that coercive measures are used as part of their treatment.

The EPA Ethical Committee carried out a survey comprising the European associations of psychiatry in which a questionnaire was circulated regarding what the different associations found were the major ethical challenges in their respective countries.

Among the issues that have given rise to particular concern are the use of physical restraints including why some countries avoid physical restraints while other – e.g. Denmark – use it extensively. Why do we find such large differences? Is this due to different approaches to coercion, different traditions? Shortage of resources?

Another concern is that certain groups seem more likely to be subject to coercion compared to others. Thus, it has been demonstrated that patients belonging to ethnic minority groups are more likely to experience this.

The paper will focus on ethical problems and issues of concern related to the use of coercion. The focus will be on facets of international relevance with the aim to remain critical towards the use and when needed to strengthen the quality of coercive treatment care. URL:http://www.mariannekastrup.dk

Disclosure of interest

The author has not supplied his declaration of competing interest.

Transcultural issues in diagnostic process

Diagnostic systems and methods must respond to patients’ diversity in expressions of mental distress, social and cultural context and the meanings given to illness. Due to increasing migration and globalisation the challenge of considering diagnosis in the context of culture has become increasingly significant in Europe. And globalization has further led to changes in value systems and our awareness of patients with ethnic minority background.

Over recent decades, there has been an increasing development of psychiatric diagnosing with nosological categorisation combined with multi-axial schemas. Diagnosis, besides identifying a disorder and distinguishing one disorder from another disorder - differential diagnosis, has also an aim to include an overall understanding of the patient's situation.

We witness an upsurge in the attention paid to the cultural limitations to psychiatric diagnostic practice and treatment modalities. Guidelines for the psychiatric profession are in critical focus from a transcultural perspective. Some claim their universality independent of cultural context; others find cultural adaptation useful and necessary.

Do the diagnoses and clinical and ethical guidelines give meaning in the cultural setting? Are they compatible with the cultural values of the therapist and those of the patient and the family? Several sources claim the biomedical paradigm for being Western with insufficient consideration of the socio-political context.

The cultural formulation developed as part of DSM-IV and now DSM-5 is one model to support a systematic review of culture and context in psychiatric diagnosing.

The paper will discuss the advantages and shortcomings of current diagnostic categories and guidelines vis-à-vis the universe of traumatized refugees with other ethnic backgrounds.

URL:http://www.mariannekastrup.dk/

Disclosure of interest

The author has not supplied his declaration of competing interest.

Feasibility and influence of hTEE monitoring on postoperative management in cardiac surgery patients

Monoplane hemodynamic TEE (hTEE) monitoring (ImaCor(®) ClariTEE(®)) might be a useful alternative to continuously evaluate cardiovascular function and we aimed to investigate the feasibility and influence of hTEE monitoring on postoperative management in cardiac surgery patients. After IRB approval we reviewed the electronic data of cardiac surgery patients admitted to our intensive care between 01/01/2012 and 30/06/2013 in a case-controlled matched-pairs design. Patients were eligible for the study when they presented a sustained hemodynamic instability postoperatively with the clinical need of an extended hemodynamic monitoring: (a) hTEE (hTEE group, n = 18), or (b) transpulmonary thermodilution (control group, n = 18). hTEE was performed by ICU residents after receiving an approximately 6-h hTEE training session. For hTEE guided hemodynamic optimization an institutional algorithm was used. The hTEE probe was blindly inserted at the first attempt in all patients and image quality was at least judged to be adequate. The frequency of hemodynamic examinations was higher (ten complete hTEE examinations every 2.6 h) in contrast to the control group (one examination every 8 h). hTEE findings, including five unexpected right heart failure and one pericardial tamponade, led to a change of current therapy in 89% of patients. The cumulative dose of epinephrine was significantly reduced (p = 0.034) and levosimendan administration was significantly increased (p = 0.047) in the hTEE group. hTEE was non-inferior to the control group in guiding norepinephrine treatment (p = 0.038). hTEE monitoring performed by ICU residents was feasible and beneficially influenced the postoperative management of cardiac surgery patients.

EPA Guidance Mental Health Care of Migrants

Migration is an increasingly commonplace phenomenon for a number of reasons. People migrate from rural to urban areas or across borders for reasons including economic, educational or political. There is increasing recent research evidence from many countries in Europe that indicates that migrants are more prone to certain psychiatric disorders. Because of their experiences of migration and settling down in the new countries, they may also have special needs such as lack of linguistic abilities which must be taken into account using a number of strategies at individual, local and national policy levels. In this guidance document, we briefly present the evidence and propose that specific measures must be taken to improve and manage psychiatric disorders experienced by migrants and their descendants. This improvement requires involvement at the highest level in governments. This is a guidance document and not a systematic review.

An electronic tool for visual feedback to monitor the adherence to quality indicators in intensive care medicine

Evidence-based medicine is often inadequately implemented in intensive care units (ICU); the aim of this study was to improve its implementation via a technical feedback system, using key performance indicators (KPI). The study evaluated 205 patients treated in a cardiac surgical ICU over a 6-month period (3 months before and 3 months after implementation of the feedback system). KPI adherence rates for sedation, delirium and pain monitoring, and completion of a weaning protocol before and after the implementation of the feedback system, were compared. Adherence rates for pain and delirium monitoring, and implementation of the weaning protocol, were significantly increased by the intervention. Adherence to KPIs for sedation, which were high at baseline, could not be further improved. Daily display of KPI implementation had a positive effect on adherence to standard operating procedures. Adherence to guidelines may be improved by using this feedback system as part of the clinical routine.

S3 guidelines for intensive care in cardiac surgery patients: hemodynamic monitoring and cardiocirculary system

Hemodynamic monitoring and adequate volume-therapy, as well as the treatment with positive inotropic drugs and vasopressors are the basic principles of the postoperative intensive care treatment of patient after cardiothoracic surgery. The goal of these S3 guidelines is to evaluate the recommendations in regard to evidence based medicine and to define therapy goals for monitoring and therapy. In context with the clinical situation the evaluation of the different hemodynamic parameters allows the development of a therapeutic concept and the definition of goal criteria to evaluate the effect of treatment. Up to now there are only guidelines for subareas of postoperative treatment of cardiothoracic surgical patients, like the use of a pulmonary artery catheter or the transesophageal echocardiography. The German Society for Thoracic and Cardiovascular Surgery (Deutsche Gesellschaft für Thorax-, Herz- und Gefässchirurgie, DGTHG) and the German Society for Anaesthesiology and Intensive Care Medicine (Deutsche Gesellschaft für Anästhesiologie und lntensivmedizin, DGAI) made an approach to ensure and improve the quality of the postoperative intensive care medicine after cardiothoracic surgery by the development of S3 consensus-based treatment guidelines. Goal of this guideline is to assess the available monitoring methods with regard to indication, procedures, predication, limits, contraindications and risks for use. The differentiated therapy of volume-replacement, positive inotropic support and vasoactive drugs, the therapy with vasodilatators, inodilatators and calcium sensitizers and the use of intra-aortic balloon pumps will also be addressed. The guideline has been developed following the recommendations for the development of guidelines by the Association of the Scientific Medical Societies in Germany (AWMF). The presented key messages of the guidelines were approved after two consensus meetings under the moderation of the Association of the Scientific Medical Societies in Germany (AWMF).

Key performance indicators in intensive care medicine. A retrospective matched cohort study

Expert panel consensus was used to develop evidence-based process indicators that were independent risk factors for the main clinical outcome parameters of length of stay in the intensive care unit (ICU) and mortality. In a retrospective, matched data analysis of patients from five ICUs at a tertiary university hospital, agreed process indicators (sedation monitoring, pain monitoring, mean arterial pressure [MAP] >or= 60 mmHg, tidal volume [TV] <or= 6 ml/kg body weight, peak inspiratory pressure [PIP] <or= 35 cmH(2)O and blood glucose [BG] >or= 80 and <or= 130 mg/dl) were validated using a prospective dataset of 4445 consecutive patients. After matching for age, sex and ICU, 634 patients were analysed. Logistic regression of the 634 patients showed that monitoring analgesia and sedation, MAP >or= 60 mmHg and BG >or= 80 mg/dl were relevant for survival. Linear regression of the 634 patients showed that analgesia monitoring, PIP <or= 35 cmH(2)O and TV <or= 6 ml/kg were associated with reduced length of ICU stay. Linear regression on all 4445 patients showed analgesia, sedation monitoring, MAP >or= 60 mmHg, BG >or= 80 mg/dl and <or= 130 mg/dl, PIP <or= 35 cmH(2)O and TV <or= 6 ml/kg were associated with reduced length of ICU stay, indicating that adherence to evidence-based key process indicators may reduce mortality and length of ICU stay.

Performance of the A-line Autoregressive Index (AAI) and of the Bispectral Index (BIS) at assessing depth of short-term sedation following cardiac surgery

This study evaluated the correlation and agreement between the Bispectral Index (BIS) or A-line Autoregressive Index (AAI) and a clinical scoring system, the Ramsay Sedation Scale (RSS), in 40 patients after elective cardiac surgery and admission to the intensive care unit. All patients received sedation with propofol according to the study protocol. BIS, AAI and RSS were documented at two different levels of sedation: deep sedation RSS 4 - 6; and slight sedation/extubation RSS 2 - 3. Both the BIS and AAI agreed well with the RSS (eta-coefficients of 0.902 and 0.836, respectively, for mean overall RSS stages). The systems agreed well among each other (overall intra-class correlations of 0.670 for consistency and 0.676 for absolute agreement). There was significant discrimination between RSS 2 - 3 and RSS 4 - 6 with BIS and AAI (BIS mean difference of 24.73, 95% confidence intervals [CI] 21.08 - 28.37; AAI mean difference of 20.90, 95% CI 14.64 - 27.16). In conclusion, BIS and AAI correlated well with RSS overall and also at different levels of sedation.

How Art may be a Tool for Understanding Other Cultures and their Perception of Illness

Cultural background has a significant influence upon how we perceive illness, our attitudes to illness and our help-seeking behaviour.

But culture is only one of many influences on our health related beliefs and behaviours. Other factors include e.g. individual factors related to age, gender, sociodemographic background, but also environmental factors such as urban or rural setting, pollution, globalization.

If we want to understand and assess the impact of culture in a particular clinical case, the use of art may be a valuable tool to facilitate this understanding and serve as a bridge over cultural incongruities.

The paper will discuss ways in which the application of artistic elements in the therapeutic process may serve as a useful intervention and ultimately as a vehicle to increase the cultural competence of mental health staff. In an increasingly complex, globalised world with patient populations originating from all parts of the world this may prove to be a profitable instrument.

Diagnostic Differences Among Different Ethnic Groups Contacting Mental Health Services

Aim:

A nationwide register study was carried out in Denmark comprising 50,877 persons aged 18-66, who were registered in 2003 in the Danish Psychiatric Register or the National Patient Register with a psychiatric ICD-10 diagnosis with the aim to compare diagnostic profiles and use of services.

Method:

The study is a register survey linking Psychiatric/and National Patient Register with Statistical Bureau data.

Results:

Of the population 87.1% were ethnic Danes, 7.8% migrants, 4.0% descendants with one Danish born parent, 0.7% descendants with both parents born outside Denmark and 0.3% foreign adoptees. Males comprised 49%, women 51% of the population. The 5 ethnic groups had significant differences in utilization of care, in diagnostic distribution and in the use of coercion. Diagnostically, contacts due to schizophrenia were significantly higher among non-Danish patients and highest among young descendant males. Personality disorders were significantly higher among women than men and highes in adopted and descendant young women. PTSD had a preponderance among migrant men. Substance abuse was higher among men in all ethnic groups, but lower among migrant groups compared to Danes. Self-mutilating behaviour was seen more frequently among female descendants from non-Western countries than among migrant women from non-Western countries as well as among young adopted women.

Conclusion:

Significant diagnostic differences were observed. Possible explanatory models to these findings will be discussed.

Adherence to Standard Operating Procedures is Crucial for Intensive Care Unit Survival of Elderly Patients

Elderly patients account for 42–52% of intensive care unit (ICU) admissions and for almost 60% of all ICU days in the USA and up to 50% receive inappropriate antibiotic treatment. The aim of this study was to evaluate whether adherence to Standard Operating Procedures (SOPs) reduced ICU mortality in an elderly population. The study included consecutive patients ( n = 228) aged ≤ 60 years with an ICU stay of > 72 h. SOPs were based on evidence-based medicine guidelines for diagnosis and treatment of infections, and on local resistance rates. According to preset indicators of quality management standards and assessment of different degrees of adherence, an implementation rate > 70% was considered adherent (high adherence group [HAG]) and ≤ 70% was considered non-adherent (low adherence group [LAG]). Patients in the HAG ( n = 137) had significantly reduced mortality compared with LAG patients ( n = 91): 5.8% versus 19.8%, respectively. It was concluded that adherence to SOPs based on evidence-based medicine that consider local resistance rates for antibiotic treatment in elderly ICU patients is associated with a lower mortality rate.

Hyperactive delirium and blood glucose control in critically ill patients

Delirium is a common complication of critically ill patients and is often associated with metabolic disorders. One of the most frequent metabolic disorders in intensive care unit (ICU) patients is hyperglycaemia. The aim of this retrospective study of 196 adult ICU patients was to determine if there is an association between hyperactive delirium and blood glucose levels in ICU patients. Hyperactive delirium was diagnosed using the delirium detection score. Blood glucose levels were monitored by blood gas analysis every 4 h. Hyperactive delirium was detected in 55 (28%) patients. Delirious patients showed significantly higher blood glucose levels than non-delirious patients Higher overall complication rates, length of ventilation, ICU stay and mortality rates were seen in the delirium group. In a multivariate analysis, glucose level, alcohol abuse, APACHE II score, complication by hospital-acquired pneumonia and a diagnosis of polytrauma on-admission all significantly influenced the appearance of delirium.

[Guidelines for intensive care in cardiac surgery patients: haemodynamic monitoring and cardio-circulatory treatment guidelines of the German Society for Thoracic and Cardiovascular Surgery and the German Society of Anaesthesiology and Intensive Care Medicine]

Hemodynamic monitoring and adequate volume-therapy, as well as the treatment with positive inotropic drugs and vasopressors, are the basic principles of the postoperative intensive care treatment of patient after cardiothoracic surgery. The goal of these S3 guidelines is to evaluate the recommendations in regard to evidence based medicine and to define therapy goals for monitoring and therapy. In context with the clinical situation the evaluation of the different hemodynamic parameters allows the development of a therapeutic concept and the definition of goal criteria to evaluate the effect of treatment. Up to now there are only guidelines for subareas of postoperative treatment of cardiothoracic surgical patients, like the use of a pulmonary artery catheter or the transesophageal echocardiography. The German Society for Thoracic and Cardiovascular Surgery and the German Society for Anaesthesiology and Intensive Care Medicine made an approach to ensure and improve the quality of the postoperative intensive care medicine after cardiothoracic surgery by the development of S3 consensus-based treatment guidelines. Goal of this guideline is to assess available monitoring methods and their risks as well as the differentiated therapy of volume-replacement, positive inotropic support and vasoactive drugs, the therapy with vasodilators, inodilators and calcium-sensitizers and the use of intra-aortic balloon pumps. The guideline has been developed according to the recommendations for the development of guidelines by the Association of the Scientific Medical Societies in Germany (AWMF). The presented key messages of the guidelines were approved after two consensus meetings under the moderation of the Association of the Scientific Medical Societies in Germany (AWMF).

[Analysis of personnel costs after reorganization of intensive care using calculated diagnosis-related groups comparative data. An investigation at the Charité Berlin]

BACKGROUND

In an extensive project intensive care units (ICUs) of the Charité University Hospital were reorganized. The aim of this investigation was to determine if staff costs after this reorganization are financed by modular profits of diagnosis-related groups (DRGs).

METHODS

Staff costs of all non-pediatric intensive care units, including ICUs, intermediate care units and post-anaesthesia care units (PACUs) in the Charité University Hospital were compared with the modular profits of all DRGs of patients older than 14 years in 2005. These DRGs were converted into the German refined DRG (GDRG) system 4.0 from 2006 with calculations based on actual income for medical doctors and nurses in 2006. Due to changed wage agreements for the incomes of physicians in 2006 there was an increase of costs. For the other professional groups an increase in income is expected, which cannot be estimated at present.

RESULTS

The calculation revealed that staff costs of the ICUs at the Charité University Hospital based on a current German mean base rate of 2,836 EUR were 4.2% above the modular profits of the DRGs. As a result of a structural reorganization of the ICUs, the costs of staff could be adapted to the modular profits. Under the conditions of the actual reduced base rate of Berlin of 2,955 EUR the costs and profits were nearly equal. As the financial impact of the reorganization of the ICUs will take full effect in the coming years, it can be anticipated that with an expected base rate of 2,949 EUR in 2010 the intensive care medicine of a University hospital in Germany can become profitable.

DISCUSSION

The spectrum of intensive care medicine at the Charité University Hospital covers the maximum range of operative and non-operative medicine. After an extensive reorganization of the ICUs under the aspect of staff costs, intensive care medicine can become profitable under the 4.0 G-DRG system. With consequent reorganization the cost efficiency of staff can be optimized, particularly in the setting of high-end intensive care medicine.

Barrier function of the gut and multiple organ dysfunction after cardiac surgery

We studied the influence of sequential involvement of the gastrointestinal (GI) tract on the development of multiple organ dysfunction (MOD) after cardiopulmonary bypass (CPB). One hundred and forty-six patients undergoing elective cardiac surgery were included in this prospective observational study. Standardized oral inert-sugar tests (sucrose, lactulose, mannitol, sucralose) were performed before and after CPB in different patients. Enzyme-linked immunosorbent assay of plasma levels of endotoxin core antibodies (EndoCAb) were performed peri-operatively. The functional mucosal surface was calculated from the amount of mannitol absorbed from the GI tract. Lower urine concentrations of absorbed mannitol were observed pre-operatively in patients developing MOD. In binary logistic regression this was an independent parameter. Decreased plasma concentrations of EndoCAb after surgery were seen in every patient, but were more significant in patients developing MOD. A reduced pre-operative functional mucosal surface may predict the early occurrence of MOD after surgery.

Current practice of hemodynamic monitoring and vasopressor and inotropic therapy in post-operative cardiac surgery patients in Germany: results from a postal survey

BACKGROUND

In Germany, more than 100,000 patients are monitored and treated in 80 intensive care units (ICUs) following cardiac surgery each year. The controversies concerning the different methods of hemodynamic monitoring and the appropriate agents for volume therapy and inotropic support are well known. However, little is known about how monitoring and treatment are currently performed.

METHODS

A questionnaire with 39 questions was sent to the leading physicians of 80 ICUs in Germany, treating patients after cardiac surgery. The questions to be answered covered the current practice of hemodynamic monitoring, volume replacement, inotropic/vasopressor support and transfusions in patients after cardiac surgery.

RESULTS

Sixty-nine per cent of the questionnaires were completed and returned. All ICUs used basic monitoring as recommended by the societies. The use of advanced hemodynamic monitoring included the pulmonary artery catheter (58.2%), transesophageal echocardiography (38.1%) and transpulmonary dilution techniques (13%). Crystalloids (21.2%) and colloids (73%) were used for volume replacement. Epinephrine (41.8%) and dobutamine (30.9%) were the first-choice inotropic drugs for the treatment of low cardiac output syndrome, followed by phosphodiesterase inhibitors (14.5%). Second-choice drugs for the treatment of low cardiac output syndrome were enoximone (29%), milrinone (25%) and dobutamine (25%). A written transfusion protocol and a transfusion threshold for red blood cells existed in 59% and 79% of ICUs, respectively.

CONCLUSION

Hemodynamic monitoring and the variability in clinical practice with regard to volume replacement, transfusion triggers and the use of vasopressors/inotropes in cardiac surgery patients tend to follow the results of traditional experience rather than current scientific knowledge. Guidelines are therefore necessary to help to improve the standards of intensive care after cardiac surgery and thus the outcome of patients.