Patient Factors Associated with Extended Length of Stay in the Psychiatric Inpatient Units of a Large Urban County Hospital

Associations between recorded loneliness and adverse mental health outcomes among patients receiving mental healthcare in South London: a retrospective cohort study

PURPOSE

Loneliness disproportionately affects people with mental disorders, but associations with mental health outcomes in groups affected remain less well understood.

METHOD

A cohort of patients receiving mental healthcare on 30th June 2012 was assembled from a large mental health records database covering a south London catchment area. Recorded loneliness within the preceding 2 years was extracted using natural language processing and outcomes were measured between 30th June 2012 until 30th December 2019, except for survival which applied a censoring point of 6th December 2020 according to data available at the time of extraction. The following mental healthcare outcomes: (i) time to first crisis episode; (ii) time to first emergency presentation; (iii) all-cause mortality; (iv) days active to service per year; and (v) face-to-face contacts per year.

RESULTS

Loneliness was recorded in 4,483 (16.7%) patients in the study population and fully adjusted models showed associations with subsequent crisis episode (HR 1.17, 95% CI 1.07-1.29), emergency presentation (HR 1.30, 1.21-1.40), days active per year (IRR 1.04, 1.03-1.05), and face-to-face contacts per year (IRR 1.28, 1.27-1.30). Recorded loneliness in patients with substance misuse problems was particularly strongly associated with adverse outcomes, including risk of emergency presentation (HR 1.68, 1.29-2.18) and mortality (HR 1.29, 1.01-1.65).

CONCLUSION

Patients receiving mental healthcare who are recorded as lonely have a higher risk of several adverse outcomes which may require a need for higher service input.

Analysis of hospital costs by morbidity group for patients with severe mental illness

OBJECTIVES

The goal of this study is to analyse hospital costs and length of stay of patients admitted to psychiatric units in hospitals in a European region of the Mediterranean Arc. The aim is to identify the effects of comorbidities and other variables in order to create an explanatory cost model.

METHODS

In order to carry out the study, the Ministry of Health was asked to provide data on access to the mental health facilities of all hospitals in the region. Among other questions, this database identifies the most important diagnostic variables related to admission, like comorbidities, age and gender. The method used, based on the Manning-Mullahy algorithm, was linear regression. The results were measured by the statistical significance of the independent variables to determine which of them were valid to explain the cost of hospitalization.

RESULTS

Psychiatric inpatients can be divided into three main groups (psychotic, organic and neurotic), which have statistically significant differences in costs. The independent variables that were statistically significant (p <.05) and their respective beta and confidence intervals were: psychotic group (19,833.0 ± 317.3), organic group (9,878.4 ± 276.6), neurotic group (11,060.1 ± 287.6), circulatory system diseases (19,170 ± 517.6), injuries and poisoning (21,101.6 ± 738.7), substance abuse (20,580.6 ± 514, 6) and readmission (19,150.9 ± 555.4).

CONCLUSIONS

Unlike most health services, access to psychiatric facilities does not correlate with comorbidities due to the specific nature of this specialization. Patients admitted to psychosis had higher costs and a higher number of average staysKEY MESSAGESThe highest average hospital expenditure occurred in patients admitted for psychotic disorders.Due to the particularities of psychiatry units and unlike other medical specialties, the number of comorbidities did not influence the number of hospital stays or hospital expenditure.Apart from the main diagnostic group, the variables that were useful to explain hospital expenditure were the presence of poisoning and injuries as comorbidity, diseases of circulatory system as comorbidity, history of substance abuse and readmission.

[Individual and contextual factors associated with violent behaviours during psychiatric hospitalizations]

BACKGROUND

The prevention of Physical Violent Behavior (VB) toward others during psychiatric hospitalization is a major concern of clinicians. These VBs can have a deleterious impact on the victims, inpatients or caregivers, as well as on the therapeutic milieu. Such violence can also have negative consequences for the assailant patients, such as repeatedly being hospitalized under restraint, stigmatization, and difficulties reintegrating into the community.

OBJECTIVES

This study explored individual (age, gender, marital status, living status, diagnostic) and institutional (type of admission, length of stay, number of previous hospitalizations) risk factors, and how their interactions could increase the risk of VB during psychiatric hospitalizations.

METHOD

The study was carried out over a period of four years in the psychiatry department of the Lausanne University Hospital, on the 15 wards (219 beds) specialized in acute psychiatric care for adults. All the patients admitted to one of these wards during this period (n=4518), aged between 18 and 65 years, were included in the study. The sample was divided in two groups: non-violent patients (NVPs) and violent patients (VPs). VBs, defined as physical aggressions against another person, were assessed by the Staff Observation Aggression Scale - Revised (SOAS - R). Only physical assaults, associated or not with other types of violence, involving hospitalized patients were analyzed. Personal and institutional factors were extracted from the hospital database. Chi² independence tests were used to assess differences between groups. Logistic regression models were used to identify the links between each factor and the VB. Classification and regression trees were used to study the hierarchical effect of factors, and combinations of factors, on VBs.

RESULTS

During the study period, 414 VBs were reported involving 199 patients (4.40 % of all patients). VPs were significantly younger, male, more likely to be unmarried and living in sheltered housing before hospitalization. In this group, the proportion of patients with diagnoses of schizophrenia, and/or schizophrenia with comorbid substance abuse and cognitive impairment, were higher compared to NVPs. VPs were more frequently admitted involuntarily, had a longer average length of stay and a greater number of previous hospitalizations. The logistic regression model performed on individual factors have shown a significant link between age (OR=0.99; CI: 0.97-1.00; P-value=0.024), living in sheltered housing before admission (OR=2.46; CI: 1.61-3.75; P-value<0.000), schizophrenic disorders (OR=2.18; CI: 1.35-3.57; P-value=0.001), schizophrenic disorders with substance abuse comorbidity (OR=2.00; CI: 1.16-3.37; P-value=0.016), cognitive impairment (OR=3.41; CI: 1,21-8.25; P-value=0.010), and VBs. The logistic regression model on institutional factors have shown a significant link between involuntary hospitalization (OR=4.38; CI: 3.20-6.08; P-value<0.000), length of previous stay (OR=1.01; CI: 1.00-1.01; P-value<0.000), number of previous hospitalizations (OR=1.06; CI: 1.00-1.12; P-value=0.031), and VBs. The logistic regression model on individual and institutional factors have shown a significant link between age (OR=0.99; CI: 0.97-1.00; P-value=0.008), living in sheltered housing before admission (OR=2.46: CI: 1.61-3.75; P-value=0.034), cognitive impairment (OR=3.41; CI: 1.21-8.25; P-value=0.074), involuntary hospitalization (OR=3.46; CI: 2.48-4.87; P-value<0.000), length of previous stay (OR=1.01; CI: 1.00-1.01; P-value<0.000), and VBs. The classification and regression trees have shown that the relationship between long length of stay and repeated hospitalizations mainly potentiate the risk of violence.

CONCLUSION

The results of this study have shown the existence of a small group of vulnerable patients who accumulate constrained hospital stays during which violence occurs. Exploring the clinical profiles and institutional pathways of patients could help to better identify these patients and promote a more appropriate mode of support, such as intensive clinical case management. This model could facilitate the development of a clinical network and the links between the structures and partners caring for a patient. This would create a continuous support, avoiding or limiting the lack of continuity of care and care disruption.

AI in patient flow: applications of artificial intelligence to improve patient flow in NHS acute mental health inpatient units

Introduction

Growing demand for mental health services, coupled with funding and resource limitations, creates an opportunity for novel technological solutions including artificial intelligence (AI). This study aims to identify issues in patient flow on mental health units and align them with potential AI solutions, ultimately devising a model for their integration at service level.

Method

Following a narrative literature review and pilot interview, 20 semi-structured interviews were conducted with AI and mental health experts. Thematic analysis was then used to analyse and synthesise gathered data and construct an enhanced model.

Results

Predictive variables for length-of-stay and readmission rate are not consistent in the literature. There are, however, common themes in patient flow issues. An analysis identified several potential areas for AI-enhanced patient flow. Firstly, AI could improve patient flow by streamlining administrative tasks and optimising allocation of resources. Secondly, real-time data analytics systems could support clinician decision-making in triage, discharge, diagnosis and treatment stages. Finally, longer-term, development of solutions such as digital phenotyping could help transform mental health care to a more preventative, personalised model.

Conclusions

Recommendations were formulated for NHS trusts open to adopting AI patient flow enhancements. Although AI offers many promising use-cases, greater collaborative investment and infrastructure are needed to deliver clinically validated improvements. Concerns around data-use, regulation and transparency remain, and hospitals must continue to balance guidelines with stakeholder priorities. Further research is needed to connect existing case studies and develop a framework for their evaluation.

Factors predicting discharge after two years for inpatients in the psychiatric long-term care wards who can walk independently

[Purpose] The purpose of this study was to investigate the factors that affected the discharge of walkable patients admitted to psychiatric long-term care wards. [Participants and Methods] The participants were walkable patients admitted to psychiatric long-term care wards at three different hospitals in Japan. The baseline assessments of all 73 patients were conducted between September and December 2018. During the 2 year follow-up period, five patients died, while 68 were included in the analysis. The baseline assessment includes the basic information of the participants and the risk of locomotive syndrome. [Results] In the comparisons between the discharged (n=12) and hospitalizing groups (n=56), the age, length of stay, and two-step and stand-up test scores at the baseline assessment were significantly different. The multiple logistic regression analysis, which discriminates between the two groups, adopted age as a significant variable in the baseline assessment as a predictor of dischargeability (odds ratio: 1.08; 95% confidence interval: 1.01, 1.16). [Conclusion] Age was considered to be a discharge likelihood predictor, as it affects the decline in motor function, such as locomotive syndrome, as well as the social resources that would be needed after discharge, such as family support.

Factors associated with repetitive violent behavior of psychiatric inpatients

A small number of psychiatric inpatients displays a large proportion of Violent Behaviors (VB). These can have a major impact on both victims and patients themselves. This study explored personal, situational and institutional risk factors and their combined effects, which could lead to repetitive VB (three or more assaults). Data from 4518 patients, aged 18 to 65, admitted to an acute psychiatric care facility, were included in the analysis. VB, defined as physical aggressions against another person, were assessed by the Staff Observation Aggression Scale-Revised. 414 VB were reported during the study period, involving 199 patients. 0.75 % of all patients were repetitively violent and committed 43% of all VB. Factors that were linked to repetitive VB were living in sheltered housing before hospitalization, suffering from schizophrenia with substance abuse comorbidity, cumulating hospitalization days and some situational factors, like the fact of being in nursing offices and pharmacies. When all personal, situational and institutional factors were considered together, the combined effects of length of stay and living in sheltered housing increased the risk of repetitive VB. We have identified a small group of vulnerable patients for whom new modalities of inter-institutional networking should be developed to prevent repetitive VB.

Relationship between whether the planned discharge destination is decided and locomotive syndrome for admitted patients in psychiatric long-term care wards

OBJECTIVE

We focused on locomotive syndrome as a low physical function factor that may prevent patients with psychiatric disease from being discharged. The purpose of this study is to clarify the factors, including locomotive syndrome, that prevent discharge from psychiatric long-term care wards.

METHOD

We enrolled 74 patients who were admitted to psychiatric long-term care wards at three different hospitals in Japan. Nurses or medical social workers in the ward were asked whether the planned discharge destination had been decided, and patients were categorized into a decided group and an undecided group. Outcome measures were age, sex, F code in the ICD-10 Classification of Mental and Behavioral Disorders, length of stay, chlorpromazine equivalent dose of antipsychotics, locomotive syndrome test scores (25-question GLFS, two-step test, stand-up test), and Barthel Index.

RESULTS

Based on the multivariate logistic regression analysis results, the length of stay and the two-step test score significantly explained the difference between the two groups. The odds ratio of a length of stay greater than 10 years was 8.42 times that of a length of stay less than 2 years (P=0.012, 95% CI=1.59, 44.53). Regarding the twostep test, the odds ratio for obtaining stage 2 was 10.62 times that for obtaining stage 0 (P=0.013, 95% CI=1.65, 68.23).

CONCLUSION

Those who with longer length of stays and lower two-step test scores tended not to be decided the planned discharge destination.

Violent Behavior Prior to Admission Is Not a Factor in Further Prolonged Length of Stay: A Retrospective Cohort Study in a Japanese Psychiatric Hospital

Background: This study assessed the hypothesis that violent behavior prior to admission prolongs psychiatric hospitalization and evaluated the likelihood of hospital discharge to a community care setting based on demographic and clinical factors, with an emphasis on violent behavior. Methods: We retrospectively selected 362 patients who were involuntarily admitted to a psychiatric hospital in Japan from December 1, 2015 to November 30, 2017, stayed longer than planned, and underwent review by a multidisciplinary team. We assessed (a) education and marital status and history of substance abuse, (b) the presence/absence and type of violent behavior that led to hospital admission, and (c) the discharge criteria. We divided the subjects into groups according to whether they had demonstrated violent behavior prior to admission and compared demographic and clinical variables between the groups using bivariate analysis. We also analyzed data using the Cox proportional hazard model, defining discharge to the community as the outcome. Age, sex, and variables that were significant at a level of P < 0.05 based on Cox univariate analysis were included in the multivariate models using the forced entry method. Results: The Violent group included 94 patients (26%). There were no significant between-group differences in age, sex, educational background, marital history, career history, or the history of substance abuse. However, hospitalization was significantly longer in the Non-violent group. The Cox proportional multivariate hazard ratios revealed that violent behavior prior to admission resulted in a higher probability of hospital discharge. Conclusion: Violent behavior prior to admission did not significantly contribute to prolonged hospitalization in patients who deviated from the treatment plan and had exceeded the planned hospitalization duration. Our findings recommend caution when using violence and impulsiveness observed during the acute stage to predict the difficulty of long-term treatment.

Cannabis use the week before admission to psychiatric in-patient service as a marker of severity

OBJECTIVE

To evaluate if cannabis dose recorded as standard joint unit (SJU) consumed before admission and other related factors have an influence on psychiatric inpatient's symptom severity and clinical outcomes.

METHODS

Cross-sectional study in an acute psychiatric inpatient unit including 106 individuals. Quantity of cannabis was measured as SJU and symptoms severity through the Brief Psychiatric Rating Scale (BPRS). Secondary outcomes (e.g. length of stay) were also assessed. Bivariate analyses and multivariate analyses were performed to determine the effect of SJU consumed before admission on measures of clinical severity.

RESULTS

Point prevalence of cannabis use before admission was 25.5%. Mean BPRS score was 55.8 (SD = 16.1); and 62.9 (SD = 11.1) among cannabis users. A low degree positive correlation between SJU consumed the week before admission and BPRS score (r_s = 0.28, p = 0.03) was found. In the multivariate analyses both main diagnostic group, Schizophrenia and other psychotic disorders vs. others (Bipolar and Unipolar Affective Disorders and Addictive disorders) (B = 8.327; 95% CI 4.976-11.677) and need of PRN ("pre re nata" or when necessary) administration of antipsychotics and benzodiazepines (B = 12.13; 95% CI 6.868-17.393) were significant predictors, both increasing BPRS score.

CONCLUSIONS

The study did not find a correlation between SJU consumed last week and psychiatric severity. On the other hand, individuals with psychotic disorders reported a higher prevalence of cannabis use the week before admission and displayed higher BPRS scores, which points to the need for the development of tailored interventions for high-risk groups. The SJU is a useful quantification tool suitable for further clinical research.

[The Intensive Psychiatric Care Unit at a Hospital with Maximum Care - An Analysis of Treatment Variables in the Therapy of Psychiatric and comorbid Somatic Disorders]

ZIEL DER STUDIE UND METHODIK

Alle 873 Behandlungsakten einer psychiatrischen Intensivstation aus einem Zeitraum von 5 Jahren gingen in eine Analyse des Patientenkollektivs, des Behandlungsoutcomes und von Prädiktoren für die stationäre Behandlungsdauer ein.

ERGEBNISSE UND SCHLUSSFOLGERUNG

Auf der beschriebenen Station wurden sowohl Patienten mit psychiatrischen Notfallsyndromen als auch Patienten mit komorbiden psychischen und somatischen Erkrankungen behandelt. Somatische Zusatzerkrankungen beeinflussen den stationären Behandlungsverlauf psychisch Erkrankter erheblich, z. B. durch eine um durchschnittlich 2,4 Wochen kürzere intensivpsychiatrische stationäre Behandlungsdauer bei häufiger Notwendigkeit (41,3%) einer stationären, z. B. rehabilitativen Anschlussbehandlung. Die Stationsauslastung von 110 % und die durchschnittliche Behandlungsdauer von 63 Tagen deuten auf einen hohen Bedarf an interdisziplinären psychiatrisch-somatischen Behandlungsmöglichkeiten hin. In Zukunft ist ein Zusammenwachsen von Psychiatrie und somatischer Medizin anzustreben. Untersuchungen zu Versorgungssituation und Wirtschaftlichkeit interdisziplinärer Behandlungsangebote stehen aus.

BACKGROUND AND METHOD

All 873 medical files of psychiatric inpatients treated over a 5 year period at a psychiatric intensive care unit were analyzed in regard to characteristics of the patient group, outcome and predictors for the length of stay.

RESULTS AND CONCLUSIONS

Patients with psychiatric emergency syndromes and patients with comorbid psychiatric and somatic disorders were treated on the described unit. Somatic comorbidities have a considerable effect on the course of treatment for patients with psychiatric disorders. They have to receive stationary treatment for a shorter period (2.4 weeks) but often need further stationary, e. g. rehabilitative treatment. The utilization of this specific unit (110%) and the above average length of stay (63 days) point to an increasing need in inpatient treatment capacities for patients with psychiatric and somatic comorbidities. In future a growing together of somatic medicine and psychiatry in Germany is worthwhile. The evaluation of the treatment situation and aspects of cost effectiveness are yet to come.

Retrospective Analysis of Factors Associated with Long-Stay Hospitalizations in an Acute Psychiatric Ward

Purpose

To evaluate the longest hospitalizations in an acute psychiatric ward [Service of Psychiatric Diagnosis and Treatment (SPDT)] and the related demographic, clinical and organizational variables to understand the factors that contribute to long-stay (LOS) phenomenon. The term “long stay” indicates clinical, social and organizational problems responsible for delayed discharges. In psychiatry, clinical severity, social dysfunction and/or health-care system organization appear relevant factors in prolonging stays.

Patients and Methods

We divided all the SPDT hospitalizations from 1 January 2010 to 31 December 2015 into two groups based on the 97.5^th percentile of duration: ≤36 day (n=3254) and >36 day (n=81) stays, in order to compare the two groups for the selected variables. Comparisons were made using Pearson’s chi-square for categorical data and t-test for continuous variables, the correlation between the LOS, as a dependent variable, and the selected variables was analyzed in stepwise multiple linear regression and in multiple logistic regression models.

Results

The longest hospitalizations were significantly related to the diagnosis of “schizophrenia and other psychosis” (Pearson Chi²=17.24; p=0.045), the presence of moderate and severe aggressiveness (Pearson chi²=29; p=0.000), compulsory treatment (Pearson Chi²=8.05; p=0.005), parenteral or other route administration of psycho-pharmacotherapy (Pearson Chi²=12.91; p=0.007), poli-therapy (Pearson Chi²=6.40; p=0.041), complex psychiatric activities (Pearson Chi²=12.26; p=0.002) and rehabilitative programs (Pearson Chi²=37.05; p=0.000) during the hospitalization and at discharge (Pearson Chi²=29.89; p=0.000). Many demographic and clinical variables were statistically significantly correlated to the LOS at our multiple linear and logistic regression model.

Conclusion

In our sample, clinical illness severity and need for complex therapeutic and rehabilitative treatments were associated with prolonged psychiatric hospitalizations. Understanding this phenomenon can have not only economic but also clinical, ethical and social relevance.

Implementation of the Brøset Violence Checklist on an Acute Psychiatric Unit

BACKGROUND: Violence on inpatient psychiatric settings has significant consequences for patients and staff. Research is needed to determine if Brøset Violence Checklist (BVC) is an accurate predictor of violence. AIMS: The study aims were to determine the relationship between BVC scores and incidence of violent behavior within 24 hours, to compare scores among those requiring high-level nursing interventions for violence, and to investigate the impact of scores on length of stay (LOS) and 30 day-readmission rates. METHOD: Retrospective cohort study. RESULTS: Logistic regression indicates 3.4 times greater risk of violence for every additional point on admission BVC (odds ratio = 3.4, 95% confidence interval = [2.29, 5.08], p < .0001). Patients requiring high-level interventions for violence had higher mean BVC scores on both Day 1 and 2 of admission. Pearson correlation was significant for positive association between BVC on admission and LOS (p < .001). Findings did not establish a link between BVC scores and violence with 30-day readmission rates. CONCLUSIONS: Efforts toward early identification and management of agitation and disruptive behavior is encouraged. Results showed increased risk of violence with every additional point on BVC on admission; further attention should be paid to these patients on admission when using violence screening tools.

Locked in and Growing Old: The Psychiatric, Forensic, and Cognitive Correlates of 30 Years of Psychiatric Hospitalization

OBJECTIVE

As the number of older adults in the United States continues to grow, the population of older adults with severe mental illness in institutional settings (OASIS) is expected to place a significant demand on healthcare resources. This study presents an update to research regarding the clinical characteristics of OASIS inpatients with histories of extensive hospitalization through the use of a newly developed psychiatric measure: the Clinician-Rated Dimension of Psychosis Symptom Severity.

METHODS

We investigated an OASIS sample (N = 55) with an average of nearly 30 continuous years of hospitalization at a forensic state psychiatric hospital.

RESULTS

The average OASIS patient exhibited the most prominent psychiatric symptoms via delusions and negative symptoms, received psychotropic medications at substantially higher doses than recommended therapeutic levels, rarely committed acts of institutional violence (IV), and performed more than two standard deviations below the normative mean on cognitive testing. More severe hallucination symptoms were associated with higher psychotropic medication dosage, and more severe depressive symptoms were associated with more IV incidents. OASIS inpatients performed moderately worse than general psychiatric inpatients in the areas of overall cognition, immediate memory, and delayed memory; older age was associated with poorer language and attention. No psychiatric or cognitive factors predicted IV incidents.

CONCLUSION

These results highlight the continued importance of understanding the psychiatric, forensic, and cognitive factors associated with aging in an institutional setting and how these factors among OASIS inpatients may vary from general psychiatric inpatients.

Predictors of length of stay in psychiatric inpatient units: Does their effect vary across countries?

BACKGROUND

Previous studies in individual countries have identified inconsistent predictors of length of stay (LoS) in psychiatric inpatient units. This may reflect methodological inconsistencies across studies or true differences of predictors. In this study we assessed predictors of LoS in five European countries and explored whether their effect varies across countries.

METHODS

Prospective cohort study. All patients admitted over 14 months to 57 psychiatric inpatient units in Belgium, Germany, Italy, Poland and United Kingdom were screened. Putative predictors were collected from medical records and in face-to-face interviews and tested for their association with LoS.

RESULTS

Average LoS varied from 17.9days in Italy to 55.1days in Belgium. In the overall sample being homeless, receiving benefits, social isolation, diagnosis of psychosis, greater symptom severity, substance use, history of previous admission and being involuntarily admitted predicted longer LoS. Several predictors showed significant interaction effects with countries in predicting LoS. One variable, homelessness, predicted a different LoS even in opposite directions, whilst for other predictors the direction of the association was the same, but the strength of the association with LoS varied across countries.

CONCLUSIONS

The same patient characteristics have a different impact on LoS in different contexts. Thus, although some predictor variables related to clinical severity and social dysfunction appear of generalisable relevance, national studies on LoS are required to understand the complex influence of different patient characteristics on clinical practice in the given contexts.