Length of stay of acute psychiatric inpatients: an exponential model

Models of care in forensic psychiatry

Forensic psychiatry services have grown and become more complex in structures, processes and pathways. Legacy customs, practices and changing policy are now organised into formal models of care. These are written accounts of how a health service is delivered, outlining best practice and services for patients progressing through the stages of their condition and the care and treatment available. This article explores the four key elements of a model of care: goals; pathways and processes; treatment programmes; and systematic evaluation. It describes the most common model of care in forensic services, which builds on structures of stratified therapeutic security. It also considers variations on this basic or standard model matched to needs arising from the complex interrelationship with other parts of the mental health service for the population served and with criminal justice, primary care and physical health, housing and welfare agencies.

Trends in the use of the Italian Mental Health Act, 1979–1997

Italian statistics on psychiatric bed availability, voluntary and compulsory admissions were examined from 1979 to 1997. Although the number of psychiatric beds dropped by 62.5%, the absolute number of compulsory admissions has remained substantially stable. The proportion of all admissions that were compulsory decreased from 17.1% to 11%. This study shows that a shift to community care was not associated with an increase in compulsory admissions in Italy.

Controlled comparison of two crisis resolution and home treatment teams

Aims and method

To compare an existing crisis resolution service with a new crisis resolution team (CRT) in Wales. The impact of the new team was measured by changes in bed days and admissions. A random sample of patients from each service was assessed for service satisfaction, social functioning and quality of life after first presentation.

Results

The total number of bed days was reduced following the introduction of the new CRT (27.3%). The frequency and duration of compulsory admissions increased by 31% in the CRT between the first and second years and by 7% in the control service, offset by a greater reduction in informal admissions in the CRT (23.5%) compared with the control group (13.3%); overall bed usage was unchanged. Service satisfaction, social functioning and quality of life showed no important differences between the services.

Clinical implications

Crisis resolution teams may reduce informal admissions in the short term but at the cost of more compulsory admissions later.

Patterns of psychiatric admissions and predictors of patient's outcome in Jimma University Teaching and Referral Hospital: a retrospective study

Background

Psychiatric morbidity burden accounts 12.45% of the disease admission burden in Ethiopia; only two referral hospitals are found to manage all cases. The aim of this study is to assess the predictors of patient outcomes.

Method

A 3 years retrospective patients’ cards, charts and medical notes review in psychiatry case admission department of Jimma university teaching and training specialised hospital was conducted. All the admitted cases included in this study. Bivariate and multivariable logistic regression analyses were conducted to identify independent predictors of outcomes.

Result

Among 402 study participants, the majority of them 301 (74.9%), were improved from their mental illnesses. First to eight grades completed study participants were found to be 1.34 times more likely improved mental illness than not able to read or write [AOR = 1.34, 95% CI (1.18–2.78), P < 0.009)]. The probability of improving from mental illness on married study participants was found 2.81 times more likely than single study participants [AOR = 2.81, CI (1.90–4.50), P < 0.043]. First time admitted cases improved 2.82 times more likely than those having a previous admission history [AOR = 2.82, CI (2.05–3.17), P < 0.05]. Duration of stay from 31 to 44 days showed more likely than from 1 to 20 days on patient improvement, [AOR = 1.88, CI (1.42–2.65), P < 0.034]. However, the hospital stay above 44 days does not show any statistical association with patient’s medical improvement.

Conclusion

Married, better educated, and the hospital stay of one to one-and-half month predicts better health outcome. Thus, this study suggests, psychiatric case management needs the collaborative care of the family in concurrence with counselling and guidance with enough time to better-off patients’ outcomes. Our findings are useful in designing and improving—patient services for psychiatric patient programs and focused health communication and counselling strategies in relation to psychoactive substances in Ethiopia.

Using the M/G/∞ queueing model to predict inpatient family medicine service census and resident workload

The number and timing of unplanned admissions to inpatient teaching services vary. Recent changes to resident duty hours make it essential to maximize learning experiences and balance workload on these services. Queueing theory provides a mechanism for understanding and planning for the variations in admissions and daily census. Daily admissions, length of stay, and daily census were modeled for a teaching inpatient family medicine service over 46 months using an M/G/∞ queueing model. Q–Q plots and a Kolmogorov–Smirnov test were used to check the fit of actual data to the model. Admissions and daily census followed a Poisson distribution (λ = 3.28 and λ = 8.28, respectively), while length-of-stay followed a lognormal distribution (µ = 0.49, σ2 = 0.83). The M/G/∞ queueing model proved useful for predicting overflow admission frequency, defining expected resident workload in terms of patient-days, and determining hospital unit size requirements.

The virtual institution: cross-sectional length of stay in general adult and forensic psychiatry beds

Background

Length of stay in psychiatric hospitals interests health service planners, economists and clinicians. At a systems level it is preferable to study general adult and forensic psychiatric beds together since these are likely to be inter-dependent. We examined whether patients were placed according to specialist need or according to their cross-sectional length of stay.

Methods

A one night census of all registered mental nursing home (RMNH) beds was carried out for a defined catchment area of 1.2 m population in north London in November 1999. This included all public sector psychiatric hospital beds, independent sector and forensic beds in and outside the catchment area. Cross-sectional length of stay was defined as time since the date of admission from the community. Log rank (Mantel-Cox) Chi squared was used to test for differences between groups and hierarchical logistic regression for statistical modelling.

Results

There were 1,085 occupied psychiatric beds. Cross-sectional LOS was greater than 365 days in 43.5%. Forensic beds had longer cross-sectional LOS than general beds. LOS increased with the level of therapeutic security from open through low, medium and high secure. Cross-sectional LOS was shorter for open hospital beds than community RMNH beds, shorter for informal patients than those detained under civil mental health law, and longest for forensic detentions. Longest cross-sectional LOS were for patients placed in RMNHs in the community, 10.7% of whom were ‘forensic’ as were 25.4% of low secure patients. Designated length of stay (acute, rehab/medium term and long term) was also associated with increasing cross-sectional LOS. In regression analysis only three variables contributed to a model of cross-sectional LOS, commissioning status (general or forensic), designated length of stay and designated level of therapeutic security.

Conclusions

Studying cross-sectional LOS for whole systems (all psychiatric beds) is essential for operational health service management. At the time of this survey ‘forensic’ status was the main way of accessing long term high dependency places. This has been an organic development over time, a response to patient needs rather than the outcome of any specific policy or plan.

Hospital stay in patients admitted for acute bipolar manic episodes prescribed quetiapine immediate or extended release: a retrospective non-interventional cohort study (HOME)

BACKGROUND

Bipolar manic episodes often require hospital admission to ensure patient safety. The antipsychotic quetiapine is a common treatment for bipolar mania and is available in immediate release (IR) and extended release (XR) formulations; however, outcomes in patients receiving these different formulations have not been directly compared in an acute hospital setting.

METHODS

We conducted a multinational, observational, retrospective cohort study to describe and compare hospital stay in patients admitted for an acute bipolar manic episode treated with quetiapine IR or XR from 1 October 2009-1 October 2010. The primary outcome measure was comparison of length of stay (LOS) using zero-truncated negative binomial regression.

RESULTS

In total, 1230 patients were included (659 in the IR cohort; 571 in the XR cohort). The median LOS (interquartile range) was 18.0 days (12.0, 28.0) in the IR cohort and 20.0 days (12.0, 34.0) in the XR cohort, respectively. LOS was not significantly associated with quetiapine formulation irrespective of whether or not clinical characteristics were taken into account (p = 0.820 and p = 0.386, respectively). Overall, 84.2% and 84.4% of patients in the IR and XR cohorts, respectively, had not previously used quetiapine; of these patients, 78.7% and 68.9% received one total daily dose, and 14.4% and 23.9% received dose titration. Over half of patients received antipsychotic monotherapy (53.1% and 58.3% in the IR and XR cohorts, respectively) and most received a daily quetiapine dose ≥ 400 mg (64.9% and 71.8%, respectively, for quetiapine monotherapy and 59.9% and 80.3%, respectively, for combination treatment). As a secondary outcome, multivariate analysis was used to identify other factors that affect LOS. Factors associated with a longer hospital stay included public funding versus private, maximum number of new medications administered, did not receive lithium and did not receive anxiolytics, sedatives/hypnotics (all p < 0.0001). Factors associated with a shorter hospital stay included presence of drug/alcohol abuse, living accompanied and having a psychiatric medical history (all p < 0.05).

CONCLUSIONS

LOS was not found to be associated with quetiapine formulation. However, most patients received only one total daily dose of quetiapine without dose titration, which was unexpected and contrary to current recommendations.

TRIAL REGISTRATION

TRIAL REGISTRATION

NCT01239589.

Outcome and length of stay in psychiatric hospitalization, the experience of the University Clinic of Turin

BACKGROUND

Given the current tendency to shorten psychiatric hospitalization and change its organization, an issue could be raised regarding its outcomes.

PURPOSE

To analyze features related to length of stay in a short-term inpatient treatment, to study outcomes and to evaluate the diagnosis-specific effects of hospitalization.

METHOD

A sample of 310 consecutive hospitalized patients, with psychotic disorder, depressive disorder and bipolar disorder (DSM IV-TR), was recruited at the University Psychiatric Clinic, Service for Cognitive Disorders, Department of Neuroscience, University of Turin. Severity of illness was rated using the brief psychiatry rating scale (BPRS). We evaluated relations between length of stay and clinical and socio-demographic features (linear regression) and possible differences confronting BPRS scores at admission and discharge in the different diagnostic subgroups (ANOVA for repeated measures).

RESULTS

All the sample of patients showed a significant improvement in symptomatology during hospitalization. Worse symptomatology in anxiety-depression domain of BPRS at admission in the whole sample was positively correlated with length of stay. A longer length of stay was also shown in patients with diagnosis of depressive disorder. Finally, a different pattern of improvement of BPRS (total score and domains) was shown between the different diagnostic groups.

CONCLUSION

Brief hospitalization in our service was shown to be highly effective. Different diagnostic groups had different response to hospitalization, showing faster improvement in characteristic symptomatology, but the anxiety-depression domain showed the highest percentage of change for all the diagnostic groups. We therefore suppose that hospitalization has two effects: a specific (due to tailored therapies) and a non-specific one (due to non-specific therapy and to a placebo-like effect).

Co-morbid substance misuse in psychiatric patients: prevalence and association with length of inpatient stay

Improved management of mental illness with co-morbid substance misuse is an important clinical objective. This study aimed to assess the prevalence of substance misuse in psychiatric inpatients, and to examine the relationship between alcohol misuse and length of hospital admission. A prevalence study conducted over four months, examined rates of co-morbid substance misuse in patients admitted for psychiatric inpatient care. Demographic details and length of hospital stay were collected for all patients and those who gave informed consent were screened for levels of alcohol and substance misuse. Two hundred and thirty-eight patients were admitted during the study period in which 178 (74.8%) consented to take part in the study. A group of 44 (50.6%) men and 26 (29.2%) women were screened positive for alcohol misuse (chi(2) = 8.7, P = 0.003). Cannabis use was acknowledged by 31 (35.2%) men and 10 (11.2%) women (chi(2) = 13.5, P < 0.0001). Presence of co-morbid alcohol misuse was associated with a significantly shorter hospital admission (z = 3.34, P = 0.0008). Co-morbid substance misuse (including alcohol) was reported significantly more frequently by men than women. Overall, patients with co-morbid alcohol misuse had shorter hospital admissions, suggesting different patterns of presentation and progress in hospital. Hospital admission presents an opportunity to identify substance misuse and evaluate treatments for co-morbid conditions within a safe environment.

A methodology for timing reviews of inpatient hospital stay

OBJECTIVE

This paper aims to describe a methodology to inform decisions about the optimal time to schedule reviews of a patient's hospital stay and to provide an example of its implementation.

METHOD

Length of hospital stay was assessed in 1227 consecutive inpatient admissions. Data were transformed to reflect the probability of discharge from hospital in the following 7 days.

RESULTS

The resulting data reflected the points at which the conditional probability of being discharged were declining, revealing the potentially efficient times to conduct reviews of inpatient admissions.

CONCLUSIONS

The methodology outlined appears useful in assisting psychiatrists responsible for inpatient care to decide upon optimal times to review a patient's stay in hospital.

Patterns of hospital admission for adult psychiatric illness in England: analysis of Hospital Episode Statistics data

BACKGROUND

The assessment and reporting of national patterns of psychiatric hospital admissions is important for strategic service development and planning.

AIMS

To investigate patterns of psychiatric hospital admissions of patients aged 16-64 years in England.

METHOD

We used the Department of Health's national Hospital Episode Statistics data on admissions to National Health Service hospitals in England between April 1999 and March 2000, to investigate patterns by region, gender, age and diagnosis.

RESULTS

The annual admission rate for England was 3.2 per 1000 population. There were marked regional variations and rates were higher in males than in females. Depression and anxiety together were the most common (29.6%) reason for admission. Length of stay exceeded 90 days in 9.2% of admissions and 1 year in 0.9% (highest in London and for psychoses).

CONCLUSIONS

Depression and anxiety together were the most frequent diagnoses leading to hospitalisation. There has been a reversal of the previously reported predominance of female admissions. Regional variations in activity and the significant numbers of patients remaining for long periods in'acute' inpatient care have important policy implications.

Observed-predicted length of stay for an acute psychiatric department, as an indicator of inpatient care inefficiencies. Retrospective case-series study

Background

Length of stay (LOS) is an important indicator of efficiency for inpatient care but it does not achieve an adequate performance if it is not adjusted for the case mix of the patients hospitalized during the period considered. After two similar studies for Internal Medicine and Surgery respectively, the aims of the present study were to search for Length of Stay (LOS) predictors in an acute psychiatric department and to assess the performance of the difference: observed-predicted length of stay, as an indicator of inpatient care inefficiencies.

Methods

Retrospective case-series of patients discharged during 1999 from the Psychiatric Department from General Hospital "Hermanos Ameijeiras" in Havana, Cuba. The 374 eligible medical records were randomly split into two groups of 187 each. We derived the function for estimating the predicted LOS within the first group. Possible predictors were: age; sex; place of residence; diagnosis, use of electroconvulsive therapy; co morbidities; symptoms at admission, medications, marital status, and response to treatment. LOS was the dependent variable. A thorough exam of the patients' records was the basis to assess the capacity of the function for detecting inefficiency problems, within the second group.

Results

The function explained 37% of LOS variation. The strongest influence on LOS came from: age (p = 0.002), response to treatment (p < 0.0001), the dummy for personality disorders (p = 0.01), ECT therapy (p = 0.003), factor for sexual and/or eating symptoms (p = 0.003) and factor for psychotic symptoms (p = 0.025). Mean observed LOS is 2 days higher than predicted for the group of records with inefficient care, whereas for the group with acceptable efficiency, observed mean LOS was 4 days lower than predicted. The area under the ROC curve for detecting inefficiencies was 69%

Conclusions

This study demonstrates the importance of possible predictors of LOS, in an acute care Psychiatric department. The proposed indicator can be readily used to detect inefficiencies.

What is the usual length of stay in a psychiatric ward?

INTRODUCTION

Admission statistics can provide valuable data for planning and policy in the NHS. However, there has been little agreement about meaningful ways of summarising and expressing such data. We set out to (i) explore the distribution of length of inpatient stay and to examine the most appropriate measure of central tendency; and (ii) examine the relationship between severity of mental illness and length of stay.

METHOD

Length of stay was recorded for a 12-month cohort of psychiatric admissions to a district general hospital psychiatric unit. These data were compared with a previous cohort study and also with DoH statistics.

RESULTS

Length of inpatient stay followed an exponential decay curve. The median length of stay for all three cohorts examined was approximately 15 days. Absence of serious mental illness was significantly associated with shorter length of stay.

CONCLUSION

Length of stay is not normally distributed and so the median value is the preferred measure of central tendency. All cohorts examined showed a median value of around 15 days. Large numbers of patients are admitted for a week or less which has implications for inpatient and community services. Qnt] Psych Clin Pract 2004; 8: 53-56).

Do suicidal ideation and behaviour influence duration of psychiatric hospitalization?

Suicidal ideation and behaviour are sometimes considered to be manipulative, with the intention of escaping from intolerable situations leading to prolonged hospitalization. The present study examined the length of hospitalization of those who had attempted suicide or had suicidal ideation compared to non-suicidal patients, as measured by the Health of the Nation Outcome Scales in two private psychiatric hospitals. Suicidal patients had a significantly shorter length of hospitalization, despite their significantly greater degree of psychiatric morbidity. Results indicated that it is erroneous to preclude inpatient care for those who are suicidal on the assumption that it will promote prolonged hospitalization.

A statistical model for length of psychiatric in-patient treatment and an analysis of contributing factors

OBJECTIVE

Direct illness costs in psychiatry are strongly related to the length of in-patient stay (LOS). Prior studies have shown that LOS depends upon many factors; however, there is no systematic work on their interrelation and relative contribution.

METHOD

A detailed statistical analysis of the factors explaining LOS for n = 4,706 consecutive admissions (1994-97) to the psychiatric hospital of the University of Tübingen is presented.

RESULTS

The distribution of LOS follows an exponential decay function, suggesting a hazard-based process. Cox regression indicates that the incidence of discharge and hence LOS is modulated by a number of illness-related and other factors, and their relationship is explored.

CONCLUSION

While a linear model is commonly assumed, LOS in psychiatry is governed by a hazard-based process. As a tool in quality management, LOS data for psychiatric hospitals might be routinely analyzed and the effects of non-illness-related factors minimized.

Recovery from depressive illness does fit an exponential model

A very large number of therapeutic trials of antidepressant drugs have been reported in the scientific literature. Until now, the comparison of one drug with another, or with placebo, has been performed typically by comparing the scores on depression rating scales of the two groups of patients at fixed points of time after the beginning of therapy. It was postulated in 1989 that the curves of the recovery scores followed an exponential curve of the formula y = ae-bx + c. This hypothesis was tested in a double-blind controlled trial of the antidepressant minaprine, with the use of the scores on the Hamilton Rating Scale for Depression (HAM-D). We found that the correlation coefficient, Pearson's r, between the log of the HAM-D value and the week number of the study was -0.99. This gives a coefficient of determination of 0.98, which makes it clear that the model adequately fits the data. We conclude that the use of the formula gives a method of testing the statistical significance of the difference between treatments as a valuable alternative to traditional tests. We believe that this would give a much more sensitive discrimination between treatments because all of the data points are used to calculate a single parameter--the slope of the curve.