Liaison psychiatry-measurement and evaluation of service types, referral patterns and outcomes (LP-MAESTRO): a protocol

Evaluating mental health decision units in acute care pathways (DECISION): a quasi-experimental, qualitative and health economic evaluation

Background

People experiencing mental health crises in the community often present to emergency departments and are admitted to a psychiatric hospital. Because of the demands on emergency department and inpatient care, psychiatric decision units have emerged to provide a more suitable environment for assessment and signposting to appropriate care.

Objectives

The study aimed to ascertain the structure and activities of psychiatric decision units in England and to provide an evidence base for their effectiveness, costs and benefits, and optimal configuration.

Design

This was a mixed-methods study comprising survey, systematic review, interrupted time series, synthetic control study, cohort study, qualitative interview study and health economic evaluation, using a critical interpretive synthesis approach.

Setting

The study took place in four mental health National Health Service trusts with psychiatric decision units, and six acute hospital National Health Service trusts where emergency departments referred to psychiatric decision units in each mental health trust.

Participants

Participants in the cohort study (n = 2110) were first-time referrals to psychiatric decision units for two 5-month periods from 1 October 2018 and 1 October 2019, respectively. Participants in the qualitative study were first-time referrals to psychiatric decision units recruited within 1 month of discharge (n = 39), members of psychiatric decision unit clinical teams (n = 15) and clinicians referring to psychiatric decision units (n = 19).

Outcomes

Primary mental health outcome in the interrupted time series and cohort study was informal psychiatric hospital admission, and in the synthetic control any psychiatric hospital admission; primary emergency department outcome in the interrupted time series and synthetic control was mental health attendance at emergency department. Data for the interrupted time series and cohort study were extracted from electronic patient record in mental health and acute trusts; data for the synthetic control study were obtained through NHS Digital from Hospital Episode Statistics admitted patient care for psychiatric admissions and Hospital Episode Statistics Accident and Emergency for emergency department attendances. The health economic evaluation used data from all studies. Relevant databases were searched for controlled or comparison group studies of hospital-based mental health assessments permitting overnight stays of a maximum of 1 week that measured adult acute psychiatric admissions and/or mental health presentations at emergency department. Selection, data extraction and quality rating of studies were double assessed. Narrative synthesis of included studies was undertaken and meta-analyses were performed where sufficient studies reported outcomes.

Results

Psychiatric decision units have the potential to reduce informal psychiatric admissions, mental health presentations and wait times at emergency department. Cost savings are largely marginal and do not offset the cost of units. First-time referrals to psychiatric decision units use more inpatient and community care and less emergency department-based liaison psychiatry in the months following the first visit. Psychiatric decision units work best when configured to reduce either informal psychiatric admissions (longer length of stay, higher staff-to-patient ratio, use of psychosocial interventions), resulting in improved quality of crisis care or demand on the emergency department (higher capacity, shorter length of stay). To function well, psychiatric decision units should be integrated into the crisis care pathway alongside a range of community-based support.

Limitations

The availability and quality of data imposed limitations on the reliability of some analyses.

Future work

Psychiatric decision units should not be commissioned with an expectation of short-term financial return on investment but, if appropriately configured, they can provide better quality of care for people in crisis who would not benefit from acute admission or reduce pressure on emergency department.

Study registration

The systematic review was registered on the International Prospective Register of Systematic Reviews as CRD42019151043.

Funding

This award was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme (NIHR award ref: 17/49/70) and is published in full in Health and Social Care Delivery Research; Vol. 11, No. 25. See the NIHR Funding and Awards website for further award information.

A framework for the implementation of consultation-liaison psychiatry from the characteristics of psychosomatic consultations at a general hospital in china

OBJECTIVE

To understand the current situation and characteristics of consultation-liaison psychiatry (CLP) service in general hospital, to compare the results of the literature on CLP published in other hospitals in China and abroad, and to find deficiencies for the current differences.

METHODS

The medical records of all inpatients who had liaison consultations in the first year of the establishment of Xi'an International Medical Center Hospital, China, were collected. Statistical analysis was performed on the general demographic data, department origin, number of consultations, the reason for consultation, diagnosis of consultation, and follow-up of patients.

RESULTS

A total of 630 patients were enrolled in the past 1 year, of which, 45.23% were males and 54.8% were females. 89.2% of non-psychiatric departments applied for psychosomatic consultation. The percentage of middle-aged and elderly patients was 75.6%, including 61.6% of patients aged 45-74 years. The internal medicine department had the highest number of consultations (48.2%), including respiratory medicine (12.1%), neurology (12.1%), gastroenterology (12.1%), and cardiology (12.1%). For surgical patients, orthopedic patients (rehabilitation, 6.5%) comprised the majority of consults. The main reasons for requesting psychosomatic consultations included depressive symptoms (139 cases, 22.8%), anxiety symptoms (137 cases, 22.5%), sleep problems (111 cases, 18.2%), as well as hallucinations and delusions or behavioral disorders (68 cases, 11.2%), accounting for a total of 74.59% (455/630).

CONCLUSION

A significant gap exists between the level of CLP services in China and developed regions in Europe and the United States, mainly due to low consultation rates and referrals and imperfect CLP service.

Liaison psychiatry before and after the COVID-19 pandemic

INTRODUCTION

the COVID-19 pandemic had an impact on hospital admissions. The clinical profiles of patients referred to liaison psychiatry teams (LPT) remained stable over the last few decades. We postulate changes in patient profiles due to the COVID-19 pandemic.

MATERIALS AND METHODS

a total of 384 patients admitted to a tertiary care University Hospital in Madrid (Spain) and referred to LPTs were recruited. Patients referred 5 months before and after the first admission for COVID-19 were included. Clinical and sociodemographic characteristics were collected, and non-parametric hypothesis contrast tests were used to study possible differences between both periods.

RESULTS

patients referred during the pandemic were significantly older (U = 2.006; p = .045), most of them were admitted to medical hospitalization units (χ2 (2) = 5.962; p = 015), and with a different reason for admission. There was an increase in the rate of adjustment disorders (χ2 (1) =7.893; p = 005) and delirium (χ2 (1) =9.413; p = 002), as well as psychiatric comorbidity (χ2 (2) = 9.930; p = .007), and a reduction in the proportion of patients treated for substance misuse (χ2 (5) = 19.152; p = .002). The number of deaths increased significantly (χ2 (1) = 6.611; p = .010). In persons over 65 years inappropriate prescription was significantly lower (χ2 (1) = 8.200; p = .004).

CONCLUSIONS

the pandemic had an impact on the activity of the LPTs due to the change in the clinical profile and evolution of referred patients, maintaining standards of care that are reflected through prescription.

Consultation-Liaison Psychiatry Services in Ireland: A National Cross-Sectional Study

Objective: This study aimed to describe the provision of consultation-liaison psychiatry (CLP, also known as liaison psychiatry) services in acute hospitals in Ireland, and to measure it against recommended resourcing levels. Methods: This is a survey of all acute hospitals in Ireland with Emergency Departments, via an electronic survey sent by email and followed up by telephone calls for missing data. Data were collected on service configuration, activity, and resourcing. Data were collected from CLP or proxy services at all acute hospitals with an Emergency Department in Ireland (n = 29). This study measured staffing and activity levels where available. Results: None of the services met the minimum criteria set out by either national or international guidance per 500 bed general hospital. Conclusions: CLP is a relatively new specialty in Ireland, but there are clear international guidelines about the staffing levels required to run these services safely and effectively. In Ireland, despite clear national guidance on staffing levels, no services are staffed to the levels suggested as the minimum. It is likely that patients in Ireland's acute hospitals have worse outcomes, and hospitals have unnecessary costs, due to this lack. This is the first study of CLP provision in Ireland and demonstrates the resource constraints under which most services work and the heterogeneity of services nationally.

Liaison psychiatry-measurement and evaluation of service types, referral patterns and outcomes (LP-MAESTRO): a protocol

INTRODUCTION

We describe the protocol for a project that will use linkage of routinely collected NHS data to answer a question about the nature and effectiveness of liaison psychiatry services in acute hospitals in England.

METHODS AND ANALYSIS

The project will use three data sources: (1) Hospital Episode Statistics (HES), a database controlled by NHS Digital that contains patient data relating to emergency department (ED), inpatient and outpatient episodes at hospitals in England; (2) ResearchOne, a research database controlled by The Phoenix Partnership (TPP) that contains patient data relating to primary care provided by organisations using the SystmOne clinical information system and (3) clinical databases controlled by mental health trusts that contain patient data relating to care provided by liaison psychiatry services. We will link patient data from these sources to construct care pathways for patients who have been admitted to a particular hospital and determine those patients who have been seen by a liaison psychiatry service during their admission.Patient care pathways will form the basis of a matched cohort design to test the effectiveness of liaison intervention. We will combine healthcare utilisation within care pathways using cost figures from national databases. We will compare the cost of each care pathway and the impact of a broad set of health-related outcomes to obtain preliminary estimates of cost-effectiveness for liaison psychiatry services. We will carry out an exploratory incremental cost-effectiveness analysis from a whole system perspective.

ETHICS AND DISSEMINATION

Individual patient consent will not be feasible for this study. Favourable ethical opinion has been obtained from the NHS Research Ethics Committee (North of Scotland) (REF: 16/NS/0025) for Work Stream 2 (phase 1) of the Liaison psychiatry-measurement and evaluation of service types, referral patterns and outcomes study. The Confidentiality Advisory Group at the Health Research Authority determined that Section 251 approval under Regulation 5 of the Health Service (Control of Patient Information) Regulations 2002 was not required for the study 'on the basis that there is no disclosure of patient identifiable data without consent' (REF: 16/CAG/0037).Results of the study will be published in academic journals in health services research and mental health. Details of the study methodology will also be published in an academic journal. Discussion papers will be authored for health service commissioners.