Characteristics and Needs of Psychiatric Patients With Prolonged Hospital Stay

Delayed discharge in inpatient psychiatric care: a systematic review

BACKGROUND

Delayed discharge is problematic. It is financially costly and can create barriers to delivering best patient care, by preventing return to usual functioning and delaying admissions of others in need. This systematic review aimed to collate existing evidence on delayed discharge in psychiatric inpatient settings and to develop understanding of factors and outcomes of delays in these services.

METHODS

A search of relevant literature published between 2002 and 2022 was conducted on Pubmed, PsycInfo and Embase. Studies of any design, which published data on delayed discharge from psychiatric inpatient care in high income countries were included. Studies examining child and adolescent, general medical or forensic settings were excluded. A narrative synthesis method was utilised. Quality of research was appraised using the Mixed Methods Appraisal Tool (MMAT).

RESULTS

Eighteen studies from England, Canada, Australia, Ireland, and Norway met the inclusion criteria. Six main reasons for delayed discharge were identified: (1) accommodation needs, (2) challenges securing community or rehabilitation support, (3) funding difficulties, (4) family/carer factors, (5) forensic considerations and (6) person being out of area. Some demographic and clinical factors were also found to relate to delays, such as having a diagnosis of schizophrenia or other psychotic disorder, cognitive impairment, and increased service input prior to admission. Being unemployed and socially isolated were also linked to delays. Only one study commented on consequences of delays for patients, finding they experienced feelings of lack of choice and control. Four studies examined consequences on services, identifying high financial costs.

CONCLUSION

Overall, the findings suggest there are multiple interlinked factors relevant in delayed discharge that should be considered in practice and policy. Suggestions for future research are discussed, including investigating delayed discharge in other high-income countries, examining delayed discharge from child and forensic psychiatric settings, and exploring consequences of delays on patients and staff. We suggest that future research be consistent in terms used to define delayed discharge, to enhance the clarity of the evidence base.

REVIEW REGISTRATION NUMBER ON PROSPERO

292515.

DATE OF REGISTRATION

9th December 2021.

What Does the Military Health System Need to Support Future Combat Operations? Lessons from Aeromedical Evacuations from 2008 to 2020

INTRODUCTION

Aeromedical evacuations from the past few decades have yielded massive amounts of data that may inform the Military Health System (MHS) on patient needs, specifically for understanding the inpatient and outpatient needs of evacuees. In this study, we evaluate inpatient and outpatient trends based on aeromedical evacuation data from recent conflicts. We anticipate that evacuations requiring MHS inpatient beds are primarily trauma-related and necessitate an increased need for inpatient trauma care.

MATERIALS AND METHODS

We conducted a descriptive analysis of aeromedical evacuations using the U.S. Transportation Command Regulating and Command & Control Evacuation System database. We queried the database for aeromedical evacuations originating from the U.S. EUCOM and ending in the CONUS, from January 1, 2008 to June 4, 2020. With the resultant data, evacuee demographics were characterized by gender, age, active duty (AD) versus non-AD, and branch of service. Following this, the proportion of battle injury to disease and non-battle injury was categorized by both patient age ranges and year. Additionally, evacuations were stratified by their ICD codes, as well as the primary specialty responsible for care. Lastly, evacuations were categorized by inpatient and outpatient care status.

RESULTS

The final dataset yielded 32,485 unique patients. The majority of evacuees were male (86.9%) with a mean age of 29.0 ± 9.6 years. Evacuees were primarily AD Military (96.7%), with the majority of those personnel being in the Army (70.2%). The total number of evacuations steadily increased from 2008 (n = 3,703) until a peak in 2010 (n = 4,929), which was also the peak year for battle injury (n = 1,472). Battle injury was also most prevalent in the 21 to 24 age group (24.7%) and declined in older age groups. Regarding diagnoses, the leading categories were injury/poisoning (33.1%), psychiatric (28.1%), and musculoskeletal (12.1%). As for specialty care of evacuees, psychiatry received the largest share of total evacuations (28.1%), followed by orthopedic surgery (22.7%) and general surgery (8.6%). Looking at proportions of inpatient and outpatient care, the majority of evacuees required outpatient care (65.6%) with a sizable minority requiring inpatient care (34.4%). Inpatient evacuations peaked in 2010 (n = 2,013), accounting for 40.8% of all evacuations that year. Orthopedic surgery had the largest share of inpatient evacuations (27.3%), followed by psychiatry (21.5%) and general surgery (18.2%). As for outpatient care, the specialties with the largest proportion of outpatient evacuations were psychiatry (33.6%), orthopedic surgery (20.3%), and neurology (9.8%).

CONCLUSIONS

The results of this study reveal what the MHS can expect in future conflicts. Most evacuations are for psychiatric-/injury-/musculoskeletal-related diagnoses, typically requiring care by psychiatrists, orthopedic surgeons, or general surgeons. Outpatient care is important, though it is critical to bolster inpatient care requirements as future conflicts may bring extensive numbers of inpatient casualties. The MHS should program and plan resources accordingly, planning for the care of surgical/injured and psychiatric patients.

Predictors of long-stay in a tertiary care psychiatry hospital in India

BACKGROUND

Many psychiatric patients continue to stay for longer duration in psychiatric institutions. Community reintegration and rehabilitation of such patients needs to be explored to ensure appropriate bed occupancy rates and access to in-patient care for newer patients in need of the same.

OBJECTIVES

The aim is to identify the risk and protective factors leading to long-term admission of mentally ill patients in tertiary care hospital.

METHODOLOGY

A cross-sectional study was conducted with all patients in the long-stay ward between May 2018 and February 2023. A retrospective chart review followed by cross sectional assessment of risks and disability was carried out with all the patients living in a long-stay psychiatric ward (N = 101) at a tertiary hospital in Bangalore, India, between May 2018 and February 2023.

RESULTS

The hospital's average length of stay (LOS) was 5.70 ± 8.30 years. The risk and protective factors for LOS in psychiatric hospitals were analyzed using the Poisson Regression model. The results revealed that the male gender, diagnosis of schizophrenia or psychosis, clinicians' knowledge of family information, good clinical improvement, and higher participation in ward activities are the protective factors for a shorter hospital stay. While higher age, family history of mental illness, being married and employed, absence of children, and/or having family members rarely visiting the patient at the hospital were some factors that increased the risk of LOS.

CONCLUSION

This study highlighted the importance of possible LOS predictors in the tertiary care psychiatric hospital. The multi-disciplinary team may utilize risk and protective factors for delayed LOS to introduce comprehensive psychosocial interventions and policies that reduce the risk of delays or length of stay in mental health hospitals.

Associations Between Psychiatric Diagnoses on Length of Stay and Mortality After Rib Fracture: A Retrospective Analysis

INTRODUCTION

Concurrent psychiatric diagnoses adversely impact outcomes in surgical patients, but their relationship to patients with rib fracture after trauma is less understood. We hypothesized that psychiatric comorbidity would be associated with increases in hospital length of stay (LOS) and mortality risk after rib fracture.

MATERIALS AND METHODS

The 2017 National Inpatient Sample was queried for adult patients who were admitted with rib fracture after trauma. Mental health disorders were categorized into 34 psychiatric diagnosis groups (PDGs) using clinical classifications software refined for International Classification of Diseases-10. Outcomes of interest were LOS and mortality. Bivariable analysis determined associations between PDGs, patient demographics, hospital characteristics, and outcomes. Logistic regression was performed to identify adjusted effects on mortality, and linear regression was performed to identify effects on LOS.

RESULTS

Of 32,801 patients, median age was 61 y (IQR 46-76), and median LOS was 5 d (IQR 3-9). No PDGs were associated with increased odds of mortality. Concurrent diagnosis of schizophrenia spectrum (Coeff. 3.5, 95% CI 2.7-4.4, P < 0.001) or trauma- or stressor-related (Coeff. 1.6, 95% CI 0.9-2.5, P < 0.001) disorders demonstrated the greatest association with prolonged LOS. Increased odds of death and prolonged hospital stay were also associated with male sex, non-White patient race, and surgery occurring at urban and public hospitals.

CONCLUSIONS

Psychiatric comorbidities are associated with death after rib fracture but are associated with increased LOS. These findings may help promote multidisciplinary patient management in trauma.

A Quality Improvement Approach to Violence Reduction: Standardizing the Risk Identification Process

BACKGROUND

The impact of aggressive and violent behaviors directed toward staff in psychiatric facilities has layers of implications tied to recruitment and retention, cost, quality and safety.

LOCAL PROBLEM

Increased patient aggressive behaviors contributed to staff dissatisfaction and high turnover rates, triggering an analysis of current aggression management approaches.

METHODS

The Plan-Do-Study-Act quality improvement method was used for this project.

INTERVENTIONS

The Dynamic Appraisal of Situational Aggression (DASA) risk assessment tool was implemented.

RESULTS

Daily aggression risk identification increased by 69%, and aggressive incidents toward staff and patients decreased by 64% and 28%, respectively, when the tool was completed more consistently. Surveys revealed acceptance of the tool by nurses.

CONCLUSIONS

Quality improvement statistical tools supported evidence-based strategies. A risk for aggression assessment laid the foundations for implementing strategies for reducing aggression and violence.

The cost-effectiveness of a nursing home-based transitional care unit for increasing the potential for independent living in the community among hospitalized older adults

OBJECTIVE

In Canada, a persistent barrier to achieving healthcare system efficiency has been patient days accumulated by individuals with an alternate level of care (ALC) designation. Transitional care units (TCUs) may address the capacity pressures associated with ALC. We sought to assess the cost-effectiveness of a nursing home (NH) based TCU leveraging existing infrastructure to support a hospitalized older adult's transition to independent living at home.

METHODS

This case-control study included frail, older adults who received care within a function-focused TCU following a hospitalization between 1 March 2018 and 30 June 2019. TCU patients were propensity score matched to hospitalized ALC patients ("usual care"). The primary outcome was days without requiring institutional care six months following discharge, defined as institutional-free days. This was calculated by excluding all days in hospitals, rehabilitation facilities, complex continuing care facilities and NHs. Using the total direct cost of care up to discharge from TCU or hospital, the incremental cost-effectiveness ratio was calculated.

RESULTS

TCU patients spent, on average, 162.0 days institution-free (95% CI: 156.3-167.6d) within six months days post-discharge, while usual care patients spent 140.6 days institution-free (95% CI: 132.3-148.8d). TCU recipients had a lower total cost of care, by CAN$1,106 (95% CI: $-6,129-$10,319), due to the reduced hospital length of stay (mean [SD] 15.6d [13.3d] for TCU patients and 28.6d [67.4d] days for usual care). TCU was deemed the more cost-effective model of care.

LIMITATIONS

The main limitation was the potential inclusion of patients not eligible for SAFE in our usual group. To minimize this selection bias, we expanded the geographical pool of ALC patients to patients with SAFE admission potential in other area hospitals.

CONCLUSIONS

Through rehabilitative and restorative care, TCUs can reduce hospital length of stay, increase potential for independent living, and reduce risk for subsequent institutionalization.

The Impact of 90-day Physician Follow-up Care on the Risk of Readmission Following a Psychiatric Hospitalization

AIMS

This study measures the impact of 90-day physician follow-up care after psychiatric hospitalization among 3,311 adults and youth, with risk of subsequent readmission within six months.

METHODS

A 5-year investigation was conducted based on Quebec (Canada) medical administrative databases. Cox proportional-hazards regression was performed, with 90-day follow-up care as the main independent variable, controlling for various sociodemographic, clinical, and other service use variables.

RESULTS

Within the 90-day follow-up period after patient discharge, or in the first 30 days, receiving at least one consultation per month as opposed to no consultation was associated with a reduced risk of psychiatric readmission. Women showed an increased readmission risk compared to men, while those living in less materially deprived areas a decreased risk as opposed to more deprived areas. Patients hospitalized for suicide attempt or schizophrenia spectrum and other psychotic disorders, and those with co-occurring mental and substance-related disorders or chronic physical illnesses, especially illnesses high on the severity index, also presented a heightened risk of hospitalization. Patients hospitalized for personality disorders or receiving a high continuity of physician care showed a reduced risk of readmission.

CONCLUSION

This study demonstrates that follow-up care, if provided within the first 30 days of discharge or monthly during the 90-day follow-up period, decreased the risk of readmission, as did having a high continuity of physician care prior to and within the 90-day follow-up period. However, few patients in this study had received such high-quality care, indicating that the Quebec system needs to considerably improve its discharge planning processes.

Prevalence and factors associated with relapse and long hospital stay among adult psychiatric patients with a history of childhood trauma

This cross-sectional multicentre-based study determined the magnitude of relapse, long hospital stay and factors of mental illness associated with a history of childhood trauma. We assessed 335 adult psychiatric patients and living in conflict areas, using a questionnaire established from items of the Adverse Childhood Experience International Questionnaire, Multidimensional Scale of Perceived Social Support, Rosenberg Self-esteem Questionnaire, Relapse Assessment Tool, and Self-report of hospital stay. Logistic regression analyses were used to determine associations between predictors and relapse and long hospital stay. 298 participants (88.9%) had experienced childhood adversities, among which 44.4% reported more than five childhood traumas. Relapse occurred in 40.9% of participants, whereas long hospital stay occurred in 71.1% of cases. Predictors of long hospital stay were emotional abuse, substance use and living in rural settings. Being an employed and experiencing a childhood trauma committed by a parent increase the likelihood risk of relapse of mental illness associated with childhood trauma. Being treated by childhood trauma-focused interventions decreases the risk of relapse and shorter the length of hospital stay. Building a mental health capacity should be centered on detecting patients with childhood trauma committed by the parent, those with low-self esteem, and victims of emotional abuse.

Structural magnetic resonance imaging findings in severe mental disorders adult inpatients: A systematic review

In severe presentations, major depressive disorder (MDD), schizophrenia (SZ), and bipolar disorder (BD) can be categorized as severe mental disorders (SMD). Our aim is to evaluate structural magnetic resonance imaging and computed tomography findings in adult inpatients diagnosed with SMD and hospitalized at psychiatric wards. PubMed, Embase, PsycInfo, Cochrane Library, and Web of Science were searched up to May 27th, 2021. Articles were screened and extracted by two independent groups, with third-party raters for discrepancies. Quality of evidence was evaluated with the Newcastle-Ottawa Scale. Synthesis was made by qualitative analysis. This study was registered on PROSPERO (CRD42020171718) and followed the PRISMA protocol. 35 studies were included, of which none was considered to likely introduce bias in our analyses. Overlapping areas in MDD, SZ, and Affective Psychosis (AP) patients, that include BD and MDD with psychotic features, are presented in the inferior temporal and cingulate gyri. MDD and SZ had commonly affected areas in the inferior and middle frontal gyri, transverse temporal gyrus, insula, and hippocampus. SZ and AP had commonly affected areas in the temporal pole. Overlapping affected areas among SMD patients are reported, but the heterogeneity of studies' designs and findings are still a limitation for clinically relevant guidelines.

The level of formal support received by people with severe mental illness living in supported accommodation and participation: A systematic review

AIM

The review aimed to identify and explore the association of level of support received by people with severe mental illness in supported accommodation and participation.

METHOD

The authors conducted a systematic search in MEDLINE, PsychINFO, PsychARTICLES, CINAHL Plus and ASSIA. Searches were restricted to articles published in English and participants aged 18 years and over with severe mental illness. Articles were included based on level of support received in mental health supported accommodation, classified according to the Simple Taxonomy for Supported Accommodation, and three factors of participation: social participation, daily living functioning and personal empowerment. Studies of in-patient settings and nursing homes were excluded. The review protocol is registered on PROSPERO (registration number: CRD42019161808).

RESULTS

Six articles were included in the review from USA, Australia, Sweden and Taiwan. Factors of participation for people living in accommodation with moderate support and accommodation with high support were explored. Data indicated an association between level of support and participation showing that people living in accommodation with moderate support had increased participation compared to people living in accommodation with high support.

CONCLUSION

This review identified an association between level of formal support and participation. People with SMI living in accommodation with medium support participated in more community occupations, more activities and had a higher level of personal empowerment than people living in accommodation with high support.

Cognitive Impairment and Length of Stay in Acute Care Hospitals: A Scoping Review of the Literature

Older persons experiencing a longer length of stay (LOS) or delayed discharge (DD) may see a decline in their health and well-being, generating significant costs. This review aimed to identify evidence on the impact of cognitive impairment (CI) on acute care hospital LOS/DD. A scoping review of studies examining the association between CI and LOS/DD was performed. We searched six databases; two reviewers independently screened references until November 2019. A narrative synthesis was used to answer the research question; 58 studies were included of which 33 found a positive association between CI and LOS or DD, 8 studies had mixed results, 3 found an inverse relationship, and 14 showed an indirect link between CI-related syndromes and LOS/DD. Thus, cognitive impairment seemed to be frequently associated with increased LOS/DD. Future research should consider CI together with other risks for LOS/DD and also focus on explaining the association between the two.

Implementation of nurse navigation for behavioral health inpatient services to divert early readmissions: A pilot program

OBJECTIVE

Inpatient behavioral health units across the United States have high readmission rates. The Centers for Medicare and Medicaid Services (CMS) as well as healthcare organizations are focused on reducing readmission rates, especially those readmissions that occur within 30-90 days. Behavioral Health Nurse Navigation was implemented at St. Luke's University Health Network's Sacred Heart Campus to investigate, address, and divert early behavioral health readmissions through evidence-based discharge calls and problem-solving methods.

METHOD

Following approval for Behavioral Health Nurse Navigation, workflow and discharge call screens were developed for behavioral health discharge calls. Discharge call screens populated at specific intervals and calls were made at those times. Data was maintained on those patients who participated in calls. Increased collaboration and dissemination of information ensued.

RESULTS

613 patients participated in discharge calls from March 2020 to October 2020 as 98% of patients liked receiving calls. 56% of participants used substances; the most commonly used substance was THC. MDD was the most common diagnosis among participants and most patients utilized St. Luke's Psychiatric Associates for outpatient mental health care. Participants most often required assistance in the areas of medication, community coordination, and support/reassurance. The Behavioral Health Nurse Navigation diversion rate ranged from 81% to 96%.

CONCLUSION

Behavioral Health Nurse Navigation promotes patients' successful adherence to discharge plans through increased collaboration, communication, and skillful problem-solving in the areas of medication, community coordination, and therapeutic reassurance/support. The outcome of Behavioral Health Nurse Navigation is increased patient satisfaction, compliance with treatment, and diversion of patients at high risk for early readmission.

An alternate level of care plan: Co-designing components of an intervention with patients, caregivers and providers to address delayed hospital discharge challenges

Objective

To engage with patients, caregivers and care providers to co‐design components of an intervention that aims to improve delayed hospital discharge experiences.

Design

This is a qualitative study, which entailed working groups and co‐design sessions utilizing World Café and deliberative dialogue techniques to continually refine the intervention.

Setting and Participants

Our team engaged with 61 participants (patients, caregivers and care providers) in urban and rural communities across Ontario, Canada. A 7‐member Patient and Caregiver Advisory Council participated in all stages of the research.

Results

Key challenges experienced during a delayed discharge by patients, caregivers and care providers were poor communication and a lack of care services. Participants recommended a communication guide to support on‐going conversation between care providers, patients and caregivers. The guide included key topics to cover and questions to ask during initial and on‐going conversations to manage expectations and better understand the priorities and goals of patients and caregivers. Service recommendations included getting out of bed and dressed each day, addressing the psycho‐social needs of patients through tailored activities and having a storyboard at the bedside to facilitate on‐going engagement.

Discussion and Conclusions

Our findings outline ways to meaningfully engage patients and caregivers during a delayed hospital discharge. Combining this with a minimal basket of services can potentially facilitate a better care experience and outcomes for patients, their care providers and families.

Socio-demographic characteristics and factors associated with hospitalization in psychiatry of old age patients: an international comparison between Ireland and Turkey

BACKGROUND

Taking predictors of hospitalization characteristics into consideration internationally would broaden our understanding of this population on a local basis.

AIMS

We aimed to examine and compare socio-demographic profiles along with hospitalization characteristics including length of hospital stay (LOS), reasons for admission and diagnoses among older adult inpatients hospitalized in Ireland and Turkey, and to assess factors predicting these features.

METHODS

The admission charts of 356 psychiatric inpatients over 65 years of age who were admitted to two different acute psychiatric hospitals (Sligo/Ireland and Istanbul/Turkey) were analysed by means of descriptive modalities and logistic regression.

RESULTS

There were significant differences in several domains of socio-demographics, reasons of admission and diagnoses. LOS was significantly longer in Ireland. Living alone was the only significant predictor for longer LOS in both countries, whereas in addition to living alone, younger age was also a contributor for longer LOS in Turkey.

DISCUSSION

Given that the only factor predicting LOS both in Turkey and Ireland was living alone, helping to identify more acceptable ways of providing social support for living arrangements constitutes an important service to shorten LOS in old age psychiatric population.

CONCLUSIONS

It is possible to infer that independent from the cultural diversities, living arrangement is a consistent entity to influence length of hospital stay in older adult population.

"It's a waiting game" a qualitative study of the experience of carers of patients who require an alternate level of care

BACKGROUND

Delayed hospital discharge (also known as Alternate Level of Care or ALC) is a global health care quality issue with negative implications for people (e.g., functional decline) and the health care system (e.g., costly interruptions in hospital flow and procedures). ALC disproportionately impacts people with cognitive impairment, and insight into the needs and experiences of this specific sub population and their carers is lacking. The purpose of this study was to understand the hospital experience of carers (e.g., family members) of patients with ALC and cognitive impairment who were waiting for long-term care from the hospital.

METHODS

This is a qualitative descriptive study entailing 12 semi-structured interviews with 15 carers of patients with ALC from three hospitals in Northwestern Ontario. Interviews were conducted between October 2015 and February 2016. Two reviewers thematically analyzed the interview data.

RESULTS

Five core themes were identified from the interview data: patient over person, uncertain and confusing process, inconsistent quality in care delivery, carers addressing gaps in the system, and personalization of long-term care.

CONCLUSIONS

Waiting for long-term care from the hospital is a stressful and uncertain time for family carers. ALC is an 'in-between' phase when patients and carers may be at their most vulnerable yet receive the least care from the formal care system. Carers provide critical insight into the needs and behaviors of patients as well as processes that need to be improved to enhance their experience. Such insights will help health systems internationally as they grapple with the issue of ALC whilst trying to optimize engagement with patients and their families.