Development of a joint mental-health and drug health assessment unit and short-stay unit

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.

24 hours - Life in the E.R.: A state-wide data linkage analysis of in-patients with prolonged emergency department length of stay in New South Wales, Australia

OBJECTIVE

Describe the characteristics and predictors of mortality for patients who spend more than 24 h in the ED waiting for an in-patient bed and compare baseline clinical and demographic characteristics between tertiary and non-tertiary hospitals.

METHODS

This was a state-wide analysis data linkage analysis of adult (age >16 years) ED presentations across New South Wales from 2019 to 2020. Cases were included if their mode of separation from ED indicated admission to an in-patient unit including critical care ward and their ED length of stay was greater than or equal to 24 h. Cases were categorised by service-related groups based on principle diagnosis.

RESULTS

A total of 26 854 eligible cases were identified. The most common diagnosis groups were psychiatry, cardiology and respiratory. The odds ratio (OR) for 30-day all-cause mortality in admitted patients with an ED length of stay greater than 24 h were highest in those aged >75 years (OR 15.18, 95% confidence interval [CI] 9.99-23.07, P < 0.001), oncology (OR 10.45, 95% CI 7.93-13.77, P < 0.001) and haematology patients (OR 2.95, 95% CI 2.01-4.33, P < 0.001).

CONCLUSION

Interventions and models of care to address ED access block need to focus on mental health patients, older patients particularly those with cardiorespiratory illness and oncology and haematology patients for whom risk of mortality is disproportionately higher.

Service use preceding and following first referral for psychiatric emergency care at a short-stay crisis unit: A cohort study across three cities and one rural area in England

BACKGROUND

Internationally, hospital-based short-stay crisis units have been introduced to provide a safe space for stabilisation and further assessment for those in psychiatric crisis. The units typically aim to reduce inpatient admissions and psychiatric presentations to emergency departments.

AIMS

To assess changes to service use following a service user's first visit to a unit, characterise the population accessing these units and examine equality of access to the units.

METHODS

A prospective cohort study design (ISCTRN registered; 53431343) compared service use for the 9 months preceding and following a first visit to a short-stay crisis unit at three cities and one rural area in England. Included individuals first visited a unit in the 6 months between 01/September/2020 and 28/February/2021.

RESULTS

The prospective cohort included 1189 individuals aged 36 years on average, significantly younger (by 5-13 years) than the population of local service users (<.001). Seventy percent were White British and most were without a psychiatric diagnosis (55%-82% across sites). The emergency department provided the largest single source of referrals to the unit (42%), followed by the Crisis and Home Treatment Team (20%). The use of most mental health services, including all types of admission and community mental health services was increased post discharge. Social-distancing measures due to the COVID-19 pandemic were in place for slightly over 50% of the follow-up period. Comparison to a pre-COVID cohort of 934 individuals suggested that the pandemic had no effect on the majority of service use variables.

CONCLUSIONS

Short-stay crisis units are typically accessed by a young population, including those who previously were unknown to mental health services, who proceed to access a broader range of mental health services following discharge.

Clinical care of patients with dual disorders in India: diverse models of care delivery

Purpose

This study aims to offer an overview of the models of clinical care of the patients with dual disorders in India.

Design/methodology/approach

All the members of the Dual Diagnosis India Network (DDIN) who shared the clinical care delivery at their center were invited to share the details of their model. In addition, an invite was also sent to those members who could not attend the online session but were interested in contributing the required information about their model. The information shared by the respondents was collated. The different models were then categorized based on their features.

Findings

Following the categorization of the clinical care services organization across different settings, five different models emerged. These were specialized dual diagnosis clinic; services for dual disorders offered as substance use disorder (SUD) treatment services within general psychiatry care; services for dual disorders in general psychiatry care; services for dual disorders offered as SUD treatment services separated from general psychiatry care; and services for dual disorders offered in general psychiatry services combined with exclusive SUD treatment services.

Originality/value

Currently, there is limited literature on models of dual disorders from the low- and middle-income countries. The authors believe that the documentation of these models from India shall be of help while setting up services for dual disorders in other health-care settings. This study can be a valuable resource for making informed choices while setting up new services.

Short-stay crisis units for mental health patients on crisis care pathways: systematic review and meta-analysis

BACKGROUND

Internationally, an increasing proportion of emergency department visits are mental health related. Concurrently, psychiatric wards are often occupied above capacity. Healthcare providers have introduced short-stay, hospital-based crisis units offering a therapeutic space for stabilisation, assessment and appropriate referral. Research lags behind roll-out, and a review of the evidence is urgently needed to inform policy and further introduction of similar units.

AIMS

This systematic review aims to evaluate the effectiveness of short-stay, hospital-based mental health crisis units.

METHOD

We searched EMBASE, Medline, CINAHL and PsycINFO up to March 2021. All designs incorporating a control or comparison group were eligible for inclusion, and all effect estimates with a comparison group were extracted and combined meta-analytically where appropriate. We assessed study risk of bias with Risk of Bias in Non-Randomized Studies - of Interventions and Risk of Bias in Randomized Trials.

RESULTS

Data from twelve studies across six countries (Australia, Belgium, Canada, The Netherlands, UK and USA) and 67 505 participants were included. Data indicated that units delivered benefits on many outcomes. Units could reduce psychiatric holds (42% after intervention compared with 49.8% before intervention; difference = 7.8%; P < 0.0001) and increase out-patient follow-up care (χ² = 37.42, d.f. = 1; P < 0.001). Meta-analysis indicated a significant reduction in length of emergency department stay (by 164.24 min; 95% CI -261.24 to -67.23 min; P < 0.001) and number of in-patient admissions (odds ratio 0.55, 95% CI 0.43-0.68; P < 0.001).

CONCLUSIONS

Short-stay mental health crisis units are effective for reducing emergency department wait times and in-patient admissions. Further research should investigate the impact of units on patient experience, and clinical and social outcomes.

The dual diagnosis clinician shared care model – a clinical mental health dual diagnosis integrated treatment initiative

Purpose

To improve outcomes for people with co-occurring mental health and substance use disorders, the Eastern Health Mental Health Service implemented an integrated treatment model known as the dual diagnosis clinician shared care model. This study aims to provide evidence for a relatively unexplored model in clinical mental health services within the state of Victoria, Australia.

Design/methodology/approach

Dual diagnosis clinicians were placed into community mental health clinics in a shared-care, modified case management role, to provide primary and secondary consultations to select consumers and/or their carers, as well as to provide capacity-building training to the mental health staff facing real world clinical challenges in dual diagnosis service delivery.

Findings

Since the commencement of this service, more than 800 consumers of the adult mental health service have been supported to concurrently address their harmful substance use, while receiving recovery-focused community mental health care. Preliminary findings include previously unknown figures on the prevalence for co-occurring substance use at the point of referral and a demonstrated preference by consumers for treatment of both disorders at the same time by the same service (in-house treatment).

Originality/value

The establishment of a dedicated, integrated dual diagnosis team has significantly increased the capacity of a community-based clinical mental health service to engage with and treat consumers with dual diagnosis disorders. This model is beginning to produce evidence challenging traditional siloed approaches to mental health and alcohol and drug treatment.

Use of a quality improvement strategy to increase drug and alcohol consultation and care opportunities for mental health inpatients in rural and remote New South Wales

PROBLEM

Mental health inpatients have high rates of co-morbid substance use disorders which may exceed 50% in addition to the presenting complaint(s). Treating teams may prioritise, and substance use disorders are often not addressed.

SETTING

Dubbo inpatient mental health units.

KEY MEASURES FOR IMPROVEMENT

Rates of drug and alcohol consult of inpatients.

DESIGN

Retrospective audit of all inpatient records for mental health units at Dubbo Hospital (May-October period 2018 and 2019) following the intervention. Qualitative reflections of clinical staff were also included.

STRATEGIES FOR CHANGE

From early 2019, the problem was communicated with staff via education and open discussion. Modelling of the expected numbers of referral was understood as manageable within existing resources. The agenda of the morning meeting then always included an item that asked all team members to identify and refer a person if they needed drug and alcohol care.

EFFECT OF CHANGE

Consultation by the drug and alcohol clinical nurse consultant increased from 48 of 228 (21%) patients in the 2018 period to 83 of 232 (35.8%) patients in the 2019 period.

LESSONS LEARNT

The community and inpatient multidisciplinary team can correctly inform and increase drug and alcohol referral for mental health inpatients.

Implementation of three innovative interventions in a psychiatric emergency department aimed at improving service use: a mixed-method study

Background

Emergency department (ED) use is often viewed as an indicator of health system quality. ED use for mental health (MH) reasons is increasing and costly for health systems, patients, and their families. Patients with mental disorders (MD) including substance use disorders (SUD) and suicidal behaviors are high ED users. Improving ED services for these patients and their families, and developing alternatives to ED use are thus key issues. This study aimed to: (1) describe the implementation of three innovative interventions provided by a brief intervention team, crisis center team, and family-peer support team in a Quebec psychiatric ED, including the identification of implementation barriers, and (2) evaluate the impacts of these ED innovations on MH service use and response to needs.

Method

Using mixed methods with data triangulation, the implementation and impact of the three above-named ED interventions were studied. Quantitative data were collected from 101 participants (81 patients, 20 family members) using a user questionnaire and patient medical records. Qualitative data were gathered from focus groups (n = 3) with key intervention staff members (n = 14). The user questionnaire also included open-ended questions. Descriptive, comparative and content analyses were produced.

Results

Key implementation issues were identified in relation to system, organizational and patient profiles, similar to results identified in most studies in the ED implementation literature aimed at improving responsiveness to patients with MD. Results were encouraging, as the innovations had a significant impact for improved patient MH service use and adequacy of care. Services also seemed adapted to patient profiles. Family members were grateful for the help received in the ED.

Conclusions

Before implementing innovations, managers need to recognize the basic issues common to all new healthcare interventions: the need for staff training and strong involvement, particularly among physicians, development of collaborative tools especially in cases of potential cultural clash between staff and organizations, and continuous quality assessment. Future research needs to confirm the pertinence of these interventions, especially use of family-peer support teams in ED, as a highly innovative intervention. Broader ED strategies could also be deployed to improve MH services and decrease ED use for MH reasons.