The nature and activity of liaison mental services in acute hospital settings: a multi-site cross sectional study

Experiences of delivering and receiving mental healthcare in the acute hospital setting: a qualitative study

BACKGROUND

Recent investment in UK liaison psychiatry services has focused on expanding provision for acute and emergency referrals. Little is known about the experiences of users and providers of these services. The aim of this study was to explore the experiences of users of acute liaison mental health services (LMHS) and those of NHS staff working within LMHS or referring to LMHS. A secondary aim was to explore the potential impact of a one-hour service access target on service delivery.

METHODS

Cross-sectional qualitative study. Individual interviews were audio-recorded, transcribed verbatim and interpreted using framework analysis.

RESULTS

Service users reported mixed experiences of LMHS, with some reporting positive experiences and some reporting poor care. Most service users described the emergency department (ED) environment as extremely stressful and wished to be seen as quickly as possible. Staff described positive benefits of the one-hour access target but identified unintended consequences and trade-offs that affected other parts of the liaison service.

CONCLUSIONS

The assessment and treatment of people who attend ED with mental health problems needs to improve and particular attention should be given to the stressful nature of the ED environment for those who are extremely agitated or distressed.

A comparison of daytime and out of hour mental health presentations to Beaumont Hospital Emergency Department between 2018 and 2020

BACKGROUND

In 2018, there were more than 12,000 self-harm presentations to emergency departments (EDs) in Ireland with 50% occurring between 7p.m. and 3a.m. There is evidence that the assessment quality and follow-up is variable across clinicians. To address this, The National Clinical Programme for the Management of Self-Harm in the ED (NCPSH 2016) was developed to set clear standards.

AIM

Our aim was to compare diagnosis and management of patients presenting to Beaumont Hospital (BH) ED, across a 3-year period, by the on-site Liaison Psychiatry Service, during normal working hours, to the off-site on call service outside of normal working hours (OOH).

METHODS

This is a retrospective audit of BH ED patients referred for psychiatric assessment between 2018 and 2020, using patient electronic records for data collection, and Pearson's chi square testing for group differences. Post hoc analysis was performed using adjusted residuals and Bonferroni correction.

RESULTS

Of 3659 psychiatric referrals to Beaumont ED from 2018 to 2020, alcohol-related disorders were the most common diagnosis and were diagnosed more frequently during normal working hours (n = 592, 16.2%; 22.9% normal hours vs 8.5% OOH, p < 0.001), while personality disorder was diagnosed more frequently out of hours. (n = 432, 11.8%; 9.6% normal hours vs 14.4% out of hours, p < 0.001). There was a statistically significant difference in referral to voluntary services out of hours (7.2% normal hours vs 0.3% OOH).

CONCLUSION

In contrast to previous findings, our study found higher rates of alcohol-related disorders diagnosed during normal hours vs OOH. Furthermore, voluntary and addiction services were under-utilised OOH and this presents an important teaching opportunity.

Liaison psychiatry practitioners' views on accessing aftercare and psychological therapies for patients who present to hospital following self-harm: multi-site interview study

BACKGROUND

Timely provision of aftercare following self-harm may reduce risks of repetition and premature death, but existing services are frequently reported as being inadequate.

AIMS

To explore barriers and facilitators to accessing aftercare and psychological therapies for patients presenting to hospital following self-harm, from the perspective of liaison psychiatry practitioners.

METHOD

Between March 2019 and December 2020, we interviewed 51 staff members across 32 liaison psychiatry services in England. We used thematic analyses to interpret the interview data.

RESULTS

Barriers to accessing services may heighten risk of further self-harm for patients and burnout for staff. Barriers included: perceived risk, exclusionary thresholds, long waiting times, siloed working and bureaucracy. Strategies to increase access to aftercare included: (a) improving assessments and care plans via input from skilled staff working in multidisciplinary teams (e.g. including social workers and clinical psychologists); (b) supporting staff to focus on assessments as therapeutic intervention; (c) probing boundaries and involving senior staff to negotiate risk and advocate for patients; and (d) building relationships and integration across services.

CONCLUSIONS

Our findings highlight practitioners' views on barriers to accessing aftercare and strategies to circumvent some of these impediments. Provision of aftercare and psychological therapies as part of the liaison psychiatry service were deemed as an essential mechanism for optimising patient safety and experience and staff well-being. To close treatment gaps and reduce inequalities, it is important to work closely with staff and patients, learn from experiences of good practice and implement change more widely across services.

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.

Analysis of the care provided over a six-month period by the liaison psychiatry unit at a general hospital in Lima, Peru

INTRODUCTION

Consultation-liaison psychiatry is a branch of clinical psychiatry that enables psychiatrists to carry out a series of activities within a general hospital. The number of liaison psychiatry units around the world has increased significantly, and Peru is no exception. However, this development is heterogeneous and unknown, so recent study reports are required to reveal the characteristics and details of the clinical care services provided by these units.

AIM

To describe and report the socio-demographic and clinical characteristics of patients evaluated in the Liaison Psychiatry Unit of the Guillermo Almenara Irigoyen National Hospital in Lima, Peru, and to analyse the symptomatic and syndromic nature of the identified conditions.

METHODS

Cross-sectional descriptive study. Referrals to the Liaison Psychiatry Unit of the Guillermo Almenara Irigoyen National Hospital between May and October 2019 were studied, and a factor analysis of the symptoms was conducted.

RESULTS

In a total of 400 referrals evaluated, the average age was 58 ± 17.09 years and 61.5% of the patients were women. The rate of psychiatric consultation was 2.73%. Internal medicine (13.9%) was the service that most frequently requested a psychiatric consultation. The disorder most frequently diagnosed was anxiety (44%), and the symptoms most frequently found were depression (45.3%), insomnia (44.5%), and anxiety (41.3%). The most used treatments were antidepressants (44.3%). The exploratory factor analysis of the symptoms showed three syndromic components: delirium, depression, and anxiety.

CONCLUSIONS

The typical patient of this sample is a woman in her late 50s, suffering from a non-psychiatric medical illness, and with anxiety disorders as the main diagnosis resulting from the psychiatric consultation.

Psychiatric liaison service referral patterns during the UK COVID-19 pandemic: An observational study

BACKGROUND AND OBJECTIVES

COVID-19 has had a profound effect on mental health. Liaison psychiatry teams assess and treat people in mental health crises in emergency departments (EDs) and on hospital wards. During the first pandemic wave, new Mental Health Crisis Assessment Services (MHCAS) were created to divert people away from EDs. Our objective was to describe patterns in referrals to psychiatric liaison services across the North Central London care sector (NCL) and explore the impact of a new MHCAS.

METHODS

Retrospective study using routinely collected data (ED and ward referrals) from five liaison psychiatry services across NCL (total population 1.5 million people). We described referrals (per week and month) by individual liaison services and cross-sector, and patterns of activity (January 1st 2020 -September 31st 2020, weeks 1-39) compared with the same period in 2019. We calculated changes in the proportion of ED attendees (all-cause) referred to liaison psychiatry.

RESULTS

From 2019-2020, total referrals decreased by 16.5% (12,265 to 10,247), a 16.4% decrease in ED referrals (9528 to 7965) and 16.6% decrease in ward referrals (2737 to 2282). There was a marked decrease in referrals during the first pandemic wave (March/April 2020), which increased after lockdown ended. The proportion of ED attendees referred to liaison psychiatry services increased compared to 2019.

CONCLUSIONS

People in mental health crisis continued to seek help via ED/MHCAS and a higher proportion of people attending ED were referred to liaison psychiatry services just after the first pandemic wave. MHCAS absorbed some sector ED activity during the pandemic.

Experiences of care for self-harm in the emergency department: comparison of the perspectives of patients, carers and practitioners

Background

Each year, 220 000 episodes of self-harm are managed by emergency departments in England, providing support to people at risk of suicide.

Aims

To explore treatment of self-harm in emergency departments, comparing perspectives of patients, carers and practitioners.

Method

Focus groups and semi-structured interviews with 79 people explored experiences of receiving/delivering care. Participants were patients (7 young people, 12 adults), 8 carers, 15 generalist emergency department practitioners and 37 liaison psychiatry practitioners. Data were analysed using framework analysis.

Results

We identified four themes. One was common across stakeholder groups: (a) the wider system is failing people who self-harm: they often only access crisis support as they are frequently excluded from services, leading to unhelpful cycles of attending the emergency department. Carers felt over-relied upon and ill-equipped to keep the person safe. Three themes reflected different perspectives across stakeholders: (b) practitioners feel powerless and become hardened towards patients, with patients feeling judged for seeking help which exacerbates their distress; (c) patients need a human connection to offer hope when life feels hopeless, yet practitioners underestimate the therapeutic potential of interactions; and (d) practitioners are fearful of blame if someone takes their life: formulaic question-and-answer risk assessments help make staff feel safer but patients feel this is not a valid way of assessing risk or addressing their needs.

Conclusions

Emergency department practitioners should seek to build a human connection and validate patients’ distress, which offers hope when life feels hopeless. Patients consider this a therapeutic intervention in its own right. Investment in self-harm treatment is indicated.

Analysis of the Care Provided Over a Six-Month Period by the Liaison Psychiatry Unit at a General Hospital in Lima, Peru

INTRODUCTION

Consultation-liaison psychiatry is a branch of clinical psychiatry that enables psychiatrists to carry out a series of activities within a general hospital. The number of liaison psychiatry units around the world has increased significantly, and Peru is no exception. However, this development is heterogeneous and unknown, so recent study reports are required to reveal the characteristics and details of the clinical care services provided by these units.

AIM

To describe and report the socio-demographic and clinical characteristics of patients evaluated in the Liaison Psychiatry Unit of the Guillermo Almenara Irigoyen National Hospital in Lima, Peru, and to analyse the symptomatic and syndromic nature of the identified conditions.

METHODS

Cross-sectional descriptive study. Referrals to the Liaison Psychiatry Unit of the Guillermo Almenara Irigoyen National Hospital between May and October 2019 were studied, and a factor analysis of the symptoms was conducted.

RESULTS

In a total of 400 referrals evaluated, the average age was 58±17.09 years and 61.5% of the patients were women. The rate of psychiatric consultation was 2.73%. Internal medicine (13.9%) was the service that most frequently requested a psychiatric consultation. The disorder most frequently diagnosed was anxiety (44%), and the symptoms most frequently found were depression (45.3%), insomnia (44.5%), and anxiety (41.3%). The most used treatments were antidepressants (44.3%). The exploratory factor analysis of the symptoms showed three syndromic components: delirium, depression, and anxiety.

CONCLUSIONS

The typical patient of this sample is a woman in her late 50s, suffering from a non-psychiatric medical illness, and with anxiety disorders as the main diagnosis resulting from the psychiatric consultation.

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.

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.