Clinical outcomes and mortality associated with weekend admission to psychiatric hospital

Beyond Patient Characteristics: A Narrative Review of Contextual Factors Influencing Involuntary Admissions in Mental Health Care

Variations in the rates of involuntary admission (IA) reflect the influence of unexplained contextual variables that are typically too heterogeneous to be included in systematic reviews. This paper attempts to gather and analyze factors unrelated to the patients that have been linked to IA. The articles included in this review were selected by iteratively searching four electronic databases (PubMed, PsychINFO, EMBASE, and Web of Science). A total of 54 studies from 19 different countries and regions, including 14 European countries, the United States, Canada, China, Vietnam, and Taiwan, were selected. The factors were categorized as service-related factors, impactful events, seasonal and temporal factors, mental health legislation, staff factors, and public attitudes. The factors rarely act in isolation but rather interact and reinforce each other, causing a greater influence on IA. This paper explains how these factors present opportunities for robust and sustainable interventions to reduce IAs. The paper also identifies future directions for research, such as examining the effects of economic recessions. Enhancing global reporting standards is essential to validate future research and support further in-depth studies. The complexity of the factors influencing IA and the implicit role of society suggest that resolving it will require social change.

Weekend Admissions for Somatic Symptom and Related Disorders and Length of Stay

OBJECTIVES

To evaluate whether admission on weekends affects the length of stay (LOS) for patients hospitalized with somatic symptom and related disorders (SSRDs).

METHODS

Data from 2012-2018 was obtained for all patients aged 4 to 21 years (N = 5459) with a primary discharge diagnosis of SSRDs from 52 tertiary care pediatric hospitals in the United States. We obtained patient demographics, admission date and/or time, LOS, procedure count, and comorbid conditions. We defined a weekend as 3 pm Friday to 3 pm Sunday. The Wilcoxon rank test was used for unadjusted analysis. Multiple logistic regression was used to estimate the odds of having LOS >1 day, >2 days, >3 days, and >4 days in weekend versus weekday groups.

RESULTS

Weekend admission significantly correlated with increased LOS (P < .001). Compared with weekdays, a weekend admission was associated with increased odds of having LOS >1, >2, and >3 days. This remained statistically significant while adjusting for the number of chronic conditions, procedures, and individuals with Black or Hispanic ethnicity compared with White ethnicity. LOS was not associated with sex or age of the patients.

CONCLUSIONS

Patients with SSRDs admitted on the weekend have an increased LOS compared with those admitted on a weekday. This may be due to a decrease in multidisciplinary care available during weekends. In future studies, researchers should aim to better understand the specific factors that contribute to this disparity and test interventions that may close the gap in care, including expanding to 7-day services, increasing mental health resources, and working to decrease the need for inpatient admissions.

Relationship Between Time of Admission, Help-Seeking Behavior, and Psychiatric Outcomes: "From Dusk Till Dawn"

INTRODUCTION

Day and time of admission influence treatment outcomes and prognosis in several medical specialties; this seems related to resources' ability. It is largely unknown whether this also applies to mental health services. We investigate the relationship between time of admission, patients' demographic and clinical profile, and treatment outcomes.

METHODS

Demographic and clinical profiles of admitted and discharged patients to a general psychiatric ward between January 1st, 2013 and December 31st, 2020, were analyzed. In addition, we used the last year (i.e., 2020) to monitor rehospitalization. Time of admission was defined as weekdays (working day, weekend) and dayshifts (daytime, dusk, and dawn).

RESULTS

During the study period, 12,449 patient admissions occurred. The mean age of the sample was 48.05 ± 20.90 years, with 49.32% (n = 6,140) females. Most admissions (n = 10,542, 84%) occurred on working days. Two-fifths of admissions (39.7%, n = 4,950) were compulsory, with a higher rate outside daytime hours. Patients had slight differences in the clinical profile, resulting from evaluating the different items of the Health of Nation Outcome Scale (HoNOS). Patients admitted on night shifts, weekends, and holidays showed a shorter length of stay; patients compulsorily admitted during daytime (disregarding the day of the week) had a longer length of stay. All patient groups achieved a robust clinical improvement (i.e., an HoNOS score reduction of around 50%), with similar readmission rates.

DISCUSSION

The main finding of our study is the relationship between "daytime hours" and fewer compulsory admissions, a result of the interplay between demographics, clinical characteristics, and out-of-clinic service availability (such as ambulatory psychiatric- psychological praxis; day-clinic; home-treatment). The differing clinical profile, in turn, determines differences in treatment selection, with patients admitted after office hours experiencing a higher rate of coercive measures. The shorter length of stay for out-of-office admissions might result from the hospitalization as an intervention. These results should encourage the implementation of outpatient crisis-intervention services, available from dusk till dawn.

Protocol to assess performance of crisis standards of care guidelines for clinical triage

During the COVID-19 pandemic, US states developed Crisis Standards of Care (CSC) algorithms to triage allocation of scarce resources to maximize population-wide benefit. While CSC algorithms were developed by ethical debate, this protocol guides their quantitative assessment. For CSC algorithms, this protocol addresses (1) adapting algorithms for empirical study, (2) quantifying predictive accuracy, and (3) simulating clinical decision-making. This protocol provides a framework for healthcare systems and governments to test the performance of CSC algorithms to ensure they meet their stated ethical goals.

For complete details on the use and execution of this protocol, please refer to Jezmir et al. (2021).

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Scoring with Crisis Standards of Care (CSC) triage algorithms

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Assessing the predictive accuracy of triage algorithms

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Simulating clinical decision-making by triage algorithms

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Troubleshooting disease severity, comorbidity scoring, and ties

Managing restricted patients in acute, non-secure in-patient services: clinical, ethical and resource implications of long waits for a response from the Ministry of Justice

AIMS AND METHOD

In-patients subject to Section 37/41 of the Mental Health Act 1983 (MHA) require permission from the Ministry of Justice (MoJ) for leave, transfer and discharge. This study aimed to quantify the time spent waiting for the MoJ to respond to requests, using data on restricted patients recalled to a non-forensic unit over 8 years.

RESULTS

Eleven admissions were identified. The mean total time waiting for response was 95 days per admission, with an estimated cost of £40 922 per admission.

CLINICAL IMPLICATIONS

Current procedures may contribute to considerable increases in length of stay. This goes against the principles of the MHA, as non-secure services rarely provide the range of interventions which justify prolonged admission. We suggest several ways to resolve this issue, including broadening the guidance for the use of voluntary admissions and civil sections, and allowing clinicians to make decisions on leave and transfer where there is little risk.

Aggressive Behavior and Psychiatric Inpatients: a Narrative Review of the Literature with a Focus on the European Experience

PURPOSE OF REVIEW

We summarized peer-reviewed literature on aggressive episodes perpetrated by adult patients admitted to general hospital units, especially psychiatry or emergency services. We examined the main factors associated with aggressive behaviors in the hospital setting, with a special focus on the European experience.

RECENT FINDINGS

A number of variables, including individual, historical, and contextual variables, are significant risk factors for aggression among hospitalized people. Drug abuse can be considered a trans-dimensional variable which deserves particular attention. Although mental health disorders represent a significant component in the risk of aggression, there are many factors including drug abuse, past history of physically aggressive behavior, childhood abuse, social and cultural patterns, relational factors, and contextual variables that can increase the risk of overt aggressive behavior in the general hospital. This review highlights the need to undertake initiatives aimed to enhance understanding, prevention, and management of violence in general hospital settings across Europe.

Variation in clinical care associated with weekend admission and discharge in psychiatric in-patient units: retrospective case-note review

BACKGROUND

Questions have been raised regarding differences in the standards of care that patients receive when they are admitted to or discharged from in-patient units at weekends.

AIMS

To compare the quality of care received by patients with anxiety and depressive disorders who were admitted to or discharged from psychiatric hospital at weekends with those admitted or discharged during the 'working week'.

METHOD

Retrospective case-note review of 3795 admissions to in-patient psychiatric wards in England. Quality of care received by people with depressive or anxiety disorders was compared using multivariable regression analyses.

RESULTS

In total, 795 (20.9%) patients were admitted at weekends and 157 (4.8%) were discharged at weekends. There were minimal differences in quality of care between those admitted at weekends and those admitted during the week. Patients discharged at weekends were less likely to be given sufficient notification (48 h) in advance of being discharged (OR = 0.55, 95% CI 0.39-0.78), to have a crisis plan in place (OR = 0.65, 95% CI 0.46-0.92) or to be given medication to take home (OR = 0.45, 95% CI 0.30-0.66). They were also less likely to have been assessed using a validated outcome measure (OR = 0.70, 95% CI 0.50-0.97).

CONCLUSIONS

There is no evidence of a 'weekend effect' for patients admitted to psychiatric hospital at weekends, but the quality of care offered to those who were discharged at weekends was relatively poor, highlighting the need for improvement in this area.

Seclusion: A Patient Perspective

The appropriate treatment of mentally unwell, aggressive patients has challenged psychiatry for centuries. Seclusion is practiced worldwide, but concerns remain regarding its appropriateness and lack of alternatives. Patients generally report seclusion as a negative experience, though there is a paucity of literature exploring this in detail. This investigation was a service evaluation appraising inpatients' perspective of processes occurring before (information, communication), during (review, care), and after (debrief, reflection) seclusion in a psychiatric intensive care unit (PICU). In this phenomenological study, qualitative data were gathered using a questionnaire in a structured interview. All patients had been nursed in seclusion during admission to a male PICU at South London and the Maudsley NHS Foundation Trust. Ten patients were interviewed over 4 months. The central theme was perceived lack of communication in the patient-professional relationship, which manifested itself as (i) violence against patients, (ii) lack of psychological support, and (iii) the need for alternatives. Such feedback from patients queries whether national guidelines are appropriate and/or being adhered to. Healthcare practitioners have a responsibility to challenge accepted practice to continually improve the standard of patient-centred care. Utilising patient perspectives can be a powerful driver of change towards more humane treatment of vulnerable patients.

Analysis of weekend effect on mortality by medical specialty in Helsinki University Hospital over a 14-year period

BACKGROUND

The weekend effect, the phenomenon of patients admitted at the weekend having a higher mortality risk, has been widely investigated and documented in both elective and emergency patients. Research on the issue is scarce in Europe, with the exception of the United Kingdom. We examined the situation in Helsinki University Hospital over a 14-year period from a specialty-specific approach.

MATERIALS AND METHODS

We collected the data for all patient visits for 2000-2013, selecting patients with in-hospital care in the university hospital and extracting patients that died during their hospital stay or within 30 days of discharge. These patients were categorized according to urgency of care and specialty.

RESULTS

A total of 1,542,230 in-patients (853,268 emergency patients) met the study criteria, with 47,122 deaths in-hospital or within 30 days of discharge. Of 12 specialties, we found a statistically significant weekend effect for in-hospital mortality in 7 specialties (emergency admissions) and 4 specialties (elective admissions); for 30-day post-discharge mortality in 1 specialty (emergency admissions) and 2 specialties (elective admissions). Surgery, internal medicine, neurology, and gynecology and obstetrics were most sensitive to the weekend effect.

CONCLUSIONS

The study confirms a weekend effect for both elective and emergency admissions in most specialties. Reducing the number of weekend elective procedures may be necessary. More disease-specific research is needed to find the diagnoses most susceptible.

Mental health-related conversations on social media and crisis episodes: a time-series regression analysis

We aimed to investigate whether daily fluctuations in mental health-relevant Twitter posts are associated with daily fluctuations in mental health crisis episodes. We conducted a primary and replicated time-series analysis of retrospectively collected data from Twitter and two London mental healthcare providers. Daily numbers of ‘crisis episodes’ were defined as incident inpatient, home treatment team and crisis house referrals between 2010 and 2014. Higher volumes of depression and schizophrenia tweets were associated with higher numbers of same-day crisis episodes for both sites. After adjusting for temporal trends, seven-day lagged analyses showed significant positive associations on day 1, changing to negative associations by day 4 and reverting to positive associations by day 7. There was a 15% increase in crisis episodes on days with above-median schizophrenia-related Twitter posts. A temporal association was thus found between Twitter-wide mental health-related social media content and crisis episodes in mental healthcare replicated across two services. Seven-day associations are consistent with both precipitating and longer-term risk associations. Sizes of effects were large enough to have potential local and national relevance and further research is needed to evaluate how services might better anticipate times of higher risk and identify the most vulnerable groups.

Weekend admissions and mortality for major acute disorders across England and Wales: record linkage cohort studies

Background

To establish which major disorders are susceptible to increased mortality following acute admissions on weekends, compared with week days, and how this may be explained.

Methods

Cohorts based on national administrative inpatient and mortality data for 14,168,443 hospitalised patients in England and 913,068 in Wales who were admitted for 66 disorders that were associated with at least 200 deaths within 30 days of acute admission. The main outcome measure was the weekend mortality effect (defined as the conventional mortality odds ratio for admissions on weekends compared with week days).

Results

There were large, statistically significant weekend mortality effects (> 20%) in England for 22 of the 66 conditions and in both countries for 14. These 14 were 4 of 13 cancers (oesophageal, colorectal, lung and lymphomas); 4 of 13 circulatory disorders (angina, abdominal aortic aneurysm, peripheral vascular disease and arterial embolism & thrombosis); one of 8 respiratory disorders (pleural effusion); 2 of 12 gastrointestinal disorders (alcoholic and other liver disease); 2 of 3 ageing-related disorders (Alzheimer’s disease and dementia); none of 7 trauma conditions; and one of 10 other disorders (acute renal failure). Across the disorders, 64% of the variation in weekend mortality effects in England and Wales was explained by reductions in admission rates at weekends and the medical disease category.

Conclusions

The effect of weekend admission on 30 day mortality is seen mainly for cancers, some circulatory disorders, liver disease and a few other conditions which are mainly ageing- or cancer-related. Most of the increased mortality is associated with reduced admission rates at weekends and the medical disease category.

Electronic supplementary material

The online version of this article (10.1186/s12913-019-4286-8) contains supplementary material, which is available to authorized users.

Clinical characteristics and outcomes associated with weekend admissions to psychiatric wards in Taiwan

OBJECTIVE

This study aimed to investigate whether weekend admissions to psychiatric wards in Taiwan were associated with different patient characteristics or worse clinical outcomes.

METHOD

Patients with acute psychiatric admissions between 1996 and 2012 were included based on the National Health Insurance Research Database. The patients' baseline characteristics were recorded. The study outcomes included inpatient mortality, length of stay, and readmission within 30 days. Multivariable linear regression and multivariable logistic regression with adjustment for age, sex, diagnosis, and compulsory hospitalization status were performed.

RESULTS

Among 661,709 acute psychiatric admissions, there were 82,450 weekend admissions. The patients with weekend admissions tended to be younger and the proportion of patients with schizophrenia, bipolar affective disorder, substance use disorder, and compulsory hospitalization were higher. Weekend admissions were associated with a shorter length of stay (30.3 days vs. 33.3 days, p < 0.001), lower inpatient morality rate (0.07% vs. 0.11%, p = 0.007), but higher readmission rate (26.8% vs. 25.3%, p < 0.001).

CONCLUSION

The impact of weekend admission on clinical outcomes was relatively small compared to the differences in demographic and clinical characteristics. Despite the small influence of weekend admission, evaluation of the quality of care provided at weekends requires further attention and research to improve mental health care.

The weekend effect: does hospital mortality differ by day of the week? A systematic review and meta-analysis

BACKGROUND

The concept of a weekend effect, poorer outcomes for patients admitted to hospitals at the weekend is not new, but is the focus of debate in England. Many studies have been published which consider outcomes for patients on admitted at the weekend. This systematic review and meta-analysis aims to estimate the effect of weekend admission on mortality in UK hospitals.

METHODS

This is a systematic review and meta-analysis of published studies on the weekend effect in UK hospitals. We used EMBASE, MEDLINE, HMIC, Cochrane, Web of Science and Scopus to search for relevant papers. We included systematic reviews, randomised controlled trials and observational studies) on patients admitted to hospital in the UK and published after 2001. Our outcome was death; studies reporting mortality were included. Reviewers identified studies, extracted data and assessed the quality of the evidence, independently and in duplicate. Discrepancy in assessment was considered by a third reviewer. All meta-analyses were performed using a random-effects meta-regression to incorporate the heterogeneity into the weighting.

RESULTS

Forty five articles were included in the qualitative synthesis. 53% of the articles concluded that outcomes for patients either undergoing surgery or admitted at the weekend were worse. We included 39 in the meta-analysis which contributed 50 separate analyses. We found an overall effect of 1.07 [odds ratio (OR)] (95%CI:1.03-1.12), suggesting that patients admitted at the weekend had higher odds of mortality than those admitted during the week. Sub-group analyses suggest that the weekend effect remained when measures of case mix severity were included in the models (OR:1.06 95%CI:1.02-1.10), but that the weekend effect was not significant when clinical registry data was used (OR:1.03 95%CI: 0.98-1.09). Heterogeneity was high, which may affect generalisability.

CONCLUSIONS

Despite high levels of heterogeneity, we found evidence of a weekend effect in the UK, even after accounting for severity of disease. Further work is required to examine other potential explanations for the "weekend effect" such as staffing levels and other organisational factors.

TRIAL REGISTRATION

PROSPERO International Prospective Register of Systematic Reviews -registration number: CRD42016041225 .

Is paliperidone palmitate more effective than other long-acting injectable antipsychotics?

BACKGROUND

Paliperidone palmitate is one of the most widely prescribed long-acting injectable (LAI) antipsychotics in the UK. However, it is relatively expensive and there are few data comparing its effectiveness to that of other LAI antipsychotics. We sought to address this issue by analyzing a large anonymized electronic health record (EHR) dataset from patients treated with LAI antipsychotics.

METHODS

EHR data were obtained from 1281 patients in the South London and Maudsley NHS Foundation Trust (SLaM) who started treatment with a LAI antipsychotic between 1 April 2011 and 31 January 2015. The number of days spent as a psychiatric inpatient and the number of admissions to a psychiatric hospital were analyzed in each of the 3 years before and after LAI prescription.

RESULTS

Patients treated with paliperidone palmitate (n = 430; 33.6%) had a greater number of inpatient days and a greater number of admissions in the year prior to treatment than those treated with other LAI antipsychotics. Nevertheless, in the 3 years after initiation there were no significant differences between paliperidone and the other LAI antipsychotics in the number of days as an inpatient (B coefficient 5.4 days, 95% confidence interval (CI) -57.3 to 68.2, p = 0.86) or number of hospital admissions (Incidence rate ratio 1.07, 95% CI 0.62 to 1.83, p = 0.82).

CONCLUSION

Paliperidone palmitate was more likely to be prescribed in patients with more frequent and lengthy hospital admissions prior to initiation. However, the absence of differences in outcomes after initiation indicates that paliperidone palmitate was not more effective than other cheaper LAI antipsychotics.

Weekday and seasonal patterns in psychiatric referrals in three major London A&E departments, 2012-2014

Aims and method To identify temporal and demographic trends in referrals made to psychiatric liaison services. Routine clinical data from 16 105 individual referrals from three central London accident and emergency (A&E) departments to psychiatric liaison services from 2012 to 2014 were obtained and analysed using the Clinical Record Interactive Search (CRIS).

RESULTS

Referrals from A&E to psychiatric liaison services increased 16% over the 3-year study period. There were fewer referrals to psychiatric liaison services in winter months compared with other seasons. There were fewer referrals to psychiatric liaison services over the weekend compared with weekdays (average 15.4 daily weekday referrals v. 13.2 weekend, z = 5.1, P < 0.001), and weekend referrals were slightly less likely to result in admission to psychiatric hospital (11.3% v. 12.8%, respectively, χ2 = 6.33, P = 0.01). Clinical implications Psychiatric staffing in A&E and inpatient psychiatric wards requires planning to meet temporal and regional variations in the pattern of demand. Declaration of interest None.

What proportion of patients with psychosis is willing to take part in research? A mental health electronic case register analysis

OBJECTIVE

The proportion of people with mental health disorders who participate in clinical research studies is much smaller than for those with physical health disorders. It is sometimes assumed that this reflects an unwillingness to volunteer for mental health research studies. We examined this issue in a large sample of patients with psychosis.

DESIGN

Cross-sectional study.

SETTING

Anonymised electronic mental health record data from the South London and Maudsley NHS Foundation Trust (SLaM).

PARTICIPANTS

5787 adults diagnosed with a psychotic disorder.

EXPOSURE

Whether approached prior to 1 September 2014 for consent to be approached about research participation.

MAIN OUTCOME MEASURES

Number of days spent in a psychiatric hospital, whether admitted to hospital compulsorily, and total score on the Health of the Nation Outcome Scale (HoNOS) between 1 September 2014 and 28 February 2015 with patient factors (age, gender, ethnicity, marital status and diagnosis) and treating clinical service as covariates.

RESULTS

1187 patients (20.5% of the total sample) had been approached about research participation. Of those who were approached, 773 (65.1%) agreed to be contacted in future by researchers. Patients who had been approached had 2.3 fewer inpatient days (95% CI -4.4 to -0.3, p=0.03), were less likely to have had a compulsory admission (OR 0.65, 95% CI 0.50 to 0.84, p=0.001) and had a better HoNOS score (β coefficient -0.9, 95% CI -1.5 to -0.4, p=0.001) than those who had not. Among patients who were approached, there was no significant difference in clinical outcomes between those agreed to research contact and those who did not.

CONCLUSIONS

About two-thirds of patients with psychotic disorders were willing to be contacted about participation in research. The patients who were approached had better clinical outcomes than those who were not, suggesting that clinicians were more likely to approach patients who were less unwell.

Mental health services, suicide and 7-day working

BACKGROUND

Patients admitted to hospital at the weekend appear to be at increased risk of death compared with those admitted at other times. However, a 'weekend effect' has rarely been explored in mental health and there may also be other times of year when patients are vulnerable.

AIMS

To investigate the timing of suicide in high-risk mental health patients.

METHOD

We compared the incidence of suicide at the weekend v. during the week, and also in August (the month of junior doctor changeover) v. other months in in-patients, patients within 3 months of discharge and patients under the care of crisis resolution home treatment (CRHT) teams (2001-2013).

RESULTS

The incidence of suicide was lower at the weekends for each group (incidence rate ratio (IRR) = 0.88 (95% CI 0.79-0.99) for in-patients, IRR = 0.85 (95% CI 0.78-0.92) for post-discharge patients, IRR = 0.87 (95% CI 0.78-0.97) for CRHT patients). Patients who died by suicide were also less likely to have been admitted at weekends than during the week (IRR = 0.52 (95% CI 0.45-0.60)). The incidence of suicide in August was not significantly different from other months.

CONCLUSIONS

We found evidence of a weekend effect for suicide risk among high-risk mental health patients, but with a 12-15% lower incidence at weekends. Our study does not support the claim that safety is compromised at weekends, at least in mental health services.

Lack of a “Weekend Effect” for Renal Transplant Recipients

The “weekend (WE) effect” defines the association between WE hospital admissions and higher rate of mortality. The aim of this study was to evaluate the relationship between WE effect and renal transplant recipients (RTRs) using the database of the Emilia-Romagna region (ERR), Italy. We included ERR admissions of RTRs ( International Classification of Diseases, Ninth Revision, Clinical Modification [ ICD-9-CM] code V420) between 2000 and 2013. In-hospital mortality, admissions due to cardiovascular events (CVEs), and the Elixhauser score were evaluated on the basis of ICD-9-CM codification. Out of 9063 hospital admissions related to 3648 RTRs (mean age 53 ± 13 years, 62.9% male), 1491 (16.5%) were recorded during the WE. During the follow-up period, 1581 (17.4%) patients deceased and 366 (4%) had CVEs. Length of hospital stay (LOS) was 9.7 ± 12.1 days. Logistic regression analysis showed that only LOS was independently associated with WE admissions (odds ratio: 1594, confidence interval: 1.385-1.833; P < .001). Renal transplant recipients are not exposed to higher risk of adverse outcome during WE admissions. However, WE admissions were characterized by an increased duration of hospitalization.