Outcome of acute psychiatric in-patient care where there are no crisis or home treatment teams

AIMS AND METHOD

To examine the pathways and outcomes of in-patient care in ourlocality before crisis teams were introduced details of allemergency referrals to psychiatry were recorded and all admissionsto hospital were assessed within 24 h of admission and discharge.

RESULTS

Over a 6-month period, 88% (n=1852) of calls to the duty psychiatristoccurred between 09.00 and 01.00 h. Referrals from accidentand emergency and general practice represented the majorityof calls (80%); 40% of patients were admitted. Highest admissionrates were for patients who were psychotic, suicidal or depressed.Admission led to improvement in all symptoms.

CLINICAL IMPLICATIONS

In-patient care is a valuable resource for stabilising patientswho are acutely ill. Routine monitoring of unscheduled activitycan inform service delivery.

Introduction

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Introduction

Recent years have seen the development of specialist crisisand home treatment teams for managing patients who would previouslyhave been admitted for in-patient care (Glover et al, 2006).Despite the expansion of these community-based services, in-patientpsychiatric care is necessary for patients who cannot be managed safely or effectively in the community. Admission to hospitalis one of the oldest and most frequently used interventionsin psychiatry, however, surprisingly little has been writtenabout its use and outcome, although there has been concernabout standards of in-patient care (Quirk & Lelliot, 2004; Lelliot et al, 2006). Studies of acute hospitalisation inpsychiatry have been comparisons between forms of home treatmentor day hospital care and the ‘treatment as usual’of in-patient psychiatric care (for example, Priebe et al, 2006). To our knowledge there has been no systematic or prospectivedescription of the use and outcomes of acute psychiatric in-patientcare, despite the upheaval to the patient and cost of hospitalisation.We note the recent comment by Holloway (2006) that ‘...admission is construed as representing a failure of the individual patient or the service, rather than a potentially valuabletherapeutic option.’ We aimed to examine the pathwaysto and therapeutic value of in-patient care in our service(NHS Lanarkshire), where crisis or home treatment teams haveyet to be developed.

Method

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Method

Lanarkshire has a population of approximately 550 000 with relativelyhigh deprivation ratings (Director of Public Health, 2005).There are no local private psychiatry facilities and communitymental health teams (CMHTs) are the mainstay of community care for mental health services, and operate between 09.00 and 17.00h without any specialised crisis assessment or home treatmentteams. Decisions to admit are traditionally made by the junioron-call psychiatrist, supported by advice from senior colleagues.To measure psychiatric on-call activity a duty log-book wasintroduced to all three psychiatric admission units in Lanarkshirein February 2003. Every on-call psychiatrist was instructedto note down details of all referrals, excluding those fromthe acute (internal) in-patient psychiatric wards. The firstnoted problem was used for analysis, and problems were groupedinto those related to alcohol, illicit drugs, psychosis, bipolardisorder, anxiety/depression, self-harm or suicidal behaviour,aggression, confusion or other problems. The clinical outcomeof in-patient care was examined in two acute adult in-patientwards of one hospital between January 2004 and March 2005.These wards consisted of 46 beds and ran at an average 106%occupancy rate. Objective ratings utilised the validated FunctionalAnalysis of Care Environments (FACE) instrument (http://www.facecode.com). Prior training was provided to nursing staff on the use ofthis scale. Self-rating of depressive symptoms was recordedusing the Zung scale (Zung, 1965). Patients also completeda further self-assessment symptom questionnaire (copies available from authors on request). All measures were recorded within24 h of admission and 24 h of discharge.

The FACE components were scored 1=no symptoms, 2=mild, 3=moderate,4=severe and 5=very severe. The individual self-rating componentsexamined are listed in Table 1. The scoring mechanism forthe self-rating symptoms was 1–5, with 1 ‘not at all’ through to 5 ‘all the time’. The ZungDepression Scale was scored using standard methodology. Ethicalapproval was not sought as this work constituted service evaluation.

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Table 1. Change in symptom scores at discharge compared with admission

Results

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Results

The total number of contacts for all three hospitals was 2104for the 6-month period, of which 51% were male. The mean ageof patients was 38.3 years for males and 40.4 years for females.The mean percentage of patients admitted was 39%. On average88% of contacts occurred between 09.00 and 01.00. There wereno significant differences between the hospitals.

The source and number of referrals were as follows (relativeproportion admitted in parentheses): general practitioners,n=606 (43%); emergency department, n=546 (38%); physicians,n=301 (15%); CMHTs, n=154 (73%); transfers from other hospitals,n=147 (63%); liaison psychiatry, n=57 (46%); psychiatric dayhospital, n=35 (23%), non-psychiatric wards, n=28 (14%); others, n=149 (54%).

The problems identified were as follows: self-harm or suicidalbehaviour, n=989 (39%); anxiety or depression, n=588 (43%);psychosis, n=443 (60%); alcohol problems, n=437 (37%); illicitdrug problem, n=103 (47%); bipolar disorder, n=95 (59%); confusion,n=72 (31%); aggression, n=70 (41%); others, n=136 (32%).

Of those admitted, 53% were male. The mean age of in-patientswas 40 years for males and 41 years for females. Out of 1183,115 (9.7%) required one-to-one ‘special’ nursingobservations at some point during their admission, 524 (44%)required ‘constant’ observations. The majority(84%) were treated on a voluntary basis and the mean durationof stay was 24.9 days.

Improvement was seen in virtually all symptoms for both selfand observer ratings, as illustrated in Table 1. The greatestpercentage improvements were seen for suicidality and depressedmood. The Spearman’s correlation between self-reportedand observer (FACE) suicidal ideation was 0.48 (P $≤$ 0.0001). The correlation between self-reported and FACE depressed mood was0.43 (P $≤$ 0.0001).

Discussion

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Discussion

The Lanarkshire model of ‘on-call psychiatry’ wasthe traditional one, where junior doctors assessed and admittedpatients throughout the 24 h period. This model is rapidlychanging within the UK, with a drive towards specialist community-basedteams who decide upon admission or intensive home and/or communitytreatment. In our traditional model of care, hospital admissionoccurred in 40% of emergency contacts with the on-call doctor.Admission was associated with improvement in all subjectiveand objective symptoms. The main reasons for being admitted(depressed mood and suicidality) were associated with the greatestdegree of improvement. The improvements seen cannot necessarilybe attributed to the effects of hospitalisation, as withinthe same time period (mean duration of stay 25 days) medicationeffects are also likely to occur. In this study, the single clinical problem with the highest admission rate (60%) was ‘psychosis’. In areas where specialist teams aredeveloped, hospital admission is probably being reserved forpatients who are more severely ill (Commander & Disanyake, 2006).Nevertheless, one such home treatment team found a 54% admissionrate over 1 year for first-episode psychosis (Gould et al, 2006). This was similar to the 60% admission rate for psychosis foundin this study. Although our ‘psychosis’ does notequate to first-episode psychosis, such a relatively high ratefor a home treatment team reflects the fact that admissionis often necessary and unavoidable for certain conditions tofacilitate a favourable outcome.

All three hospitals had consistent activity over time, with9 out of 10 unscheduled contacts occurring between 09.00 and01.00 h. Admission rates for all unscheduled contacts between09.00 and 17.00 h were only 10% lower when CMHTs and seniormedical staff who are familiar with the patients were availableto provide advice to on-call doctors. This has implicationsfor the development of home treatment or crisis services ina particular area. It is probably unnecessary to provide suchcrisis cover at the same intensity throughout the 24 h period.The availability of the CMHT or sector psychiatrist did notseem to influence the proportion of patients admitted to asignificant degree.

The profile of our patients who were admitted was comparableto a large database of admissions in English hospitals (Thompson et al, 2004),although the database showed a median duration of stay of 15days for mental illness (adult psychiatry) compared with ourmean of 25 days. Again, this may be related to specific teamswhich facilitate early discharge planning being available inparts of England. Thompson et al (2004) also found that depressionand anxiety were the most commonly recorded reason for admission, and we have shown that both patients and their treating cliniciansrate depression, anxiety and suicidal thoughts as the symptomsmost amenable to improvement in the in-patient setting.

In-patient care is an expensive but essential resource for mental healthcare. It is effective in gaining control of severe symptomsand providing safety for patients and others. Even with thedevelopment of specialist community teams, in-patient carecannot be replaced and will remain as a valuable therapeuticoption rather than a failure of community care. Accreditationof in-patient mental health services is now considered a priority(Lelliot et al, 2006). As part of this accreditation, we believecollection of routine clinical outcome measures will be ofbenefit in service evaluation and therefore delivery.

Acknowledgments

We thank G. Martin, M. Hughes and F. Shuel for their invaluablehelp with data collection and Drs M. Connolly and J. Burleyfor their helpful comments during preparation of this manuscript.

References

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