Survey of long-stay patients on acute psychiatric wards

AIMS AND METHOD

To describe the profile of patients staying on acute wards forlonger than 6 months and to compare staff appraisals of accommodationneeds with patients’ placements at 2 years.

RESULTS

Long-stay patients consistently occupied around a fifth of allacute beds. The nursing and medical staff recommendations andpatients’ placements at 2 years showed only moderateagreement. Aside from remaining in hospital, patients weremost likely to be living in a residential or nursing home at follow-up.

CLINICAL IMPLICATIONS

There is a need to sharpen the focus of mental health strategyon non-acute hospital provision and 24-h-staffed communityfacilities. In particular, it is important to recognise thecontribution of clinical expertise to the assessment and placementof long-stay in-patients.

Introduction

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Introduction

On busy acute wards long-stay patients may lose out to the moreimmediate demands of those newly admitted. The often highlystimulating environment may, on prolonged exposure, be detrimentalto their recovery. Their progress may also be hindered by thelack of opportunity to rehearse appropriate social roles andpractical skills (Lelliottt & Quirk, 2004). The unacceptablyhigh number of long-stay patients stuck on acute wards hasbeen consistently reported and the associated shortcomingsin community and longer stay in-patient provision have beenhighlighted (Kurian et al, 1994; Shepherd et al, 1997; Rowlands et al, 1998).The role of rehabilitation, whether in the hospital or in anotherplacement, has largely been neglected (Holloway, 2005) duringa decade that has seen national policy initiatives focus chieflyon the development of non-residential community services, notablyassertive outreach and home treatment teams (Department of Health, 1999).Despite the anticipated progress in reducing bed occupancy,the limitations of these teams in meeting the needs of the most disruptive and disabled service users in the community is alreadyapparent (Commander et al, 2005; Commander & Disanyake, 2006).

This 2-year longitudinal survey describes the profile of patientson acute psychiatric wards staying longer than 6 months inall acute wards in Birmingham where assertive outreach andhome treatment teams are well established. It examines thereasons why they remain there for lengthy periods and comparesstaff appraisals of future accommodation needs with patients’placements 2 years on.

Method

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Method

We identified individuals aged 16 years old or more and occupyingan acute psychiatric bed (including intensive care) for morethan 6 months (without a break of 3 weeks or more) on a nominatedcensus day (1 June 2005); forensic and older adult serviceswere excluded. The census was repeated 6-monthly over the following2 years to ascertain the number of new in-patients staying in acute psychiatric wards longer than 6 months as well as todetermine the final location of those recruited at the outset.The details of eligible patients were ascertained through contactwith the wards and a simple pro forma was used to collect dataon the in-patients at the initial census. A ward nurse familiarwith the patient provided information on a range of risk behaviours derived from the Functional Analysis of Care Environments (FACE, www.facecode.com). The consultant psychiatrist gave an opinionabout risk should the patient be discharged and, where relevant,the reason for any delay. In addition, both the nurse and psychiatristidentified whether the patient was appropriately placed onthe ward, and if not, where they considered the patient more suitably placed (based on categories derived from the CommunityPlacement Questionnaire; Clifford, 1993).

We compared our findings with the national audit of new long-stay psychiatric patients (Lelliott et al, 1994) undertaken in1992, prior to recent reforms in mental health services. Incontrast to the present study, the audit covered an age rangeof 18–64 years old, included individuals in any residential place fully funded by the National Health Service (NHS) andrestricted entry to those who had been there less than 3 years.

Results

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Results

At the outset, 38 in-patients met the study criteria, occupying18% of the 208 acute beds. The mean length of stay was 15 months(s.d.=9; range 6–40) compared with 16 months (s.d.=9)in the national audit (Lelliott et al, 1994). The number ofpatients staying longer than 6 months was 32, 38, 33 and 42at each subsequent census. Of these, 22 (69% of the total),14 (37%), 18 (55%) and 28 (67%) respectively were ‘new’patients whose stay was now over 6-months duration. The meanage of patients in the study was 43 years old (s.d.=13; range22–67) compared with 42 years old (s.d.=13) in the nationalaudit (Lelliott et al, 1994). Nearly two-thirds had never beenmarried and none were currently in work (Table 1). Schizophreniawas the most frequent diagnosis.

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Table 1. Demographic, clinical and problem behaviour profile of long-stay in-patients in acute psychiatric wards

The majority of patients had lengthy previous involvement withmental health services and had been detained compulsorily duringthis admission. Fifteen patients were under the supervisionof an assertive outreach team; one, an early intervention team;and three, a rehabilitation and recovery team. The remainingpatients were under the care of a primary care liaison or communitymental health team. They all had a substantial level of problem behaviours, notably violence and threatening behaviour (Table 1).Five patients (13%) had a conviction for a violent or sexualoffence, 16 (42%) had a lifetime history of physical violenceto others and 6 (16%) of setting fire; 1 patient had previouslybeen in a special hospital. The proportion of patients consideredby psychiatrists a moderate to high risk for neglect (n=25;66%), violence (n=11; 29%) and suicide/deliberate self-harm(n=11; 29%) should they be discharged compares with the 42%,30% and 20% respectively identified in the national audit (Lelliott et al, 1994).

Psychiatrists considered that 6 patients (16%) only initiallyneeded to remain on an acute ward and a further 14 (36%) weredeemed to require a longer in-patient stay. At baseline, therewas a consensus between psychiatrists and nursing staff aboutthe most appropriate placement for only 18 out of 38 patients(kappa=0.34 – fair; Table 2). Of the 32 patients consideredby their psychiatrist to no longer require acute inpatientcare, the majority (n=24; 75%) had as yet no accommodationto go to. A further 2 patients were waiting for a forensicassessment, 5 had been accepted for a place but lacked funding,and the remaining patient was waiting for adaptations to becompleted on her house. The location of patients at 2-yearfollow up is shown in Table 2. Of the 5 patients who remainedon an acute ward, 4 had been there for the duration of the studyand 1 had left but had then been readmitted from their supportedaccommodation. One other individual was readmitted but subsequentlyreturned to their care home. For those who did move on andat the outset were deemed to be inappropriately placed, bothpsychiatrist and nurses initial recommendations showed onlymoderate agreement with the patients final placement (kappa=0.41 and 0.43 respectively).

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Table 2. Initial staff recommendations and final placement at 2 years

Discussion

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Discussion

The profile of long-stay patients we arrived at needs to beunderstood within its local context and the overall patternof services. Birmingham has a population of 1 006 500 with30% from Black and minority ethnic groups (Birmingham City Council, 2006).The city is ranked the 15th most deprived local authority inEngland (Index of Multiple Deprivation, 2004). The number ofavailable acute beds is lower than projected figures basedon the National Beds Inquiry (Department of Health, 2000), while the number of rehabilitation and low secure beds (n=74)is in line with estimates in a recent review of the government’smental health policies (Boardman & Parsonage, 2007).

The long-stay patients in this study consistently occupied arounda fifth of all acute beds, which is comparable with figuresreported in surveys (Kurian et al, 1994; Rowlands et al, 1998) undertaken prior to the reform agenda set out in the NationalService Framework for Mental Health (Department of Health, 1999).Although encouragement can be taken from the finding that mostpatients had moved on from an acute ward after 2 years, this needs to be set against the fact that at any one time fourout of five were considered inappropriately placed and theaverage length of stay was well over a year.

The enduring evidence of a substantial number of long-stay patientsstuck on acute wards is of particular concern given the Departmentof Health’s focus on delayed transfers of care reflectedin an extension, in April 2006, of the reporting of such cases(via weekly situation reports) to include all mental healthNHS trusts. Delayed transfers/discharges have been further highlightedin the Ten High Impact Changes for Mental Health Services (Care Services Improvement Partnership, 2006)and a good practice toolkit aimed at improving discharge fromin-patient units (Care Services Improvement Partnership, 2007).These documents address the importance of local data collectionand appraisal of the reasons for any delays in conjunctionwith problem-solving sessions involving senior managers andclinicians. They also stress the need for early discharge planningand the potential role of discharge facilitators as well asthe critical contribution of home treatment services. Yet inBirmingham, despite seeking to optimise performance in theways suggested, at any one time the majority of long-stay patientswere considered inappropriately placed.

Shepherd et al (1997) found that almost two-thirds of long-staypatients on acute psychiatric wards required a specialist rehabilitationplacement or a setting with higher supervision. Likewise, inBirmingham around a half of all in-patients were initially deemed to need ongoing treatment in hospital and just over a thirdremained there 2 years on, indicating that in-patient provisionis crucial to resolving the issue of long-stay patients onacute wards. A shortage of medium-term beds was identifiedin the national audit (Lelliott et al, 1994) but, as in ourstudy, it is uncertain whether this reflects a deficit in capacityor arises from lack of accessibility due to the delayed dischargeof patients awaiting community placement. Certainly, wherethere were community service recommendations, and eventuallyplacements, by far the majority involved nursing and care homesor supported accommodation with 24-h staffing, challenginga notion that these individuals are likely to be supportedin their own homes albeit with the supervision of newly establishedand well-resourced community teams. Alongside the noteworthyomission of longer stay in-patient settings from national policyinitiatives (Holloway, 2005), there has been a dearth of thesophisticated cross-agency commissioning necessary to delivera comprehensive range of accommodation for people with mentalhealth problems in the community (Shepherd et al, 1997).

There was only fair agreement between psychiatrists’ and nurses’ opinions regarding the most appropriate placementsfor patients. Likewise, for those considered in a positionto move on, there was only moderate concordance between therecommendations and the patients’ final location. Itmay be that changing circumstances and presentation partially accounts for that as may the constraints of working with alimited range of disposal options. However, it may also berelevant that half of the Birmingham in-patients were underthe supervision of primary care liaison or community mentalhealth teams and so involved staff who may have little expertisein assessing and placing such individuals, or indeed in advocatingfor the necessary funding. Specialist rehabilitation teams,which for many years worked to resettle individuals from long-staywards into the community, have often had their profile changedto assertive outreach teams or simply disbanded in recent years.The government’s failure to endorse their role in itsnew service model (Department of Health, 1999) may now needto be reconsidered (Holloway, 2005).

References

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