Nurse-led liaison psychiatry service for older adults: service evaluation

AIMS AND METHOD

To comprehensively describe a nurseled consultation liaisonservice for older adults by retrospectively reviewing all referralsreceived in 2006 and comparing them against other servicesand benchmark reports.

RESULTS

Of the 298 individuals referred to psychiatric services fromother hospital wards, 120 were aged 85–94 years old (40%),193 were male (65%) and 152 were referred from geriatrics (51%).A majority of 204 have not had previous contact with psychiatricservices (69%). The most common diagnosis was dementia (33%,n=88), with 27% individuals (n=65) being referred onwards tosecondary care.

CLINICAL IMPLICATIONS

This nurse-led service, using a novel approach of a supportworker providing further community support, functions wellcompared with traditional consultation models. It helps identifymany individuals with dementia and engages them into communitypsychiatric services.

Introduction

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Introduction

The publication of Who Cares Wins by the Royal College of Psychiatrists(2005) has provided the best available benchmark for the servicestructure of liaison psychiatry for older adults. The developmentof specific liaison services is now a priority. Nurse-led consultationfor older adult liaison services is gaining popularity. Thebiggest contribution of liaison nursing teams lies in planningeffective discharge, continuity of care and education (Mukaetova-Ladinska, 2006).A randomised controlled trial showed it can be effectivelyimplemented (Baldwin et al, 2004). The efficacy is equivalentto doctor-led consultation models which may have cost-savingimplications (Baldwin et al, 2004).

Who Cares Wins states that the multidisciplinary approach has advantages over the consultation method in terms of a morespecialist assessment, shortened length of stay, decreasedmortality, more mental health reviews and increased compliancewith the management plan (Royal College of Psychiatrists, 2005),which has been confirmed through other surveys (Whelan et al, 2007). Despite this, 73% of mental health services in the UK use thetraditional sector-based consultation model (Bentley et al, 2003).This evaluation comprehensively reviews, over a 1-year period,all liaison referrals to old age psychiatry services. We areunaware of any studies which comprehensively describe a nurse-ledold age liaison service detailing patient demographics andoutcomes over a year.

Method

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Method

Setting and service
The study was carried out at Wrexham Maelor Hospital, part ofthe North East Wales National Health Service (NHS) Trust whichserves approximately 330 000 people. The liaison service, usinga consultation nurse model, has been operating there since2000. The team was composed of a registered mental nurse band6, working full time, who assessed all referrals, includingthose from accident and emergency, with additional input froma healthcare support worker. The nurse also received 1-hourweekly supervision from a consultant old age psychiatrist.If required, brief community support by the support workerwas possible upon discharge. Referrals were made on standardisedforms which included two non-mandatory instruments –the 6-item Cognitive Impairment Test (Brooke & Bullock, 1999)and the 4-item Geriatric Depression Scale (Shah et al, 1999). For individuals presenting with acute confusion, it was expectedthat the local acute hospital trust protocol for managing deliriumhad been first tried.

The individuals referred, already open to the community psychiatricteam, were not assessed by the liaison service because of thelimited capacity of the nurse and to improve continuity ofcare. Such individuals were seen by their own community psychiatricnurse and were excluded from this study. The previous serviceused the traditional doctor-led sector-based model, with referralsbeing assessed by the relevant staff grade doctor or consultant, with limited opportunity for follow-up or staff and familyeducation because of time constraints. Since the introductionof the liaison service, it is the team’s impression thatreferral rates have not increased, but detection rates haveimproved for dementia owing to their ability to spend longer assessing each individual. Staff and family satisfaction throughimproved communication and education have also improved. Patientsand carers particularly appreciated the opportunity for briefcommunity follow-up, with fewer requiring a community mentalhealth team referral.

Evaluation
Each standardised referral form was scrutinised for the person’s demographics, their type of accommodation, the specialty ofthe referrer, the reason for admission and the referrer’sstatement of the presenting problem. The length of stay inhospital prior to referral was also recorded, as was whetherassessment tools were used and which psychotropic medications were prescribed on referral. The psychiatric diagnosis, theoutcome for assessed individuals, the subsequent dischargeaccommodation and, if an assessment did not actually occur,why that was so, was obtained from the liaison assessment.

Diagnoses were established using the ICD–10 criteria (World Health Organization, 1992).The data were analysed using Simple Interactive Statistical Analysis (Uitenbroek, 1997); chi-squared tests were used toinvestigate the significant characteristics of particular groups,with the P-value for statistical significance set at 0.05.Odds ratios were calculated to measure effect size. The teamchose groups of individuals for analysis and comparison basedon whether it could make an important contribution, namelythose with no previous or current psychiatric history, thosereferred into secondary care and those discharged into care.

Results

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Results

Wrexham Maelor Hospital has a 659-bed capacity. It received24 812 acute admissions in 2006, of which 4906 were for surgery,4663 for medicine, 2414 for orthopaedics and 2365 for geriatrics.The study identified 298 referrals (the total number for 2006)to psychiatry from the four units, all for people aged over65 years. Seven of them died prior to being assessed and 13more died prior to discharge; the mean length of stay priorto referral was 13.7 days. Most referrals were made by nursingstaff rather than medical staff. In only 36% of referrals (n=107)had screening instruments been used. Athird (69%, n=204) hadno previous or current contact with psychiatric services; 95%of those referred and accepted (n=283) were seen within the3-day policy limit. Basic demographics including gender, age, accommodation type and referral source are described in Table 1(the reason for admission, the referring problem, previouscontact with psychiatric services and psychotropic medicationslisted on referral are also described).

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Table 1. Basic demographics and referral information

The outcomes for assessed individuals, including reasons for non-assessment, psychiatric diagnosis, onward referrals anddischarge placement, are presented in Table 2. The team’sinterventions included a one-off assessment in 62% individuals(n=184), with the rest requiring further reviews by the liaisonnurse because of the complexity of presentation and risk. All those who received brief community liaison follow-up by thesupport worker (13%, n=33) also received weekly support duringtheir in-patient stay, as decided by the team according towho needed further emotional support, including carers. Thesupport worker also tended to use community support for thoseentering into a care home to provide a link between in-patientstay and primary care during the transition period.

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Table 2. Outcomes for assessed patients

For those who saw a staff grade or a consultant psychiatristduring their in-patient admission, this was mainly attributedto diagnostic difficulty, psychotropic medication review, reviewbefore admission to the psychiatry ward, challenging capacityassessments, and where the nurse was experiencing undue difficultyin the staff dynamic between psychiatry and the general hospital.At discharge from the team, 27% of individuals (n=65) were referredto secondary care, namely older person’s mental healthservices such as a community mental health team, memory clinic,out-patient clinic and day hospital. (The significance of differencesbetween selected variables is presented in Table 3.)

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Table 3. Characteristics of the variables analysed

Discussion

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Discussion

The service received a large number of referrals for its size,comparable to King’s College Hospital, London (336 patientsin 2001; Hanlon et al, 2004); this has not changed over thepast 5 years. Referrals were more frequent during winter, confirmingprevious research (Benbow et al, 1998), and may have implicationsfor staffing. The majority of individuals lived independentlyprior to admission, challenging the stereotyped view of the incapacitated elderly person. There was a reluctance to usethe non-mandatory assessment tools before referral and thesetended to be used on people with behavioural disturbance ornon-adherence.

Most individuals were referred from geriatrics, with littlereferrals from surgery and orthopaedics, in line with previousstudies (Bentley et al, 2003). There are noticeable differencesin the number of referrals of people aged over 65 years oldin medicine (34%), surgery (42%), and elective (72%) and trauma(21%) orthopaedics, and also in numbers of admission per yearper specialty with the referral rate per specialty. It is estimatedthat for one old age psychiatry referral, 16 admissions aremade to geriatrics, 18 to medicine, 38 to orthopaedics and121 to surgery (Boddy et al, 1977; Burley et al, 1979; Asimakopoulous et al, 1998;Gomberg et al, 1999).

‘Acute emergency’, confusion, falls and fracturesconstituted the most common reasons for acute admission. With69% of those referred having no previous contact with psychiatricservices, many elderly individuals present via such acute events.Liaison services have an important role in detecting mentalillness and signposting thereafter, which compares well with published data (Ashaye et al, 2006). The most common referringproblem was confusion. Other problems included a mood disorder,self-harm, capacity assessment, anxiety and assessment of placement,and compares similarly with other surveys (Rao, 2001; Ashaye et al, 2006). The rate of self-harm (4%) was comparable with that in otherservices (Gash et al, 2005). Over half of those referred werealready prescribed psychotropic medications which tended tobe antidepressants. With only five referrals asking for a psychotropicmedication review, medication management should become an areafor potential service development.

This survey re-affirms the three D’s of old age psychiatry– dementia, delirium and depression – and is comparablewith Who Cares Wins, with prevalence of 31%, 20% and 29% respectively,and other surveys such as Whelan et al’s (2007) withprevalence of 37%, 26% and 24% respectively. For rarer diagnoses(anxiety, psychosis and alcohol dependence) the prevalencewas within the ranges in Who Cares Wins, except for alcoholdependence (it was diagnosed in 8% of individuals which may be caused by local patterns of use – Who Cares Wins andother surveys (Whelan et al, 2007) state a range of 1–5%).

Of those referred to a community mental health team, day hospital,memory clinic or out-patient clinic, individuals tended tocome from their own home, be diagnosed with dementia and beless likely to receive liaison support worker follow-up owingto their more complex needs requiring a community psychiatricnurse support. For those who returned home without a secondary care referral, brief community liaison support has been usedfrequently to bridge the gap between in-patient stay and primarycare, and to provide post-delirium counselling. Individualsdischarged into care were mostly those presenting with acuteevents such a fracture, fall and delirium. They received briefliaison follow-up only, considering the enhanced support inthe care home environment.

The results of our survey are limited by the subjective natureof diagnosis, omitted information on the assessment forms andthose patients with psychiatric morbidity not referred. Basedon the data collected, the nurse-led consultation service modelfunctions well in comparison with others which mainly use thetraditional medically-led consultation model. The service uses a novel approach for post-discharge community support witha healthcare support worker. Being nurse-led, with targetedmedical support as needed, the service may be cost-saving.It identifies many individuals with dementia that had no previouscontact with psychiatry, and engages them into community services.As referrals from orthopaedics and surgery are improved, itis likely that even more people with dementia would be identifiedearlier.

Acknowledgments

We thank the North East Wales NHS Trust and Dr M. Krishna forhis statistical and editorial support.

References

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