Utility of routine drug screening in a psychiatric emergency setting

OBJECTIVE: The study determined whether dispositions from an urban psychiatric emergency service would differ between patients who received a mandatory urine drug test and those who may or may not have had a test based on the attending psychiatrist's clinical judgment. The accuracy of clinicians' suspicion of substance use among mandatorily screened patients was also examined. METHODS: A total of 392 consenting patients presenting to an urban psychiatric emergency service were randomly assigned to a mandatory-screen group (N=198) or a usual-care group (N=194). Physicians ordered screens based on clinical judgment. Additional screens were performed without physicians' knowledge for patients in the mandatory-screen group for whom no screen was ordered. Demographic and clinical information, results of drug screens, and information about dispositions were collected from clinical charts or hospital databases. RESULTS: No difference in dispositions was found between the mandatory-screen group and the usual-care group. Survival analysis did not reveal a difference between the two groups in length of stay in inpatient psychiatric units. As for accuracy of physicians' suspicion of substance use, positive drug screens were recorded for 10.2 percent of the 198 patients in the mandatory-screen group who did not admit drug use or for whom physicians did not expect drug use. A total of 39.3 percent of the patients who were suspected of use and 88.2 percent of those who admitted use had positive drug screens. Only 20.8 percent of patients who denied substance use had positive screens. CONCLUSIONS: Routine urine drug screening in a psychiatric emergency service did not affect disposition or the subsequent length of inpatient stays. The results do not support routine use of drug screens in this setting.     

Canadian psychiatric inpatient religious commitment: an association with mental health.

BACKGROUND: Research indicates that religion may have a positive effect on coping and possibly enhance clinical outcomes. This study aims to determine the level of religious interest of psychiatric inpatients and to assess whether religious commitment has an impact on selected outcome variables. METHODS: There were 88 consecutive adult patients (50% men) who were admitted to a Canadian tertiary care psychiatry inpatient unit and were interviewed about their religious beliefs and practices. Patients with a Beck Depression score of 12 or more were included for outcome analysis. RESULTS: A total of 59% believed in a God who rewards and punishes, 27% had a high frequency of worship attendance, and 35% prayed once or more daily. More frequent worship attenders had less severe depressive symptoms, shorter current length of stay, higher satisfaction with life, and lower rates of current and lifetime alcohol abuse (P < 0.05), when compared with those with less frequent or no worship attendance. In contrast, private spirituality was associated with lower depressive symptoms and current alcohol use only (P < 0.05), and prayer frequency had no significant associations. DISCUSSION: This study indicates that certain religious practices may protect against severity of symptoms, hospital use, and enhance life satisfaction among psychiatric inpatients. This is the first known Canadian study that examines religious commitment among psychiatric inpatients.     

A Canadian medical-psychiatric inpatient service.

Patients with both psychiatric and medical illnesses present complex and, at times, difficult diagnostic and management problems. Medical-psychiatric units designed to provide integrated medical and psychiatric care have been established in the United States. This paper describes the development and structure of such a unit established at a Canadian general hospital, using psychiatric facilities and resources already in place. A one year review of the characteristics of patients discharged from the service found that their mean length of stay was similar to that of inpatients discharged from the general adult inpatient services, but shorter than that of patients discharged from the psychogeriatric service. Many of these patients had neurological conditions; coexisting affective disorders, substance abuse, organic mental syndromes and somatoform disorders were diagnosed frequently. We believe that a medical-psychiatric inpatient unit can provide integrated care to patients who might otherwise receive less than adequate care.     

Preadmission care as a new mental health performance indicator

OBJECTIVE: This study examined the relationship between receipt of preadmission outpatient care during the month before an episode of hospitalization and the patients' subsequent treatment. METHODS: A total of 37,852 psychiatric inpatients who were discharged from 122 Veterans Affairs medical centers between October 1, 1997, and March 31, 1998, were studied. Linear and logistic regression were used to examine the relationship between receipt of preadmission outpatient care and length of hospital stay, use of postdischarge aftercare, and readmission. RESULTS: Having at least one outpatient visit in the month before admission was associated with a significantly shorter inpatient stay (16 days compared with 26 days, a difference of more than 60 percent) and with significantly greater use of postdischarge aftercare (odds ratio=1.83). However, the number of outpatient visits beyond one visit in the month before admission did not increase the effect on length of stay. These effects were strongest among patients with schizophrenia. CONCLUSIONS: Patients who have received outpatient care before hospital admission have shorter hospital stays and are more likely to use postdischarge aftercare than those who have not received outpatient care in the month before admission. Receipt of preadmission care itself rather than the intensity of such care seems to be the greatest predictor of length of stay.     

Supported discharge service versus inpatient care evaluation (SITE): a randomised controlled trial comparing effectiveness of an intensive community care service versus inpatient treatment as usual for adolescents with severe psychiatric disorders: self-harm,functional impairment,and educational and clinical outcomes

Clinical guidelines recommend intensive community care service treatment (ICCS) to reduce adolescent psychiatric inpatient care. We have previously reported that the addition of ICCS led to a substantial decrease in hospital use and improved school re-integration. The aim of this study is to undertake a randomised controlled trial (RCT) comparing an inpatient admission followed by an early discharge supported by ICCS with usual inpatient admission (treatment as usual; TAU). In this paper, we report the impact of ICCS on self-harm and other clinical and educational outcomes. 106 patients aged 12–18 admitted for psychiatric inpatient care were randomised (1:1) to either ICCS or TAU. Six months after randomisation, we compared the two treatment arms on the number and severity of self-harm episodes, the functional impairment, severity of psychiatric symptoms, clinical improvement, reading and mathematical ability, weight, height and the use of psychological therapy and medication. At six-month follow-up, there were no differences between the two groups on most measures. Patients receiving ICCS were significantly less likely to report multiple episodes (five or more) of self-harm (OR = 0.18, 95% CI: 0.05–0.64). Patients admitted to private inpatient units spent on average 118.4 (95% CI: 28.2–208.6) fewer days in hospitals if they were in the ICCS group compared to TAU. The addition of ICCS to TAU may lower the risk of multiple self-harm and may reduce the duration of inpatient stay, especially in those patients admitted for private care. Early discharge with ICCS appears to be a viable alternative to standard inpatient treatment.

     

The consequences of non-cognitive symptoms of dementia in medical hospital departments

OBJECTIVE: To our knowledge, there are no studies investigating the non-cognitive symptoms of patients with dementia such as depression, agitation, or delusions among general hospital inpatients. The aim of this study was to investigate the frequency of such non-cognitive symptoms among medical inpatients and to analyze their impact on the length of hospital stay and on admission to nursing homes. METHOD: The sample consisted of 372 elderly inpatients admitted to four internal medical departments (i.e., not including psychiatric wards) in Austria. Patients were investigated by research psychiatrists using the Clinical Interview Schedule. For the analyses of the non-cognitive symptomatology, only marked and severe symptoms were included. To identify predictors for the length of hospital stay and for nursing home placement, multivariate regression procedures were used. RESULTS: Of all inpatients, 27.4% met criteria for dementia according to DSM-III-R. Of those with dementia, 27.8% had marked or severe non-cognitive symptoms. A diagnosis of dementia markedly increased the risk for nursing home referral and prolonged the duration of inpatient treatment. Among the demented, both, cognitive and non-cognitive symptoms turned out to be significant predictors for nursing home placement and for prolonged duration of acute hospital stay, even when controlling for other independent variables. CONCLUSIONS: Non-cognitive symptoms occur frequently among medical inpatients with dementia and considerably increase both the duration of inpatient treatment and the risk of nursing home placement. Since such non-cognitive symptoms are treatable, they should receive attention from the hospital staff.     

Trends in the inpatient mental health treatment of children and adolescents in US community hospitals between 1990 and 2000

CONTEXT: Previous work has demonstrated marked changes in inpatient mental health service use by children and adolescents in the 1980s and early 1990s, but more recent, comprehensive, nationally representative data have not been reported. OBJECTIVE: To describe trends in inpatient treatment of children and adolescents with mental disorders between 1990 and 2000. DESIGN AND SETTING: Analysis of the Healthcare Cost and Utilization Project Nationwide Inpatient Sample, a nationally representative sample of discharges from US community hospitals sponsored by the Agency for Healthcare Research and Quality. PATIENTS: Patients aged 17 years and younger discharged from US community hospitals with a principal diagnosis of a mental disorder. MAIN OUTCOME MEASURES: Changes in the number and population-based rate of discharges, total inpatient days and average length of stay, charges, diagnoses, dispositions, and patient demographic and hospital characteristics. RESULTS: Although the total number of discharges, population-based discharge rate, and daily charges did not significantly change between 1990 and 2000, the total number of inpatient days and mean charges per visit each fell by approximately one half. Median length of stay declined 63% over the decade from 12.2 days to 4.5 days. Declines in median and mean lengths of stay were observed for most diagnostic categories and remained significant after controlling for changes in background patient and hospital characteristics. Discharge rates for psychotic and mood disorders as well as intentional self-injuries increased while rates for adjustment disorders fell. Discharges to short-term, nursing, and other inpatient facilities declined. CONCLUSIONS: The period between 1990 and 2000 was characterized by a transformation in the length of inpatient mental health treatment for young people. Community hospitals evaluated, treated, and discharged mentally ill children and adolescents far more quickly than 10 years earlier despite higher apparent rates of serious illness and self-harm and fewer transfers to intermediate and inpatient care.     

Treatment of schizophrenia: implications derived from an intercultural hospital comparison between Germany and Japan

OBJECTIVES: The study was aimed at evaluating facets of psychiatric inpatient care of patients with schizophrenia in a German and a Japanese hospital. METHODS: Based upon a sample of 865 inpatients of the Psychiatric State Hospital Regensburg (BKR) and 50 inpatients of the Tokyo Women's Medical University (TWMU) admitted in 1997, data of a psychiatric basic documentation system (BADO) were analysed with regard to essential process and outcome indicators. RESULTS: Despite dissimilarities between both patient groups with respect to schizophrenic subtype, duration of illness as well as severity of illness and psychosocial functioning, the differences regarding therapeutic treatment and outcome were marked. In 1997, the rate of atypical neuroleptics was 18% at the BKR and 12% at the TWMU. Inpatients of the TWMU were given benzodiazepines and anticholinergic drugs significantly more frequently. Male patients of the TWMU showed more severe side-effects. Psychotherapy and sociotherapy were less frequently applied at the TWMU. Although the patient groups did not differ with regard to suicidal behaviour and overt aggressions during hospitalisation, we found a higher rate of mechanical restraints at the TWMU. In 1997, the average length of stay was significantly higher at the TWMU (153 days) than at the BKR (52 days), but inpatients of the TWMU improved only slightly better with regard to global psychosocial functioning (GAF) and severity of illness (CGI). CONCLUSIONS: The revealed differences in treatment are likely due to differences in service provision and national practices in Germany and Japan and provide clues for quality improvements. The BADO is a useful tool for continuous quality management and an ongoing international exchange concerning psychiatric inpatient care.     

Sind die Aufenthaltsdauern von psychisch Kranken an internen, chirurgischen und gynäkologischen Abteilungen länger?

Several studies from Anglo-American countries indicate that in non-psychiatric hospital departments mentally ill patients have a longer length of hospital stay than mentally well, while in Austria and Germany, until now, no studies concerning this question exist. Therefore, we investigated the influence of psychiatric comorbidity on the length of stay in 608 patients of medical, surgical and gynecological departments in Vienna and Tyrol. Based on the Clinical Interview Schedule, 28.1% of the patients in this sample suffered from psychiatric disorders. The presence of psychiatric disorders, as well as type of hospital department (medical department), higher age, more previous non-psychiatric treatment periods, and more somatic diagnoses predicted a longer duration of inpatient treatment. To avoid the influence of cofounding variables, psychiatric cases were matched with psychiatric non-cases. The mentally ill group was treated for a markedly longer period as inpatients than the mentally well. Patients with a diagnosis of dementia or of substance abuse showed a significantly increased length of stay, while we could not confirm this for other psychiatric diagnoses.     

Identifying risk factors and key strategies in linkage to outpatient psychiatric care

OBJECTIVE: The substantial failure of psychiatric patients to engage in outpatient specialty mental health care after an acute hospitalization at a time when managed care companies and others increasingly hold hospitals accountable for outcomes underscores the importance of identifying patients at high risk for not completing referrals. This study explored patient risk factors for not completing referrals and examined the success of several interventions targeted to achieving linkage with outpatient care. METHOD: A clinically detailed, structured form was used in abstracting information from the medical records of 229 inpatients with a primary psychiatric diagnosis. Clinicians and staff at outpatient programs were contacted to determine whether patients completed their referrals. RESULTS: Approximately two-thirds (65%) of the patients failed to attend scheduled or rescheduled initial outpatient mental health appointments after a hospital discharge. At high risk for unsuccessful linkage to outpatient care were patients with a persistent mental illness and those who had no prior public psychiatric hospitalization, were admitted involuntarily, and had longer lengths of stay. Controlling for risk factors, three clinical interventions used during the hospital stay more than tripled the odds of successful linkage to outpatient care: communication about patients' discharge plans between inpatient staff and outpatient clinicians, patients' starting outpatient programs before discharge, and family involvement during the hospital stay. CONCLUSIONS: Effective clinical bridging strategies can be used to avoid unnecessary gaps in the delivery of psychiatric services. Incorporating these strategies into routine care would enhance continuity of care, especially for some high-risk patients.     

Psychiatric hospitals in motion

Papers in respect to the topic "On the possibility of influencing the course of psychiatric illness" which were presented at the 5th Steinhof Symposium, October 1979 in Vienna, are summarized with the aim to focus on and to support necessary efforts for an improvement of psychiatric care. Investigations in inpatient populations (Str?mgren, E.: Past and future changes in inpatient population; Gabriel, E.: Modifications in inpatient populations of big psychiatric hospitals) showed the importance of institutional differentiation and the similarity of problems in different countries, e.g. Denmark and Austria is mentioned. The papers of Ciompi (Prognosis in rehabilitation of chronic psychiatric patients) and Pfolz et al. (Factors preventing discharge of long-term inpatients from hospital) summarize concepts of inpatient care. In the papers of Sch?ny et. al. (Ward group therapy--its importance for the opening of psychiatric wards) and Lyon (Supervision of community--auxiliary lay workers) modern concepts of a pragmatic psychiatry are described. Trends in psychiatric inpatient care are becoming apparent which raise the hope that psychiatric hospitals will provide--through the aforementioned differentiation--more adequate care for the individual patient.     

Psychiatric inpatient care and the availability of hospital beds: A comparison of three catchment areas

Tysk L, Wessén B. Psychiatric inpatient care and the availability of hospital beds: A comparison of three catchment areas.

The psychiatric care in Gävleborg county was formerly centralized to a mental hospital and a small psychiatric department at a general hospital. It was then decided that the care system should be reorganized. The county was divided into three catchment areas. Each of these will have a comprehensive psychiatric care with both in- and out-patient facilities, but the intramural care will be reduced considerably. During the reorganization phase an almost experimental situation existed, as accessibility and availability of hospital beds differed among the three sectors. The inpatients for each sector were counted, and some patient characteristics were compared. Except for a considerable difference in the use of hospital beds small differences were otherwise noted. The sector with the smallest number of inpatients had relatively more schizophrenic patients. The accessibility and availability of hospital beds seemed to decide the number of inpatients even when deinstitutionalization was an accepted common goal. Local habits and traditions may also be important.     

A self-report symptom and problem rating scale to increase inpatients' involvement in treatment

OBJECTIVE: The study sought to determine whether psychiatric inpatients who completed a self-report symptom and problem rating scale on admission and reviewed the results with a clinician would perceive at discharge that they had been more involved in their treatment than patients who did not complete the scale. METHODS: In a quasiexperimental design, 109 inpatients were assigned to one of three groups. Patients in one group met individually with a psychiatric resident to review their responses to the Behavior and Symptom Identification Scale (BASIS-32), a self-report outcome assessment tool. Patients' views of their difficulties were then used by the treatment team to build a therapeutic alliance and to inform treatment planning. The remaining two groups received treatment as usual by either a psychiatric resident or an attending psychiatrist. Patients' perceived involvement in decisions about their treatment, perceptions of other aspects of care, and treatment outcome were compared. RESULTS: Patients in the intervention group rated their involvement in decisions about their treatment significantly higher than patients in either of the comparison groups. Patients in the intervention group more frequently reported that they were treated with respect and dignity by the staff than did patients in the comparison group treated by attending psychiatrists. Compared with patients treated by attending psychiatrists, patients treated by residents, whether they received the intervention or not, were more likely to say that they would recommend the hospital to others. Treatment outcome did not differ among the groups. CONCLUSIONS: The results suggest that an outcome assessment tool can be used to engage patients in the treatment process.     

Effectiveness of a High End Users Program for Persons with Psychiatric Disorders

To evaluate the effectiveness of an intensive system of case management for high end users of inpatient care in reducing psychiatric inpatient utilization. A pre-post study design with a contemporaneous comparison group was employed to determine the effects of a State designed intervention to reduce inpatient care for adults with a mental health disorder who had high utilization of inpatient psychiatric care between 2004 and 2007. Logit and negative binomial regression models were used to determine the likelihood, frequency and total days of inpatient utilization in the post period as a function of the intervention. Data from administrative reporting forms and Medicaid claims were used to construct inpatient utilization histories and characteristics of 176 patients. Patients in both groups had a significant reduction in mean inpatient days. However, being in the intervention program did not result in lower odds of being re-hospitalized or in fewer episodes during the study period.     

Have general hospitals become chronic care institutions for the mentally ill?

OBJECTIVE: Dramatic increases in lengths of stay for general hospital psychiatric patients in New York City in recent years have raised speculation that general hospitals are assuming a large responsibility for care of the chronically mentally ill. This study examines changes in utilization patterns and patient characteristics to assess whether such a trend is occurring. METHOD: The authors obtained discharge abstract data for all New York City general hospital adult psychiatric patients in 1985 and 1988 as well as utilization data from the public general hospital system for 1977-1989. Three measures of chronicity were chosen: hospital stays longer than 60 days, discharges to long-term care, and three or more admissions per year. Data on psychiatric diagnoses and comorbid diagnoses for chronically ill patients were also reviewed. RESULTS: The mean length of stay of psychiatric patients in general hospitals has increased substantially in recent years and nearly tripled in the public hospitals during 1977-1989. Between 1985 and 1988, citywide increases were due largely to a growing proportion of patients with very long stays. Patients with stays longer than 60 days accounted for 35% of all inpatient days in 1988, compared with 27% in 1985. Patients with chronic illness accounted for half of all days in 1988, compared with 38% in 1985. CONCLUSIONS: Although many factors have contributed to these trends, the leading cause has been reimbursement policies favoring short-term inpatient care. Improving accountability for community treatment programs will be the key to redirecting funding priorities and creating more appropriate alternatives for the chronically mentally ill.     

Clinical outcomes of a specialised inpatient unit for adults with mild to severe intellectual disability and mental illness

Background   Limitations of general psychiatric services have led to the development of specialised psychiatric programmes for patients with intellectual disability (ID) and mental health needs. Few studies have examined treatment outcomes of specialised inpatient units, and no studies have explored how the effects of intervention may differ for individuals at varying levels of cognitive ability. The present study examined clinical outcomes of inpatients with mild ID in contrast to inpatients with moderate to severe ID within the same service.
Method   Thirty-three patients (17 with mild ID and 16 with moderate to severe ID) discharged between 2006 and 2008 from a specialised inpatient unit in Canada for adults with ID and mental illness were studied. In addition to examining change in scores on clinical measures, outcomes with regard to length of stay, diagnostic change, residential change and re-admission to hospital were explored.
Results   Both groups demonstrated clinical improvement from admission to discharge. However, only patients with mild ID demonstrated improvements on the Global Assessment of Functioning.
Conclusions   This study is one of the first to consider outcomes of higher and lower functioning individuals with ID on a specialised inpatient unit. Results suggest that outcomes may be different for these groups, and some clinical measures may be more sensitive to changes in patients with more severe disabilities.     

Consumer satisfaction at a child and adolescent state psychiatric hospital

OBJECTIVE: This study examined satisfaction with services among patients in a child psychiatric hospital and their parents, and assessed the relationship between consumer satisfaction and the perception of improvement in the problem that led to hospitalization. METHODS: A consumer satisfaction survey developed by the investigators was administered to three sampling waves of child and adolescent psychiatric inpatients (N=157) and their parents or guardians (N=111). Ninety-five percent of patients contacted and 97 percent of their parents or guardians agreed to participate in the study. The survey provided data about the children's and parents' satisfaction with inpatient care and their perceptions of the children's clinical improvement. RESULTS: Most parents and children reported high satisfaction with patient care. Twenty-eight percent of children and 21 percent of parents reported some form of abuse by the staff during the hospital stay. Those who reported abusive behavior were significantly less satisfied with the hospital experience than those who did not report abuse. The participants' perception of clinical improvement was only weakly related to their satisfaction. CONCLUSIONS: Most child psychiatric patients and their parents will participate in consumer satisfaction surveys about inpatient care. Consumers are critical of a hospital if specific prompts in the survey are provided. An unexpectedly high level of consumer-reported abuse was found. Consumer-perceived clinical improvement was only weakly related to satisfaction.     

Length of stay,referral to aftercare,and rehospitalization among psychiatric inpatients

OBJECTIVE: This retrospective study explored the interrelationship among aftercare, length of hospital stay, and rehospitalization within six months of discharge in a sample of psychiatric inpatients. METHODS: Data were analyzed for 1,481 patients who had received inpatient care at a state psychiatric hospital from November 1991 to July 1994. Logistic regression models were estimated to predict the likelihood of referral to aftercare and of readmission to a hospital within six months of the index discharge. Variables controlled for were patients' characteristics; psychiatric status at the time of discharge, including length of stay; and the availability of informal support. RESULTS: Sixteen percent of the patients received a referral to aftercare, and about 13 percent of the patients were readmitted within six months of discharge. White patients were twice as likely as African Americans to receive a referral to aftercare. Length of hospitalization and having a diagnosis of schizophrenia were also predictors of referral to aftercare. Referral to aftercare was not shown to mediate the relationship between length of stay and rehospitalization. However, having a schizoaffective disorder, a poor discharge prognosis, and a high number of previous admissions were associated with an increased risk of readmission. No other demographic characteristics were related to readmission within six months of discharge, but referral to aftercare significantly increased the risk of readmission. CONCLUSIONS: The study suggested the possibility of racial disparities in referral to aftercare and a complex relationship between referral and rehospitalization. Both these findings warrant further investigation that gives particular attention to individual-level indicators of need and system-level barriers to and facilitators of psychiatric care.     

Consultation outcomes. The psychiatrist as consultee

The frequent coexistence of psychiatric and medical illness supports the need for excellent medical care on inpatient psychiatric services. Effective use of consultation is an important element in ensuring this care. In our study of medical-surgical consultation to an inpatient psychiatric service during a two-year period, outcome variables, such as frequency of and concordance with drug and diagnostic action recommendations, were determined and compared with similar data for psychiatric consultations to medical-surgical services. Thirty-eight percent of cases received a consultation. Patients seen by a consultant had a longer hospital stay. Twenty-seven and forty-six percent of consultantions contained a drug or a diagnostic action recommendation, respectively. The concordance of psychiatric consultees was 79% for drugs and 75% for diagnostic action recommendations. Comparison with medical-surgical consultations done by psychiatric consultants revealed important important differences and similarities.