Patient feedback on liaison mental health care in A&E

Standard 4 of the National Service Framework for Mental Health states that all mental health service users should have access to services at all times. Liaison mental health services in A&E departments across the country are central to the realization of this objective. This article reports on a study carried out in an East London A & E departments to evaluate the effectiveness of liaison mental health nursing. Quantitative data was collected on referrals made to the service and qualitative data was collected through interviews with clients and a postal questionnaire to determine client satisfaction.     

Evaluation of an electroconvulsive therapy service in a general hospital

There has been much recent literature on the technical parameters of electroconvulsive therapy (ECT) with regard to improving efficacy and minimizing adverse effects, but relatively little on ECT service delivery. This paper will discuss the development and characteristics of an ECT service at a teaching hospital in metropolitan Sydney, New South Wales, Australia. A mixture of qualitative and quantitative methods, including a selective literature review and audit of ECT use were used. The results of the audit were compared with the 2007 revision of the Royal Australian and New Zealand College of Psychiatrists' clinical memorandum on ECT. We discuss issues, such as the optimal site for ECT delivery, ECT mental health nurse coordinator role, credentialing of psychiatrists, registrar supervision, and the development of an ECT committee. A significant finding of the audit was that the majority of patients were treated under the New South Wales Mental Health Act, and voluntary patients were more likely to have a diagnosis of a depressive disorder, whereas involuntary patients were more likely to have a non-mood disorder diagnosis. This study has shown that auditing of ECT practices and services by mental health nurses is essential for quality improvement processes. The audit highlighted areas of service delivery that should be subject to review and evaluation against professional standards.     

Audit: an exploration of two models from outside the health care environment

Whilst there has been exponential growth in auditing health care services and a proliferation of the instruments involved, there seems to have been less cross-fertilization of audit systems and instruments between health care environments and other environments. This paper identifies and explores two audit systems and instruments outside the health care environment. The objective is to seek to improve the level of common understanding, communication and collaboration amongst those who are interested or involved in audit in any sector of the economy. This exercise offers an opportunity and incentive for cross-fertilization of ideas with respect to audit concepts, systems, instruments, results and experiences. Yet there is a more fundamental question to be considered: why bother with audit? This paper identifies core reasons for performing audit which, although they have been mentioned elsewhere, are worth recalling once again. The two non-health care audit systems and instruments are then identified and explored. On the one hand it is seen that the two audit systems and instruments outside health care have common features with audits in health care. On the other hand, it is also suggested that there are some significant differences in the two audit systems and instruments when compared to health care audits. This paper identifies and discusses similarities and differences. Finally, if we fail to learn from the mixture of experiences and insights of various audit exercises, not only will be doing our professions and our customers a disservice but we will lower the chances of continuous improvement in knowledge and understanding.     

Improving and standardizing metabolic screening for people prescribed antipsychotic medication who are at risk of developing metabolic syndrome within the community mental health setting

Aim and objective of the audit. The purpose of this audit was to identify the number of people prescribed antipsychotic medication who are at risk of developing metabolic syndrome in a community mental health service area with the aim of improving and standardising metabolic screening practices within this setting. Community mental health services are secondary care services in which individuals are referred from Primary Care (General Practitioners). The catchment area of this audit is within the South East Region of Ireland and offers adults community mental health services to a population of approximately 57 000. For the purpose of this audit we focused on one community mental health team within the service.     

Characteristics of an Accident and Emergency liaison mental health service in East London

AIM OF THE STUDY: To analyse the work of a liaison mental health service at the Accident and Emergency (A & E) department of a hospital in East London. BACKGROUND: The English National Service Frameworks (NSF) for Mental Health recommend that A & E departments provide liaison mental health services and this study reports how a service in East London is responding to this challenge. RESEARCH METHODS: Data were collected during a 14-month period using a specially designed audit form. RESULTS: The typical referral was aged 36, of either sex, United Kingdom (UK) non-White with a diagnosis of depression. The majority of referrals were in the afternoon and seen immediately. A slight majority were known to mental health services; many were new referrals. Older and male clients were more likely, and Bengali and other Asian clients were less likely, to be registered with a psychiatrist. There were seasonal variations in referral type. Emergency referrals tended to have a diagnosis of schizophrenia; urgent and non-urgent referrals were more likely to be depressed. The outcome for the majority of referrals was referral to appropriate community services. The majority of non-clinical referrals were for advice, information and support. DISCUSSION AND CONCLUSIONS: The service seems a useful resource for A & E staff, and clients with mental health problems. The service is a channel through which people access mental health services and appears to address the NSF for Mental Health.     

An evaluation of services for women with long-term mental health problems

This paper presents the results of an evaluation study of services for women with long-term mental health problems. The study, which was conducted in a long-term rehabilitation and community care service, examined the adequacy, accessibility, and responsiveness of services provided for women users; explored differences between the men and women using the service and those newly admitted to it; and explored the views and experiences of service providers and the women users themselves. The results of the study confirm and extend those of previous studies and suggest a number of service recommendations. The unevenness in attention to the needs of women across services needs to be addressed. Services should be more attractive to women. Agencies and facilities for women outside mental health services should be supported to ensure the they can accommodate women with long-term mental health problems, and the women themselves need to be offered the support necessary to ensure they have access to such facilities. Finally, efforts must be made to ensure that services both recognize the losses that women with long-term mental health problems have experienced and foster their continued hopes and aspirations for the future.     

Perceived barriers to mental health service use among individuals with mental disorders in the Canadian general population

BACKGROUND: Eliminating barriers to care is important for improving health service use. However, the barriers to mental health care have not been well investigated. OBJECTIVES: This study was designed to provide information about the barriers to mental health service use and to identify clinical factors associated with perceived barriers among individuals with depressive-, anxiety-, and substance use-related disorders in the communities. DESIGN: A cross-sectional analysis using data from the Canadian Community Health Survey-Mental Health and Well-being was instituted. SUBJECTS: Participants with depressive-, anxiety-, and substance use-related disorders in the past 12 months, assessed by the World Mental Health-Composite International Diagnostic Interview, were included (n = 4094). RESULTS: In participants with mental disorders, 19.5% reported barriers to mental health service use. The percentage of perceived barriers due to acceptability was higher than those for barriers due to accessibility and availability. Participants with comorbid mental disorders were more likely to have experienced barriers than those with one disorder in both mental health service users and in the nonusers. Role impairment was a significant factor predicting barriers to care, overall and in the service nonusers, in the groups having anxiety disorders only, having any depressive or anxiety disorders, and having any alcohol or drug dependence. CONCLUSIONS: Clinical characteristics play an important role in perceiving barriers to mental health care. Future efforts should pay particular attention to the needs of those with chronic and severe mental health problems and focus on improving the effectiveness of mental health services.     

An audit of interventions for dual diagnosis in a psychiatric unit

A programme of training on dual diagnosis was implemented for mental health nurses working in an acute psychiatric unit following recommendations at both a national and local level. An audit of the key standards was carried out to examine the interventions offered to patients with a dual diagnosis. An improvement was observed in the standards of care, but the sample size was small and without further statistical analysis it would be difficult to determine whether the improvement is statistically significant.     

The multidisciplinary approach to mental health crisis management: an Australian example

Changes within the Australian health care system have led many people with mental health disorders to use emergency departments as the point of access to mental health services. Staff in emergency departments are not necessarily equipped to assess the needs of such clients. This paper briefly describes the development of a multidisciplinary mental health liaison team, within the emergency department of one hospital in Sydney, which was designed to assist both staff and clients. Available evidence suggests the implementation of the team has been a success, however, more research is required to confirm the effectiveness of this approach. Questions are raised about appropriate referral and follow-up for some clients. The study also found deficiencies in the method of routine data collection (Emergency Department Identification System), which makes formal auditing of the team and the services it provides a difficult task.     

Lived experience of involuntary transport under mental health legislation

Police have historically been responsible for transporting people during a mental health crisis in Australia. A major change to the New South Wales (NSW) Mental Health Act (MHA) in 2007 expanded the range of coercive transportation agencies to include NSW Ambulance (paramedics) and NSW Health (mental health nurses). Anecdotal reports, however, describe a lack of clarity around how these changes should be implemented in practice. This research aims to explore this lack of clarity through qualitative analysis of interviews with people with the lived experience of involuntary transport under the MHA. Sixteen interviews were conducted; most (n = 14) interviews in northern NSW regions: six with people who had been transported (consumers), four with carers, and six with service providers (two police, one paramedic, and three mental health nurses). For consumers and carers, the police response was often perceived as too intense, particularly if the person was not violent. Carers were often conflicted by having to call for emergency intervention. Service providers were frustrated by a lack of a coordinated interagency response, resourcing issues, delays at emergency departments, and lack of adequate training. A central theme across all groups was the importance of communication styles. As one participant (consumer) said: ‘Everybody needs a lesson in kindness’. All groups agreed that high‐risk situations necessitate police involvement. However, invocation of the MHA during a high‐risk situation is fraught with stress and difficulties, leaving little room for empathetic communications. Effective and diverse, evidence‐based, early intervention strategies – both consensual and non‐consensual – are necessary to reduce the requirement for police involvement in mental health transports.     

Redesigning acute mental health services: an audit into the quality of inpatient care before and after service redesign in Grampian

Redesigning acute mental health services: an audit into the quality of inpatient care before and after service redesign in Grampian As part of the redesign of adult mental health services in Grampian and in line with the Scottish Framework for Mental Health (1997), the decision was made to close one of the five acute mental health admission wards within Royal Cornhill Hospital. Inpatient services were to be provided within the remaining four admission wards by increasing their bed compliment from 25 to 28 and by increasing the staffing compliment of the community mental health teams serving Aberdeen city and Aberdeenshire. The adult mental health directorate commissioned an audit to measure certain key items in the 6 months leading up to the redesign and in the 6 months post redesign. This audit focused on the number of admissions, the bed occupancy, the number of incidents, the number of days the ward doors were locked, observation levels, sickness levels and the number of bank hours used. These factors were felt to be important indicators in the monitoring of the quality of patient care as any increase in the instance of these factors could be seen as detrimental to patient care. Therefore, a comparison of these factors, pre- and post-ward closure, was seen as a useful method of assessing the effect of the ward closure and the subsequent loss of seven acute inpatient beds. As the results of the audit showed that the rate of these factors had not increased, it was assumed the quality of care in the inpatient service was as at least as good following the redesign as it was before it. Two issues arose from the audit that merit further discussion, that is, the differences in the numbers of observations and in the numbers of times the ward doors were locked. Two G grade community psychiatric nurses were employed on a 0.5 session per week basis to collect and collate the data.     

How effective are mental health nurses in A&E departments?

Background

A&E departments are key points of contact for many people with mental health problems. Various models of care have been developed in A&E departments for delivering mental health services, but few have been assessed for effectiveness. The present study aimed to assess the impact of a dedicated A&E psychiatric nurse service on several outcomes relevant to patients and clinicians.

Methods

A crossover design was used to introduce a dedicated psychiatric nurse service (comprising four experienced community psychiatric nurses) into two busy UK A&E departments. Standardised assessments were completed for each patient, and a random sample of these independently assessed for quality. Data were also collected on the number of patients assessed, psychiatric nurse time employed, waiting times, onward referrals, repeat attendances, patient satisfaction, and staff views.

Results

A&E staff referred about a third of patients judged to have mental health problems to the psychiatric nurse service; approximately half of those assessed had a psychiatric history. On average, assessments took 60 min and over 90% of the formulated management plans were judged appropriate by independent assessors. The psychiatric nurse intervention had little impact on waiting times or satisfaction levels for mental health patients, although there was evidence of a change in onward referral patterns.

Comment

Psychiatric nurse assessment services have been introduced in many A&E departments, although the evidence base for the effectiveness of this development is not well established. This study presents evidence that psychiatric nurses can provide an accurate assessment and referral service with advantages for patient care.     

Measuring how well the NHS looks after its own staff: methodology of the first national clinical audits of occupational health services in the NHS

Rationale, aims and objectives Little is known about the quality of occupational health care provided to National Health Service (NHS) staff. We designed the first national clinical audits of occupational health care in England. We chose to audit depression and back pain as health care workers have high levels of both conditions compared with other employment sectors. The aim of the audits was to drive up quality of care for staff with these conditions. The object of this paper is to describe how we developed an audit methodology and overcame challenges presented by the organization and delivery of occupational health care for NHS staff. Methods We designed two retrospective case note audits which ran simultaneously. Sites submitted up to 40 cases for each audit. We used duplicate case entry to test inter‐rater reliability and performed selection bias checks. Participants received their site's audit results, benchmarked against the national average, within 4 months of the end of the data entry period. We used electronic voting at a results dissemination conference to inform implementation activities. Results Occupational Health departments providing services to 278 (83%) trusts in England participated in one or both audits. Median kappa scores were above 0.7 for both pilot and full audits, indicating ‘good’ levels of inter‐rater reliability. In total, 79% of participants at a dissemination conference said that they had changed their clinical practice either during data collection (52%) or following receipt of their audit results (27%). Conclusions Clinical audit can be conducted successfully in the occupational health setting. We obtained meaningful data that have stimulated local and national quality improvement activities. Our methodology would be transferable to occupational health settings outside the NHS and in other countries.     

Nurses' practice in health audit

The objective of this investigation was to identify nurses' practice in heath audit. The hermeneutic-dialectic method was used for the analysis. The study was performed in three loci: the internal audit service of a hospital; the external audit service of a private health service buyer, and the state audit service of the public health system (SUS, acronym in Portuguese for Sistema Unico de Saúde-Unique Health System), in Bahia. Nine audit nurses were interviewed. In the SUS audit, the nurses report being fulfilled with their practice and with the valorization of their professional role. In the private audit--both inside and outside of health organizations--the nurses' activities are focused on meeting the interests of their contractors, and do not get much involved with the care delivered by the nursing team and with the needs of service users.     

Mental Health Nurse Incentive Program: Facilitating physical health care for people with mental illness?

People with serious mental illness have increased rates of physical ill‐health and reduced contact with primary care services. In Australia, the Mental Health Nurse Incentive Program (MHNIP) was developed to facilitate access to mental health services. However, as a primary care service, the contribution to physical health care is worthy of consideration. Thirty‐eight nurses who were part of the MHNIP participated in a national survey of nurses working in mental health about physical health care. The survey invited nurses to report their views on the physical health of consumers and the regularity of physical health care they provide. Physical health‐care provision in collaboration with general practitioners (GPs) and other health‐care professionals was reported as common. The findings suggest that the MHNIP provides integrated care, where nurses and GPs work in collaboration, allowing enough time to discuss physical health or share physical health activities. Consumers of this service appeared to have good access to physical and mental health services, and nurses had access to primary care professionals to discuss consumers’ physical health and develop their clinical skills in the physical domain. The MHNIP has an important role in addressing physical health concerns, in addition to the mental health issues of people accessing this service.     

Strike contingency planning.

On Monday, February 26, 1996, the Ontario Public Service Employees Union (OPSEU) went on strike. The month-long strike included the 10 provincial psychiatric hospitals in Ontario. Within the psychiatric hospitals, the included direct care providers--RNs, RPNs, psychologists, social workers, occupational therapists--as well as support workers (food service, maintenance, housekeeping, and office employees). In anticipation, the mental health program at the London Health Science Centre (LHSC) developed a contingency plan that went into action when the strike was announced. This paper outlines the plan, describes what happened and makes recommendations for nurses who may be faced with similar situations.