Predicting community tenure in patients with recurrent utilization of a psychiatric emergency service

OBJECTIVE: Factors determining community tenure (CT) between subsequent referrals to a psychiatric emergency room (PER) are only partly understood. We investigated the differential effect of patient and health system characteristics on the CT of patients with a previous referral to a PER. METHOD: Data were collected for patients with a history of PER referrals (N=531) in a university hospital in Leuven, Belgium, between March 2000 and March 2002. Using logistic regression analysis, we compared patients with a short (<2 months), intermediate (2--12 months) and long (>or=12 months) CT between previous and current referrals. RESULTS: A short CT (53% of the patients) was predicted by not receiving aftercare at the previous PER visit (OR=6.43) or by not complying with recommended aftercare (OR=3.89). An intermediate CT (38% of the patients) was predicted by an adjustment disorder (OR=6.72) or a substance use disorder (OR=3.47) or by the absence of a mental disorder (OR=4.13). Nine percent had a long CT. Protective factors of a long CT were noncompliance with aftercare at the last PER visit (OR=0.09) and currently being in outpatient treatment (OR=0.05). CONCLUSION: For patients with a previous use of a PER, short CT was highly influenced by aftercare arrangements and not by clinical characteristics.     

Who comes from where and who goes where? Treatment methods for psychiatric inpatients

Based on data of the psychiatric basic documentation of 4066 patients, predictors of type of referral as well as outpatient aftercare were analyzed by means of logistic regression analyses. Of the patients, 25.7% were admitted without any referral, 18.4% were referred by a general practitioner, and 9.8% by a psychiatrist in private practice. Patients referred by a general practitioner suffered more frequently from an affective disorder or schizophrenia and were residents of senior citizen homes. Inpatients sent by a psychiatrist were more often residents of sheltered homes, showed a present episode lasting more than 3 months, and had undergone psychopharmacological pretreatment with an atypical antipsychotic or SSRI. Outpatient aftercare was recommended to 83.1% of inpatients: 49.4% by a general practitioner and 32.1% by a psychiatrist in private practice. Outpatient aftercare by a general practitioner was more frequent in the elderly and patients with addiction disorders. Referral by a psychiatrist in private practice as well as schizophrenia or an affective disorder led more often to outpatient aftercare by a psychiatrist. The small number of patients referred by general practitioners and psychiatrists in private practice has to become the focus of quality management.     

Who visits the psychiatric emergency room for the first time?

OBJECTIVE: To examine patient and system characteristics of first-time ("incident") vs. recurrent ("recurrent") use of a psychiatric emergency room (PER). METHODS: Data on demographic and clinical characteristics and health service utilization were collected for incident and recurrent users (n=3,719) who visited the PER of the university hospital in Leuven, Belgium, between March 2000 and March 2002. RESULTS: About 64% (n=2,368) were incident and 36% (n=1,351) were recurrent users. The PER was the first treatment setting ever for 50% of the incident users. Incident users were most likely over 69 years (OR=2.84, P<0.001), employed (OR=2.21, P<0.001), or referred by a health care professional (OR=1.72, P<0.001). They were less likely to have a personality disorder (OR=0.40, P<0.001) or to have used inpatient or outpatient services in the past (OR's 0.11 and 0.65, respectively, P<0.001). About 44% were admitted, 38% referred for outpatient treatment, 9% referred to the outpatient crisis-intervention program, and 9% refused any follow-up. CONCLUSIONS: The PER was a first treatment setting ever for 1 in 3 patients. Incident and recurrent users differed in sociodemographic characteristics, pathways to care, service use, and the presence of a personality disorder. They did not differ in axis 1 disorders, comorbid mental disorders, or pathways after care.     

Attempted suicide and psychiatric consultation.

This study investigated the differences in clinical characteristics between suicide attempters referred or not referred to psychiatric consultation after a suicide attempt and factors affecting such referral to psychiatric aftercare after attempted suicide. All 1198 consecutive suicide attempters treated in hospital emergency rooms in Helsinki during a 12-month period were identified. Data were gathered on any psychiatric consultation after the attempt and on all health care contacts 1 year before and after the index attempt. We found that half of the suicide attempters who were not referred to psychiatric consultation were without any aftercare recommendation and treatment contact soon after their attempt. Factors predicting referral to psychiatric consultation were age, psychotic disorder, lack of substance use disorder and, most strongly, the hospital where the suicide attempt was treated. Although the characteristics of a patient attempting suicide do play a role in determining whether a psychiatric consultation will take place or not, the most important factor is the consultation practices of the particular hospital. This in turn influences the probability of adequate aftercare.     

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.     

Hospitalized patients and alcohol: who is being missed?

Research and clinical experience have shown that alcohol use disorders are neither sufficiently identified nor addressed in hospitalized patients. This study sought to quantify and localize these missed opportunities. The setting was an urban medical center with a Level 1 trauma designation. The only eligibility requirement was a Blood Alcohol Level (BAL) greater than 300 ng/dl upon hospital admission, a "nonsubtle" value more than three times the legal intoxication limit. Charts [58] were retrospectively reviewed for treating service (medical, trauma services, or psychiatric) and evidence of psychological signs or behavioral symptoms of withdrawal. Also assessed were the presence or absence of withdrawal monitoring, withdrawal prophylaxis orders, inpatient addictions consultation, and referral for addictions aftercare. Numerous patients with admission BALs >300 failed to be identified as needing assessment for alcohol-related disorders. Patients admitted to medical or psychiatric services were significantly more likely to be diagnosed than those on trauma services (P =.02). Patients on medical or psychiatric services were also more likely to be assessed for withdrawal and referred for after-care (P <.0001) than those cared for on trauma services. The delivery of care for alcohol-related disorders was deficient, particularly for patients with traumatic injuries, even among patients severely intoxicated at admission. Failure to identify such patients represented a missed opportunity to address this vital contributor to trauma. It is suggested that both the origins of this shortfall and its resolution depend not just upon trauma providers but upon the entire medical system.     

Utilization of an evening/night hospital: first two years of operation

This study examined the utilization of an integrated evening/night hospital by 234 psychiatric patients referred to the hospital during its first two years of operation. Neither age, sex, marital status, referral source or diagnosis were related to utilization. However, patients whose previous treatment involved traditional psychiatric care, either inpatient or outpatient, were less frequently admitted and less likely to complete the program once admitted, than were those patients reporting either day hospitalization or no treatment prior to their admission. There were steady increases in the number of referrals, number of different referring agents, average length of stay and average daily census as the program matured during the first two years of operation. While these data indicated an increase in the utilization of the evening portion of the program, there was a commensurate decrease in the utilization of the night portion of the program. As a result, the provision of overnight accommodation has been discontinued altogether.     

Determinants of indicated versus actual level of care in psychiatric emergency services

OBJECTIVE: This study was undertaken to improve understanding of the admission decision process by distinguishing between the clinically indicated level of care and actual level-of-care decisions in emergency psychiatry. METHODS: Clinicians in emergency psychiatric services in Rotterdam, The Netherlands, prospectively rated 720 patients by using the Severity of Psychiatric Illness Scale and collected information on demographic, clinical, and contextual parameters. The clinically indicated level of care and actual level-of-care decisions were studied independently, by using multivariate logistic regression analyses. The decision-making process was divided into three consecutive steps: evaluation of clinically indicated inpatient or outpatient level of care (step 1), voluntary or involuntary admission (step 2), and actual admission of patients for whom voluntary admission was indicated (step 3). RESULTS: Each step was determined by separate factors. Specifically, clinically indicated admission (step 1) was associated with family or friends' desire for admission (odds ratio [OR]=3.7), previous admissions (OR=2.9), symptom severity (OR=2.7), and personality disorder (OR=.4). Involuntary admission (step 2) was associated with lack of motivation (OR=5.7), symptom severity (OR=3.7), time of referral (OR=3.5) and danger to self or others (OR=2.7). Actual voluntary admission (step 3) was associated mainly with bed availability (OR=8.7). The overall percentage of correctly predicted cases was 82 percent for all steps in the decision process. CONCLUSIONS: This study showed that each step in the admission decision process is determined by a unique set of variables and provided evidence that contextual factors influence decision making. Guidelines for voluntary admission and civil commitment need to be based on the results of studies that distinguish between the clinical needs of patients and contextual factors.     

Crack/cocaine abusers in the general hospital: assessment and initiation of care.

OBJECTIVE: Cocaine, either smoked (as "crack") or taken intranasally, is now a common cause of psychiatric illness. This study was designed to assess the impact of cocaine abuse on a general psychiatric service and an obstetrics service in an urban general hospital and to evaluate a program for engaging affected patients in addiction treatment. METHOD: The charts of 300 general psychiatric patients (not admitted for addiction treatment) and 60 cocaine-abusing prenatal or postpartum patients were reviewed. A treatment referral program based on professionally directed peer leadership was established for patients with cocaine abuse. Results of evaluation and referral of 100 other cocaine-abusing psychiatric patients and the 60 prenatal or postpartum patients were then determined. RESULTS: Fully 64% (N = 191) of the 300 psychiatric patients were diagnosed as substance abusers; 38% (N = 113) of them abused cocaine. Almost one-third of these cocaine abusers had no axis I diagnosis other than substance abuse/dependence, and the majority were homeless. Urine samples were positive for cocaine in a majority of the obstetric patients studied. A majority of the psychiatric patients who were referred through the peer-led program enrolled in outpatient cocaine treatment--three times as many as in the chart review group. Most of the obstetric patients suitable for referral enrolled for treatment as well. CONCLUSIONS: Cocaine abuse may be responsible for a large portion of psychiatric admissions in urban public general hospitals. Cocaine abusers in psychiatric and obstetrics services are apparently responsive to a peer-oriented mode of referral into treatment.     

Is assessing for borderline personality disorder useful in the referral after a suicide attempt?

BACKGROUND: Management of suicide attempters accounts for 10% of the psychiatric activity in the emergency room. In this population, the prevalence of borderline personality disorder (BPD) is high (10 - 55%). These patients present poorer psychosocial outcome and more frequent suicide attempts repetitions. However, the utility of the assessment of BPD in the referral to a specific treatment plan has not been yet studied. OBJECTIVE: To examine the association between the assessment of a diagnosis of BPD after a suicide attempt and the referral from the emergency room to a specific treatment plan. HYPOTHESIS: Suicide attempters with BPD, according to clinicians diagnosis, differ in terms of severity from those without more risk factors of suicide attempt repetitions and poorer psychosocial functioning, and in psychiatric referral from the emergency room. METHOD: Our case-control study took place during 10 months in the Geneva general hospital. We continuously enrolled patients admitted to the emergency room for deliberate self poisoning and separated them into two groups (BPD and control) according to the clinician's diagnosis. Data from medical records were systemically and anonymously gathered. We compared BPD patients' socio-demographic and clinical characteristics, as well as psychiatric referral, with the control group. RESULTS: Of the 478 subjects admitted to the emergency room for deliberate self-poisoning, 99 (22.6%) were diagnosed BPD by clinicians. Compared to controls, they were more frequently female (OR=3.9) and living alone (OR=3.8) and more often resorted to psychiatric care (OR=2.9), notably to emergency care (OR=3.8). Past history of suicide attempt was also more frequent (OR=1.9) as was the use of neuroleptics in the attempt (OR=2.7). No difference was detected in terms of psychiatric referral after emergency room care. CONCLUSION: Even if borderline personality disorder in suicide attempters is associated with more severity criteria, it is not associated with a referral to a specific treatment plan.     

Referral pattern of neurological patients to psychiatric Consultation-Liaison Services in 33 European hospitals.

The referral pattern of neurological patients to 33 European psychiatric consultation-liaison (C-L) services in the general hospital was examined. Analyses were conducted on the ECLW CS data set, which consists of 14,717 psychiatric C-L referrals made in 56 European hospitals during 1991. Psychiatric referrals of patients admitted to neurological wards were compared to referrals from other wards. Information was obtained from 33 neurological wards, consisting of 34,506 neurological admissions. Of these admissions, 839 were referred to C-L psychiatry. The median consult rate among the hospitals was 1.8%. Compared to other hospital wards, patients referred from neurology were more frequently diagnosed as suffering from somatoform (P<.01) and dissociative disorders (P<.01), and less from substance abuse (P<.01) and delirium (P<.01). Referral to C-L psychiatry from neurological wards is characterized by an underestimation of psychiatric co-morbidity and a late detection, comparable to other medical specialties. An appeal is made for a standardized referral procedure including admission screening method, detecting patients at risk for nonstandard care during their hospital admission.     

A follow-up of chronic patients committed to outpatient treatment

Data collected in a statewide study of psychiatric patients involved in civil commitment hearings in North Carolina were used to evaluate the effectiveness of outpatient commitment as a less restrictive alternative to involuntary hospitalization. Six months after the commitment hearings, outcome data for patients who were committed to outpatient treatment were compared with outcome data for patients who were released and patients who were involuntarily hospitalized. All three groups comprised patients who were chronically mentally ill, had previously been hospitalized, and had histories of medication refusal and dangerousness. Patients who were committed to outpatient treatment were significantly more likely than patients with the other two dispositions to utilize aftercare services and to continue in treatment.     

Suicide after discharge from psychiatric inpatient care: a case-control study in Hong Kong

OBJECTIVE: To identify the risk period and the risk factors for suicide in Chinese psychiatric patients after discharge from inpatient psychiatric treatment. The nature of psychiatric aftercare provided to these patients was also explored. METHOD: A case control study with 73 patients who were discharged from a large psychiatric unit in Hong Kong between January 1996 and December 1999 and had received coroners' verdict of suicide or undetermined death within the same period. Controls were 73 surviving patients discharged from the same unit. They were individually matched for sex, age, psychiatric diagnosis, and date of discharge. RESULTS: Post-discharge clustering of suicides was observed among the cases. Nearly 80% of them died within 1 year of discharge. The most common principal diagnosis among the cases was schizophrenia and related psychotic disorders. Multivariate analysis showed that suicide was associated with: unemployment (OR = 12.2, 95% CI = 2.1 - 70.4), past suicidal attempts (OR = 3.4, 95% CI = 1.2 - 9.6), maternal mental illness (OR = 13.4, 95% CI = 1.0 - 170.0), and suicidal ideation or attempt before the last admission (OR = 5.0, 95% CI = 1.4 - 18.0). The psychiatric aftercare received by cases and controls were generally similar. However, cases were more likely to have had contact with health care services in the last week before death (OR = 4.0, 95% CI = 1.3 - 11.9). CONCLUSIONS: Suicidal risk is high in Chinese psychiatric patients soon after discharge. They share some common risk factors for suicide identified in Western studies but several differences are evident: the predominance of schizophrenia in the suicides; the lower prevalence of substance abuse and comorbidity; the low proportion of patients living alone; and the increased clinical contact before death but the less suicidal intent expressed in Chinese patients. It is necessary to consider these socio-cultural factors in assessment of suicidal risk and implementation of suicide prevention strategies in Chinese psychiatric patients.     

The children of the Lundby study as adults: A salutogenic perspective

In this study, 100 patients consecutively admitted to four child psychiatric inpatient wards in Finland were prospectively followed 12 months after discharge from short-term inpatient treatment. It turned out that 50 patients were discharged back to their previous residence and to outpatient treatment, 40 patients were admitted to long-term inpatient treatment and 10 patients were placed in some institution. The child's antisocial behaviour on admission was the strongest determinant for long-term treatment or placement at the 12 month follow-up. Other predictors of long-term treatment or placement in an institution included a high total score in teacher's behaviour ratings, being referred by a psychiatric agency and living in a semi-rural area. No statistically significant relationship was found in the child's age, gender, parents' education level or occupation, family characteristics, total life events, parent's ratings of total behaviour, total life events, parent's ratings of total behaviour, CGAS ratings by a clinician or a wide range of treatment variables.     

Management of suicide attempts in Italy and Sweden. A comparison of services offered to consecutive samples of suicide attempters

The aim of the study was to compare the management of suicide attempts by patients in Sweden and Italy with a view to providing a perspective on differences in treatment. Two consecutive samples of suicide attempters from Huddinge (n=97) and Padua (n=100) were studied in terms of sociodemographic characteristics, previous care, referral, medical and psychiatric care, hospitalization, aftercare, and short-term compliance. In Italian somatic management of acute suicidal crises, there are more physicians specializing in anesthesia or internal medicine working in ambulances and emergency wards, and there is a heavier emphasis on somatic care. Swedish management procedures seem to entail more medical examinations and biohumoral tests. Moreover, the procedures at the Swedish hospital give priority to early psychiatric intervention, and admission to psychiatric inpatient care is more frequent. However, it is not normal practice in emergency psychiatric care at either of the centers for specialists to serve in the immediate liaison consultation. There are differences in assessment and treatment between the two countries that may provide a perspective on their procedures, implying that current procedures for managing patients belonging to groups identified as “high-risk” in terms of suicide may be modified.     

Prädeliktische Behandlungswege schizophrener Patienten der forensischen Psychiatrie

Background

The number of schizophrenic patients admitted to forensic hospitals according to section 63 of the German Criminal Code has increased continuously over the past years. Prior to admission to a forensic ward, two thirds of schizophrenic patients have been admitted to a general psychiatric institution at least once. Among other factors, forensic admission is seen as a consequence of insufficient pretreatment in general psychiatry. This study aims to identify differences regarding the history of treatment of forensic and general psychiatric patients diagnosed with schizophrenia.

Method

The matched samples include 72 male patients from forensic wards and 72 male patients from general psychiatry diagnosed with schizophrenia. The history of psychiatric treatment was reconstructed by interviewing the patients as well as the outpatient psychiatrists and by analyzing these patients’ medical records.

Results

Both groups showed similar risk factors, however, forensic patients had a higher number of previous convictions and were convicted more often for violent offences. Furthermore, the data indicate that forensic patients are less integrated into psychiatric care and showed a lower rate of treatment compliance prior to admission to a forensic ward.

Conclusions

The results provide support for the arrangement of an intensive outpatient aftercare, especially for schizophrenic patients with comorbid substance abuse disorders and previous convictions for violent offences.     

Alcohol use predicts emergency psychiatric unit admission for non-fatal suicidal behaviour in the Western Cape (South Africa): a case–control study

Abstract

Objective: We aimed to describe patterns of substance use among patients admitted to an emergency psychiatric unit for non-fatal suicidal behaviour (NFSB) or another psychiatric reason and establish whether there were significant differences in patterns of substance use between the two groups.

Methods: We employed a case–control design (N?=?50) and collected data about participants' substance use in Cape Town, South Africa. Data were analysed using Chi-square and Mann–Whitney tests, factor analysis, and logistic regressions.

Results: Prevalence of lifetime Alcohol Use Disorder (AUD) was 60% in the NFSB group and 28% in the control group. 12% of the NFSB group and 20% of the control group had a lifetime Tobacco Use Disorder. Prevalence of lifetime illicit Substance Use Disorder was 44% in the NFSB group and 60% in the control group. Hospital admission for NFSB was associated with: any past 24-hour alcohol use; quantity of past 24-hour alcohol use; quantity of past-month alcohol use; lifetime AUD; past 12-month AUD; and current AUD; and was not associated with the use of any other substances (p<.05). Past 12-month AUD was the best predictor of hospital admission for NFSB, controlling for, respectively, any past 24-hour alcohol use (aOR = 13.33, p?=?.023) and quantity of past 24-hour alcohol use (aOR = 9.01, p?=?.022)

Conclusions: Patients admitted to emergency psychiatric units for NFSB have increased needs for the treatment of AUDs compared to patients admitted for another psychiatric emergency. Findings support calls for interventions to prevent NFSB among psychiatric patients with a history of AUD.

• Key points

• Rates of substance use among patients admitted to emergency psychiatric units in South Africa were high compared to the general population.

• Hazardous alcohol use was uniquely associated with hospital admission for non-fatal suicidal behaviour compared to another psychiatric emergency.

• Tobacco use and illicit substance use were not associated with hospital admission for non-fatal suicidal behaviour compared to another psychiatric emergency.

• The association between hazardous alcohol use and hospital admission for non-fatal suicidal behaviour did not appear to be affected by demographic variables.

• Patients admitted to hospital for non-fatal suicidal behaviour have increased needs for the treatment of alcohol use disorders compared to other psychiatric patients.

     

The Nordic Comparative Study on Sectorized Psychiatry: continuity of care related to characteristics of the psychiatric services and the patients

The problem addressed in this paper is how continuity of care is related to characteristics of psychiatric services, previous events in a patient's pattern of care and patient characteristics. The present paper is a part of a Nordic Comparative Study on Sectorized Psychiatry in seven catchment areas in four Nordic countries. One-year-treated-incidence cohorts were used. Each patient was followed for 1 year after the first contact with the psychiatric service. Continuity of care was measured by the time from discharge from hospital to the first subsequent day-patient or outpatient contact. Notable findings were large differences in the continuity of care in the seven services, high proportions of discharges without any aftercare contacts and long time lags between discharges and aftercare contacts in most of the catchment areas. A Cox regression analysis revealed that aftercare following hospitalisation seems to be more probable if the outpatient services are located geographically close to the patients, if the hospitalisation lasted between 2 and 4 weeks, if there was a community care contact shortly before the hospital admission and if the patient is not retired and not divorced. Staff resources were not related to continuity of care. Accepted: 14 March 1998     

Non-compliance in community psychiatry: Failed appointments in the referral system to psychiatric outpatient treatment

Knowledge about the drop-out pattern of psychiatric patients in the referral phase for outpatient treatment is limited. The aim of the present study was to investigate the importance of selected psychiatric, demographic and administrative parameters in this matter. In a newly opened community psychiatric unit with an open referral system, available relevant data concerning the referred patients were gathered over a 6-month period. Of the 137 patients included in the study, 32% did not show up for their first appointment. On making further attempts to contact the patients, the drop-out frequency dropped to 16%, demonstrating that it is worthwhile offering new appointments to the patients who do not show up. There was no demonstrable relation between the time the patients had waited for the first appointment with a psychiatrist and the drop-out frequency. For patients who had been referred with a diagnosis of psychosis (F 20-29, WHO criteria), or addiction, or had been previously admitted to psychiatric hospital, there was a significant increase in the drop-out rate.     

The Nordic comparative study on sectorised psychiatry: repeated emergency admissions to inpatient care during a 1-year follow-up

The emergency admissions to hospital care in six psychiatric services in four Nordic countries were explored as a part of a Nordic comparative study on sectorised psychiatry. One year treated incidence cohorts were used, with the total cohort comprising 2,454 patients. Of the 803 patients who were admitted to inpatient care during a 1-year follow-up, 82% had at least one emergency admission and 23% repeated emergency admissions. The definition for the repeated emergency admissions was at least two admissions during the follow-up. The mean length of stay in emergency inpatient care per treatment episode for this patient subgroup was 28 days. Their emergency inpatient episodes constituted 30% of all inpatient days during the follow-up. However, the variations between the services and diagnostic subgroups were large. The results of a logistic regression analysis indicated that the following variables predicted repeated emergency admissions: inpatient care at index contact, emergency outpatient contacts or no planned hospital admissions during the follow-up, psychiatric service, age under 45 years, and a diagnosis of psychosis, personality disorder or dependency. The repeated emergency admissions were related to the existence of a special service unit for abusers but not to the rates of outpatient staff or acute beds in the services, to geographical distances, referral practice or existence of emergency services.