A psychiatric patient classification system. An alternative to diagnosis-related groups

It is generally accepted that diagnosis-related groups (DRGs) for alcohol, drug, and mental disorders are inappropriate for inpatient prospective payment. To address this issue, the Veterans Administration (VA) supported a project to construct alternative classes that are more clinically meaningful, more homogeneous in their resource use, and that account for more variation in resource use among psychiatric and substance use cases than existing DRGs. This paper reports on this project. Using a data set containing universally available discharge data plus behavioral, social, and functional information obtained by a survey of 116,191 discharges from VA psychiatric beds, and with AUTOGRP as the classifying algorithm, a classification system was formed. Twelve psychiatric diagnostic groupings (PDGs) were identified, analogous to major diagnostic groups in the DRG system. Within each PDG, from 4 to 9 terminal groups of Psychiatric Patient Classes (PPCs) were formed and validated. The 12 substance abuse PPCs explain greater than 31% of the variation in length of stay; for the mental disorder PPCs the variance explanation is greater than 11%, a substantial improvement over DRGs that, for the same data set, explain less than 2 and 3%, respectively. With the addition of only 5 variables beyond those presently included in discharge data sets, greater precision for payment purposes can be achieved. Implications for adoption of this classification system are discussed.     

Home treatment as an alternative to inpatient admission: characteristics of those treated and factors predicting hospitalization

In response to the NHS Plan, crisis and home treatment teams will be developed across the UK in order to provide intensive home treatment as an alternative to inpatient admission for individuals with severe, acute mental health problems. This study describes aspects of the work of two teams in Hertfordshire. A total of 293 individuals were taken on for intensive home treatment in a 12-month period. A range of social and demographic variables was recorded at the point of initial assessment regarding each individual, as well as two rating scales: the Brief Psychiatric Rating Scale and the Scale for Suicide Ideation. Sixty-two individuals (21.1%) required admission to hospital after a median period of home treatment of 11 days. The most frequently recorded reason for admission taking place was 'risk to self' (n = 33, 53.2%). Two variables were identified by logistic regression analysis as being predictive of an increased risk of hospitalization: high suicidal ideation at initial assessment (P < 0.01) and previous hospital admission (P < 0.01). Although statistically significant, these variables were only weakly predictive of whether admission would actually take place.     

An alternative to sutures.

Cyanoacrylate tissue adhesives are used in numerous settings to close wounds without the use of sutures. The product and its use for closing chest tube wounds is discussed.     

An alternative to sutures.

Cyanoacrylate tissue adhesives are used in numerous settings to close wounds without the use of sutures. The product and its use for closing chest tube wounds is discussed.     

Expressed emotion and the inpatient psychiatric facility--expressed emotion and the inpatient psychiatric facility with low functioning psychiatric patients

The age of deinstitutionalizing asylums and sanitariums brought about interest in the environment that newly discharged patients were entering into. Many of the schizophrenic patients were relapsing and returning to their caregivers for hospitalization. Psychiatry was involved in research that would illuminate what environmental factors had an impact on their deterioration. George W. Brown (as cited in Harris, 2000)) explored this phenomenon. His investigation exposed variables that ultimately lead to the concept of Expressed Emotion (EE). Much of the literature and research on EE revolves around the family environment; however there is some literature that identifies that EE may not only occur with family members. EE may also be attributed to staff and their interaction with patients. This paper presents two case studies that will help elucidate EE with staff, family and the environment. More research is needed to investigate this phenomenon as it relates to staff and inpatients and the refractory, treatment resistant effects it may play in psychiatric inpatient facilities.     

Effectiveness of psychiatric inpatient care

Scand J Caring Sci; 2013; 27; 319–326 Effectiveness of psychiatric inpatient care There is a growing demand for evaluating the process and outcome of mental health care. Most healthcare providers routinely collect and register data related to the process of treatment, and it is important to acquire more knowledge about how to make use of these databases. The aim of this study was to investigate the outcome of psychiatric inpatient care in relation to different clinical factors, using the Global Assessment of Functioning Scale (GAF) as a measure of outcome. Another objective was to explore the ability of routinely collected and registered data to provide valuable information about patients and their care. The studied psychiatric inpatient sample consisted of 816 care episodes with GAF ratings made both at admission and at discharge for 648 patients. Variables used in the study included GAF score at admission and at discharge, age, gender, diagnosis, length of stay and ward affiliation. The overall mean GAF change was 20.74, and the overall effect size Cohen’s d 1.67, which corresponds to a large effect. The mean GAF change for women was 21.6, with an effect size of 1.80, and for men 19.4 with an effect size of 1.52. The effect size spectra including all groups of diagnoses ranged from 1.03 (substance‐related disorders) to 2.33 (other mood disorders). Length of stay and ward affiliation also showed significant results concerning GAF change. Some limitations in this study could depend on the absence of randomization procedures and a control group. Another limitation concerns the insufficient control of the inpatient care interventions performed. The results support the capacity of the GAF to function as a measure of outcome in relation to different clinical factors, such as length of stay and diagnosis. Support was also found for the importance and usefulness of routinely collected and registered data.     

Risk factors for psychiatric re‐hospitalization: An exploration

Predecessor research suggests that anything from 37% to 53% of hospitalized service users are readmitted within 12 months of discharge. This cycle of frequent admissions represents a serious challenge to clinicians and service users alike. Critically, much of the research in this field has relied exclusively on professional attributions for readmission with little acknowledgement of service user or patient viewpoints. This paper reports on a phenomenological study which used multiple data collection approaches to explore service user and clinician attributions for frequent hospitalization to an identified psychiatric unit over a 24‐month index period. Methods included a retrospective review of multi‐professional case notes, clinician and service user semi‐structured interviews, and focus groups. Service users cited ‘situational circumstances’, rather than medically accepted relapse indicators such as ‘non‐adherence with prescribed medication’ as the main reasons for readmission. Notable disagreement existed between clinician and service user data sources. Hospitalization is a complex, individually determined experience. Clinicians and service users have differing perspectives on the causal risk factors and this presents complications for those developing relapse prevention strategies. However, a shared appreciation of the multiple realities paves the way for the development of a conceptual risk‐factor identification model which may serve as a guide to practitioners in relapse prevention.     

Organic organizational research in a psychiatric inpatient setting.

The author proposes that most traditional methods of collecting data about life in mental health settings tend to produce inaccurate information. He suggests a procedure of information-gathering that may be useful and illustrates the theory of organic research in application with a case study of a psychiatric inpatient setting attempting to develop a recreational program.     

Cross-cultural differences in psychiatric nurses' attitudes to inpatient aggression

Little is currently known about the attitudes of psychiatric nurses toward patient aggression, particularly from an international perspective. Attitudes toward patient aggression of psychiatric nurses from five European countries were investigated using a recently developed and tested attitude scale. Data were collected from a convenience sample of 1,769 student nurses and psychiatric nurses. Regression analysis was performed to identify personal and occupational characteristics of the respondents able to predict their attitude toward aggression. Analysis of variance was used to identify significant differences in attitudes between and among countries. Attitude was predicted by sex, contractual status (full vs. part time), and the type of ward on which subjects worked. With one exception (communicative attitude), attitudes differed across countries. More research on attitude formation is needed to determine which factors account for these differences.     

Introducing solution-focused approaches to staff in inpatient psychiatric settings

The authors describe several approaches to introducing solution-focused ideas to inpatient psychiatric nursing staff and psychiatric nursing students. The approach is intended to show the basic values of this approach in the process of helping participants become acquainted with concepts central to newer models of brief psychotherapy. The format uses humor, small group experiential case examples along with didactic approaches to facilitate new ways of thinking congruent with new models of therapy.     

An alternative to urinary conduit.

The author outlines the procedures involved in creating a Mitrofanoff pouch as an alternative to urinary conduit. Patients who have such a procedure must learn to alter their lifestyles and acquire skills such as self-catheterisation, but early results suggest that they find the procedure acceptable and preferable to other options.