Case-control study of frequent visitors to an urban psychiatric emergency service

OBJECTIVE: The purpose of this study was to identify risk factors for people who use psychiatric emergency services repeatedly and to estimate their financial charges. METHODS: The authors used interviews and chart reviews to compare 74 patients who had six or more visits to an urban psychiatric emergency service in the 12 months before an index visit with 74 patients who had five or fewer visits. Multivariate logistic regression was used to identify independent risk factors. RESULTS: Independent risk factors for frequent visitors were self-reported hospitalization in the past 12 months, need for medications as the self-reported reason for seeking care, being homeless or living in an institution, and not giving the name of a friend or family member for interview. The level of burden for support of persons who were interviewed was low and did not differ between frequent and infrequent visitors. Compared with infrequent visitors, frequent visitors had greater utilization of inpatient and outpatient behavioral health services, general emergency services, and crisis residential services in the 12 months before the index visit and greater utilization of general emergency services and psychiatric emergency services in the three months after the index visit. Frequent visitors' median financial charge for those services was 16,200 US dollars greater (5.9 times greater) than that of infrequent visitors. CONCLUSIONS: Frequent visitors represent resource-poor mentally ill persons who have high levels of utilization of health care facilities besides psychiatric emergency services. Possible clinical interventions for these patients include focused medication reviews.     

A comparison in hospitalization rates between a community-based mobile emergency service and a hospital-based emergency service

OBJECTIVES: The aims of this study were to compare the rates of inpatient admission between a mobile community-based psychiatric emergency service and a hospital-based psychiatric emergency service, and to identify the clinical characteristics of consumers more likely to be admitted to hospital. METHODS: A retrospective, quasi-experimental design was used with a 3-month cohort of all face-to-face emergency service contacts presenting at the mobile and hospital-based sites. The Health of the Nation Outcome Scales and details of the outcome following initial assessment were completed for all contacts, and each group was compared for differences in clinical characteristics and outcome. RESULTS: Hospital-based emergency service contacts were found to be more than three times as likely to be admitted to a psychiatric inpatient unit when compared with those using a mobile community-based emergency service, regardless of their clinical characteristics. Those with severe mental health disorders such as schizophrenia and major affective disorder, and experiencing problems with aggression, non-accidental self-injury, hallucinations and delusions, problems with occupation, activities of daily living, and living conditions were more likely to be admitted to hospital. Nevertheless, after controlling for clinical characteristics, site of initial assessment accounted for a substantial proportion of the variance in decisions to admit to hospital. CONCLUSIONS: Emergency psychiatric services which include a mobile component and provide a specialized multidisciplinary team approach appear to be most effective in providing services in the least restrictive environment and avoiding hospitalization.     

The psychiatric clinical specialist''s impact on psychiatric emergency services

Psychiatric emergency services have evolved into more comprehensive programs during the past two decades. With this evolution other disciplines have gained access to the services and integrated their expertise and philosophy into the daily care of patients. Nursing has been an integral part of this process and contributed its perspective in nursing care. This paper outlines the development of psychiatric emergency services with a special emphasis on the contribution of nursing specialists who have developed their role within the psychiatric emergency service.

What has been unique about the nursing contribution is the attention to individualizing patient care and modifying treatment approaches to meet the patients' needs and interests in psychiatric treatment. Additionally, nursing has complemented the physician's role by developing expertise in assessment that is both psychologically and biologically oriented. Nursing's future contribution to psychiatric emergency services should address mechanisms for tracking patients who enter the psychiatric emergency service system with an emphasis on linkage with other programs or resolution of the crisis episode.     

Integration of general hospital psychiatric services with freestanding psychiatric hospitals

General medical hospitals and freestanding psychiatric hospitals usually function independently. The authors review the relative strengths and weaknesses of the two settings and suggest a plan for a rational coordination of services. In an efficient integrated system, the general hospital would provide emergency psychiatric services and treat patients with combined medical and psychiatric conditions. The freestanding facility would offer inpatient and outpatient services, as well as partial hospitalization and transitional living arrangements, to psychiatric patients without medical complications. All facilities would share professional staff and data processing capabilities and would have common policies and procedures, reducing the cost of treatment and facilitating patient transfers.     

Psychiatric emergency services in a Canadian city: II. Clinical characteristics and patients' disposition.

The clinical characteristics of patients seen at the psychiatric emergency facilities in a Canadian city and the determinants of decisions regarding their treatment were investigated. A total of 544 patients who sought psychiatric emergency services from the three hospitals in Saskatoon during a three month period were studied. Cognitive disturbance, past psychiatric history, previous psychiatric hospitalization and diagnoses of substance use disorders, affective disorders, anxiety disorders and schizophrenic disorders were associated with psychiatric emergencies. Psychiatric diagnoses and availability of social support were significantly associated with disposition. The implications of these findings for psychiatric emergency services are discussed.     

Geropsychiatric emergency services: utilization and outcome predictors

Chart data on emergency room visits by elderly patients and a younger control group were examined in an exploratory study of utilization of psychiatric emergency services by the elderly and factors predictive of their subsequent admission to a psychiatric inpatient unit. Elderly patients had lower utilization of psychiatric services than their younger counterparts, but they were significantly more likely to be hospitalized following an emergency room visit. Dementia, the single most frequent diagnosis of the elderly patients, increased the likelihood of hospitalization only if it existed in combination with another psychiatric diagnosis. Medical comorbidity appeared to have no effect on whether the elderly patient was subsequently hospitalized.     

Psychiatric emergency services in a Canadian city: I. Prevalence and patterns of use.

The patterns of use of psychiatric emergency services in Saskatoon, Saskatchewan were studied. A total of 576 patients who had received psychiatric emergency care from any of the four major health care facilities in Saskatoon during a three month period were included in the study. Visits for psychiatric emergency services during the study period represented 2.32% of the total number of visits to emergency facilities. Most patients with psychiatric emergencies went to hospitals with psychiatric units. The characteristics of patients served by the four facilities and those who visited the psychiatric emergency services on more than one occasion during the study period are reported. The implications of these findings for health care planning are discussed.     

Repeated users of a psychiatric emergency service in a Canadian general hospital

The authors of this study examine the demographic and clinical characteristics of repeated users of psychiatric emergency room services in a general hospital. 37.8% of all the patients (913) seen during one year had one or more visits to the emergency room in the six months preceding the index emergency room consultation. Repeaters were more likely than non-repeaters to be unmarried, self referred and with a history of previous psychiatric treatment for a chronic psychiatric disorder. Factors affecting frequency of use of psychiatric emergency room services among different diagnostic groups were also studied. These results demonstrated the heterogeneity of the needs of the diverse diagnostic groups who over-utilize costly emergency room services. Our findings showed that in a country with universal health insurance, psychiatric emergency services also tend to reflect the gaps in the delivery of health services in the hospital and the community.     

Factors in the use of coercive retention in civil commitment evaluations in psychiatric emergency services

OBJECTIVE: The authors examined whether factors other than civil commitment criteria influence the involuntary retention of patients who are evaluated for civil commitment in psychiatric emergency services in California general hospitals. METHODS: Logistic regression analysis was used to determine whether admission criteria, institutional constraints, social biases, and procedural justice indicators contributed to the use of coercive retention in the evaluations of 583 patients in the psychiatric emergency services of nine California county general hospitals. RESULTS:Of the 583 patients, 109 (18.7 percent) were retained against their wishes. Clinicians relied primarily on admission criteria in making the decision to retain a patient, which suggests that patients were generally afforded procedural due process during the evaluation in the psychiatric emergency service. Staff workload was a possible factor in violations of due process. CONCLUSIONS: Psychiatric emergency services need additional resources to ensure procedural due process protection for patients who are being evaluated for civil commitment.     

Repeated use of psychiatric emergency out-patient services among new patients: a 3-year follow-up study

The aim of this study was to examine repeated use of psychiatric emergency out-patient services during the second and third years after the first contact. A 1-year treated incidence cohort of 537 new patients was studied in the Department of Psychiatry in Oulu, Finland. Repeat users were defined as patients belonging to the upper 10th percentile of the emergency out-patient contacts. The median of emergency out-patient contacts among repeaters was 4. The repeaters constituted 8% of the cohort and they used 65% of the cohort's emergency contacts. They were more likely to be male and living alone, and they tended to have more serious diagnoses than non-repeaters. Having hospital admissions, planned out-patient contacts and repeated emergency out-patient contacts also during the first year of follow-up was associated with an increased probability of repeatedly using emergency services during the second and third years. Living alone and having hospital admissions during the follow-up period were associated with being a continuous repeat visitor during the whole follow-up period. It is concluded that the extended repeated use of emergency services is associated with inadequate social support and serious psychiatric problems.     

The nature of help-seeking during psychiatric emergency service visits by a patient and an accompanying adult

Utilization rates for urban psychiatric emergency services remain high, and the decision to seek care in this setting is poorly understood. Three hundred individuals accompanying patients to a psychiatric emergency service were interviewed about their help seeking and choice of treatment setting. Twenty-three of the interviewees (7.7 percent) were caregivers accompanying patients with severe and persistent mental illness. They were significantly more likely than other interviewees to know the difference between psychiatric emergency services and services offered by other outpatient providers. More than half reported that the patient they accompanied was intermittently noncompliant, which required visiting either a walk-in service during a moment when the patient was cooperative or a facility equipped to provide involuntary treatment.     

Psychiatric emergency services and the system of care

OBJECTIVE: Admissions to psychiatric emergency services have frequently been cited as a gauge of how well a mental health system manages behavioral disorders. However, few measurements of the longitudinal association between psychiatric emergencies and characteristics of a mental health system have been described. The purpose of this study was to assess whether weekly admissions to psychiatric emergency services would increase when outpatient services were reduced, whether weekly admissions would increase when greater effort was made to identify and treat persons with acute mental illness, and whether weekly admissions would decrease when emergency services were enhanced to include postrelease case management. METHODS: Time-series methods were applied to approximately 29,010 admissions to three psychiatric emergency services of the San Francisco Department of Public Health over a 180-week period. RESULTS: Reduced outpatient services, efforts to identify acutely ill persons, and changes in emergency services themselves were found to affect admissions to emergency services. However, community events such as extreme weather, holidays, job loss, and the scheduling of receipt of income also affected the workload of the emergency service. CONCLUSIONS: The causes and course of mental illness inextricably tie a psychiatric emergency service to the overall mental health system and to events in the community it serves. These connections make it possible for managers to anticipate the use of emergency services and to detect disruptions in the remainder of the mental health services systems.     

Service expectations and clinical characteristics of patients receiving psychiatric emergency services

Previous studies suggest that patients use medical emergency departments for nonurgent care. However, relatively little has been published about the use of psychiatric emergency services. Eighty-two patients who visited the psychiatric emergency department in a free-standing psychiatric hospital during July 2003 participated in a self-report survey about patients' expectations. Almost all respondents had acute psychiatric needs on presentation to the psychiatric emergency department, and 45 (75 percent) had urgent needs that required inpatient or partial hospitalization. However, there was considerable mismatch between some patients' expectations and the types of services available. Patients' use of this psychiatric emergency department was generally consistent with the department's mission, but many respondents endorsed a need for a service that was not available, such as family therapy. These findings suggest the importance of efforts to educate the public about how to obtain mental health services.     

Hospital based psychiatric emergency services: a guide to service delivery and clinical best practices

Hospital based psychiatric emergency services play an integral role in the initiation of mental health and psychiatric service delivery worldwide. Whenever possible, hospital based psychiatric emergency services should be delivered in accordance to best practice standards. Unfortunately, no such standards exist internationally in the case of hospital based psychiatric emergency services. This paper represents an attempt to rectify this problem. International mental health and psychiatric literature pertaining to hospital based psychiatric emergency services was reviewed and a guide to service delivery and clinical best practice was generated.     

Redesigning emergency room psychiatry in New York

Significant changes in the characteristics of persons using psychiatric emergency services have resulted in increased demands beyond the needs emergency services traditionally have been expected to meet. In New York City, these changes caused a crisis in psychiatric emergency services. The authors report a state statute that gave the New York State Office of Mental Health the authority to license a specialized psychiatric emergency service, a comprehensive psychiatric emergency program, within general hospitals designed to provide specialized assessment, stabilization, and referral services.At the time this article was written, he was Counsel and Deputy Commissioner of the New York State Office of Mental Health.     

Does the use of Health Care and Special School Services, Prior to Admission for Psychiatric Inpatient Treatment, Differ Between Adolescents Housed by Child Welfare Services and Those Living with Their Biological Parent(s)?

We examined whether the use of health care and special school services, prior to admission for psychiatric inpatient treatment, differed between adolescents from child welfare units and those living at their parental home. 208 boys and 300 girls aged 12–17 years were admitted for psychiatric hospital between 2001 and 2006. Child welfare adolescents had used more health services/treatments prior to psychiatric hospital admission than adolescents living with their biological family. The best discriminating factors between study groups for both genders, were previous psychiatric hospitalizations, unemployed parents, use of special school services and self-perceived serious anxiety/tension or trouble controlling violent behavior. Repeated school grades and previous use of psychotropic medications were discriminating factors only in girls. Adolescents in child welfare deserve adequate mental health evaluations at an early stage, with referral to appropriate adolescent psychiatric services if required. Appropriate service provision and properly planned treatments may reduce the amount of intensive and sometimes unnecessary psychiatric inpatient treatments.     

Psychiatric morbidity and social functioning among adults with borderline intelligence living in private households

Background Approximately one‐eighth of the population will have DSM‐IV borderline intelligence. Various mental disorders and social disability are associated with it. Method The paper uses data (secondary analysis) from a UK‐wide cross‐sectional survey of 8450 adults living in private households. Data were collected on psychiatric disorders, intellectual level, social functioning and service use. Results In total, 12.3% of the sample had borderline intelligence. The prevalence of psychotic disorder was not significantly increased, but the group showed significant social disadvantage and increased rates of neurotic disorders, substance misuse and personality disorders when compared with their counterparts of normal intelligence. The borderline group was more likely to receive psychiatric medication, but not talking therapies. They appear to use significantly more services, including emergency services. Conclusion Adults with borderline intelligence are more likely to suffer from treatable mental disorders and an excess of substance misuse. Services should be aware of hidden morbidity in this group.     

What do consumers say they want and need during a psychiatric emergency?

Behavioral emergencies are a common and serious problem for consumers, their families and communities, and the healthcare providers on whom they rely for help. In recent years, serious concerns about the management of behavioral and psychiatric emergencies-in particular, the misapplication and overuse of physical and chemical restraints and seclusion-have become a focus of attention for mental health professionals and policy makers as well as for the lay public, the media, and patient advocacy organizations. Policy leaders and clinicians are searching for ways to balance the rights of consumers with considerations of safety and good care in an area in which it is difficult to conduct research. A survey of mental health professionals who are experts on the treatment of psychiatric and behavioral emergencies identified consumer input and collaboration between patient and clinician whenever possible as being extremely important in achieving the best short-term and particularly the best long-term outcomes for patients. The survey of consumer perspectives described in this article was undertaken in response to the need to better understand consumer experiences and preferences. The authors describe four emergency services forums conducted in 2002, which involved a total of 59 consumers. Each forum involved a written consumer survey as well as a workshop to develop and prioritize recommendations for improving psychiatric emergency care. The authors present the results of the consumer survey and summarize the top recommendations from the workshops. In both the survey and the workshops, the consumers repeatedly stressed the importance of having staff treat them with respect, talk to them, listen to them, and involve them in treatment decisions. There were a number of important areas of agreement between the recommendations of the consumer panel and those of the experts in emergency psychiatry surveyed for the Expert Consensus Guidelines on the Treatment of Behavioral Emergencies. These include the desirability of verbal interventions, the use of a collaborative approach, and the use of oral medications guided by the individual consumer's problems, medication experiences, and preferences. The majority of the consumer panel reported adverse experiences with general hospital emergency rooms and, in fact, called for the development of specialized psychiatric emergency services such as those recommended in the Expert Consensus Guidelines. One-fifth of the consumer panel attributed their emergency contact to lack of access to more routine mental health care. The consumers clearly do not reject medications categorically. Almost half indicated that they wanted medications and a similar number indicated benefit from medications, although many complained of forced administration and unwanted side effects. The consumer panel preferred benzodiazepines and ranked haloperidol as a least preferred option. Among their key recommendations for improving psychiatric emergency care, the consumer panel stressed the development of alternatives to traditional emergency room services, the increased use of advance directives, more comfortable physical environments for waiting and treatment, increased use of peer support services, improved training of emergency staff to foster a more humanistic and person-centered approach, increased collaboration between practitioners and patients, and improved discharge planning and post-discharge follow-up. The implications of these findings for improving psychiatric emergency care are considered.     

Patient and contextual factors related to the decision to hospitalize patients from emergency psychiatric services

OBJECTIVE: Mental health care reform has brought an increasing emphasis on community care, with concomitant reductions in inpatient psychiatric resources. Hospitalization remains a necessary and integral component of the mental health care system, but it is taking on a more specialized role. Examining the circumstances in which hospitalization is indicated can help clarify emergency psychiatric practices and determine whether patients' needs are being met within this changing environment. This pilot study examined the impact of selected patient and contextual characteristics on the decision to admit patients to inpatient psychiatric units and assessed the utility of the Severity of Psychiatric Illness (SPI) scale for monitoring clinical practice in emergency psychiatric services. METHODS: Crisis workers in two emergency psychiatric services crisis teams in Toronto, Canada, used the SPI in the assessment of 205 visitors to the services during the winter of 1998-1999. Contextual characteristics, including bed availability, service site, and the admitting physician's level of training, were recorded. Multivariate logistic regression was used to assess the relative contribution of patient and contextual variables in the admission decision. RESULTS: The severity of axis I symptoms and difficulties with self-care were significantly associated with the decision to admit. Site, bed availability, and the admitting physician's level of training did not appear to be associated with clinical decisions. CONCLUSIONS: Patients with the most need are being admitted to inpatient units despite significant systemic pressures on inpatient services. The SPI is a useful and discriminating tool for evaluating clinical practice in emergency services.     

Emergency psychiatry in the general hospital: Staffing, training, and leadership issues

Psychiatric services in general medical hospitals have increased in the past two decades. More and more, emergency services are being used for less urgent problems, and have created difficulties in health care delivery for all physicians. This is especially true for psychiatrists, since emergency psychiatric care is more time- and staff-intensive, and the need for it is unpredictable. The important issues of staffing, training, and the need for creative leadership for emergency psychiatric services are discussed.