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McCullough MH, Small M, Jayawardena B, Hood S. Mapping clinical interactions in an Australian tertiary hospital emergency department for patients presenting with risk of suicide or self-harm: Network modeling from observational data. PLoS Med 2024; 21:e1004241. [PMID: 38215082 PMCID: PMC10786386 DOI: 10.1371/journal.pmed.1004241] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2023] [Accepted: 12/11/2023] [Indexed: 01/14/2024] Open
Abstract
BACKGROUND Reliable assessment of suicide and self-harm risk in emergency medicine is critical for effective intervention and treatment of patients affected by mental health disorders. Teams of clinicians face the challenge of rapidly integrating medical history, wide-ranging psychosocial factors, and real-time patient observations to inform diagnosis, treatment, and referral decisions. Patient outcomes therefore depend on the reliable flow of information through networks of clinical staff and information systems. This study aimed to develop a quantitative data-driven research framework for the analysis of information flow in emergency healthcare settings to evaluate clinical practice and operational models for emergency psychiatric care. METHODS AND FINDINGS We deployed 2 observers in a tertiary hospital emergency department during 2018 for a total of 118.5 h to record clinical interactions along patient trajectories for presentations with risk of self-harm or suicide (n = 272 interactions for n = 43 patient trajectories). The study population was reflective of a naturalistic sample of patients presenting to a tertiary emergency department in a metropolitan Australian city. Using the observational data, we constructed a clinical interaction network to model the flow of clinical information at a systems level. Community detection via modularity maximization revealed communities in the network closely aligned with the underlying clinical team structure. The Psychiatric Liaison Nurse (PLN) was identified as the most important agent in the network as quantified by node degree, closeness centrality, and betweenness centrality. Betweenness centrality of the PLN was significantly higher than expected by chance (>95th percentile compared with randomly shuffled networks) and removing the PLN from the network reduced both the global efficiency of the model and the closeness centrality of all doctors. This indicated a potential vulnerability in the system that could negatively impact patient care if the function of the PLN was compromised. We developed an algorithmic strategy to mitigate this risk by targeted strengthening of links between clinical teams using greedy cumulative addition of network edges in the model. Finally, we identified specific interactions along patient trajectories which were most likely to precipitate a psychiatric referral using a machine learning model trained on features from dynamically constructed clinical interaction networks. The main limitation of this study is the use of nonclinical information only (i.e., modeling is based on timing of interactions and agents involved, but not the content or quantity of information transferred during interactions). CONCLUSIONS This study demonstrates a data-driven research framework, new to the best of our knowledge, to assess and reinforce important information pathways that guide clinical decision processes and provide complementary insights for improving clinical practice and operational models in emergency medicine for patients at risk of suicide or self-harm. Our findings suggest that PLNs can play a crucial role in clinical communication, but overreliance on PLNs may pose risks to reliable information flow. Operational models that utilize PLNs may be made more robust to these risks by improving interdisciplinary communication between doctors. Our research framework could also be applied more broadly to investigate service delivery in different healthcare settings or for other medical specialties, patient groups, or demographics.
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Affiliation(s)
- Michael H. McCullough
- School of Computing, The Australian National University, Acton, ACT, Australia
- Eccles Institute of Neuroscience, John Curtin School of Medical Research, The Australian National University, Acton, ACT, Australia
| | - Michael Small
- Complex Systems Group, Department of Mathematics and Statistics, The University of Western Australia, Crawley, WA, Australia
- Mineral Resources, Commonwealth Scientific and Industrial Research Organisation, Kensington, WA, Australia
| | - Binu Jayawardena
- North Metropolitan Health Service, Government of Western Australia, WA, Australia
- Division of Psychiatry, UWA Medical School, The University of Western Australia, Crawley, WA, Australia
| | - Sean Hood
- North Metropolitan Health Service, Government of Western Australia, WA, Australia
- Division of Psychiatry, UWA Medical School, The University of Western Australia, Crawley, WA, Australia
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McIntosh JT. Emergency department nurses' perceptions of caring behaviors toward individuals with mental illness: A secondary analysis. Int Emerg Nurs 2023; 68:101271. [PMID: 37003054 DOI: 10.1016/j.ienj.2023.101271] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2022] [Revised: 01/20/2023] [Accepted: 02/01/2023] [Indexed: 04/03/2023]
Abstract
AIM The aim of this study was to determine emergency department (ED) nurses' caring behaviors toward individuals with mental illness; and the influence of stigma on their caring behaviors. METHOD This is a secondary analysis of a cross-sectional study with (n = 813) ED nurses working in the United States from March 2021 to April 2021. The Caring Behaviors Inventory-24 item (CBI-24) and the Mental Illness: Clinicians' Attitudes Scale-4 (MICA v4) were used to collect data. RESULTS The mean CBI-24 score was 4.6 (SD = 0.8).The MICA v4 had an overall sum of 53.4 (SD = 9.2). Caring behaviors and stigma were found to have significant weak inverse relationship (r = - 0.23, p <.001). Age and level of education had a significant inverse relationship with caring behaviors (r = - 0.12; r = -. 19, p <.01 respectively). CONCLUSION The results of this study may contribute to the quality, equity, and safety of the emergency nursing care of individuals with mental illness, thereby improving health outcomes. It is recommended that the diversity of nurses and the characteristics of the ED be taken into consideration when designing trainings, providing leadership support, and managing resources to support the care of individuals with mental illness.
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Affiliation(s)
- Jennifer T McIntosh
- Adelphi University, College of Nursing and Public Health, One South Street, Garden City, NY 11530, USA; Yale University School of Nursing, 400 West Campus Drive, Orange, CT 06477, USA.
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Pascoe SE, Aggar C, Penman O. Wait times in an Australian emergency department: A comparison of mental health and non-mental health patients in a regional emergency department. Int J Ment Health Nurs 2022; 31:544-552. [PMID: 35029024 DOI: 10.1111/inm.12970] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2021] [Revised: 12/08/2021] [Accepted: 12/16/2021] [Indexed: 11/28/2022]
Abstract
Worldwide, emergency departments in regional and remote areas have a higher per capita mental health presentation rate than their metropolitan counterparts. Evidence suggests that mental health presentations to metropolitan or city emergency departments are exposed to longer waiting times, extended length of stays, and higher rates of access block than non-mental health presentations. However, there is little research investigating the experiences for mental health and non-mental health presentations in the emergency department in regional and remote areas. The aim of the current study was to explore wait time and length of stay for mental and non-mental health patients at a regional emergency department. Audit data from 38,782 presentations to a regional emergency department in NSW over a 12-month period in 2019 were reviewed. The STROBE cross-sectional research checklist was adhered to for reporting of results. Time to be seen, length of stay, and access block (length of stay longer than 8 hours) were described and compared for mental and non-mental health patients. It was found that mental health patients in this study disproportionately experience longer wait times and length of stay in a regional emergency department. Future research is needed to identify whether this issue is present across other Australian regional emergency departments and review funding models to address the discrepancy. These findings make a unique contribution to the literature as previous research focussed on metropolitan emergency departments and only identified time to be seen and length of stay, largely ignoring differences in access block between mental health and non-mental health patients.
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Affiliation(s)
- Sharene E Pascoe
- Northern NSW Local Health District, Lismore Base Hospital, Lismore, New South Wales, Australia
| | - Christina Aggar
- Faculty of Health, Southern Cross University, Southern Cross Drive, Bilinga, Queensland, Australia
| | - Olivia Penman
- Faculty of Health, Southern Cross University, Southern Cross Drive, Bilinga, Queensland, Australia
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Glowacki K, Whyte M, Weinstein J, Marchand K, Barbic D, Scheuermeyer F, Mathias S, Barbic S. Exploring how to enhance care and pathways between the emergency department and integrated youth services for young people with mental health and substance use concerns. BMC Health Serv Res 2022; 22:615. [PMID: 35525965 PMCID: PMC9077976 DOI: 10.1186/s12913-022-07990-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2022] [Accepted: 04/20/2022] [Indexed: 11/10/2022] Open
Abstract
Background Integrated youth services (IYS) provide multidisciplinary care (including mental, physical, and social) prioritizing the needs of young people and their families. Despite a significant rise in emergency department (ED) visits by young Canadians with mental health and substance use (MHSU) concerns over the last decade, there remains a profound disconnect between EDs and MHSU integrated youth services. The first objective of this study was to better understand the assessment, treatment, and referral of young people (ages 12–24 years) presenting to the ED with MHSU concerns. The second objective was to explore how to improve the transition from the ED to IYS for young people with MHSU concerns. Methods We conducted semi-structured one-on-one video and phone interviews with stakeholders in British Columbia, Canada in the summer of 2020. Snowball sampling was utilized, and participants (n = 26) were reached, including ED physicians (n = 6), social workers (n = 4), nurses (n = 2), an occupational therapist (n = 1); a counselor (n = 1); staff/leadership in IYS organizations (n = 4); mental health/family workers (n = 3); peer support workers (n = 2), and parents (n = 3). A thematic analysis (TA) was conducted using a deductive and inductive approach conceptually guided by the Social Ecological Model. Results We identified three overarching themes, and factors to consider at all levels of the Social Ecological Model. At the interpersonal level inadequate communication between ED staff and young people affected overall care and contributed to negative experiences. At the organizational level, we identified considerations for assessments and the ED and the hospital (wait times, staffing issues, and the physical space). At the community level, the environment of IYS and other community services were important including wait times and hours of operation. Policy level factors identified include inadequate communication between services (e.g., different charting systems and documentation). Conclusions This study provides insight into important long-term systemic issues and more immediate factors that need to be addressed to improve the delivery of care for young people with MHSU challenges. This research supports intervention development and implementation in the ED for young people with MHSU concerns.
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Affiliation(s)
- Krista Glowacki
- Department of Occupational Science and Occupational Therapy, The University of British Columbia, Faculty of Medicine, T325 - 2211 Wesbrook Mall, Vancouver, BC, V6T 2B5, Canada. .,Foundry Central Office, Providence Health Care, 1881 Burrard, Vancouver, BC, V5G 7H9, Canada. .,Centre for Health Evaluation & Outcome Sciences, Providence Health Care, #588-1081 Burrard Street, Vancouver, BC, V6Z 1Y6, Canada. .,Providence Health Care Research Institute 1081 Burrard Street, Vancouver, BC, V6Z 1Y6, Canada.
| | - Madelyn Whyte
- Foundry Central Office, Providence Health Care, 1881 Burrard, Vancouver, BC, V5G 7H9, Canada
| | - Jade Weinstein
- Department of Occupational Science and Occupational Therapy, The University of British Columbia, Faculty of Medicine, T325 - 2211 Wesbrook Mall, Vancouver, BC, V6T 2B5, Canada
| | - Kirsten Marchand
- Department of Occupational Science and Occupational Therapy, The University of British Columbia, Faculty of Medicine, T325 - 2211 Wesbrook Mall, Vancouver, BC, V6T 2B5, Canada.,Foundry Central Office, Providence Health Care, 1881 Burrard, Vancouver, BC, V5G 7H9, Canada.,Centre for Health Evaluation & Outcome Sciences, Providence Health Care, #588-1081 Burrard Street, Vancouver, BC, V6Z 1Y6, Canada.,Providence Health Care Research Institute 1081 Burrard Street, Vancouver, BC, V6Z 1Y6, Canada
| | - David Barbic
- Centre for Health Evaluation & Outcome Sciences, Providence Health Care, #588-1081 Burrard Street, Vancouver, BC, V6Z 1Y6, Canada.,Department of Emergency Medicine, St Paul's Hospital and the University of British Columbia, 1081 Burrard St, Vancouver, BC, V6Y 1Z6, Canada
| | - Frank Scheuermeyer
- Department of Emergency Medicine, St Paul's Hospital and the University of British Columbia, 1081 Burrard St, Vancouver, BC, V6Y 1Z6, Canada
| | - Steve Mathias
- Foundry Central Office, Providence Health Care, 1881 Burrard, Vancouver, BC, V5G 7H9, Canada.,Providence Health Care Research Institute 1081 Burrard Street, Vancouver, BC, V6Z 1Y6, Canada.,Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada.,Department of Psychiatry, University of British Columbia, Vancouver, British Columbia, Canada.,Department of Psychiatry, Providence Health Care, St. Paul's Hospital, Vancouver, British Columbia, Canada
| | - Skye Barbic
- Department of Occupational Science and Occupational Therapy, The University of British Columbia, Faculty of Medicine, T325 - 2211 Wesbrook Mall, Vancouver, BC, V6T 2B5, Canada.,Foundry Central Office, Providence Health Care, 1881 Burrard, Vancouver, BC, V5G 7H9, Canada.,Centre for Health Evaluation & Outcome Sciences, Providence Health Care, #588-1081 Burrard Street, Vancouver, BC, V6Z 1Y6, Canada.,Providence Health Care Research Institute 1081 Burrard Street, Vancouver, BC, V6Z 1Y6, Canada
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Perrone McIntosh JT. Emergency department nurses' care of psychiatric patients: A scoping review. Int Emerg Nurs 2020; 54:100929. [PMID: 33302241 DOI: 10.1016/j.ienj.2020.100929] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2020] [Revised: 08/06/2020] [Accepted: 09/08/2020] [Indexed: 10/22/2022]
Abstract
The emergency department (ED) is a difficult place for psychiatric patients. However, individuals with mental illness often use the Emergency Department as a primary source of healthcare. This study was conducted to identify and examine published literature related to ED nurses' care of individuals with mental illness and to identify associated research gaps. A scoping review within the Arksey and O'Malley [11] framework was undertaken to answer, "what factors influence ED nurses' care of individuals with mental illness?" Sixteen studies met the inclusion criteria. The PRISMA method [16] was used to illustrate the flow of studies. The review resulted in three main themes influencing ED nurses' care for psychiatric patients. These were concerns related to environment; beliefs and perceptions; and knowledge and confidence. The results are described and framed within Biddle's role theory [33], and the gaps in the literature related to research and recommendations for specific investigations are presented.
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Affiliation(s)
- Jennifer T Perrone McIntosh
- Adelphi University, Garden City, NY 11531, United States; Farmingdale State College, Farmingdale, NY 11735, United States.
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Marynowski-Traczyk D, Broadbent M, Kinner SA, FitzGerald G, Heffernan E, Johnston A, Young JT, Keijzers G, Scuffham P, Bosley E, Martin-Khan M, Zhang P, Crilly J. Mental health presentations to the emergency department: A perspective on the involvement of social support networks. Australas Emerg Care 2019; 22:162-167. [PMID: 31300299 DOI: 10.1016/j.auec.2019.06.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2019] [Revised: 06/19/2019] [Accepted: 06/24/2019] [Indexed: 12/30/2022]
Abstract
The involvement of families, carers and significant others (i.e. social support networks) has a positive corollary for a person experiencing mental health problems. Accordingly, in Australia involvement of social support networks within mental health services is endorsed in national health policy and service guidelines. Despite the endorsement, this is yet to be fully realised in all areas that provide mental health services, including emergency departments. Social support networks are integral in the provision of mental health consumers' care. Supporting the involvement of social support networks in the emergency department can provide healthcare services with opportunities for enhanced and cost-effective care, contributing to improved outcomes for consumers. An overview of some of the barriers and facilitators of social support network involvement is provided. The intention of this paper is to encourage reflection and dialogue on this important area of mental health service provision and support the evolution of a new paradigm of research into social support network involvement in the emergency department.
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Affiliation(s)
- Donna Marynowski-Traczyk
- Griffith University, Menzies Health Institute Queensland, QLD, Australia; University of the Sunshine Coast, School of Nursing, Midwifery and Paramedicine, QLD, Australia.
| | - Marc Broadbent
- University of the Sunshine Coast, School of Nursing, Midwifery and Paramedicine, QLD, Australia
| | - Stuart A Kinner
- Murdoch Children's Research Institute, Centre for Adolescent Health, VIC, Australia; University of Melbourne, Melbourne School of Population and Global Health, VIC, Australia; University of Queensland, Mater Research Institute-UQ, QLD, Australia; Griffith University, Griffith Criminology Institute, QLD, Australia; Monash University, School of Public Health and Preventive Medicine, VIC, Australia
| | - Gerard FitzGerald
- Queensland University of Technology, School of Public Health and Social Work, QLD, Australia
| | - Ed Heffernan
- Queensland Forensic Mental Health Service, Queensland Health, QLD, Australia
| | - Amy Johnston
- University of Queensland, School of Nursing, Midwifery and Social Work, QLD, Australia; Department of Emergency Medicine, Princess Alexandra Hospital, QLD, Australia
| | - Jesse T Young
- Murdoch Children's Research Institute, Centre for Adolescent Health, VIC, Australia; University of Melbourne, Melbourne School of Population and Global Health, VIC, Australia; University of Western Australia, School of Population and Global Health, WA, Australia; Curtin University, National Drug Research Institute, WA, Australia
| | - Gerben Keijzers
- Department of Emergency Medicine, Gold Coast Health, QLD, Australia; Bond University, School of Medicine, QLD, Australia; Griffith University, School of Medicine, QLD, Australia
| | - Paul Scuffham
- Griffith University, Menzies Health Institute Queensland, QLD, Australia; Griffith University, School of Medicine, QLD, Australia
| | - Emma Bosley
- Queensland Ambulance Service, Information Support, Research and Evaluation, QLD, Australia
| | - Melinda Martin-Khan
- University of Queensland, Centre for Health Services Research, QLD, Australia
| | - Ping Zhang
- Griffith University, Menzies Health Institute Queensland, QLD, Australia
| | - Julia Crilly
- Griffith University, Menzies Health Institute Queensland, QLD, Australia; Department of Emergency Medicine, Gold Coast Health, QLD, Australia
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Wand T, Crawford C, Bell N, Murphy M, White K, Wood E. Documenting the pre-implementation phase for a multi-site translational research project to test a new model Emergency Department-based mental health nursing care. Int Emerg Nurs 2019; 45:10-16. [DOI: 10.1016/j.ienj.2019.04.001] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2018] [Revised: 03/31/2019] [Accepted: 04/11/2019] [Indexed: 10/26/2022]
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The impact of different liaison psychiatry models on the emergency department: A systematic review of the international evidence. J Psychosom Res 2019; 119:53-64. [PMID: 30947819 DOI: 10.1016/j.jpsychores.2019.01.013] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2018] [Revised: 01/13/2019] [Accepted: 01/17/2019] [Indexed: 11/22/2022]
Abstract
OBJECTIVE This review aimed to evaluate the current evidence for what impact different Liaison Psychiatry (LP) services are having on Emergency Departments (ED). Mental Health (MH) problems contribute to 12 million annual US ED attendances and 5% in the UK. METHODS Databases were searched for articles describing LP services for adult MH patients attending EDs which reported ED care-related outcomes, published since 2000. Articles were screened and relevant articles quality assessed and narratively synthesized. RESULTS 3653 articles were identified and 17 included in the review. Study designs were overall of poor-moderate quality, using retrospective before-and-after study designs. LP services were categorized into four models. Models with MH personnel integrated into the ED team or triage reduced patient waiting time to be seen, may reduce patients leaving without being seen and have high staff satisfaction. Co-located MH space or personnel reduced patient waiting times. Care agreements with existing psychiatry teams don't affect waiting times or ED length of stay. Transferring patients to external services reduces patients' time in the ED. There is insufficient evidence about patient satisfaction, costs, and onward care. CONCLUSIONS Waiting times are shortened by MH personnel integrated into the ED and are more satisfactory to staff than other LP models. The involvement of a psychiatrist in the LP team improves the care quality. All models may improve safety for patients but most evaluations are of poor quality and therefore there is still insufficient evidence to recommend one service model over another and further robust research is required.
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House A, Guthrie E, Walker A, Hewsion J, Trigwell P, Brennan C, Crawford M, Murray CC, Fossey M, Hulme C, Martin A, Quirk A, Tubeuf S. A programme theory for liaison mental health services in England. BMC Health Serv Res 2018; 18:742. [PMID: 30261875 PMCID: PMC6161457 DOI: 10.1186/s12913-018-3539-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2018] [Accepted: 09/13/2018] [Indexed: 11/11/2022] Open
Abstract
Background Mechanisms by which liaison mental health services (LMHS) may bring about improved patient and organisational outcomes are poorly understood. A small number of logic models have been developed, but they fail to capture the complexity of clinical practice. Method We synthesised data from a variety of sources including a large national survey, 73 in-depth interviews with acute and liaison staff working in hospitals with different types of liaison mental health services, and relevant local, national and international literature. We generated logic models for two common performance indicators used to assess organisational outcomes for LMHS: response times in the emergency department and hospital length of stay for people with mental health problems. Results We identified 8 areas of complexity that influence performance, and 6 trade-offs which drove the models in different directions depending upon the balance of the trade-off. The logic models we developed could only be captured by consideration of more than one pass through the system, the complexity in which they operated, and the trade-offs that occurred. Conclusions Our findings are important for commissioners of liaison services. Reliance on simple target setting may result in services that are unbalanced and not patient-centred. Targets need to be reviewed on a regular basis, together with other data that reflect the wider impact of the service, and any external changes in the system that affect the performance of LMHS, which are beyond their control.
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Affiliation(s)
- Allan House
- Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
| | - Elspeth Guthrie
- Leeds Institute of Health Sciences, University of Leeds, Leeds, UK.
| | - Andrew Walker
- Clinical Research Network National Coordinating Centre, National Institute of Health Research Clinical Research Network, Leeds, UK
| | - Jenny Hewsion
- Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
| | - Peter Trigwell
- National Inpatient Centre for Psychological Medicine, Leeds and York Partnership NHS Foundation Trust, Leeds, UK
| | - Cathy Brennan
- Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
| | - Mike Crawford
- Faculty of Medicine, Department of Medicine, Imperial College, London, UK
| | | | - Matt Fossey
- Veterans and Families Institute for Military Research, Faculty of Health, Social Care and Education, Anglia Ruskin University, Chelmsford, UK
| | - Claire Hulme
- Academic Unit of Health Economics, Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
| | - Adam Martin
- Academic Unit of Health Economics, Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
| | - Alan Quirk
- College Centre for Quality Improvement, Royal College of Psychiatrists, London, UK
| | - Sandy Tubeuf
- Academic Unit of Health Economics, Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
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Uspal NG, Rutman LE, Kodish I, Moore A, Migita RT. Use of a Dedicated, Non-Physician-led Mental Health Team to Reduce Pediatric Emergency Department Lengths of Stay. Acad Emerg Med 2016; 23:440-7. [PMID: 26806468 DOI: 10.1111/acem.12908] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2015] [Revised: 10/20/2015] [Accepted: 11/05/2015] [Indexed: 11/27/2022]
Abstract
OBJECTIVES Utilization of emergency departments (EDs) for pediatric mental health (MH) complaints is increasing. These patients require more resources and have higher admission rates than those with nonpsychiatric complaints. METHODS A multistage, multidisciplinary process to reduce length of stay (LOS) and improve the quality of care for patients with psychiatric complaints was performed at a tertiary care children's hospital's ED using Lean methodology. This process resulted in the implementation of a dedicated MH team, led by either a social worker or a psychiatric nurse, to evaluate patients, facilitate admissions, and arrange discharge planning. We conducted a retrospective, before-and-after study analyzing data 1 year before through 1 year after new process implementation (March 28, 2011). Our primary outcome was mean ED LOS. RESULTS After process implementation there was a statistically significant decrease in mean ED LOS (332 minutes vs. 244 minutes, p < 0.001). An x-bar chart of mean LOS shows special cause variation. Significant decreases were seen in median ED LOS (225 minutes vs. 204 minutes, p = 0.001), security physical interventions (2.0% vs. 0.4%, p = 0.004), and restraint use (1.7% vs. 0.1%, p < 0.001). No significant change was observed in admission rate, 72-hour return rate, or patient elopement/agitation events. Staff surveys showed improved perception of patient satisfaction, process efficacy, and patient safety. CONCLUSIONS Use of quality improvement methodology led to a redesign that was associated with a significant reduction in mean LOS of patients with psychiatric complaints and improved ED staff perception of care.
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Affiliation(s)
- Neil G. Uspal
- The Department of Pediatrics Division of Emergency Medicine; University of Washington; Seattle Children's Hospital; Seattle WA
- The Center for Clinical and Translational Research; Seattle Children's Research Institute; Seattle WA
| | - Lori E. Rutman
- The Department of Pediatrics Division of Emergency Medicine; University of Washington; Seattle Children's Hospital; Seattle WA
- The Center for Clinical and Translational Research; Seattle Children's Research Institute; Seattle WA
| | - Ian Kodish
- The Department of Psychiatry; University of Washington; Seattle Children's Hospital; Seattle WA
- The Center for Child Health, Behavior and Development; Seattle Children's Research Institute; Seattle WA
| | - Ann Moore
- Psychiatry and Behavioral Medicine; Seattle Children Hospital; Seattle WA
| | - Russell T. Migita
- The Department of Pediatrics Division of Emergency Medicine; University of Washington; Seattle Children's Hospital; Seattle WA
- The Center for Clinical and Translational Research; Seattle Children's Research Institute; Seattle WA
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Evaluating psychiatric nursing competencies applied to emergency settings: A pilot role delineation study. Int Emerg Nurs 2016; 25:37-42. [DOI: 10.1016/j.ienj.2015.07.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2015] [Revised: 07/05/2015] [Accepted: 07/16/2015] [Indexed: 11/23/2022]
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Evaluating a new model of nurse-led emergency department mental health care in Australia; perspectives of key informants. Int Emerg Nurs 2016; 24:16-21. [DOI: 10.1016/j.ienj.2015.05.003] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2015] [Revised: 05/01/2015] [Accepted: 05/17/2015] [Indexed: 11/23/2022]
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13
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Clarke DE, Boyce-Gaudreau K, Sanderson A, Baker JA. ED Triage Decision-Making With Mental Health Presentations: A “Think Aloud” Study. J Emerg Nurs 2015; 41:496-502. [DOI: 10.1016/j.jen.2015.04.016] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2014] [Revised: 04/01/2015] [Accepted: 04/28/2015] [Indexed: 10/23/2022]
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14
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Wolf LA, Perhats C, Delao AM. US emergency nurses’ perceptions of challenges and facilitators in the management of behavioural health patients in the emergency department: A mixed-methods study. ACTA ACUST UNITED AC 2015; 18:138-48. [DOI: 10.1016/j.aenj.2015.03.004] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2014] [Revised: 03/25/2015] [Accepted: 03/25/2015] [Indexed: 11/26/2022]
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Stephens RJ, White SE, Cudnik M, Patterson ES. Factors associated with longer length of stay for mental health emergency department patients. J Emerg Med 2014; 47:412-9. [PMID: 25074781 DOI: 10.1016/j.jemermed.2014.04.040] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2013] [Revised: 01/30/2014] [Accepted: 04/22/2014] [Indexed: 11/19/2022]
Abstract
BACKGROUND Mental health patients can experience long lengths of stay in the emergency department (ED). Reducing boarding times for mental health patients might improve care for all ED patients. OBJECTIVE The objective of this study was to identify patient factors that are correlated with extremely long lengths of stay (EL-LOS) for mental health patients in the ED. METHODS A retrospective, case-control study compared mental health patients experiencing lengths of stay longer than 24 h to those with lengths of stay <24 h. The study was conducted at an urban, academic ED and Level I trauma center. Sequential chi-squared tests were used to detect significant differences on the outcome measure. Logistic regression was used to determine factors that made significant contributions to predicting EL-LOS. The outcome measure was patients' length of stay in the ED. The factors analyzed were patient demographics, insurance status, day of arrival and departure, placement (admitted locally, admitted remotely, or discharged), chief complaint, and diagnostic category. RESULTS Patient-level factors associated with EL-LOS were self-pay status, admission to inpatient care, transfer to a remote facility, and suicidal ideation. Admission to inpatient care and self-pay status made significant nonredundant contributions to predicting EL-LOS. In addition, mental health patients arriving on a weekday were significantly more likely to be admitted to inpatient care than those arriving on weekends. CONCLUSIONS Factors were identified that correlated with long lengths of stay in the ED for mental health patients. Increasing timely access to inpatient beds for mental health patients, in particular by improving access to insurance that covers inpatient psychiatric care and eliminating unique mental health requirements to obtain prior authorization for placement, would likely reduce these patients' lengths of stay.
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Affiliation(s)
- Robert J Stephens
- Department of Integrated Systems Engineering, Ohio State University, Columbus, Ohio
| | - Susan E White
- School of Health and Rehabilitation Sciences, College of Medicine, Ohio State University, Columbus, Ohio
| | - Michael Cudnik
- Department of Emergency Medicine, Ohio State University, Columbus, Ohio
| | - Emily S Patterson
- School of Health and Rehabilitation Sciences, College of Medicine, Ohio State University, Columbus, Ohio
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Clarke D, Usick R, Sanderson A, Giles-Smith L, Baker J. Emergency department staff attitudes towards mental health consumers: a literature review and thematic content analysis. Int J Ment Health Nurs 2014; 23:273-84. [PMID: 23980913 DOI: 10.1111/inm.12040] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Visits to the emergency department (ED) for mental health reasons account for 10-15% of all visits. Consumers of mental health ED services, however, report that they often feel sent to the back of the queue and that their mental health concerns are not taken seriously, suggesting that societal stigma has impacted their care in the ED. In this study, we systematically explore the research concerning the attitudes of ED professional staff towards those who present with issues related to mental health. Four themes emerge from the literature: consumer perspectives, whose tenor is generally one of negativity; staff-reported attitudes and influencing factors, such as age, experience, and confidence in working with mental health presentations; the environmental climate of the ED, which might not be conducive to good mental health care; and interventions that have been used to evaluate changes in attitudes.
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Affiliation(s)
- Diana Clarke
- Faculty of Nursing, University of Manitoba, Winnipeg, Manitoba, Canada
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17
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Reducing uncertainty in triaging mental health presentations: examining triage decision-making. Int Emerg Nurs 2013; 22:47-51. [PMID: 23669028 DOI: 10.1016/j.ienj.2013.01.005] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2012] [Revised: 01/18/2013] [Accepted: 01/22/2013] [Indexed: 11/22/2022]
Abstract
Little is known about how emergency department (ED) nurses make decisions and even less is known about triage nurses' decision-making. There is compelling motivation to better understand the processes by which triage nurses make decisions, particularly with complex patient populations such as those with frequently emotive mental health and illness issues. While accuracy and reliability of triage decisions generally have been improved through the introduction of standardised triage scales and instruments, other factors such as lack of knowledge or confidence related to mental health issues, past experiences that may elicit transference and countertransference, judgments about individuals based on their behavioural presentations may impact on decisions made at triage. In this paper, we review the current research regarding the effectiveness of triage tools particularly with mental health presentations, present a theoretical framework that may guide research in understanding how triage nurses approach decision-making, and apply that framework to thinking about research in mental health-related triage. Developing a better understanding of how triage nurses make decisions, particularly in situations where issues related to mental health and illness may raise the levels of uncertainty, is crucial to ensure that they have the skills and tools they need to provide the most effective, sensitive, and compassionate care possible.
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18
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Dion J, Kennedy A, Cloutier P, Gray C. Evaluating Crisis Intervention Services for Youth within an Emergency Department: A View from Within. ACTA ACUST UNITED AC 2010. [DOI: 10.1080/13575271003789356] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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19
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Brinkman K, Hunks D, Bruggencate G, Clelland S. Evaluation of a new mental health liaison role in a rural health centre in Rocky Mountain House, Alberta: a Canadian story. Int J Ment Health Nurs 2009; 18:42-52. [PMID: 19125786 DOI: 10.1111/j.1447-0349.2008.00582.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
This paper describes the evaluation of a mental health liaison (MHL) role in a rural community in Alberta, Canada. The role provides advocacy, education, indirect and direct client intervention, and follow up. It was developed to eliminate gaps in mental health care and build collaborative cultures between the local hospital, physicians' offices, mental health clinics, and community agencies. Obtaining stakeholder feedback was an important step in assessing initial service impact while providing directions for role refinement and future programme development. A total of 116 questionnaires were distributed to physicians, hospital staff, and community mental health assessing stakeholder perception relating to various functions of the MHL. A 50% (n = 58) response rate was achieved with broad representation from different partners, including 75% of local physicians. The majority of respondents positively perceived the roles, functions, and impact of the MHL, including relationship development across the hospital community, improved access to services, and perceived improved client outcomes. The results reinforced that the MHL service meets a previously unmet need in this rural setting. Findings are being used to refine roles, provide local learning and resource development, understand issues relating to programme development in other areas, and develop client level outcomes relating to the services delivered.
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Affiliation(s)
- Karen Brinkman
- Access and Early Intervention, Dave Thompson Health Region, Alberta, Canada.
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21
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Wand T, White K, Patching J. Refining the model for an emergency department-based mental health nurse practitioner outpatient service. Nurs Inq 2008; 15:231-41. [DOI: 10.1111/j.1440-1800.2008.00407.x] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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22
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Strike C, Rufo C, Spence J, Links P, Bergmans Y, Ball J, Rhodes AE, Watson W, Eynan R. Unintended Impact of Psychiatric Safe Rooms in Emergency Departments: The Experiences of Suicidal Males With Substance Use Disorders. ACTA ACUST UNITED AC 2008. [DOI: 10.1093/brief-treatment/mhn007] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
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23
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Clarke DE, Brown AM, Giles-Smith L. Triaging suicidal patients: Sifting through the evidence. Int Emerg Nurs 2008; 16:165-74. [DOI: 10.1016/j.ienj.2008.03.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2008] [Accepted: 03/21/2008] [Indexed: 11/29/2022]
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24
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Wand T, White K. Exploring the scope of the Emergency Department mental health nurse practitioner role. Int J Ment Health Nurs 2007; 16:403-12. [PMID: 17995511 DOI: 10.1111/j.1447-0349.2007.00495.x] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
The mental health nurse practitioner (MHNP) role in the Emergency Department is focused on assessing and intervening to assist people in mental distress. The skills and expertise associated with this role are also compatible with the provision of short-term outpatient care. This scoping study investigated the potential for a MHNP outpatient service for patients presenting through the Emergency Department with a range of undifferentiated mental health concerns. The specific aim of this study was to explore the feasibility, structure, and potential outcome measures that may be used to evaluate a MHNP outpatient service. Data for the study were gathered via an extensive literature review and two separate focus group interviews. A series of semistructured interviews conducted with key informants were also undertaken to incorporate a range of clinical, academic, health manager, consumer, and carer perspectives. Findings from the study including prospective benefits and barriers associated with the implementation of this new service are highlighted and discussed. These findings indicate that a structured and formalized MHNP outpatient service has the potential to address a current deficit in the health-care system by providing timely, accessible, primary prevention, and early intervention mental health care that better meets the needs of the public and is consistent with the Australian National Mental Health Plan (2003-2008). A MHNP outpatient service also provides an important opportunity to explore, expand, and more clearly define the unique and valuable contribution of advanced mental health nursing practice to contemporary health care.
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Affiliation(s)
- Timothy Wand
- Emergency Department, Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia.
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25
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Abstract
The purpose of the present paper was to review the current models of mental health service delivery used in the emergency department (ED) setting. A search was conducted of the nursing and medical literature from 1990 to 2007 for relevant articles and reports. Consideration was also given to the global and local context influencing contemporary mental health services. Wider sociopolitical and socioeconomic influences and systemic changes in health-care delivery have dictated a considerable shift in attention for mental health services worldwide. The ED is a topical location that has attracted interest and necessitated a response. The mental health liaison nurse (MHLN) role embedded within the ED structure has demonstrated the most positive outcomes to date. This model aims to raise mental health awareness and address concerns over patient-focused outcomes such as reduced waiting times, therapeutic intervention and more efficient coordination of care and follow up for individuals presenting to the ED in psychological distress. Further research is required into all methods of mental health service delivery to the ED. The MHLN role is a cost-effective approach that has gained widespread approval from ED staff and mental health patients and is consistent with national and international expectations for mental health services to become fully integrated within general health care. The mental health nurse practitioner role situated within the ED represents a potentially promising alternative for enhanced public access to specialized mental health care.
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Affiliation(s)
- Timothy Wand
- Emergency Department, Royal Prince Alfred Hospital, Camperdown, NSW, Australia.
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26
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Abstract
General hospital emergency departments (EDs) are obvious places for individuals in psychiatric distress or a mental health crisis to seek assistance. However, the typical mental health presentation does not fit with the treatment norm of most EDs creating a tension around the care of individuals with mental illnesses. Eight focus groups were held with mental health patients and their families to determine their satisfaction with care received in regional EDs with particular emphasis on their evaluation of the role of the psychiatric emergency nurse. Themes identified were: waiting in the ED, attitudes of treatment staff, diagnostic overshadowing, 'no where else to go', family needs, and a wish list for ideal services. These issues are described in this paper along with clinical and systemic implications.
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Affiliation(s)
- Diana E Clarke
- Faculty of Nursing, University of Manitoba, Manitoba, Canada.
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