Short-stay crisis units for mental health patients on crisis care pathways: systematic review and meta-analysis

Psychiatric Emergency or General Emergency: Evolution or Involution? A Qualitative Study With Mental Health and Emergency Professionals

The treatment of individuals with psychiatric disorders who visit the Emergency Department (ED) remains a significant issue within healthcare organisations. Over the past decades, various organisational solutions have been proposed, ranging from dedicated Emergency Departments to liaison mechanisms involving mental health nurses within EDs or direct access to acute units. On one hand, there are clinical and organisational needs pushing towards the creation of dedicated pathways; on the other hand, there are concerns that such solutions may be counterproductive and dangerous in terms of health and social inclusion. The aim of this study is to assess the opinions of Mental Health and Emergency professionals on the advantages and disadvantages of clinical and organisational pathways dedicated to patients with psychiatric disorders who visit the general ED. The study was conducted using a qualitative research approach: semi-structured interviews were carried out through purposeful sampling composed of two cohorts: Emergency and Mental Health professionals. The data were analysed using content analysis with the software Atlas.ti. Forty-five interviews were collected, and six main themes/families were identified. A certain distance in opinions between the two cohorts emerged, especially regarding the adoption of dedicated pathways. In both cohorts, but particularly in the mental health cohort, there is a fear of stigmatisation and violation of patients' rights in dedicated pathways. Both groups believe that there is a need for more specific training and greater multidisciplinarity. This study adheres to the COREQ checklist for qualitative studies.

What is the purpose of Psychiatric Emergency Care Centres? A qualitative study of health care staff

BACKGROUND

Psychiatric Emergency Care Centres do not have a clear treatment model or evidence base. An understanding of the patient population, clinical practice and approaches is needed to develop an evidence-based framework.

OBJECTIVES

Identify staff perceptions of the purpose of Psychiatric Emergency Care Centres, who should be treated and how.

METHODS

A multidisciplinary sample of clinicians and administrators currently working in, or with administrative oversight of, Psychiatric Emergency Care Centres were interviewed. All New South Wales Psychiatric Emergency Care Centres were approached and staff self-selected. A total of 36 people participated, including nurses, doctors, social workers and managers. A critical realist qualitative thematic analysis approach was used, with an inductive orientation.

RESULTS

Having an achievable admission goal was important. Although 'harm minimization' was often cited as important, this meant conflicting, superimposed notions to different people, including minimizing self-harm, reducing iatrogenic harm from unnecessary or coercive intervention and limiting harm to a resource-constrained system. Participants reported significant clinical practice variation and confidence in their practice.

CONCLUSION

The approach to the primary goal of 'harm minimization' reflects conflicting priorities in a complex system which are often not explicit. However, we identified a clinical practice framework upon which to base care pathways, training, intervention development and outcome assessment.

Review of Emergent Financing Models for Mental Health Crisis Systems

Policy Points The sources and adequacy of funding for crisis systems currently varies significantly among the US states and across services in the crisis continuum. Crisis services are funded by a wide range of sources, including 988 telecom fees and other state appropriations, community mental health services block grants and other federal funding sources, Medicaid, and commercial insurance. Priority areas for research related to financing crisis systems include evaluating the effects of 988 telecom fees, value-based payment models, and non-Medicaid payors.

An Evaluation Protocol for A Stabilisation and Referral Area (SARA): A Novel Short Stay Psychiatry Unit Serving A Remote Region of Australia

Background

Stabilisation and Referral Areas (SARA) are a unique model of Short Stay Psychiatry inpatient care. This protocol details the comprehensive evaluation of a new SARA service within the Royal Darwin Hospital located in remote and regional Australia. Located in the Northern Territory (NT) there are just 17 specialised mental health beds per 100,000 compared to the national average of 27 per 100,000. There have been no previous evaluations of SARA services in regional and remote Australian settings, therefore their acceptability and potential effects on consumer outcomes in these unique settings is unknown. This study protocol attempts to address this knowledge gap.

Study Design

A mixed method study with triangulation and including mirror methodology.

Methods

A service evaluation protocol is proposed to be conducted over an initial 12 months period with a mirror image component to enable comparison of consumer outcomes prior to the service inception. The service evaluation is guided by the "Reach, Effectiveness, Adoption, Implementation and Maintenance" (RE-AIM) framework and utilized both qualitative and quantitative measures to comprehensively describe the service.

Results

Results will include both qualitative and quantitative data using the "R", "E" and "A" component (Reach, Effectiveness and Adoption) of the RE-AIM framework.

Conclusions

Emergency departments (EDs) are not well suited to persons experiencing mental health crisis and efforts need to be made to improve the delivery of service as well as patient flow. Minimizing wait times in ED is paramount. SARA is an innovative model of care that may address some of these issues. Evaluating its performance across a range of measures is key to improving and progressing the service. The unique context of the service location which has a large First Nations population and its remote setting adds further weight to the need to understand this model within this geographical context.

Review of EmPATH Units for Behavioral Health Casualties in Prolonged Field Care Environments

INTRODUCTION

Psychiatric conditions are one of the leading non-battle injury diseases resulting in medical evacuation (MEDEVAC) from combat environments. The challenge of limited MEDEVAC capability necessitating prolonged field care in future large-scale combat operations must be addressed. Therefore, a robust program is needed to address frontline care of behavioral health (BH), maximizing service members returning to duty and minimizing MEDEVAC. This review summarizes the literature on the impacts of the Emergency Psychiatric Assessment, Treatment, and Healing (EmPATH) Unit program as a solution to the challenges of treating behavioral health in future wars.

MATERIALS AND METHODS

We conducted a systematic literature search and review, and a non-systematic literature critique. We then used the Johns Hopkins evidence appraisal tool to appraise the strength and quality of the evidence. The following electronic databases were utilized for the search: Google Scholar, Embase, CINAHL, and PubMed. Search terms included: included "EmPATH," "prolonged field care," and "operational," alone and combined.

RESULTS

The literature review found that the EmPATH unit, a recently developed civilian hospital-based program, can work with higher acuity psychiatric crisis patients who would otherwise be admitted to an inpatient unit, showing promising results in avoiding the need for inpatient hospitalization. EmPATH units help decrease hospitalization rates, reduce restraints and violence, and shorten the patients' boarding time in a holding area. Such findings support the use of the EmPATH unit as a tactic for prolonged field care of psychiatric patients in a combat operational environment.

CONCLUSIONS

This is the first literature review to consider EmPATH units for psychiatric prolonged field care based on its advantages demonstrated in the civilian sector. Studies have yet to be done on EmPATH units' usefulness in the military, showing a knowledge gap in current evidence supporting its suitability. Thus, this review recommends further studies of EmPATH units in military settings, especially prolonged field care environments.

Reasons Explaining High Emergency Department Use in Patients With Mental Illnesses: Different Staff Perspectives

For patients with mental illnesses (MIs), emergency departments (EDs) are often the entry point into the healthcare system, or their only resort for quickly accessing mental health treatment. A better understanding of the various barriers justifying high ED use among patients with MIs may help recommend targeted interventions that better meet their needs. This explorative qualitative study aimed to identify such barriers and the solutions brought forth to reduce ED use based on the perspectives of clinicians and managers working in EDs, other hospital departments or the community sector. Interviews were conducted between April 2021 and February 2022; 86 mental health professionals (22% were nurses) from four large urban ED sites in Quebec (Canada) were interviewed. Barriers were identified in relation to patient profiles, healthcare system and organisational features and professional characteristics. The key barriers that were found to explain high ED use were patients having serious MIs (e.g., psychotic disorders) or social issues (e.g., poverty), lack of coordination and patient referrals between EDs and other health services, insufficient access to mental health and addiction services and inadequacy of care. Very few solutions were implemented to improve care for high ED users. Better deployment of ED interventions in collaboration with outpatient care may be prioritised to reduce high ED use for patients with MIs. Improvements to the referral and transfer processes to outpatient care, particularly through care plans and case management programs, may be implemented to reduce high ED use and improve outpatient care among patients with multiple health and social needs.

Specialized short term crisis intervention for patients with personality disorder: Effects on coercion and length of stay

BACKGROUND

Acute crises in patients with personality disorders (PD) are often accompanied by suicidal and self-harming behavior. Their management is challenging, as both coercive measures and prolonged inpatient-treatment are known to be counterproductive. Only in crises that cannot be controlled by outpatient means, inpatient treatment is to be taken into account. This treatment should be time-limited and not involve coercion.

AIMS

The aim of this study was to assess if the introduction of a specialized crisis intervention track is associated with a reduction of coercive measures as well as a shorter in-hospital stay in PD patients.

METHODS

In this 8-year, hospital-wide, longitudinal, observational study, we investigated the frequency of coercive measures and the median length of in-hospital stay in 1,752 inpatient-cases with PD admitted to the Adult Psychiatry, UPK, Basel, Switzerland, between 01.01.2012 and 31.12.2019. By means of an interrupted-time-series analysis, we compared the period before and after the implementation of a specialized crisis intervention track for PD patients.

RESULTS

Our data show a significant decrease in the median length of in-hospital stay and no significant reduction in the incidence rate of coercion among PD patients after the intervention. The latter is likely due to a floor effect, since there was a significant decrease in coercive measures over the entire observation period, already reaching very low rates before the intervention.

CONCLUSIONS

Our study underlines the clinical importance of specialized short-term crisis management in PD, which comes along with shorter lengths of in-hospital stays and a stable low rate of coercive measure.

Scoping review of the effectiveness of 10 high-impact initiatives (HIIs) for recovering urgent and emergency care services

INTRODUCTION

Prolonged ambulance response times and unacceptable emergency department (ED) wait times are significant challenges in urgent and emergency care systems associated with patient harm. This scoping review aimed to evaluate the evidence base for 10 urgent and emergency care high-impact initiatives identified by the National Health Service (NHS) England.

METHODS

A two-stage approach was employed. First, a comprehensive search for reviews (2018-2023) was conducted across PubMed, Epistemonikos and Google Scholar. Additionally, full-text searches using Google Scholar were performed for studies related to the key outcomes. In the absence of sufficient review-level evidence, relevant available primary research studies were identified through targeted MEDLINE and HMIC searches. Relevant reviews and studies were mapped to the 10 high-impact initiatives. Reviewers worked in pairs or singly to identify studies, extract, tabulate and summarise data.

RESULTS

The search yielded 20 771 citations, with 48 reviews meeting the inclusion criteria across 10 sections. In the absence of substantive review-level evidence for the key outcomes, primary research studies were also sought for seven of the 10 initiatives. Evidence for interventions improving ambulance response times was generally scarce. ED wait times were commonly studied using ED length of stay, with some evidence that same day emergency care, acute frailty units, care transfer hubs and some in-patient flow interventions might reduce direct and indirect measures of wait times. Proximal evidence existed for initiatives such as urgent community response, virtual hospitals/hospital at home and inpatient flow interventions (involving flow coordinators), which did not typically evaluate the NHS England outcomes of interest.

CONCLUSIONS

Effective interventions were often only identifiable as components within the NHS England 10 high-impact initiative groupings. The evidence base remains limited, with substantial heterogeneity in urgent and emergency care initiatives, metrics and reporting across different studies and settings. Future research should focus on well-defined interventions while remaining sensitive to local context.

Youth Crisis: The Current State and Future Directions

The number of children and youth experiencing behavioral health crisis in the United States is substantially increasing. Currently, there are shortages to home-based and community-based services as well as psychiatric outpatient and inpatient pediatric care, leading to high emergency department utilization. This article introduces a proposed crisis continuum of care, highlights existing evidence, and provides opportunities for further research and advocacy.

Reasons for High Emergency Department Use Among Patients With Common Mental Disorders or Substance-Related Disorders

Aims

This study examined the reasons for high emergency department (ED) use among patients with common mental disorders (MDs), substance-related disorders (SRDs) or co-occurring MDs-SRDs.

Method

Following content analysis, 42 high ED users (three-plus visits/year) recruited in two Quebec EDs were interviewed.

Results

The reasons included barriers to outpatient care, patient disabilities and professional practices. Patients with SRDs trust outpatient services less, those with MDs had important unmet needs and those with MDs-SRDs faced care coordination issues.

Conclusion

Improvements such as ED use monitoring, consolidating MD-SRD practices and continuous training are needed in EDs and outpatient services to enhance access and continuity of care.

Barriers and Facilitators to High Emergency Department Use Among Patients with Mental Disorders: A Qualitative Investigation

This qualitative study explored reasons for high emergency department (ED) use (3 + visits/year) among 299 patients with mental disorders (MD) recruited in four ED in Quebec, Canada. A conceptual framework including healthcare system and ED organizational features, patient profiles, and professional practice guided the content analysis. Results highlighted insufficient access to and inadequacy of outpatient care. While some patients were quite satisfied with ED care, most criticized the lack of referrals or follow-up care. Patient profiles justifying high ED use were strongly associated with health and social issues perceived as needing immediate care. The main barriers in professional practice involved lack of MD expertise among primary care clinicians, and insufficient follow-up by psychiatrists in response to patient needs. Collaboration with outpatient care may be prioritized to reduce high ED use and improve ED interventions by strengthening the discharge process, and increasing access to outpatient care.

Emergency Department Use among Patients with Mental Health Problems: Profiles, Correlates, and Outcomes

Patients with mental health (MH) problems are known to use emergency departments (EDs) frequently. This study identified profiles of ED users and associated these profiles with patient characteristics and outpatient service use, and with subsequent adverse outcomes. A 5-year cohort of 11,682 ED users was investigated (2012-2017), using Quebec (Canada) administrative databases. ED user profiles were identified through latent class analysis, and multinomial logistic regression used to associate patients' characteristics and their outpatient service use. Cox regressions were conducted to assess adverse outcomes 12 months after the last ED use. Four ED user profiles were identified: "Patients mostly using EDs for accessing MH services" (Profile 1, incident MDs); "Repeat ED users" (Profile 2); "High ED users" (Profile 3); "Very high and recurrent high ED users" (Profile 4). Profile 4 and 3 patients exhibited the highest ED use along with severe conditions yet received the most outpatient care. The risk of hospitalization and death was higher in these profiles. Their frequent ED use and adverse outcomes might stem from unmet needs and suboptimal care. Assertive community treatments and intensive case management could be recommended for Profiles 4 and 3, and more extensive team-based GP care for Profiles 2 and 1.

Management of youth with suicidal ideation: Challenges and best practices for emergency departments

Suicide is a leading cause of death among youth, and emergency departments (EDs) play an important role in caring for youth with suicidality. Shortages in outpatient and inpatient mental and behavioral health capacity combined with a surge in ED visits for youth with suicidal ideation (SI) and self-harm challenge many EDs in the United States. This review highlights currently identified best practices that all EDs can implement in suicide screening, assessment of youth with self-harm and SI, care for patients awaiting inpatient psychiatric care, and discharge planning for youth determined not to require inpatient treatment. We will also highlight several controversies and challenges in implementation of these best practices in the ED. An enhanced continuum of care model recommended for youth with mental and behavioral health crises utilizes crisis lines, mobile crisis units, crisis receiving and stabilization units, and also maximizes interventions in home- and community-based settings. However, while local systems work to enhance continuum capacity, EDs remain a critical part of crisis care. Currently, EDs face barriers to providing optimal treatment for youth in crisis due to inadequate resources including the ability to obtain emergent mental health consultations via on-site professionals, telepsychiatry, and ED transfer agreements. To reduce ED utilization and better facilitate safe dispositions from EDs, the expansion of community- and home-based services, pediatric-receiving crisis stabilization units, inpatient psychiatric services, among other innovative solutions, is necessary.

The effect of psychiatric decision unit services on inpatient admissions and mental health presentations in emergency departments: an interrupted time series analysis from two cities and one rural area in England

AIMS

High-quality evidence is lacking for the impact on healthcare utilisation of short-stay alternatives to psychiatric inpatient services for people experiencing acute and/or complex mental health crises (known in England as psychiatric decision units [PDUs]). We assessed the extent to which changes in psychiatric hospital and emergency department (ED) activity were explained by implementation of PDUs in England using a quasi-experimental approach.

METHODS

We conducted an interrupted time series (ITS) analysis of weekly aggregated data pre- and post-PDU implementation in one rural and two urban sites using segmented regression, adjusting for temporal and seasonal trends. Primary outcomes were changes in the number of voluntary inpatient admissions to (acute) adult psychiatric wards and number of ED adult mental health-related attendances in the 24 months post-PDU implementation compared to that in the 24 months pre-PDU implementation.

RESULTS

The two PDUs (one urban and one rural) with longer (average) stays and high staff-to-patient ratios observed post-PDU decreases in the pattern of weekly voluntary psychiatric admissions relative to pre-PDU trend (Rural: -0.45%/week, 95% confidence interval [CI] = -0.78%, -0.12%; Urban: -0.49%/week, 95% CI = -0.73%, -0.25%); PDU implementation in each was associated with an estimated 35-38% reduction in total voluntary admissions in the post-PDU period. The (urban) PDU with the highest throughput, lowest staff-to-patient ratio and shortest average stay observed a 20% (-20.4%, CI = -29.7%, -10.0%) level reduction in mental health-related ED attendances post-PDU, although there was little impact on long-term trend. Pooled analyses across sites indicated a significant reduction in the number of voluntary admissions following PDU implementation (-16.6%, 95% CI = -23.9%, -8.5%) but no significant (long-term) trend change (-0.20%/week, 95% CI = -0.74%, 0.34%) and no short- (-2.8%, 95% CI = -19.3%, 17.0%) or long-term (0.08%/week, 95% CI = -0.13, 0.28%) effects on mental health-related ED attendances. Findings were largely unchanged in secondary (ITS) analyses that considered the introduction of other service initiatives in the study period.

CONCLUSIONS

The introduction of PDUs was associated with an immediate reduction of voluntary psychiatric inpatient admissions. The extent to which PDUs change long-term trends of voluntary psychiatric admissions or impact on psychiatric presentations at ED may be linked to their configuration. PDUs with a large capacity, short length of stay and low staff-to-patient ratio can positively impact ED mental health presentations, while PDUs with longer length of stay and higher staff-to-patient ratios have potential to reduce voluntary psychiatric admissions over an extended period. Taken as a whole, our analyses suggest that when establishing a PDU, consideration of the primary crisis-care need that underlies the creation of the unit is key.

The effectiveness of brief non-pharmacological interventions in emergency departments and psychiatric inpatient units for people in crisis: A systematic review and narrative synthesis

OBJECTIVE

Heterogeneous brief non-pharmacological interventions and guidelines exist to treat the burgeoning presentations to both emergency department and inpatient settings, for those in a crisis of mental ill-health. We systematically reviewed the literature to create a taxonomy of these brief non-pharmacological interventions, and review their evaluation methods and effectiveness.

METHOD

We conducted a systematic review across Cochrane, CINAHL, DARE, Embase, MEDLINE, PsycINFO databases. Studies meeting quality criteria, using Joanna Briggs Institute tools, were eligible. Interventions were categorised, and outcomes synthesised.

RESULTS

Thirty-nine studies were included: 8 randomised controlled trials, 17 quasi-experimental, 11 qualitative studies, and 3 file audits. Taxonomy produced six coherent intervention types: Skills-focussed, Environment-focussed, Special Observation, Psychoeducation, Multicomponent Group and Multicomponent Individual. Despite this, a broad and inconsistent range of outcome measures reflected different outcome priorities and prevented systematic comparison of different types of intervention or meta-analysis. Few brief non-pharmacological interventions had consistent evidential support: sensory modulation rooms consistently improved distress in inpatient settings. Short admissions may reduce suicide attempts and readmission, if accompanied by psychotherapy. Suicide-specific interventions in emergency departments may improve depressive symptoms, but not suicide attempt rates. There was evidence that brief non-pharmacological interventions did not reduce incidence of self-harm on inpatient wards. We found no evidence for frequently used interventions such as no-suicide contracting, special observation or inpatient self-harm interventions.

CONCLUSION

Categorising brief non-pharmacological interventions is feasible, but an evidence base for many is severely limited if not missing. Even when there is evidence, the inconsistency in outcomes often precludes clinicians from making inferences, although some interventions show promise.

Characteristics for Low, High and Very High Emergency Department Use for Mental Health Diagnoses from Health Records and Structured Interviews

Introduction

Patients with mental health diagnoses (MHD) are among the most frequent emergency department (ED) users, suggesting the importance of identifying additional factors associated with their ED use frequency. In this study we assessed various patient sociodemographic and clinical characteristics, and service use associated with low ED users (1-3 visits/year), compared to high (4-7) and very high (8+) ED users with MHD.

Methods

Our study was conducted in four large Quebec (Canada) ED networks. A total of 299 patients with MHD were randomly recruited from these ED in 2021-2022. Structured interviews complemented data from network health records, providing extensive data on participant profiles and their quality of care. We used multivariable multinomial logistic regression to compare low ED use to high and very high ED use.

Results

Over a 12-month period, 39% of patients were low ED users, 37% high, and 24% very high ED users. Compared with low ED users, those at greater probability for high or very high ED use exhibited more violent/disturbed behaviors or social problems, chronic physical illnesses, and barriers to unmet needs. Patients previously hospitalized 1-2 times had lower risk of high or very high ED use than those not previously hospitalized. Compared with low ED users, high and very high ED users showed higher prevalence of personality disorders and suicidal behaviors, respectively. Women had greater probability of high ED use than men. Patients living in rental housing had greater probability of being very high ED users than those living in private housing. Using at least 5+ primary care services and being recurrent ED users two years prior to the last year of ED use had increased probability of very high ED use.

Conclusion

Frequency of ED use was associated with complex issues and higher perceived barriers to unmet needs among patients. Very high ED users had more severe recurrent conditions, such as isolation and suicidal behaviors, despite using more primary care services. Results suggested substantial reduction of barriers to care and improvement on both access and continuity of care for these vulnerable patients, integrating crisis resolution and supported housing services. Limited hospitalizations may sometimes be indicated, protecting against ED use.

The impact of the cost-of-living crisis on population health in the UK: rapid evidence review

BACKGROUND

In the UK, unique and unforeseen factors, including COVID-19, Brexit, and Ukraine-Russia war, have resulted in an unprecedented cost of living crisis, creating a second health emergency. We present, one of the first rapid reviews with the aim of examining the impact of this current crisis, at a population level. We reviewed published literature, as well as grey literature, examining a broad range of physical and mental impacts on health in the short, mid, and long term, identifying those most at risk, impacts on system partners, including emergency services and the third sector, as well as mitigation strategies.

METHODS

We conducted a rapid review by searching PubMed, Embase, MEDLINE, and HMIC (2020 to 2023). We searched for grey literature on Google and hand-searched the reports of relevant public health organisations. We included interventional and observational studies that reported outcomes of interventions aimed at mitigating against the impacts of cost of living at a population level.

RESULTS

We found that the strongest evidence was for the impact of cold and mouldy homes on respiratory-related infections and respiratory conditions. Those at an increased risk were young children (0-4 years), the elderly (aged 75 and over), as well as those already vulnerable, including those with long-term multimorbidity. Further short-term impacts include an increased risk of physical pain including musculoskeletal and chest pain, and increased risk of enteric infections and malnutrition. In the mid-term, we could see increases in hypertension, transient ischaemic attacks, and myocardial infarctions, and respiratory illnesses. In the long term we could see an increase in mortality and morbidity rates from respiratory and cardiovascular disease, as well as increase rates of suicide and self-harm and infectious disease outcomes. Changes in behaviour are likely particularly around changes in food buying patterns and the ability to heat a home. System partners are also impacted, with voluntary sectors seeing fewer volunteers, an increase in petty crime and theft, alternative heating appliances causing fires, and an increase in burns and burn-related admissions. To mitigate against these impacts, support should be provided, to the most vulnerable, to help increase disposable income, reduce energy bills, and encourage home improvements linked with energy efficiency. Stronger links to bridge voluntary, community, charity and faith groups are needed to help provide additional aid and support.

CONCLUSION

Although the CoL crisis affects the entire population, the impacts are exacerbated in those that are most vulnerable, particularly young children, single parents, multigenerational families. More can be done at a community and societal level to support the most vulnerable, and those living with long-term multimorbidity. This review consolidates the current evidence on the impacts of the cost of living crisis and may enable decision makers to target limited resources more effectively.

Ranking important predictors of the need for a high-acuity psychiatry unit among 2,064 inpatients admitted to psychiatric emergency hospitals: a random forest model

Aims

In order to uphold and enhance the emergency psychiatric care system, a thorough comprehension of the characteristics of patients who require a high-acuity psychiatry unit is indispensable. We aimed to clarify the most important predictors of the need for a high-acuity psychiatry unit using a random forest model.

Methods

This cross-sectional study encompassed patients admitted to psychiatric emergency hospitals at 161 medical institutions across Japan between December 8, 2022, and January 31, 2023. Questionnaires were completed by psychiatrists, with a maximum of 30 patients assessed per medical institution. The questionnaires included psychiatrists' assessment of the patient's condition (exposure variables) and the need for a high-acuity psychiatry unit (outcome variables). The exposure variables consisted of 32 binary variables, including age, diagnoses, and clinical condition (i.e., factors on the clinical profile, emergency treatment requirements, and purpose of hospitalization). The outcome variable was the need for a high-acuity psychiatry unit, scored from 0 to 10. To identify the most important predictors of the need for a high-acuity psychiatry unit, we used a random forest model. As a sensitivity analysis, multivariate linear regression analysis was performed.

Results

Data on 2,164 patients from 81 medical institutions were obtained (response rate, 50.3%). After excluding participants with missing values, this analysis included 2,064 patients. Of the 32 items, the top-5 predictors of the need for a high-acuity psychiatry unit were the essentiality of inpatient treatment (otherwise, symptoms will worsen or linger), need for 24-hour professional care, symptom severity, safety ensured by specialized equipment, and medication management. These items were each significantly and positively associated with the need for a high-acuity psychiatry unit in linear regression analyses (p < 0.001 for all). Conversely, items on age and diagnosis were lower in the ranking and were not statistically significant in linear regression models.

Conclusion

Items related to the patient's clinical profile might hold greater importance in predicting the need for a high-acuity psychiatry unit than do items associated with age and diagnosis.

Association of Arizona's Implementation of a Behavioral Health Crisis Response System With Suicide Hospitalizations

OBJECTIVE

In July 2022, the 988 Suicide and Crisis Lifeline went live. The Lifeline is part of larger federal and state efforts to build comprehensive behavioral health crisis response systems that include mobile crisis units and crisis diversion and stabilization centers. Comprehensive response systems are anticipated to reduce hospitalizations for suicide and other behavioral health crises; however, research testing this assumption has been limited. The authors used Arizona-a state known for its comprehensive crisis system-to determine the association between state implementation of a comprehensive behavioral health crisis response system and suicide-related hospitalizations.

METHODS

A comparative interrupted time-series (CITS) design was used to compare changes in suicide-related hospitalizations after the 2015 implementation of Arizona's crisis response system (N=215,063). Data were from the 2010-2019 Healthcare Cost and Utilization Project (HCUP) State Inpatient Databases (SID). Nevada (N=84,091 hospitalizations) was used as a comparison state because it is a western state that had not yet implemented a comprehensive crisis system and had available HCUP SID data. The CITS model included controls for time-varying differences in state demographic composition.

RESULTS

From 2010 to 2014 to 2019, annual suicide-related hospitalizations in Arizona increased from 122.0 to 324.2 to 584.5, respectively, per 100,000 people, and in Nevada, hospitalizations increased from 94.7 to 263.2 to 595.5, respectively, per 100,000 people. Arizona's crisis response system was associated with a significant relative decrease in the quarterly trend of 2.57 suicide-related hospitalizations per 100,000 people (p=0.033).

CONCLUSIONS

More research is needed to understand how the implementation of a comprehensive crisis response system may affect suicide-related hospitalizations.

Service use preceding and following first referral for psychiatric emergency care at a short-stay crisis unit: A cohort study across three cities and one rural area in England

BACKGROUND

Internationally, hospital-based short-stay crisis units have been introduced to provide a safe space for stabilisation and further assessment for those in psychiatric crisis. The units typically aim to reduce inpatient admissions and psychiatric presentations to emergency departments.

AIMS

To assess changes to service use following a service user's first visit to a unit, characterise the population accessing these units and examine equality of access to the units.

METHODS

A prospective cohort study design (ISCTRN registered; 53431343) compared service use for the 9 months preceding and following a first visit to a short-stay crisis unit at three cities and one rural area in England. Included individuals first visited a unit in the 6 months between 01/September/2020 and 28/February/2021.

RESULTS

The prospective cohort included 1189 individuals aged 36 years on average, significantly younger (by 5-13 years) than the population of local service users (<.001). Seventy percent were White British and most were without a psychiatric diagnosis (55%-82% across sites). The emergency department provided the largest single source of referrals to the unit (42%), followed by the Crisis and Home Treatment Team (20%). The use of most mental health services, including all types of admission and community mental health services was increased post discharge. Social-distancing measures due to the COVID-19 pandemic were in place for slightly over 50% of the follow-up period. Comparison to a pre-COVID cohort of 934 individuals suggested that the pandemic had no effect on the majority of service use variables.

CONCLUSIONS

Short-stay crisis units are typically accessed by a young population, including those who previously were unknown to mental health services, who proceed to access a broader range of mental health services following discharge.

Association of Hospital Readmission Rates With Discharge Disposition for Patients With Psychotic Disorders

GOAL

We explored how readmissions may result from patients' lack of access to aftercare services, failure to adhere to psychotropic medication plans, and inability to understand and follow hospital discharge recommendations. We also investigated whether insurance status, demographics, and socioeconomic status are associated with hospital readmissions. This study is important because readmissions contribute to increased personal and hospital expenses and decreased community tenure (the ability to maintain stability between hospital admissions). Addressing hospital readmissions will promote optimal discharge practices beginning on day one of hospital admission.

METHODS

The study examined the differences in hospital readmission rates for patients with a primary psychotic disorder diagnosis. Discharge data were drawn in 2017 from the Nationwide Readmissions Database. Inclusion criteria included patients aged 0-89 years who were readmitted to a hospital between less than 24 hr and up to 30 days from discharge. Exclusion criteria were principal medical diagnoses, unplanned 30-day readmissions, and discharges against medical advice. The sampling frame included 269,906 weighted number of patients diagnosed with a psychotic disorder treated at one of 2,355 U.S. community hospitals. The sample size was 148,529 unweighted numbers of patients discharged.

PRINCIPAL FINDINGS

In a logistic regression model, weighted variables were calculated and used to determine an association between the discharge dispositions and readmissions. After controlling for hospital characteristics and patient demographics, we found that the odds for readmission for routine and short-term hospital discharge dispositions decreased for home health care discharges, which indicated that home health care can prevent readmissions. The finding was statistically significant when controlling for payer type and patient age and gender.

PRACTICAL APPLICATIONS

The findings support home health care as an effective option for patients with severe psychosis. Home health care reduces readmissions and is recommended, when appropriate, as an aftercare service following inpatient hospitalization and may enhance the quality of patient care. Improving healthcare quality involves optimizing, streamlining, and promoting standardized processes in discharge planning and direct transitions to aftercare services.

24 hours - Life in the E.R.: A state-wide data linkage analysis of in-patients with prolonged emergency department length of stay in New South Wales, Australia

OBJECTIVE

Describe the characteristics and predictors of mortality for patients who spend more than 24 h in the ED waiting for an in-patient bed and compare baseline clinical and demographic characteristics between tertiary and non-tertiary hospitals.

METHODS

This was a state-wide analysis data linkage analysis of adult (age >16 years) ED presentations across New South Wales from 2019 to 2020. Cases were included if their mode of separation from ED indicated admission to an in-patient unit including critical care ward and their ED length of stay was greater than or equal to 24 h. Cases were categorised by service-related groups based on principle diagnosis.

RESULTS

A total of 26 854 eligible cases were identified. The most common diagnosis groups were psychiatry, cardiology and respiratory. The odds ratio (OR) for 30-day all-cause mortality in admitted patients with an ED length of stay greater than 24 h were highest in those aged >75 years (OR 15.18, 95% confidence interval [CI] 9.99-23.07, P < 0.001), oncology (OR 10.45, 95% CI 7.93-13.77, P < 0.001) and haematology patients (OR 2.95, 95% CI 2.01-4.33, P < 0.001).

CONCLUSION

Interventions and models of care to address ED access block need to focus on mental health patients, older patients particularly those with cardiorespiratory illness and oncology and haematology patients for whom risk of mortality is disproportionately higher.