Recent Submissions

  • Hospital admissions and place of death of residents of care homes receiving specialist healthcare services: A systematic review without meta-analysis

    Hughes, Jane; Challis, David (2021)
    Abstract Aim To synthesize evidence on the ability of specialist care home support services to prevent hospital admission of older care home residents, including at end of life. Design Systematic review, without meta-analysis, with vote counting based on direction of effect. Data sources Fourteen electronic databases were searched from January 2010 to January 2019. Reference lists of identified reviews, study protocols and included documents were scrutinized for further studies. Review methods Papers on the provision of specialist care home support that addressed older, long-term care home residents? physical health needs and provided comparative data on hospital admissions were included. Two reviewers undertook study selection and quality appraisal independently. Vote counting by direction of effect and binomial tests determined service effectiveness. Results Electronic searches identified 79 relevant references. Combined with 19 citations from an earlier review, this gave 98 individual references relating to 92 studies. Most were from the UK (22), USA (22) and Australia (19). Twenty studies were randomized controlled trials and six clinical controlled trials. The review suggested interventions addressing residents? general health needs (p < .001), assessment and management services (p < .0001) and non-training initiatives involving medical staff (p < .0001) can reduce hospital admissions, while there was also promising evidence for services targeting residents at imminent risk of hospital entry or post-hospital discharge and training-only initiatives. End-of-life care services may enable residents to remain in the home at end of life (p < .001), but the high number of weak-rated studies undermined confidence in this result. Conclusion This review suggests specialist care home support services can reduce hospital admissions. More robust studies of services for residents at end of life are urgently needed. Impact The review addressed the policy imperative to reduce the avoidable hospital admission of older care home residents and provides important evidence to inform service design. The findings are of relevance to commissioners, providers and residents.
  • Trends in referrals to liaison psychiatry teams from UK emergency departments for patients over 65

    Junaid, Kehinde; Mittal, Shweta (2021)
    Aims The number of people over the age of 65 attending Emergency Departments (ED) in the United Kingdom (UK) is increasing. Those who attend with a mental health related problem may be referred to liaison psychiatry for assessment. Improving responsiveness and integration of liaison psychiatry in general hospital settings is a national priority. To do this psychiatry teams must be adequately resourced and organised. However, it is unknown how trends in the number of referrals of older people to liaison psychiatry teams by EDs are changing, making this difficult. Method We performed a national multi-centre retrospective service evaluation, analysing existing psychiatry referral data from EDs of people over 65. Sites were selected from a convenience sample of older peoples liaison psychiatry departments. Departments from all regions of the UK were invited to participate via the RCPsych liaison and older peoples faculty email distribution lists. From departments who returned data, we combined the date and described trends in the number and rate of referrals over a 7 year period. Result Referral data from up to 28 EDs across England and Scotland over a 7 year period were analysed (n = 18828 referrals). There is a general trend towards increasing numbers of older people referred to liaison psychiatry year on year. Rates rose year on year from 1.4 referrals per 1000 ED attenders (>65 years) in 2011 to 4.5 in 2019 . There is inter and intra site variability in referral numbers per 1000 ED attendances between different departments, ranging from 0.1 - 24.3. Conclusion To plan an effective healthcare system we need to understand the population it serves, and have appropriate structures and processes within it. The overarching message of this study is clear; older peoples mental health emergencies presenting in ED are common and appear to be increasingly so. Without appropriate investment either in EDs or community mental health services, this is unlikely to improve. The data also suggest very variable inter-departmental referral rates. It is not possible to establish why rates from one department to another are so different, or whether outcomes for the population they serve are better or worse. The data does however highlight the importance of asking further questions about why the departments are different, and what impact that has on the patients they serve.
  • Rapid tranquillisation in a psychiatric emergency hospital in Lebanon: TREC-Lebanon - a pragmatic randomised controlled trial of intramuscular haloperidol and promethazine v. intramuscular haloperidol, promethazine and chlorpromazine

    Dib, Joseph E.; Adams, Clive E. (2021)
    BACKGROUNDAgitated patients constitute 10% of all emergency psychiatric treatment. Management guidelines, the preferred treatment of clinicians differ in opinion and practice. In Lebanon, the use of the triple therapy haloperidol plus promethazine plus chlorpromazine (HPC) is frequently used but no studies involving this combination exists.METHODA pragmatic randomised open trial (September 2018-July 2019) in the Lebanese Psychiatric Hospital of the Cross in Beirut Lebanon involving 100 people requiring urgent intramuscular sedation due to aggressive behaviour were given intramuscular chlorpromazine 100 mg plus haloperidol 5 mg plus promethazine 25 mg (HPC) or intramuscular haloperidol 5 mg plus promethazine 25 mg.RESULTSPrimary outcome data were available for 94 (94%) people. People allocated to the haloperidol plus promethazine (HP) group showed no clear difference at 20 min compared with patients allocated to the HPC group [relative risk (RR) 0.84, 95% confidence interval (CI) 0.47-1.50].CONCLUSIONSNeither intervention consistently impacted the outcome of 'calm', or 'asleep' and had no discernible effect on the use of restraints, use of additional drugs or recurrence. If clinicians are faced with uncertainty on which of the two intervention combinations to use, the simpler HP is much more widely tested and the addition of chlorpromazine adds no clear benefit with a risk of additional adverse effects.
  • When people living with dementia say 'no': Negotiating refusal in the acute hospital setting

    O'Brien, Rebecca (2020)
    A quarter of UK acute hospital beds are occupied by people living with dementia (PLWD). Concerns have been raised by both policy makers and carers about the quality of communication between hospital staff and PLWD. PLWD may experience communication impairments such as word finding difficulties, limited ability to construct coherent narratives and difficulties understanding others. Since much healthcare delivery occurs through talk, healthcare professionals (HCPs) and PLWD are likely to experience increased communication barriers. Consistent with this, HCPs report stress and reduced job satisfaction associated with difficulty communicating with PLWD. HCPs face these challenges whilst striving to deliver person-centred care, respecting the autonomy and wishes of the patient before them. However, best practice recommendations in the field tend not to be based on actual interactional evidence. This paper investigates recurring interactional difficulties around HCP requests to carry out health and social care tasks and subsequent reluctance or refusal on the part of PLWD. Using conversation analysis, we examined 41 video recordings of HCP/PLWD interactions collected across three acute inpatient wards. We identify both the nature of the refusals, and any mitigation offered, and explore the requests preceding them in terms of entitlement and contingency. We also explore the nature of HCP requests which precede PLWD agreement with a course of action. We conclude that several features of requests can be seen to precede acceptance, principally the use of higher entitlement requests, and the lowering of contingencies. Our findings underline the importance of examining the contextual interactional detail involved in the negotiation of healthcare, which here leads to an understanding of how design of HCP requests can impact on an important healthcare activity being carried out. They also emphasise the power of conversation analytic methods to identify areas of frequent interactional trouble in dementia care which have not previously been articulated.
  • Does psychological trauma affect resuscitation providers?

    Penn, Matthew (2019)
    If you ask health professionals about their experiences of resuscitation, they will sometimes tell you about a case that somehow bit deeper into them than they expected. It goes without saying that some events in medicine are more poignant, more disturbing, or more stressful than others. Sometimes, however, upsetting events can have effects that stray past the boundaries of work and into our personal lives. This begs the question: can we can spot those cases likely to affect us in this way? Or perhaps instead we could identify individuals most likely to be affected? In either case, can we do anything about it or is this just part and parcel of being a doctor or nurse?
  • The challenges of training, support and assessment of healthcare support workers: A qualitative study of experiences in three English acute hospitals

    Schneider, Justine (2017)
    BACKGROUND: Ever-growing demands on care systems have increased reliance on healthcare support workers. In the UK, their training has been variable, but organisation-wide failures in care have prompted questions about how this crucial section of the workforce should be developed. Their training, support and assessment has become a policy priority. OBJECTIVES: This paper examines: healthcare support workers' access to training, support and assessment; perceived gaps in training provision; and barriers and facilitators to implementation of relevant policies in acute care. DESIGN AND SETTINGS: We undertook a qualitative study of staff caring for older inpatients at ward, divisional or organisational-level in three acute National Health Service hospitals in England in 2014. PARTICIPANTS: 58 staff working with older people (30 healthcare support workers and 24 staff managing or working alongside them) and 4 healthcare support worker training leads. METHODS: One-to-one semi-structured interviews included: views and experiences of training and support; translation of training into practice; training, support and assessment policies and difficulties of implementing them. Transcripts were analysed to identify themes. RESULTS: Induction training was valued, but did not fully prepare healthcare support workers for the realities of the ward. Implementation of hospital policies concerning supervision and formal assessment of competencies varied between and within hospitals, and was subject to availability of appropriate staff and competing demands on staff time. Gaps identified in training provision included: caring for people with cognitive impairment; managing the emotions of patients, families and themselves; and having difficult conversations. Access to ongoing training was affected by: lack of time; infrequent provision; attitudes of ward managers to additional support workforce training, and their need to balance this against patients' and other staff members' needs; and the use of e-learning as a default mode of training delivery. CONCLUSIONS: With the current and unprecedented policy focus on training, support and assessment of healthcare support workers, our study suggests improved training would be welcomed by them and their managers. Provision of training, support and assessment could be improved by organisational policy that promotes and protects healthcare support worker training; formalising the provision and availability of on-ward support; and training and IT support provided on a drop-in basis. Challenges in implementation are likely to be faced in all international settings where there is increased reliance on a support workforce. While recent policies in the UK offers scope to overcome some of these challenges there is a risk that some will be exacerbated.
  • Efficiency savings : preparing for a bleak future?

    Majumder, Pallab (2012)
    The NHS must make 20 billion pounds worth of efficiency savings over the next two years. Using the knowledge and experience of my own specialty in the historical as well as current context, I shall present my thoughts and propose a few ways to save money for NHS by trying to translate the facts from a single highly-specialised service into thinking about universal efficiency savings in NHS. I shall comment on the areas of waste and inefficiency that is being observed and commented on by clinicians working on the front line as well as by the strategic and operational leaders of different services across the regions, tiers and specialties. Finally, I shall reflect on how realistic these proposals are, and what challenges are to be expected in implementing these hypothetical cost improvement plans. [Introduction]
  • Collaboration in the emergency services

    Kane, Eddie (2018)
    Another area that the coalition government was not satisfied with was the nature and extent of collaboration or interoperability between the emergency services. Parry, Kane, Martin and Bandyopadhyay (2015) were commissioned by the government to investigate and report on the development of collaboration and suggest ideas and options for future service re-design and rationalisation. In this chapter, one of the authors of that report, Eddie Kane, outlines their key findings, considers the impact of the new service design proposals and examines some of the issues and options for realising its benefits.
  • Carers for older people with co-morbid cognitive impairment in general hospital: Characteristics and psychological well-being

    Schneider, Justine (2013)
    Objective: This analysis sought to describe the characteristics and well-being of carers of older people with mental health problems admitted to a general hospital. Methods: General medical and trauma orthopaedic patients aged 70 years or older admitted to an acute general teaching hospital were screened for mental health problems. Those screened positive, together with a carer, were invited to undergo further assessment with a battery of health status measurements. Carers were interviewed to ascertain strain (caregiver strain index (CSI)), psychological distress (12-item General Health Questionnaire) and quality of life (EQ-5D). Results: We recruited 250 patients to the study, of whom 180 were cognitively impaired and had carers willing to take part. After 6 months, 57 patients (32%) had died, and we followed up 100 carers. Carers’ own health, in terms of mobility, usual activities, and anxiety, was poor in a third of cases. At the time of admission, high carer strain was common (42% with CSI ≥ 7), particularly among co-resident carers (55%). High levels of behavioural and psychiatric symptoms at baseline were associated with more carer strain and distress. At follow-up, carer strain and distress had reduced only slightly, with no difference in outcomes for carers of patients who moved from the community to a care home. Conclusion: Hospital staff should be alert to sources of carer strain and offer carers practical advice and emotional support. Interventions are required to prevent and manage behavioural and psychiatric symptoms at the time of acute physical illness or to alleviate their effects on carers. (PsycINFO Database Record (c) 2016 APA, all rights reserved) (Source: journal abstract)
  • Factors associated with the use of physical restraints for agitated patients in psychiatric emergency rooms

    Adams, Clive E. (2008)
    Objective: To examine factors associated with physical restraint in psychiatric emergency rooms. Method: We extracted variables likely to predict use of physical restraints from a large randomised trial undertaken in three psychiatric emergency rooms in Rio de Janeiro. We fitted a Bayesian binary multivariate model using only variables clearly preceding the restraints. Results: Of 301 agitated, aggressive people admitted to emergency rooms, 73 (24%) were restrained during the first 2 h of admission. In Rio, younger people (OR = 1.03 for each year younger), exhibiting intense (OR = 2.53) or extreme agitation (OR = 7.71), thought to result from substance misuse (OR = 1.75) or diagnoses other than psychosis (OR = 1.88), arriving in the morning (OR = 1.64) were at greater risk of physical restraints than older, less severely aggressive or agitated people, arriving at the hospital during the afternoon or night. Hospital, gender, first admission to hospital and medication were not associated with risk of being restrained. Conclusion: Restraint practices in Rio are predictable and based on a limited clinical assessment. Predictive factors for physical restraint may vary worldwide, but should be monitored and studied to assist training, and to establish programs to evaluate and refine this controversial practice. (PsycINFO Database Record (c) 2016 APA, all rights reserved) (Source: journal abstract)
  • Droperidol and midazolam, alone or combined, have similar effects on duration of violent and acute behaviour disturbance in emergency department patients

    Adams, Clive E. (2011)
    Comment on: Randomized controlled trial of intramuscular droperidol versus midazolam for violence and acute behavioral disturbance: the DORM study. [Ann Emerg Med. 2010]
  • The prevalence of mental health problems among older adults admitted as an emergency to a general hospital

    Jones, Rob G. (2012)
    Background: a high prevalence of co-morbid mental health problems is reported among older adults admitted to general hospitals. Setting: an 1,800 bed teaching hospital. Design: consecutive general medical and trauma orthopaedic admissions aged 70 or older were screened for mental health problems. Those screening positive were invited to undergo further assessment, and were interviewed to complete a battery of health status measurements. Results: of 1,004 patients screened, 36% had no mental health problems or had anxiety alone. Of those screening positive 250 took part in the full study. Adjusting for the two-stage sampling design, 50% of admitted patients over 70 were cognitively impaired, 27% had delirium and 8�32% were depressed. Six percent had hallucinations, 8% delusions, 21% apathy and 9% agitation/aggression (of at least moderate severity). Of those with mental health problems, 47% were incontinent, 49% needed help with feeding and 44% needed major help to transfer. Interpretation: we confirm the high prevalence of mental health problems among older adults admitted to general hospitals. These patients have high levels of functional dependency, psychological and behavioural problems which have implications for how they are cared for. Services that identify these problems and offer therapeutic intervention should be evaluated.
  • Bed numbers and acute in-patient care

    Middleton, Hugh (2007)
    Reply by the current author to the comments made by Mat Kinton (see record 2007-03087-011) on the original article (see record 2006-21239-003). I am pleased that Mat Kinton has given some views on bed numbers as a limitation to acute in-patient care as it provides an opportunity to extend the debate further. To my mind arguing that 'improvement may be reliant upon a much more fundamental question of resources: beds for the patients' is an unjustified oversimplification. Of course it is highly unsatisfactory when over-occupancy does occur but as Mat himself acknowledges this is not a universal experience. Merely highlighting bed shortages oversimplifies and detracts from more relevant but possibly more complex and challenging aspects of the very necessary agenda to improve acute in-patient care.
  • Should I stay or should I go? How healthcare professionals close encounters with people with dementia in the acute hospital setting

    Allwood, Rebecca (2017)
    Around a quarter of hospital beds in the UK are occupied by patients living with dementia (PWD), and communication impairments are common across all types of dementia, often exacerbated by the hospital environment. Unsurprisingly, healthcare professionals (HCPs) report particular challenges in caring for this patient group, whilst trying to recognise and value their personhood as per the underpinning ethos of person-centred care. However, whilst there is a growing body of research that underlines the importance of communication in dementia care, there is far less that actually examines this communication in real time interaction. Suggestions and pointers for good communication do exist, but these do not tend to be empirically derived, and sometimes conflict with empirical findings. This paper focuses on a specific area of interaction which has previously received very little attention: the way in which healthcare encounters are ended or closed. There is potentially a conflict between a pressure to manage a patient as efficiently as possible, and endeavouring to ensure person-centred care and deal with communication difficulties arising from dementia. Using conversation analysis, we examined forty-one video recordings of HCP/PWD interactions collected from an acute inpatient ward. We identify three phenomena around which there were recurring troubles in our dataset: 'open-ended pre-closings', 'mixed messages' and 'non specifics and indeterminate terms'. We conclude that moves towards closing an encounter that appear intuitive to HCPs as competent interactants, and that may represent best practice in other healthcare settings, may in fact serve to confuse a PWD and create difficulties with closings. Our findings underline the importance of examining best practice guidance as it is actually talked into being, using approaches which can unpack the interactional detail involved. They also emphasise the importance of context in the analysis of healthcare delivery, to avoid a 'one size fits all' approach.
  • Open general medical wards versus specialist psychiatric units for acute psychoses

    Rathbone, John (2007)
    Background: As international healthcare policy has moved away from treating people with severe mental illness in large inpatient psychiatric institutions, beds for people with acute psychiatric disorders are being established in specialised psychiatric units in general hospitals. In developing countries, however, limited resources mean that it is not always possible to provide discrete psychiatric units, either in general hospitals or in the community. An alternative model of admission, used in the Caribbean, is to treat the person with acute psychosis in a general hospital ward. Objectives: To compare the outcomes for people with acute psychosis who have been admitted to open medical wards with those admitted to conventional psychiatric units. Search strategy: We searched The Cochrane Schizophrenia Group's study-based register (April 2007). This register is compiled from searches of BIOSIS, CINAHL, The Cochrane Library, EMBASE, LILACS, MEDLINE, PsycINFO, PSYNDEX, Sociofile, and many conference proceedings. Selection criteria: We would have included all relevant randomised or quasi-randomised trials, allocating anyone thought to be suffering from an acute psychotic episode to either acute management on general medical wards, or acute management in a specialist psychiatric unit. The primary outcomes of interest were length of stay in hospital and relapse. Data collection and analysis: We extracted data independently. For dichotomous data we would have calculated relative risks (RR) and their 95%confidence intervals (CI) on an intention-to-treat basis based using a fixed effects model. Main results: We didnt identify any relevant randomised trials. Copyright © 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
  • The association between depressive symptoms in the community, non-psychiatric hospital admission and hospital outcomes: A systematic review

    Dening, Tom (2015)
    OBJECTIVES: This paper aims to systematically review observational studies that have analysed whether depressive symptoms in the community are associated with higher general hospital admissions, longer hospital stays and increased risk of re-admission.
  • A systematic review of the safety and effectiveness of restraint and seclusion as interventions for the short-term management of violence in adult psychiatric inpatient settings and emergency departments

    Johnston, Susan J. (2006)
    Aims: The aim of this review was to assess whether restraint and seclusion are safe and effective interventions for the short-term management of disturbed/violent behaviour. Staff and service user perspectives on the use of these interventions were also considered. The review was undertaken as part of the development process for a national guideline on the short-term management of disturbed/violent behaviour in adult psychiatric inpatient settings and emergency departments in the United Kingdom. Method: An exhaustive literature search was undertaken. Systematic reviews, before and after studies, as well as qualitative studies were included. Searches were run from 1985 to 2002. Findings: Thirty-six eligible studies were identified. However, none were randomised controlled trials. Most of the included studies had many limitations, such as small sample sizes, confounders not adequately accounted for, potential selection bias, poorly reported results, and lack of clarity as to whether mechanical restraints were used. This review must therefore be viewed as a mapping exercise, which illustrates the range and quality of studies that have been undertaken in this area to date. Conclusions and Implications for Practice: Insufficient evidence is available to determine whether seclusion and restraint are safe and/or effective interventions for the short-term management of disturbed/violent behaviour in adult psychiatric inpatient settings. These interventions should therefore be used with caution and only as a last resort once other methods of calming a situation and/or service user have failed. Copyright © 2006 Sigma Theta Tau International.
  • A descriptive study of feelings of arrested escape (entrapment) and arrested anger in people presenting to an emergency department following an episode of self-harm

    Clarke, Martin (2016)
    Background and objectives: To explore the role of elevated feelings of anger and desires to escape (fight/flight), which are experienced as inhibited, blocked, and arrested (i.e., arrested anger and arrested flight/escape leading to feelings of entrapment). This descriptive study developed measures of arrested anger and arrested flight and explored these in the context of a recent self-harm event in people presenting to a Hospital's Emergency Department (ED). Methods: Fifty-eight individuals presenting to an ED following an act of self-harm were recruited. Participants completed newly developed measures of arrested flight, arrested anger and anger with self in regard to self-harm, and suicide intent and depression. Results: Ninety-three percent of participants presented after self-poisoning. The majority (95%) reported having experienced high escape motivation that felt blocked (arrested flight) with 69% reporting feeling angry with someone but unable to express it (arrested anger). For many participants (53.7%), strong desires to escape from current situations and/or to express anger did not diminish immediately after the act. Limitations: As with many studies, a select group of participants agreed to take part and we did not keep records of how many refused. There are no other validated measures of arrested escape and arrested anger and so for this study, our short item-focused measures rely on face validity. Conclusion: Arrested defenses of fight and flight, and self-criticism are common in those who have self-harmed and may continue after acts of self-harm. Many participants revealed that talking about their experiences of escape motivation and blocked anger (using our measures) was helpful to them. Practice points: • Feelings of entrapment and arrested anger are common in people who self-harm • Clinicians could benefit from increased awareness and measures of arrested flight and arrested anger • Discussing these concepts and experiences appears to be useful to people who have self-harmed • Further research is needed on how best to help people with such experiences. © 2016 Clarke, McEwan, Ness, Waters, Basran and Gilbert.
  • The profile of risky single occasion drinkers presenting at an emergency department

    McMurran, Mary (2013)
    In 2010/2011, there were over 21 million attendances at English Emergency Departments (EDs), of which 35% are estimated to be alcohol-related. Screening in EDs could have considerable impact in identifying alcohol use disorders and directing people to appropriate interventions. We aimed to describe the screening and profile of risky single occasion drinkers (RSOD) in Nottingham University Hospitals (NUH) NHS Trust ED. Routine admissions data and alcohol screening responses for each patient aged 18 years and over were accessed from the ED information system (EDIS) for a period of 12 months. Of the 99,728 presentations at ED, 55,564 (55.72%) were screened and, of these, 8131 (16.81%) screened positive for RSOD. Compared with those who screened negative, they were 2.63 times more likely to present with injuries. However, the majority (N = 5389, 66.28%) said their current presentation was not related to alcohol consumption. Of those who screened RSOD positive only 1.75% accepted a referral for advice; the majority (85.29%) accepted an information leaflet. Improvements to the screening process are suggested, including potentially targeting screening, using an assessment that may in itself have an impact on drinking outcomes, and improving the relevance of leaflets and brief interventions to specific subgroups of patients.© 2013 Informa UK Ltd.