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.

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.

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.

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.

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)

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.

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.

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.

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.