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Home > Library > Annotated Journal Abstracts > 2014 Q4: Emergency Psychiatry

Annotated Abstracts of Journal Articles
2014, 4th Quarter

Emergency Psychiatry

Annotations by Scott Simpson, MD, MPH
of the APM Emergency Psychiatry SIG
December 2014

 
PUBLICATION #1 — Emergency Psychiatry
Rapid follow-up for patients after psychiatric crisis

McCullumsmith C, Clark B, Blair C, Cropsey K, Shelton R
Community Ment Health J; 2014 Nov 15 [Epub ahead of print]

ANNOTATION (Scott Simpson)

The Finding: The authors describe their experience with a transitional psychiatric clinic; patients not connected with outpatient care receive an appointment within two weeks for “bridging” care until long term follow-up is identified. Scheduling patients a follow-up outpatient mental health visit within 3 days of their emergency department (compared to 4-14 days) extended the mean time to repeat emergency psychiatric consultation from 64 days to 130 days. Show rates for follow up appointments were slightly but insignificantly better for patients with sooner appointments (49% versus 39%). However, recidivism for medical complaints was common and similar in both groups (mean 75 days).

Strength and Weaknesses: This study focuses on a common intervention of emergency psychiatrists—identifying follow-up care for patients—and describes a valuable, concrete outcome related to that work. The description of these patients, currently unestablished in community mental health, is also valuable, and the high rates of medical emergency department utilization are striking. (Roughly, half of patients will return for a medical visit within two months.) Given the limitations of this unrandomized naturalistic study, the comparison groups are well chosen to isolate the benefit of sooner follow-up.
    Some questions remain unanswered and largely speak to this study’s methodological limitations: Did these patients re-present to other hospitals? Why was recidivism for medical complaints unchanged—the benefit of psychiatric follow-up may have been limited in this regard, or perhaps some patients were not re-referred for psychiatric consultation on presentation to the emergency department. A better description of medical morbidity would have been valuable. Even with smart naturalistic studies, the specter of confounding shadows the findings. That only a single hospital was studied limits generalizability, especially to systems where outpatient clinics are less well integrated into emergency care.
    This paper raises more challenging questions, include determining why the now-show rate is so poor and elucidating the mechanism by which sooner appointments reduce return emergency visits.

Relevance: Helping patients obtain an outpatient appointment as soon as possible after their emergency consultation may extend their time away from emergency psychiatric services. This supportive intervention in the emergency department has a meaningful effect months later.

ABSTRACT (PubMed)

Patients in psychiatric crisis often lack connection to community resources and present to emergency departments (EDs) for care. A transitional psychiatry clinic (TPC) bridged patients after ED visit. These retrospective chart review data of 390 patients were analyzed by ANOVA, logistic regression and survival analysis. Predictors of ED return included psychosis, personality disorder and increased number of prior ED visits. Longer wait for the TPC was associated strongly with non-attendance. TPC appointment within 3 days was associated with significantly longer time in the community without ED presentation. Rapid follow-up after ED visits increased attendance at aftercare and lengthens community tenure.

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PUBLICATION #2 — Emergency Psychiatry
Unplanned, urgent and emergency care: what are the roles that EMS plays in providing for older people with dementia? An integrative review of policy, professional recommendations and evidence
Buswell M, Lumbard P, Prothero L, et al
Emerg Med J; 2014 Dec 2 [Epub ahead of print]

ANNOTATION (Scott Simpson)

The Finding: The authors systematically review literature on the prehospital emergency medical service experiences of older people with dementia. There is little written on this topic. Important clinical concerns are identified: ambulance crews often lack training in working with patients with dementia, and many emergency service guidelines do not attend to the needs of this population. Thus, first responders often fail to collect important medical information (e.g., ascertaining contributors to a fall), adequately assess medical issues (e.g., pain), and may too often transport patients with dementia to the hospital, where these patients are frequently admitted. Calling 911 also reflects families’ underutilization or unavailability of alternatives for managing difficult behavioral symptoms of dementia.

Strength and Weaknesses: The literature review process is well-described and incorporates the diverse viewpoints of academic clinicians, patient advocates, ambulance drivers, and other emergency personnel. The review is extensive and captures published academic literature, government reports, training materials, and even conference abstracts. The authors rightfully point out the varying qualities of all these different products. Multiple authors agreed on the inclusion of each source.
    The variety of sources, however, makes it difficult to see conclusive patterns. Other than pointing out current shortcomings in care, the authors find no conclusions on how emergency medical providers’ roles might be different for patients with dementia, nor do they put forth their own original vision. No doubt the unique needs of patients with dementia is neglected in the emergency medical literature; whether better training of ambulance crews results in fewer hospitalizations or better clinical outcomes seem less certain, though the idea is unexplored. The authors call for more research on the role of prehospital providers and opportunities for intervention.

Relevance: This paper is a strong review of an underappreciated, undeveloped topic. Older patients with dementia face deficiencies in emergency care, starting with the initial 911 call and evaluation by emergency responders.

ABSTRACT (PubMed)

Objective: To synthesise the existing literature on the roles that emergency medical services (EMS) play in unplanned, urgent and emergency care for older people with dementia (OPWD), to define these roles, understand the strength of current research and to identify where the focus of future research should lie.

Design: An integrative review of the synthesised reports, briefings, professional recommendations and evidence. English-language articles were included if they made any reference to the role of EMS in the urgent or emergency care of OPWD. Preparatory scoping and qualitative work with frontline ambulance and primary care staff and carers of OPWD informed our review question and subsequent synthesis.

Results: Seventeen literature sources were included. Over half were from the grey literature. There was no research that directly addressed the review question. There was evidence in reports, briefings and professional recommendations of EMS addressing some of the issues they face in caring for OPWD. Three roles of EMS could be drawn out of the literature: emergency transport, assess and manage and a 'last resort' or safety net role.

Conclusions: The use of EMS by OPWD is not well understood, although the literature reviewed demonstrated a concern for this group and awareness that services are not optimum. Research in dementia care should consider the role that EMS plays, particularly if considering crises, urgent care responses and transitions between care settings. EMS research into new ways of working, training or extended paramedical roles should consider specific needs and challenges of responding to people with dementia.

 

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