Evolution of an active psychogeriatric day hospital

A geriatric day hospital was established as part of the psychogeriatric unit of the Royal Ottawa Hospital. While initially this day hospital was integrated with day hospital programs of other units, it became apparent that a separate facility was desirable. The activities and programs of the psychogeriatric day hospital, run by one registered nurse, were integrated with those of the geriatric inpatient unit. It was found to be advantageous for inpatients and day hospital patients to share the same physical facilities. The majority of day hospital patients came from the inpatient unit; almost all had affective disorders. The emphasis was on reintegration into the community. During the 1st year of operation there were 75 patients in the program; only 3 needed admission to the inpatient unit and 1 was readmitted after discharge.     

Membranoproliferative glomerulonephritis associated with HCV infection in native kidneys and renal allograft

STUDY OBJECTIVE: We sought to test the assumption that an emergency department observation unit can be funded through the reallocation of resources made available through the unit's impact in reducing inpatient admissions and facilitating bed closures. METHODS: We conducted our study in a tertiary care center ED with 46,000 visits annually. For a 3-month period, all patients admitted to the hospital through the ED were screened by an emergency physician for suitability for admission to an observation unit. Any patient in the hospital for 3 days or less who did not undergo surgery or other inpatient procedure, and who was admitted through the ED, was considered a candidate for the observation unit. RESULTS: Of 1,840 admissions, 147 patients met the admission criteria. Only 48 (32.2%) could have been treated in an observation unit, and these patients were not admitted to any single unit in high frequency. The potential savings from inpatient bed closures would only have amounted to 1.68 full-time equivalents-not enough to staff a 4-bed observation unit, which would require 5 full-time equivalents. CONCLUSION: Because of the diffuse and inconsistent effect such a unit had on inpatient bed use, funding for an ED observation unit at our institution could not be justified on the basis of the closure of inpatient beds and transfer of resources.     

Can a clinical classification of stroke predict complications and treatments during hospitalization?

Former patients in a rehabilitation unit at a large Midwestern hospital continued to actively seek services provided by the inpatient nursing staff, primarily through telephone contact, long after their discharge. A proactive formal follow-up program managed by an advanced practice nurse in rehabilitation was proposed as a better means of providing continuing care for rehabilitation patients after discharge. To examine the efficacy of the nurse-managed follow-up program, a randomized clinical trial was conducted. One hundred patients were randomly assigned to either the intervention group or the control group. Comparisons were made between the two groups on several outcome measures at 4 months after discharge. Outcomes included Functional Independence Measure (FIM) instrument scores, complication rates, rehospitalizations, and anxiety levels. The organizational outcomes included number and types of calls to staff, as well as time spent by staff nurses and social workers. The results indicated significant differences between the intervention and control groups in terms of anxiety levels, the number of calls made to the unit, and the amount of time spent by staff nurses and social workers.     

Survey of inpatient counseling by hospital pharmacists

A survey was conducted to determine the inpatient-counseling practices of hospital pharmacists. A questionnaire about the frequency of inpatient counseling, barriers to counseling, and suggestions for increasing the level of inpatient counseling was mailed to 667 hospital pharmacists. Recipients were asked to rate six attitudinal statements about inpatient counseling. The response rate was 30%. The largest group of respondents worked in institutions where discharge counseling was provided to specific populations or as needed. Some 67% of respondents reported not counseling any patients. Barriers to counseling most often cited were lack of time and inadequate staff; facilitators most often cited were decentralization and resource availability. The most frequent suggestions for increasing the amount of counseling were making changes that provide more time, having adequate staff to provide counseling, and having a well-designed counseling program in place. Responses about barriers and facilitators varied with practice setting and frequency of counseling. On average, pharmacists reported a belief that they are the health care professionals most qualified to counsel inpatients about medications and that this is their responsibility. More than two thirds of the responding hospital pharmacists reported counseling no patients; the barrier to counseling most frequently reported was lack of time, and the facilitator most often reported was decentralization; on average, pharmacists reported that they believed they should have a role in inpatient counseling.     

Day hospital/crisis respite care versus inpatient care, Part II: Service utilization and costs

OBJECTIVE: The authors compared service utilization and costs for acutely ill psychiatric patients treated in a day hospital/crisis respite program or in a hospital inpatient program. METHOD: The patients (N = 197) were randomly assigned to one of the two programs and followed for 10 months after discharge. Both programs were provided by a community mental health center (CMHC) in a poor urban community. Data were collected for developing service utilization profiles and estimates of per-unit costs of the inpatient, day hospital, and outpatient services provided by the CMHC. RESULTS: On average, the day hospital/crisis respite program cost less than inpatient hospitalization. The average saving per patient was +7,100, or roughly 20% of the total direct costs. There were no significant differences between programs in service utilization or costs during the follow-up phase. Cost savings accrued in the index episode because per-unit costs were lower for day hospital/crisis respite and the average stay was shorter. Significant differences in cost were found among patient groups with psychosis, affective disorders, and dual diagnoses; psychotic patients had the highest costs in both programs. The two programs had roughly equal direct service staff and capital costs but significantly different operating costs (day hospital/crisis respite operating costs were 51% of inpatient hospital costs). CONCLUSIONS: The programs were equally effective, but day hospital/crisis respite treatment was less expensive for some patients. Potential cost savings are higher for nonpsychotic patients. Cost differences between the programs are driven by the hospital's relatively higher overhead costs. The roughly equal expenditures for direct service staff costs in the two programs may be an important clue for understanding why these programs provided equally effective acute care.     

An integrated medical and psychosocial treatment program for psychotic disorders: patient characteristics and outcome

OBJECTIVES: To provide an overview of a comprehensive and integrated case-management program that incorporates principles of assertive community treatment and combines effective medical and psychosocial interventions and to present the results of a process and outcome evaluation of the program, with particular emphasis on its impact on service utilization and consumer satisfaction. METHOD: Data on demographic, clinical, and several outcome measures were collected on all patients who received care in the program for a minimum of 6 months. For process evaluation we assessed the extent to which the program adhered to its goals and satisfied the patients, their families, and community-service agencies. Outcome-evaluation data on the number and length of hospital admissions were compared for each subject with individual historical data for a period equal to the time spent in the program. In addition, relapses of psychotic symptoms that did not result in hospital admissions were calculated for each patient while in the program. RESULTS: Demographic, clinical, and treatment characteristics of clients show that the program has succeeded in maintaining its focus on providing services to relatively chronically ill patients with psychotic disorders over a mean period of 3 years. The process-evaluation data indicated a high level of satisfaction by patients, families, and other service agencies with the services received. Information on outcome variable showed that the program achieved significantly lower rates of hospital admissions and relapse of psychosis than expected. There was a highly significant reduction achieved in the utilization of inpatient hospital resources for patients receiving care in the program. Most of the inpatient service utilization was attributed to patients either who were resistant to treatment with antipsychotic agents or who refused to accept or comply with medication. CONCLUSIONS: It is possible to provide effective continuity of care from inpatient treatment to community adjustment for most individuals with psychotic disorders across the spectrum by blending hospital and community resources within an integrated case-management model of care.     

A controlled comparison of psychiatric day treatment and inpatient hospitalization.

59 seriously ill, female, 16-72 yr old psychiatric patients were randomly assigned, after 2-6 wks of inpatient evaluation, to an inpatient or day service where they were evaluated, along with a control group of 34 "usual" day hospital patients, for up to 24 mo. Data from the Psychiatric Status Schedule, Psychiatric Evaluation Form, Dynamic Assessment Scale, and other similar measures indicate that for the range of patients studied, day treatment is, on the whole, superior to inpatient treatment in 5 distinct areas: subjective distress, community functioning, family burden, total hospital cost, and days of attachment to the hospital program. The findings of other controlled studies are confirmed and extended to include previously unreported outcome dimensions and a broader socioeconomic population. (25 ref) (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Evaluating the effectiveness of innovative design for a community mental health center

The effectiveness of the design of the inpatient and day patient areas of a community mental health center was evaluated in 1969, soon after the center was opened, and again in 1974. The focal area is a large, irregularly shaped communal space; it opens onto a wide, encircling corridor ringed with bedrooms, multiuse rooms, and offices. The center was designed to encourage different behaviors and varied uses of space, to promote interaction, and to stimulate and challenge patients. In 1974 the evaluators found the design still worked well for the unit that still operated the same kind of program the center was designed for, a therapeutic community, even though the unit admitted sicker patients than planned. The design did not work as well for the second unit, which had become a crisis intervention program for patients who were often highly agitated, suicidal, or determined to escape; security and surveillance were major problems.     

Low platelet glutathione peroxidase activity and serum selenium concentration in patients with chronic renal failure: relations to dialysis treatments, diet and cardiovascular complications

Previous work has established the precision and accuracy of a portable blood coagulation analysis system using paramagnetic particles contained in a dry reagent on a disposable test card. We examined the deployment of this technology in decentralized hospital settings and compared test results obtained in the surgical intensive care unit, coronary care unit, and outpatient cardiology clinic with those obtained in the central laboratory. Nursing personnel were instructed in the use of the system, and quality control testing was performed daily by the laboratory staff. In the intensive care units, patient subjects included those on whom tests of prothrombin time and activated partial thromboplastin time had been ordered. Immediate determinations were performed by the intensive care unit nursing staff on the same citrated, whole-blood samples that were subsequently sent to the central laboratory. In the outpatient cardiology clinic, fingerstick blood samples were obtained for prothrombin time determinations with the dry chemistry system. Paired prothrombin time samples obtained by venipuncture were run in the hospital laboratory. The study involved multiple users, multiple locations, two lots of activated partial thromboplastin time cards, and several different instruments, over an extended period. Correlation coefficients between the dry chemistry system and the hospital laboratory under these conditions were in an acceptable range in all sites studied. We concluded that, with appropriate training and quality assurance, the dry chemistry system provides an acceptable alternative to the hospital laboratory for prothrombin time and activated partial thromboplastin time determinations.     

The development of a rehabilitation psychology program for persons with schizophrenia: Changes in the treatment environment.

Reports the changes that occurred over a 4-yr period at a therapeutic community for persons with schizophrenia when a rehabilitation psychology program was added to the traditional inpatient treatment and eventually replaced it. Data collected (from patients and staff members over the 4 yrs) using the Community Oriented Programs Environment Scale revealed several significant and desirable changes in the quality of the perceived treatment environment, including increases in practical orientation and autonomy. Specific interventions that accounted for improvement in the rehabilitation potential of the treatment environment are described. Conceptual differences between the traditional inpatient psychiatric model and the rehabilitation psychology model are outlined. Value differences between these 2 models are presented as an explanation for the failure of rehabilitation services offered adjunctively with traditional psychiatric services. The treatment environment changed only when rehabilitation became a central part of the treatment philosophy. The fundamental differences between these 2 treatment approaches are related to reports of improved outcome from programs using psychosocial models. (30 ref) (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Performance in occupational therapy as a predictor of successful prevocational training

Scores on three subtests of the Minnesota Follow-up Scale (MFS) were related to client outcomes in a prevocational training program in a study of 26 clients who were referred from an adult psychiatric day treatment unit. The results of the study agreed with a prediction that successful performance in occupational therapy in the day treatment unit, as measured by subtest 1, would be significantly related to successful client outcomes. the results regarding predictions for two other subtests were less conclusive because clients received high scores. Age and sex distributions showed that the younger male clients were most likely to be referred for prevocational training. The staff of the prevocational training program accepted the results of the study and also agreed that performance in occupational therapy (in the day treatment unit) should receive greater recognition by staff members as an important indicator of work potential when evaluating clients for referral to a vocational training program. It is planned to continue the use of the MFS in the day treatment unit as an aid for evaluating clients for referral purposes. Scores will continue to be related to client outcomes in the prevocational training program. Further study is also planned concerning the relationship of age and sex and sources to which clients are discharged or referred from the day treatment unit.     

A preliminary study of partial hospital management of severe obsessive-compulsive disorder

OBJECTIVE: The study examined the effectiveness of a partial hospital treatment program combining behavioral therapy, medication, and psychosocial intervention for severe and treatment-resistant obsessive-compulsive disorder. METHODS: A total of 58 patients with a primary diagnosis of obsessive-compulsive disorder who underwent treatment in a partial hospital program were assessed at baseline, at program discharge, and at six-, 12-, and 18-month follow-ups. Obsessive-compulsive symptoms, depression, anxiety symptoms, and global functioning were rated. RESULTS: The majority of patients (71 percent) met the criterion for a successful outcome, which was a 25 percent decrease in score on the Yale-Brown Obsessive Compulsive Scale (YBOCS). Fifty-five percent finished the program with YBOCS scores of 16 or less, indicating only mild symptoms. Most of these patients sustained their improvement at six, 12, and 18 months after discharge, and many showed further improvement with continued outpatient management. CONCLUSIONS: The partial hospital treatment program for obsessive-compulsive disorder appears to be an effective intervention that should be implemented and investigated further.     

Improving patient outcomes through CQI: vascular access planning

AIM: The aim of the study was to describe and analyse the hospital delivery system for patients recovering from myocardial infarction, applying the offering and value concepts from service management theory. BACKGROUND: In Nordic hospital care patients traditionally played a minor role. But changes have taken place. By means of information giving and systematic education from the staff many chronically ill patients are now taking a significant part in their treatment and care. METHOD: The method was a case study including 12 individual interviews. CONCLUSIONS: The principal conclusion is that the short and intense periods of hospital inpatient stay make it advantageous to consider the patient a member of the health care team taking an active part in the caring process.     

Culture conflict in the treatment of "mental illness" and the central role of patient leader.

Describes new treatment programs which emphasized patients' responsibility and problem-solving action and heightened the conflict with patients' expectations that they be held unaccountable for their deviant behavior and excused from taking corrective action. Results from 50 patients showed Ss' attitudes were markedly less favorable toward a new program than toward a more traditional one. Patient leaders played an important role by organizing Ss to produce an active program, thereby encouraging staff tolerance for a nonrestrictive, continuous hospital stay for all interested Ss. Leaders were evaluated more favorably than nonleaders by both Ss and staff, with the exception of behaviors related solely to staff goals. The stalemate, successfully negotiated by the leaders, was broken only after the staff imposed a time limit on hospital stay. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Awareness of guilt and shame in intimate violence

A Monte Carlo simulation model was developed for the spread of antibiotic-resistant bacteria in hospital units. The model allows for the representation of every patient and staff member. Staff-patient interactions, staff handwashing compliance, admission of colonized patients, and antibiotic use are included in the model. The simulation model provides colonization curves for patients and staff and offers the possibility of simulating different kinds of hospital units. Simulation of the spread of an antibiotic-resistant pathogen in an intensive care unit was performed. We studied the impact of handwashing compliance on colonization. The importance of handwashing in preventing colonization and the influence of admission of colonized patients in perpetuating an epidemic were confirmed by the model. The model offers a new approach to modeling the spread of nosocomial pathogens in hospital units. It allows one to study the impact of infection control measures and represents a valuable educational tool for staff.     

Comparison of usual and experimental patients in a psychiatric day center.

In a previously reported study by the authors (see record 1976-28530-001) of inpatient and day hospitalization, 59 seriously ill female psychiatric patients were randomly assigned to an inpatient or a day hospital setting. The present study compared the 29 seriously ill patients randomly assigned to the day hospital with a control group of 34 "usual" day patients. Ss were assessed on 14 outcome measures, some of which were derived from the Psychiatric Status Schedules and the Psychiatric Evaluation Form. The experimental group showed significantly more improvement from baseline to subsequent time periods in 3 distinct areas: global mental status, subjective distress, and family adjustment. The controls, on the other hand, spent fewer nights in the hospital, used the hospital facilities significantly less during the 1st 3 mo, and incurred a significantly lower cost for the same period. Two measures—number of social work contacts and amount of time spent in the treatment milieu—indicated that experimentals initially required more staff effort than controls, but at later time periods the reverse was true. (29 ref) (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Merger fantasies in individual inpatient therapy with schizophrenic patients.

This paper examines some of the differences between individual outpatient and individual inpatient psychoanalytic psychotherapy to illustrate that individual therapy on an inpatient unit is a qualitatively different modality from its outpatient counterpart with consequences for work with schizophrenics. The paper explores the manner in which the unique parameters of inpatient work interact with, sustain, and exploit the pathology of schizophrenic patients. Its focus is, specifically, on the handling of the boundary disturbances which characterize schizophrenic psychoses, and the manner in which the fluidity of boundaries is reinforced and the tendency toward symbiotic relatedness enhanced on an inpatient unit. As a result, a central fantasy develops in many schizophrenic inpatients, one wherein the therapist is transformed into the omniscient, omnipotent early mother. This fantasy, which can be considered an institutional transference, helps explain the frequently observed phenomenon that many patients show substantial symptomatic improvement while in the hospital, only to have their symptoms return after discharge. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Violence and aggression in psychiatric units

OBJECTIVE: To help predict aggressive and violent behaviors, the frequency and types of these behaviors in acute psychiatric inpatient settings were examined, and potential interactions between staffing and patient mix and rates of the behaviors were explored. METHODS: Data on violent incidents were gathered prospectively in three adult acute psychiatric units in a general hospital and two units in a primary psychiatric hospital in Sydney, Australia. Staff recorded violent and aggressive incidents, which were ranked on an 8-level scale. They also completed weekly reports of staffing levels and patient mix. Poisson regression analysis was used to calculate relative rates, 95 percent confidence intervals, and p values. RESULTS: A total of 1,289 violent incidents were recorded over a seven-month period. Based on the scale, 58 percent of the incidents were serious. Seventy-eight percent were directed toward nursing staff. Complex relationships between staffing, patient mix, and violence were found. Relative risk increased with more nursing staff (of either sex), more nonnursing staff on planned leave, more patients known to instigate violence, a greater number of disoriented patients, more patients detained compulsorily, and more use of seclusion. The relative risk decreased with more young staff (under 30 years old), more nursing staff with unplanned absenteeism, more admissions, and more patients with substance abuse or physical illness. In total these factors accounted for 62 percent of the variance in violence. CONCLUSIONS: Violent incidents in psychiatric settings are a frequent and serious problem. Incidents appear to be underreported, and the seriousness of an incident does not guarantee it will be reported.     

Use of peer ratings to assess sociability among inpatients with severe psychiatric disorders

OBJECTIVE: A critical component of inpatient treatment for persons with severe psychiatric disorders is an evaluation of their social impairments. Most existing methods for such evaluations involve staff input and can be both time-consuming and expensive. This paper reports on the use of peer ratings as a method for assessing sociability, an aspect of social functioning in this clinical population. METHODS: Thirty-two inpatients with severe psychiatric disorders who had spent an average of 18 months on an inpatient unit in a state facility rated the popularity of their inpatient peers by completing a 7-point scale measuring how much they enjoyed visiting with each patient. The reliability of peer ratings and their association with staff ratings of patients' behavior on the unit were assessed. RESULTS AND CONCLUSIONS: The peer ratings had excellent test-retest reliability and were highly associated with staff members' independent evaluations of patients' behavior. Peer ratings appear to have promise as a measure of social functioning among inpatients with severe psychiatric disorders.     

Behavioral rehabilitation of the "treatment-refractory" schizophrenia patient: Conceptual foundations, interventions, and outcome data.

This article describes an intensive, inpatient behavioral rehabilitation program for patients with schizophrenia who have been considered "treatment-refractory" at state hospitals. The program is a public-private partnership involving state and private hospitals and community residence providers. The essential elements of this program are described, along with the conceptual and philosophical bases of its treatment and examples of staff behaviors critical to treatment success. Outcome data are then discussed to emphasize the point that when evidence-based psychological treatment is implemented with this population, outcomes can be positive in most cases, and therefore, the number of treatment-refractory patients is actually far less than is estimated on the basis of response to medication alone. (PsycINFO Database Record (c) 2010 APA, all rights reserved)