Inpatient Mental Health Services Research Articles

Impact of the COVID-19 Pandemic on Utilization of Inpatient Mental Health Services in Shanghai, China.

(1) Purpose: The ongoing COVID-19 pandemic has had an impact on mental health and the utilization of hospital-based inpatient mental health care worldwide. The aim of this study was to determine the impact of this pandemic on the utilization of this service in Shanghai by comparison with hospital-based health care records during the preceding 4 years. (2) Methods: The medical records were provided by the Shanghai Municipal Health Insurance Bureau. Diagnostic coding was based on International Classification of Diseases-10th revision (ICD-10), and inpatients with codes from F00 to F99 were examined. (3) Results: Inpatients were compared according to gender, age, pandemic stage, and type of mental disease. Utilization of psychiatric inpatient care in Shanghai during each of the four stages of the pandemic (1 January 2016 to 21 January 2020; 22 January 2020 to 9 February 2020; 10 February 2020 to 1 March 2020; 2 March 2020 to 31 July 2020) was analyzed. Before the lockdown, the utilization of psychiatric inpatient care had an overall upward trend; after the lockdown, the number of inpatients dropped sharply; as of 31 July 2020, it has not been restored. The utilization of this service for most types of mental disease declined rapidly during the pandemic; for vascular dementia (VAD, F01), it was relatively steady. The observed number of inpatient patients was about 51.07% lower than the predicted number in 2020. (4) Conclusions: The COVID-19 pandemic led to the implementation of prevention and control measures that reduced the utilization of psychiatric inpatient care in Shanghai. The use of inpatient services for categories F20–F29 had the greatest decline, and VAD (F01) had the smallest change during the pandemic. This service consequence of COVID-19 is apparent; to assure access to adequate service during a pandemic, health care professionals should pay close attention to changes in the utilization of different mental health services.

Improving family engagement in an adult inpatient mental health service using an action research framework

AbstractFamily involvement in mental health treatment has been shown to improve outcomes for service users. This project used a whole system‐focused action research framework and involved service users, family members and healthcare professionals to develop ways to improve family engagement in an adult inpatient mental health service. Focus groups were conducted with two service users, two family members and four healthcare professionals to discuss their experiences of family involvement and develop initial ideas. A problem‐solving group, involving service users, family members and professionals, was used to develop the solutions. The project identified context‐specific solutions to improve family engagement, which included specific training for professionals working on the inpatient wards, questionnaires to facilitate conversations with families, and sharing information about mental health and the inpatient mental health service with families. These may be helpful for other adult inpatient services.

Health care partnership to deliver inpatient care to children

An innovative psychiatric health care system and top‐rated children's hospital, both Minnesota‐based, last week announced a new partnership that will deliver inpatient mental health services to patients as young as 6 years old. Health leaders say the move is intended to address the urgent mental health needs of vulnerable children and adolescents and provide them with age‐appropriate, personalized care.

Nutritional intake and foodservice satisfaction of adults receiving specialist inpatient mental health services.

AimMeeting the nutritional needs and foodservice expectations of hospital inpatients is challenging. This study aimed to determine whether adults receiving specialist inpatient mental health services meet their energy and protein requirements and are satisfied with the foodservice.MethodsAn observational study of adults admitted to three specialist inpatient mental health services within a large health service. Energy and protein intake were determined over 24 h via observation, and nutritional requirements were estimated using standard procedures. Validated questionnaires were used to assess satisfaction with the lunch meal, elements of the foodservice system, and overall foodservice satisfaction.ResultsAmong 74 participants, the median (IQR) energy intake (6954 [5111–10 250]kJ/day) was less than estimated requirements (8607 [7319–9951]kJ/day), whilst protein intake (85 [62–120]g/day) exceeded requirements (59 [46–70]g/day). Food from external sources was consumed by 50% of participants. Satisfaction surveys found vegetables were rated more poorly than the meat or carbohydrate portion of the meal, food quality was rated lowest compared with meal service, staffing and physical environment. The majority of participants (89%) rated their last meal as average, with the remainder (11%) rating it as poor.ConclusionThere are opportunities to improve the meal and foodservice experience for this patient group to meet their nutritional requirements and expectations. Investment in quality food and menus that are appropriate for the demographics, exploration of the most appropriate foodservice system, and adequate dietetic resourcing are needed to improve nutrition care within specialist inpatient mental health services.

Medicaid Expenditures among Children with Documented Obesity.

Background: Obesity rates continue to rise among children, but knowledge regarding medical expenditures of Medicaid enrollees with documented obesity is lacking. We aim to describe Medicaid expenditure patterns among children with documented obesity and determine the degree to which specific clinical characteristics and conditions contribute to high expenditures. Methods: We performed a retrospective cross-sectional analysis of children aged 2-17 years with a diagnosis code of obesity continuously enrolled in the 2017 Medicaid MarketScan database. Children were grouped based on annual expenditure percentiles: <80th, 80 to <95th, 95 to <99th, and ≥99th. Inpatient, outpatient, and pharmacy expenditures were analyzed. Covariates included demographics, common obesity comorbid conditions (e.g., hypertension), complex chronic conditions (CCCs), and mental health conditions (MHCs). Logistic regression assessed demographic and clinical characteristics associated with high-spending groups (≥95th%). Results: We identified 300,286 children with a diagnosis of obesity. The 1% of children with the highest spending accounted for 25.4% of annual expenditures among children with documented obesity. Annual expenditures in the highest spending groups were driven primarily by inpatient and outpatient mental health services. Characteristics associated with high-spending groups included the following: age 12-17 years, obesity comorbid conditions, and having ≥1 CCC or MHC. These associations increased with increasing number of CCCs or MHCs. Conclusions: Inpatient and outpatient mental health expenditures made up a large proportion of spending among Medicaid-enrolled children with documented obesity. Important drivers of cost in this population were medical complexity and comorbid MHCs. Future research is needed to determine if some of these costs are avoidable in children with obesity.

Antipsychotic Prescribing Practice in Adults With a First Presentation of Psychosis Amongst Bolton's Early Intervention Team and Inpatient Mental Health Services: An Audit

AimsIn Bolton Early Intervention Team (EIT) it was noticed that patients prescribed antipsychotics frequently required a change in medication due to side effects. Similar issues had been identified in Avon and Wiltshire NHS Foundation Trust where a prescribing guideline was developed which won the NICE Shared Learning Award in 2020. This recommends prescribing Aripiprazole first line and cautions using Olanzapine or typical antipsychotics first due to their side effects. The aim of this project was to identify which antipsychotic drugs are currently prescribed in first episode of psychosis (FEP) in Bolton EIT patients and to audit adherence to National Institute of Clinical Excellence antipsychotic prescribing guideline CG178.MethodsThe sample included all adults with FEP accepted by Bolton EIT across a four-month period from 01/12/20 until 31/03/21. Fifty-two people were identified.Measured standards were documentation of prescribing rationale, discussion regarding medication side effects and weekly weight monitoring for six weeks following initiation. Antipsychotic choice and need for a change within six months of initiation was recorded. Data were collected retrospectively from patients’ electronic records.ResultsThirty-eight patients had been prescribed an antipsychotic – fifteen as inpatients, seventeen by Bolton EIT and six by the Home Treatment Team.Of the fifteen inpatients Olanzapine (8) and Zuclopenthixol (3) were the most common choice. 5/15 had a documented rationale, and side effects were discussed with 3/15 patients. Weekly weight monitoring was performed in 7/15.Of the 17 people who started antipsychotic medication once under Bolton EIT Quetiapine (6), Olanzapine (6) and Aripiprazole (5) were the most common choices. 12/17 had a documented rationale and 13/17 were consulted regarding side effects. Weekly weight monitoring was not performed for any of these patients.Within six months, sixteen antipsychotic prescriptions (42%) were changed due to side effects (9), inefficacy (6) and non-compliance (1). The drugs changed were Olanzapine (6) Quetiapine (6) Zuclopenthixol (2) Aripiprazole (1) and Chlorpromazine (1).ConclusionThose initiated on antipsychotics as inpatients need better involvement in decision-making and consultation about side effects. A community initiative should be introduced to offer weekly weight monitoring. Further work is required to understand the rationale for frequently prescribing Olanzapine and Zuclopenthixol in inpatient services, and to consider why Aripiprazole is infrequently used first line.

Controversies with routine urine drug screening.

Urine drug screening (UDS) is a tool often used in a comprehensive treatment plan-even though it may cause harm to patients with mental health disorders. This article analyzes nurses' use of UDS in inpatient mental health services and offers strategies to develop policy and practice guidelines that ensure patient safety.

'I'm institutionalised … there's not much I can do': Lived experience of housing related delayed discharge.

Delayed discharge from inpatient mental health units is the continued hospitalisation of consumers after being assessed as ready to be discharged. This is common in adult inpatient mental health services and is usually due to a lack of appropriate housing for discharge. Research indicates a range of possible negative impacts, but no studies have explored consumers' perspectives on this issue. This study explores consumers' perspectives of the experience of housing related delayed discharge (HRDD). Using a grounded theory approach, in-depth interviews were conducted with 10 consumers. All consumers were experiencing HRDD from inpatient mental health units in one Sydney local health district. The data were analysed using constant comparative analysis. A lack of choice and control was the central theme that characterised participants' experiences. The combined experience of being delayed in hospital and being homeless led to a lack of choice and control over the basics in life, how consumers spent their time and with whom, and their futures. This lack of autonomy was shaped by the features of the hospital and participants' personal circumstance. The hospital features included rules and routines, physical and social environments, resources, and support from staff. Personal circumstances included individual situations, social networks, and support from community organisations. Participants described a variety of impacts, including reduced mental and physical well-being, and anticipated difficulty transitioning back into the community. This study is the first of its kind and provides consumer perspectives on the impacts of HRDD on their well-being and recovery. The inability to participate in meaningful and necessary occupations is an occupational injustice and implies the need for occupational therapists to advocate for both the prevention of HRDD through government investment in affordable and readily available housing and the mitigation of its effects through modified hospital environments and practices.

Staff perspectives on barriers to and facilitators of quality of life, health, wellbeing, recovery and reduced risk for older forensic mental-health patients: A qualitative interview study.

There is a lack of research informing service delivery for older forensic mental health patients. This study explored service provision in forensic mental health inpatient and community services in England, investigating what is required for progress in terms of quality of life, health, wellbeing, recovery and reduced risk, and the barriers and facilitators associated with this. Semi-structured interviews were undertaken with 48 members of staff working with older forensic mental health patients in secure inpatient units or the community in England. Data were analysed using thematic analysis. Two global themes 'What works' and 'What doesn't work' were identified comprising themes representing environmental, interpersonal and individual factors. 'What works' included: positive social support and relationships; individualised holistic patient-centred care; hub and spoke approach to patient care; and suitable environments. 'What doesn't work' included: absence of/or maladaptive relationships with family and friends; gaps in service provision; and unsuitable environments. For older patients to progress to improved quality of life, health, wellbeing and reduced risk, multilevel and comprehensive support is required, comprising a range of services, interventions, and multidisciplinary input, and individualised to each patient's needs. The physical environment needs to be adapted for older patients and provide a social environment that seeks to include supportive families, friends and expert professional input. A clear patient progression pathway is required; this must be reflected in policy and provision.

Suicide Attempts Rise, Yet Many Do Not Receive MH Services

Back to table of contents Previous article Next article Clinical & ResearchFull AccessSuicide Attempts Rise, Yet Many Do Not Receive MH ServicesTerri D'ArrigoTerri D'ArrigoSearch for more papers by this authorPublished Online:25 Apr 2022https://doi.org/10.1176/appi.pn.2022.05.4.4AbstractLogistical and financial barriers stand between patients who attempt suicide and the care they need.Between 2008 and 2019, the annual rate of suicide attempts per 100,000 adults in the United States rose from 481.2 to 563.9, yet the rate at which individuals who attempt suicide receive mental health services has not kept pace, according to a study in JAMA Psychiatry.Policies that improve the social conditions in which people live can help curb the rise in suicide, says Tanner Bommersbach, M.D., M.P.H.Yale School of Medicine/Robert A. LisakTanner Bommersbach, M.D., M.P.H., a psychiatry resident at Yale School of Medicine, and colleagues analyzed data from 484,732 adults who participated in the National Survey of Drug Use and Health (NSDUH) from 2008 to 2019. They defined suicide attempts as self-reported efforts to kill one’s self in the past 12 months and examined trends in past-year use of mental health services among participants who reported past-year suicide attempts. They also analyzed data about the participants’ reasons why they did not receive care.Among adults who attempted suicide, 34.8% (2010 to 2011) to 45.5% (2018 to 2019) reported needing mental health services but did not obtain them. From 2008 to 2019 there were no significant changes in the likelihood of having any mental health outpatient, inpatient, or medication services or changes in the use of substance use treatment services. The number of participants who reported not knowing where to go for treatment, lacking transportation, or reporting that services were too far away increased over the course of the study.Bommersbach told Psychiatric News that the results demonstrate a need for broad efforts to address mental health. “While access to care for individuals at high-risk is critical, mental health services alone are unlikely to curb the rise in suicide,” Bommersbach said. “We must also focus on community-based interventions and broad social policies that improve the social conditions in which people are living.”Study researcher Taeho Greg Rhee, Ph.D., an assistant professor adjunct of psychiatry at Yale School of Medicine, added that it is important for health professionals to step up in helping patients get the care they need. “Improving access to care and addressing unmet psychiatric and medical needs among individuals with suicidal ideation or suicide attempts should be clinical goals across diverse settings,” Rhee said. “We need to engage with and educate patients more actively so that they can get the help they need when they face a crisis, including suicidal ideation or suicide attempts.”Maria A. Oquendo, M.D., Ph.D., suggests partnering with schools and communities to offer education about mental health.David HathcoxAlthough there is a shortage of psychiatrists and mental health professionals, psychiatrists among the APA membership can play a role in community outreach, said suicide expert Maria A. Oquendo, M.D., Ph.D., the Ruth Meltzer Professor and Chair of Psychiatry at the Perelman School of Medicine at the University of Pennsylvania and past president of APA, who was not involved in the research.“Organizing district branches to partner with schools and communities to offer educational sessions about mental health and how to access care in the community would be useful,” Oquendo said.Social media campaigns, initiatives on college campuses, unemployment benefit programs, and financial supports may offer other ways for reaching high-risk populations, Bommersbach and colleagues wrote. Continued expansion of telehealth-based interventions for substance use, especially for medications for opioid use disorder in rural areas, may also present a way to engage more people in treatment, they added.The researchers wrote that the results underscore the importance of efforts to improve access to insurance and enforcement of mental health parity.Oquendo explained that a lack of parity serves as a barrier to care, even when patients do have insurance.“Despite being a law, many insurers still have discriminatory policies that result in mental health clinicians not being paid for their work, thus deterring [these professionals] from accepting insurance,” Oquendo said.This study was supported by the National Institute on Aging; the National Institute of Mental Health; and the Institute for Collaboration on Health, Intervention, and Policy of the University of Connecticut. ■“National Trends of Mental Health Care Among U.S. Adults Who Attempted Suicide in the Past 12 Months.” ISSUES NewArchived

Implementation of the Recovery Guide in inpatient mental health services in Sweden-A process evaluation study.

BackgroundInvolving service users in inpatient care and recovery planning has gained interest worldwide. Our purpose was to evaluate the process of implementation of a coproduced Recovery Guide (RG) intervention in 22 inpatient wards in Sweden, in terms of context, implementation process and mechanisms of impact over 12 months.MethodsA mixed method design and a process evaluation framework were used to guide data collection and to deductively analyze perspectives and descriptive statistics of delivery from three stakeholder groups.ResultsResults showed that although initial contextual barriers were present (e.g., lack of resources, and interest, uncertainty in the organization, a dominant illness perspective), it was possible to implement the RG in 14 wards, where 53% of admitted service users received the intervention. Legitimacy of the intervention, engaged managers and staff, capacity of staff and ward organization, coproduction and continuous support from user organization were critical mediators. Mechanisms of impact concerned (1) a new perspective on mental health, well‐being and recovery, (2) capacity building of a recovery approach in inpatient settings and (3) a meaningful outlet for users' thoughts and feelings on recovery, sharing narratives and influencing care and goals.ConclusionsThe RG intervention has the potential to promote a recovery approach in inpatient mental health services (MHSs). Coproduction among stakeholders created trust and a sustainable implementation that made it possible for wards to resume implementation when contextual barriers had been resolved.Patient and Public ContributionThe current study involved stakeholders including a service user organization, the public, first‐line managers and staff (including peer support workers) in inpatient and community MHS and researchers, who greatly contributed to the implementation programme, including codesign of the RG intervention as well as coproduction of the implementation in inpatient MHS. All authors have their own lived experiences of mental health problems as a service user or as a relative.

Staff perspectives on the barriers and facilitators to exercise implementation in inpatient mental health services: A qualitative study

Exercise has multiple benefits for the physical and mental health of people with severe mental health problems (SMI). However, people with SMI engage in significantly less exercise than the general population and there is an evidence-practice gap regarding the implementation of exercise in clinical services. Mental health staff in inpatient services are well placed to support people with SMI to exercise, yet little is known about staff perspectives on exercise facilitation in inpatient care. This study aimed to explore staff views on role for exercise for people with SMI and the barriers and facilitators to exercise implementation in inpatient services. Qualitative semi-structured interviews were conducted with 25 clinicians working in inpatient mental health settings. Interview topics included the role for exercise in inpatient services, staff roles in relation to exercise, the barriers and facilitators to patients’ engagement in exercise, and promotion of exercise. Interview data were analysed using Thematic Analysis. Four key themes were developed: (i) perceived patient factors, (ii) exercise in the context of relationships, (iii) the ward context, and (iv) the therapeutic role for exercise. Clinicians readily recognised the benefits of service users engaging in exercise, though identified a number of individual, systemic, and organisational barriers to exercise implementation in inpatient services. Organisational prioritisation of exercise and support for staff to develop their skills and confidence in exercise facilitation is required. Enhancing the legitimacy of exercise as a multi-beneficial intervention for people with SMI is essential. Further recommendations for services based on the study findings are provided.

Development of a wellbeing care plan for staff: Implementation and evaluation within mental health inpatient services

Development of a wellbeing care plan for staff: Implementation and evaluation within mental health inpatient services

Mental health service utilization review patterns in a Medicaid managed care program.

The current study investigated mental health utilization review (UR) clinical service authorization requests, denials, and reasons for denial in a statewide Medicaid managed care organization (MMCO) program. Retrospective analysis of utilization review data reported by MMCOs in New York State. Data from the utilization review practices of 15 MMCOs were collected and analyzed for calendar years 2017 and 2018. The data reported are specific to mental health services and include the number of authorization requests, number of clinical denials, and the reasons specified for each denial. Analyses were undertaken to determine the UR denial rates and most common reasons for denials. A total of 264,901 requests for inpatient mental health service authorizations and 53,687 requests for outpatient mental health service authorizations were made in 2017 and 2018. Of these, 1.5% of inpatient authorization requests and 0.4% of outpatient authorization requests were denied for reasons related to medical necessity. The most common reason for inpatient mental health service denials was that the patient no longer met the standard for the requested level of care. Low UR denial rates warrant further examination of the relationship between UR and both quality of care and patient outcomes in mental health care. With the substantial resources spent on UR, findings could point to areas of potential reforms to the system that may minimize these costs and improve care for patients with mental illness.

Therapeutic relationships within child and adolescent mental health inpatient services: A qualitative exploration of the experiences of young people, family members and nursing staff.

Child and adolescent mental health services (CAMHS), especially inpatient units, have arguably never been more in demand and yet more in need of reform. Progress in psychotherapy and more broadly in mental health care is strongly predicted by the therapeutic relationship between professional and service user. This link is particularly pertinent in child and adolescent mental health inpatient services where relationships are especially complex and difficult to develop and maintain. This article describes a qualitative exploration of the lived experienced of 24 participants (8 young people, 8 family members/carers and 8 nursing staff) within inpatient CAMHS across four sites in the UK. We interviewed participants individually and analysed the transcripts using thematic analysis within a critical realist framework. We synthesised data across groups and present six themes, encapsulating the intricacies and impact of therapeutic relationships; their development and maintenance: Therapeutic relationships are the treatment, Cultivating connection, Knowledge is power, Being human, The dance, and It's tough for all of us in here. We hope these findings can be used to improve quality of care by providing a blueprint for policy, training, systemic structures and staff support.

Women’s experiences of restrictive interventions within inpatient mental health services: A qualitative investigation

Restrictive interventions (RI), such as physical restraint, seclusion, and rapid tranquilization, can have negative psychological effects on service users; however, there has been little investigation regarding their effects on women. The aim of this paper was to explore women's experiences of RI within UK inpatient mental health services. Twenty women accessing inpatient mental health services participated in semi-structured interviews. Using thematic analysis (TA), three primary themes were reported from women's experiences: (1) powerlessness, (2) dehumanization, and (3) relationships and communication. Clinical recommendations included ensuring gender-awareness and trauma-informed care training is mandatory for all mental health staff, for RI training to include awareness of gender differences, and for policies to be reviewed with regard to women being invasively searched and ensuring sanitary products are safely available for women within seclusion. Directions for future research include investigating the experiences of RI for women from minority ethnic groups and exploring important moderators and mediators in the relationship between RI and re-traumatization for women.

The Feasibility of Outdoor Psychology Sessions in an Adult Mental Health Inpatient Rehabilitation Unit: Service User and Psychologist Perspectives.

Few studies have explored outdoor therapy when facilitated by clinical psychologists within an inpatient mental health service. In the present study, outdoor psychology sessions were introduced after service users (SUs) expressed a desire to return to face-to-face working during the COVID-19 pandemic. This study aimed to explore SUs’ and clinical psychologists’ perspectives on the feasibility of conducting outdoor therapy within the service. A mixed-method approach was underpinned by critical realist philosophy. Three psychologists maintained reflective diaries following outdoor therapy sessions with 16 SUs. A subsample of 14 SUs completed scales measuring therapeutic alliance and comfort during outdoor sessions. A subsample of eight SUs participated in semi-structured interviews. Data was analysed using descriptive statistics and thematic analysis. Quantitative and qualitative data demonstrated high SU satisfaction with therapeutic alliance and comfort outdoors. Six themes were identified: utilising a person-centred approach; the value of multi-disciplinary team support; enhancing therapeutic engagement; the benefits of time away from the ward; managing confidentiality; physical health and safety. This feasibility study demonstrated the introduction of outdoor psychology sessions within an inpatient mental health service to be a viable response to COVID-19. The findings suggest outdoor therapy can be an effective and safe mode of therapy, and can offset the challenges of indoor working, providing certain risk factors are considered and managed. The limitations of this study and implications for clinical practice are discussed. Further research is now required to support future integration into clinical practice.

Inpatient Mental Healthcare before and during the COVID-19 Pandemic.

Prior studies have demonstrated disruption to outpatient mental health services after the onset of the COVID-19 pandemic. Inpatient mental health services have received less attention. The current study utilized an existing cohort of 33 Veterans Health Affairs (VHA) acute inpatient mental health units to examine disruptions to inpatient services. It further explored the association between patient demographic, clinical, and services variables on relapse rates. Inpatient admissions and therapeutic services (group and individual therapy and peer support) were lower amongst the COVID-19 sample than prior to the onset of COVID-19 while lengths of stay were longer. Relapse rates did not differ between cohorts. Patients with prior emergent services use as well as substance abuse or personality disorder diagnoses were at higher risk for relapse. Receiving group therapy while admitted was associated with lower risk of relapse. Inpatient mental health services saw substantial disruptions across the cohort. Inpatient mental health services, including group therapy, may be an important tool to prevent subsequent relapse.

Promoting alternatives to PRN medicines in secure inpatient mental health services

Promoting alternatives to PRN medicines in secure inpatient mental health services

Improving mental health care transitions through information capture during admission to inpatient mental health services: a quality improvement study

BackgroundMany interventions aim to improve the transition from ward to community at the time of discharge, with varying success. Guidelines suggest that discharge planning should begin at admission, but in reality this is ideal rather than standard practice. We aimed to develop a novel information capture tool during admission that facilitates and accelerates discharge.MethodsA quality improvement study to develop, implement and evaluate a novel tool that improves information capture upon admission to acute mental health wards within a single English National Health Service (NHS) trust. We developed the tool by synthesising existing evidence and working with multi-agency and multi-disciplinary professionals in two co-design workshops. During implementation the tool was piloted on three wards. Ethnographic observations (145 h) and interviews (45) were used to evaluate the implementation of the tool across the three wards. Thematic synthesis was used to consolidate the findings.ResultsThe tool developed considerably as the process evolved. The finished product is a list of 10 information categories that should be captured from external agencies upon admission to hospital to facilitate discharge planning to community settings. Reported advantages of the tool were: (1) facilitating confidence in junior staff to legitimately question the suitability of a patient for an acute ward (2) collecting and storing essential information in a single accessible place that can be used throughout the care pathway and (3) collecting information from the services/agencies to which patients will eventually be discharged.ConclusionsImproving the quality of information at admission has the potential to facilitate and accelerate discharge. The novel tool provides a framework for capturing this information that can be incorporated into existing information systems. However, the introduction of the tool exacerbated complex, fragile distributed team dynamics, highlighting the importance of sociocultural context in information flow transitional interventions within distributed teams.