Liaison Psychiatry Service Research Articles

The impact of first COVID-19 peak on patient referrals to Liaison Psychiatry Service and staff perception about service provision in Birmingham and Solihull Mental Health Trust Birmingham - a service evaluation project

AimsBased on recommendations from the Royal College of Psychiatrists, this project aimed to evaluate the impact of the first peak of the COVID-19 pandemic on referral patterns to the Queen Elizabeth Hospital Birmingham (QEHB) Liaison Psychiatry (LP) service. Additionally, we aimed to explore staff experiences in LP services across Birmingham and Solihull Mental Health Trust (BSMHFT) in order to generate Trust recommendations promoting optimal healthcare provision amidst the on-going pandemic.MethodA mixed method service evaluation was conducted using quantitative and qualitative analysis. Quantitative methods involved reviewing referrals made to the QEHB LP service from March to June 2020, compared with the equivalent time period in 2019. Data were retrospectively extracted from the electronic clinical databases RIO and PICS, and subsequently analysed using Microsoft Office. The number of, and reasons for referrals to LP were identified, whilst focus groups were conducted to explore the subjective experiences of staff working across BSMHFT LP services.ResultBetween 1st March and 30th June 2020, 984 referrals were made to the QEHB LP service, compared to 1020 referrals in 2019, representing a 3.5% reduction. From 2019 to 2020, referrals due to psychotic symptoms and deliberate self-harm rose by 12.8% and 14.1% respectively, whilst referrals for drug and alcohol-related causes reduced by 28.3%. A significant increase (150%) in referrals for medication or management advice was seen. Focus groups indicated that staff perceived an initial reduction in number of referrals, but an increase in the acuity of patient presentations.Staff reported anxiety around contracting and transmitting SARS-Cov-2, exacerbated by uncertainty around patients’ COVID-19 status. In QEHB, sixty-five of the 984 referrals (7%) had a positive SARS-Cov-2 PCR swab, with the remaining 919 referrals being either negative (68%) or unknown (25%). Ninety-six percent of consultations were conducted face-to-face in QEHB. There were conflicting views amongst staff regarding whether more consultations could have been conducted remotely. Furthermore, varying perceptions of support and communication from both the physical and mental health trust were reported.ConclusionQuantitative data indicates that COVID-19 impacted LP healthcare provision in BSMHFT. Whilst referral numbers remained similar between the equivalent period in 2019 and 2020, a change in the nature of referrals to LP at QEHB was seen. This was corroborated by qualitative data which highlighted a perceived change in acuity of referrals. These findings have been disseminated across the Trust and subsequent recommendations are being implemented during the on-going pandemic.

Diabetes and liaison psychiatry: the characteristics of patients with diabetes referred to a liaison psychiatry service in London

AimsTo determine the characteristics of adult patients referred to a Liaison Psychiatry service in a general teaching hospital in London, UK with 950 inpatient adult beds.MethodAll referrals for adult inpatient psychiatric consultation made during a period of 9 months were reviewed; those that involved a patient with a diagnosis of diabetes were analysed. Descriptive statistics were used; data were collected on demographic characteristics and physical and mental health parameters, including type of diabetes, number of years since diabetes diagnosis, glycaemic control, presence of diabetes-related complications, reason for Psychiatry consultation request, psychiatric diagnosis, psychotropic medication, frequency of admissions to general hospital, psychiatric risk issues and outcome of psychiatric consultation.ResultPilot results indicate that 30 diabetic patients were referred for a psychiatric consultation in 9 months. Of those, 9 had type 1 diabetes, 17 had type 2 diabetes and 1had pre-diabetes 3 were unknown. 13 were male and 17 were female; the median age was 46 (range 18 to 68); the ethnicities were 6 White, 15 Black, 1 Asian and 8 other.Diabetes-related complications were present in 77% (retinopathy 10%, kidney disease 27%, neuropathy 13%, diabetic foot 16%). 6% had comorbid cardiovascular disease. 10% were on dialysis and 3% had had amputations.The main reason for referral for psychiatric consultation was low mood and self harm; other reasons were recurrent DKA, anxiety and self neglect. Psychiatric risk issues included 20% risk of self-harm/suicide; 13% risk of violence; 10 risk of self-neglect. The outcomes of liaison psychiatry consultation were: 30% received an assessment that led to recommendations to the general medical team and did not require further psychiatric input; 27% received continued psychiatric follow-up during the admission. With regards to treatment, 36% had psychiatric treatment (including medication) reviewed; 47% received general treatment recommendations, including recommendations for new laboratory or radiological investigations or change in level of nursing care. 20% required transfer to an inpatient psychiatric unit, with 33% discharged to care of community mental health.ConclusionOur findings indicate the scope of practice for a Liaison Psychiatry service with regards to adult hospital inpatients with diabetes. Our data suggest that patients with type 2 diabetes are the majority of inpatients with diabetes that require psychiatric consultations, and that the majority of those are patients already known to psychiatric services due to long-term severe mental disorders, particularly schizophrenia, schizoaffective disorder or bipolar disorder. Most of those patients have medical comorbidities and severe diabetes-related complications. Patients with type 1 diabetes, despite making up a smaller proportion of referrals for psychiatric consultations, also tend to have recurrent hospital admissions and features of self-neglect.

Suburban vs urban: do the attendee's demographic profile influence the emergency department's mental health characteristics presentation?

AimsTo compare the Emergency Department (ED) referrals to psychiatry in a suburban versus an urban setting over a one-month to evaluate mental health presentations characteristics across two locations.MethodThis study was a retrospective cross-sectional study examining ED referrals to psychiatry in an inner-city and suburban centre over one month; - one based in an inner-city setting, the other based in a suburban area outside the city. The anonymised data were collected from both hospital's electronic patient records and analysed. The authors collected data on gender, age, employment, housing, the clinical problem at presentation, time of assessment and admissions. Descriptive data and hypothesis testing were performed where appropriate using Statistical Package for Social Sciences SPSS® version 26.ResultThe total number referred was 213: inner-city n = 109 and suburban n = 104. The inner-city saw a younger population; 47/109 (43%) were aged between 20 and 29 years, compared with 28/104 (27%) of suburban presenters (P-value 0.0134). A higher number of presenters were aged over 60 years in the suburban centre n = 13/104 (12.5%) versus the inner-city centre 3/109 (2.8%) (P-value 0.0084). In the inner-city, the proportion of homeless presenters was significantly higher at 30/109 (28%) versus 5/104 (4.8%) in the suburban setting (P < 0.0001). Presentations related to substances were highest, a total of 73 (34.3%) across both centres, with no significant difference in clinical presentations across the two centres. The majority were seen in the on-call period, 74/109 (67.9%) in the inner-city centre and 66/104 (63.5%) in the suburban centre. The psychiatric admission rate was significantly different between the two centres, with 33/109 (30.3%) patients admitted to the inner-city centre and 13/104 (12.5%) patients admitted to the suburban centre (P-value 0.002).ConclusionA large proportion of ED referrals to psychiatry constitute patients with unmet social and addiction needs. The variance in capabilities of liaison psychiatry (LP) and ED services means the local population's needs may not always be adequately catered for within a typical LP setting, which in the Irish context is predominantly driven by medical and nursing staff. This study highlights many patients attend the ED who may be better assessed directly by the community as per our National Emergency Program policies. This prompts consideration of expanding both ED and community services to comprise a more integrated, multidisciplinary-resourced, 24/7 care model.

You have to acknowledge the problem before you can address the problem: Audit looking at identification of co-existing substance misuse in a Liaison Psychiatry patient population

AimsTo evaluate if patients referred to Ealing Liaison Psychiatry Service (ELPS) with co-existing substance use are being appropriately identified as per NICE guidelines.Patients with co-existing substance misuse have greater morbidity and mortality and it is therefore important to identify these patients to optimise their management. NICE recommends that all patients are asked about their substance use.Anecdotally, our team felt we were doing a good job of identifying and managing such patients but we had no objective evidence of this.MethodCompleted a retrospective audit looking at a sample of patients referred to ELPS over two weeks in December 2019.A training session for ELPS was then held to highlight the initial audit results and NICE guideline recommendations.We then repeated the audit over two weeks in March 2020.ResultInitial audit (100 patients):Only 69% of patients asked about substance use. From those asked, 50-65.2% were using a substance, most commonly alcohol.None of the patients over the age of 80 were asked about substance use vs 79.5% of patients aged 20–40 years.55% of females vs 81% of males were asked about illicit substances.33.3% of ward referrals vs 74.2% of Emergency Department referrals asked about substance useRe-audit (53 patients):Significant improvement across all areas93% now asked about substance use60% of over 80s, 96% of females and 85% of ward referrals were now being correctly asked about substance useConclusionWe were surprised to find that we were initially not meeting NICE standards regarding asking patients about their substance use.Acknowledging this problem during our training session proved to be effective.This knowledge will help us develop our care pathways with our Acute colleagues and the Drug and Alcohol Liaison Service.

ELPS helps!

AimsThis study aimed to identify whether contact with the Ealing Liaison Psychiatry Service (ELPS) improved patients’ mental health using the Clinical Global Impressions (CGI) scale, and to understand the utility of this tool.BackgroundCGI is a frequently used outcome measure in psychiatry and also forms part of the RCPsych Framework for Outcome Measures in Liaison Psychiatry (FROM-LP) across the NHS's LP Services. However, there is minimal literature discussing the meaning of the quantitative results of the questionnaire. What would be a cut-off point associated with the provision of good care? It is not possible to draw conclusions about the quality of service and care based on the proportion of the patients who report an improvement on CGI in the absence of a gold standard.MethodPatients and their ELPS clinicians filled out a CGI questionnaire, rating the patient's mental health condition after contact with the clinician. The 1-7 rated CGI scale indicated the following: 1-3 signified varying degrees of improvement, 4 signified no change and 5-7 signified varying degrees of feeling worse. This study looked at all 205 patients with completed CGI questionnaires who had more than one face-to-face contact with a clinician in 2018 and 2019.Patient and clinician ratings were compared for concordance and patient notes were reviewed to identify potential reasons for patients with low CGI scores.Randomised sampling of patients who scored 1 ‘Very much improved’, 2 ‘Much improved’ and 3 ‘Minimally improved’ was conducted to identify differences in number of face-to-face contacts between the groups.Result59% of patients reported an improvement, 40% felt that there was no change and 1% (3 patients) indicated feeling worse. Of the latter, 2 patients had been admitted to a mental health unit.91% of cases showed concordance between patient and clinician ratings.Randomised sampling identified 9 patients scoring ‘1’, 22 patients scoring ‘2’ and 16 patients scoring ‘3’. The vast majority of patients had only two contacts with ELPS (77%).ConclusionELPS intervention improves patients’ self-reported wellbeing in 59% of patients according to CGI.There was no correlation between number of face-to-face contacts and the degree to which patients felt better. However, in the absence of a nationally-recognised gold standard, it is not possible to draw conclusions about whether care provided by ELPS is good compared to other services. Data from other centres are required to elucidate what constitutes a gold standard to aspire towards.

Polypharmacy and potentially inappropriate medications (PIMS) in older adults referred to a liaison psychiatry service

AimsThe older adult is more likely to be prescribed a lot of medications (polypharmacy) on account of multi-morbidity and being under the care of several specialists. Adverse drug events and reactions account for a significant number of acute hospital presentations in this population group with increased risks of delirium, lasting cognitive impairment, falls and death.Medications are not routinely reviewed or rationalised in the elderly, often contributing to preventable harm.We sought to estimate the prevalence of polypharmacy and potentially inappropriate medications, anticholinergics in particular, in patients (65 years and older) referred to the St Mary's Hospital Liaison Psychiatry Department over a 3-month period.MethodBetween 01/06/2019 and 31/08/2019 all referral forms (from in-patient wards and A&E) for patients aged 65+ years were screened for medications currently prescribed and administered. The medications were confirmed via the St. Mary's Hospital electronic records, pharmacists’ completed Medicines Reconciliation and GP Summary Care Records. Polypharmacy was defined as patients prescribed 5 or more medications. Drugs with anticholinergic properties were considered as an example of Potentially Inappropriate Medication (PIMs) using the Anticholinergic Burden Scale. 77 patients were referred in the time period. 9 were excluded due to incomplete/unreconciled medication information.Result77.94% (n = 53) were prescribed 5 or more medications.38.24% (n = 26) were prescribed over 10 medications.10.29% (n = 7) prescribed over 15 medications.69% of (n = 47) prescribed an anticholinergic.42.65% (n = 29) prescribed more than 1 anticholinergic.ConclusionPolypharmacy and potentially inappropriate prescribing remain widespread within the older adult population.Increased anticholinergic burden further compounds risks of cognitive impairment, delirium and death.Other categories of Potentially Inappropriate Medications, including those no longer needed, ought to be identified and reviewed. Over-the-counter medications also need to be screened for.Elimination or reduction of anticholinergic burden may improve quality of life for patients, as well as cost burden on services.Pharmacovigilance, collaborative working, regular and systematic medication reviews, and on-going training are needed across services providing care for the older adult.

Evaluation of paediatric liaison psychiatry services in England 2015-2019

AimsLiaison psychiatry services (LPSs) provide psychiatric care to general medical patients. This paper aims to evaluate LPS provision for children and young people In England.MethodThe annual Liaison Psychiatry Surveys of England (LPSEs) included questions on paediatric services from 2015 (LPSE-2). Questions were developed in consultation with NHS England and the Liaison Faculty of the Royal College of Psychiatrists. We analysed data from LPSE-2 and three subsequent surveys.LPSs were systematically identified by contacting all acute hospitals with Type 1 emergency departments listed by NHS England. All identified LPSs were emailed a copy of the questionnaire, with follow-up emails and telephone contact for non-responders. Responses by email, post or telephone were accepted.ResultThe number of acute hospitals with access to paediatric LPSs increased from 29 (16%) in 2015 to 46 (27%) in 2019; all of these hospitals had access to adult LPSs. The number of paediatric LPSs with at least 11 full time equivalent (FTE) mental health practitioners (MHPs) has increased from 6% to 24% and from none to 16% with 13 FTE or more MHPs. For both LPSE-4 and LPSE-5, there were only two acute hospitals where both 8 FTE MHPs and 1.5 FTE consultants were present. For LPSE-4, only one site met the Core 24 criteria (for adults - there are no criteria for paediatric LPSs) of 11 FTE MHPs and 1.5 FTE consultants, and for LPSE-5, both these sites exceeded them. Other paediatric services did not meet the adult core 24 criteria for a LPS.Acute hospitals with access to 24/7 paediatric LPSs increased from 12% to 19% between LPSE-4 and LPSE-5. In LPSE-5 68% of paediatric LPS worked to a one-hour response time target to the ED. This is an increase from 42% (14/33) in LPSE-4.ConclusionThere are still far fewer paediatric than adult LPSs, but the provision of paediatric LPSs improved from 2015 to 2019, with more services, more staffing, and faster response times. Services need to continue to improve as few services match the adult core 24 criteria for an LPS.

The impact of the COVID-19 pandemic on referrals to liaison psychiatry services at University Hospital Hairmyres, NHS Lanarkshire

AimsThe COVID-19 pandemic has led to sweeping public health restrictions with predictable impact on mental health. In Scotland, lockdown measures during the first wave of the pandemic commenced on 23rd March 2020 and only began to ease after 29th May 2020. The aim of this study was to evaluate the impact of the first wave of the COVID-19 pandemic on the number and type of referrals made to the adult psychiatric liaison nursing service (PLNS) at University Hospital Hairmyres, NHS Lanarkshire.MethodWe collated all of the archived referrals made by our local emergency department to the PLNS at University Hospital Hairmyres for adults (aged 18–65 years) during the period of the first COVID-19 national lockdown (April-July 2020) and the corresponding period one-year prior (April-July 2019) to analyse differences in referral numbers and demographics. Additionally, for referrals made during 2020, we conducted a qualitative review of electronic records to determine the reason for referral, contributory stressors to presentation, and in particular any effect from COVID-19.ResultA total of 549 referrals were made over the study period, with 320 in 2019 and 229 in 2020, a decrease of almost 30%. In 2019, referrals fell each month from April (n = 89) to July (n = 74), while this trend was reversed in 2020, rising from April (n = 45) to near-usual levels by July (n = 68). Compared to baseline, referrals in April 2020 were for a higher proportion of men (62.2%). On qualitative analysis, 26 records (11.3%) could not be found. Otherwise, the most common reasons for referral were suicidal ideation (43.3%) and/or deliberate self-harm (39.9%). Many patients presented with comorbid substance misuse (54.2%) and the majority were not known to community services (64.5%). COVID-19 was implicated in 48 referrals (23.6%), but only 2 of these arose as a direct result of infection.ConclusionWe have observed clear differences in the pattern of referrals made to the adult PLNS during the first COVID-19 national lockdown. COVID-19 was implicated in a minority of referrals, but most were related to secondary effects of lockdown restrictions rather than COVID-19 infection. Possible reasons for fewer referrals during this time could be non-presentation through fears of contracting COVID-19 or altruistic avoidance of putting “pressure on the NHS”. Further studies would be insightful; in particular, equivalent analysis of contacts with community services; and qualitative patient perspectives regarding reasons for non-presentation during this time.

Characterising a cohort of patients referred to a liaison psychiatry service from the Intensive Care Unit

AimsThis is descriptive study of a cohort of patients referred to a liaison psychiatry service from the intensive care department of a major London teaching hospital and trauma centre. The objective was to characterise key patterns in reasons for referral, nature of input, and gain a general sense of the workload. The rationale for collating this information was the consideration to developing a specific intensive care liaison service given the increasing evidence about the cognitive and mental health impacts of post-intensive care syndrome and the need for a coordinated management approach between stakeholders.MethodA cohort of 80 patients referred to liaison psychiatry service over a 6-month period from May to October 2020 was used. Descriptive statistics were used to characterise the patient's age, referring ward, reason for admission and referral, nature of input, number of reviews, previous engagement with mental health services, whether substance abuse or self-harm were related to the admission, and the destination upon discharge.ResultThe age range of patients at point of referral was 25-80 years. For 25% of patients, this admission marked their first engagement with secondary mental health services and for around 50%, not only was a new diagnosis given during the admission, but there was no recorded history of any psychiatric diagnoses. Around 10% of patients were referred for management of delirium. Anxiety disorder accounted for the greatest proportion of diagnoses upon discharge, at 22%. There was much variability in the number of intensive care ward reviews carried out, ranging from one to over 10.In 24%, self-harm led to presentation and 18% had comorbid substance misuse. Medication review was the single most common reason for referral in 13%, whereas requests for talking therapy and capacity assessments were 5% and 2% respectively. The vast majority of patients required a level of ongoing psychiatric input warranting community involvement or admission.ConclusionThis cohort often required detailed work-ups, new diagnoses and a high level of subsequent psychiatric management following discharge from hospital. The wide age range of patients meant that both working age and older adult liaison teams were involved in assessing referrals. Consideration could be given to a specific intensive-care liaison service due to the workload and complexity of needs, as well as the increasing awareness of the need for family support and early inclusion both for their benefit and that of the patient, particularly when the proportion of new diagnoses in this cohort is considered.

A snapshot in time: a 1-month review of all referrals to paediatric liaison psychiatry services in Dublin following emergency department presentation.

An emerging picture has seen increasing numbers of young people with mental health crisis attend paediatric emergency departments in Ireland. Following paediatric review, many are referred to in-house paediatric liaison psychiatry (PLP) services. This pilot study describes referral patterns and practice over a 1-month period across three Dublin centres. Case notes of all referrals to PLP were reviewed to extract relevant clinical and administrative data. For those admitted, costs associated with length of stay were estimated. Clinical profile, management and intra-hospital pathway differences were explored. Fifty-nine young people under 16 years presented to one of the three EDs with an acute MH presentation. The sample consisted of39 females (66%) with a mean age of13.7 years. The majority (n = 34, 58%) presented out of hours. A substantial portion of youths presenting(n = 37, 63%) were admitted, and had a mean duration of stay of 4.51 days. There were differences between hospitals in terms of frequency of presentation with self-harm, admission ratesand length of stay. Different PLP service configuration, staffing and funding streams may explain some of the differences observed across centres, although the findings should be interpreted with caution given the limited sample size. Standardisation of service provision and management is needed for PLP services. Additional community CAMHS resourcing is needed to support the development of alternative pathways for youth in need of urgent MH review.

Reduced activity in a liaison psychiatry service during the peak of the COVID-19 pandemic: Comparison with 2019 data and characterisation of the SARS-COV-2 positive cohort

IntroductionThe COVID-19 pandemic led to changes in how healthcare was accessed and delivered. It was suggested that COVID-19 will lead to an increased delirium burden in its acute phase, with variable effect on mental health in the longer term. Despite this, there are limited data on the direct effects of the pandemic on psychiatric care.Objectives 1) describe the mental health presentations of a diverse acute inpatient population, 2) compare findings with the same period in 2019, 3) characterise the SARS-CoV-2 positive cohort of patients.MethodsWe present a descriptive summary of the referrals to a UK psychiatric liaison department during the exponential phase of the pandemic, and compare this to the same period in 2019.Resultsshow a 40.3% reduction in the number of referrals in 2020, with an increase in the proportion of referrals for delirium and psychosis. One third (28%) of referred patients tested positive for COVID-19 during their admission, with 39.7% of these presenting with delirium as a consequence of their COVID-19 illness. Our data indicate decreased clinical activity for our service during the pandemic’s peak. There was a marked increase in delirium, though in no other psychiatric presentations.ConclusionsIn preparation for further exponential rises in COVID-19 cases, we would expect seamless integration of liaison psychiatry teams in general hospital wards to optimise delirium management in patients with COVID-19. Further consideration should be given to adequate staffing of community and crisis mental health teams to safely manage the potentially increasing number of people reluctant to visit the emergency department.

Considerations for delirium screening in response to a case of COVID-19 on an inpatient geriatric psychiatric unit

IntroductionWhile the COVID-19 pandemic caused by the SARS-CoV2 virus has challenged healthcare systems across the country, inpatient psychiatric hospitals struggle with a unique challenge. Psychiatric patients participate in therapy groups and eat meals together on milieus. It is difficult to enforce mask use or self-isolation practices in the setting of psychosis or mania.Additionally, neuropsychiatric disorders such as new onset psychosis, delirium, and affective disorders have all been documented following a SARS-CoV2 infection. A surveillance study from the UK found that primary psychiatric diagnoses were most common in younger patients and encephalopathy was more common in older adults following a SARS-CoV2 infection. A multicenter cohort study looking specifically at older adults found that 226 (28%) of 817 geriatric patients with COVID-19 had delirium at ED presentation. Delirium was the sixth most common of all presenting symptoms of COVID-19. Of patients with delirium, 16% had delirium as a primary presenting complaint and 37% had no fever or shortness of breath.Our psychiatric hospital has a geriatric psychiatry service, which has generated further challenges during the pandemic. The hospital requires COVID-19 testing prior to admission, but false negatives are possible. We continue to adapt our procedures to best serve this vulnerable population as we learn more about COVID-19 and atypical presentations. We provide a case report of a geriatric psychiatry patient who presented with delirium secondary to COVID-19 and the subsequent consideration in our admission process.MethodsA case report of a patient who was admitted to the geriatric psychiatry inpatient service and was found to have delirium as a presenting COVID-19 symptom. A review of neuropsychiatric manifestations of COVID-19 will be presented.ResultsMs. A is an 80-year-old woman with history of major depressive disorder, recent non-ST-elevation myocardial infarction, aortic stenosis, ischemic cardiomyopathy, and hypertension. She was originally admitted to the inpatient psychiatry from the ED for suicidal ideation and worsening depression but was found to be inattentive and disoriented. She had multiple falls in the several days leading up to admission, but no respiratory symptoms or fever. The geriatric psychiatry service determined she was delirious and started medical work up for etiology. Her rapid COVID-19 test at an outside facility was negative. Her medical work up was remarkable for a leukocytosis of 11 ×109 per liter, and an acute kidney injury (AKI) with BUN 20 mg/dL and Creatinine 1.31 mg/dL increased acutely from baseline of 0.9. Urinalysis was negative for infection. She was transferred to the emergency room for encephalopathy and declining oral intake. There, she tested positive for COVID-19 by PCR and was admitted to medicine for delirium of likely multiple etiologies including COVID-19. Her EEG showed generalized slowing and her head CT was negative for hemorrhage or infarction. The consult liaison psychiatry service continued to follow Mrs. A during her three-week hospitalization, during which she required Olanzapine 2.5 mg as needed for agitation related to her hyperactive delirium. Her AKI resolved with intravenous fluids and avoidance of nephrotoxic agents. She was discharged into the care of family on psychiatric medications fluoxetine 40 mg and mirtazapine 45 mg after her delirium gradually resolved with supportive care including physical and occupational therapy.ConclusionsThe diverse clinical presentation, often multifactorial etiology and the waxing and waning course of delirium makes it difficult to diagnose in an emergency room setting even for experienced physicians. Delirium can present with depressive, cognitive, and psychotic symptoms. It is not uncommon for delirious geriatric patients to be admitted to our inpatient unit for agitation, psychosis or depression, as was the case with Ms. A. Delirium can be a presenting symptom of COVID-19. Given this and our unique circumstances on a psychiatric milieu, we need to take greater consideration when assessing for delirium and other possible neuropsychiatric symptoms of SARS-CoV2 infection prior to admission. Grossman et al. developed a modified confusion assessment method for the emergency department (mCAM-ED) that requires 3 to 5 minutes to complete the whole instrument. However, despite having this and other tools, formal assessment tools for delirium are rarely used in the ED.It is important that geriatric patients are triaged to the appropriate level of care so proper medical treatment can be initiated without delay, as prolonged encephalopathy can lead to permanent decline in cognitive function, worse outcomes, and increased mortality. This case reinforces the clinical importance of including delirium on checklists of presenting symptoms of COVID-19, specifically for geriatric patients, that guide standardized screening, evaluation, and treatment.FundingThe authors received no financial support for the research, authorship, and/or publication of this article.

Reduced Activity in an Inpatient Liaison Psychiatry Service During the First Wave of the COVID-19 Pandemic: Comparison With 2019 Data and Characterization of the SARS-CoV-2 Positive Cohort.

Background: The COVID-19 pandemic led to changes in the way that healthcare was accessed and delivered in the United Kingdom (UK), particularly during the peak of the first lockdown period (the “first wave”) beginning in March 2020. In some patients, COVID-19 is associated with acute neuropsychiatric manifestations, and there is suggestion that there may also be longer term neuropsychiatric complications. Despite this, at the time of writing there are only emerging data on the direct effects of the COVID-19 pandemic on psychiatric care.Methods: In this retrospective study we analyzed referrals to an inpatient liaison psychiatry department of a large acute teaching hospital during the first wave of covid-19 in the UK and compared this data to the same period in 2019.Results: We saw a 40% reduction in the number of referrals in 2020, with an increase in the proportion of referrals for both psychosis or mania and delirium. Almost one third (28%) of referred patients tested positive for COVID-19 at some point during their admission, with 40% of these presenting with delirium as a consequence of their COVID-19 illness. Save delirium, we did not find evidence for high prevalence of new-onset acute mental illness in COVID-19 positive patients.Conclusion: Our data indicate decreased clinical activity in our inpatient psychiatry liaison department during the first wave of the COVID-19 pandemic, although a relative increase in relative increase in referrals for psychosis or mania, suggesting less of a relative decrease in more severe cases of mental illness. The reasons for this are likely multifactorial, including structural changes in the NHS and patient reluctance to present to emergency departments (ED) due to infection fears and Government advice. Our data also supports the literature suggesting the high relative prevalence of delirium in COVID-19, and we support integration of psychiatry liaison teams in acute general hospital wards to optimize delirium management. Finally, consideration should be given to adequate staffing of community and crisis mental health teams to safely manage the mental health of people reluctant to visit EDs.

Patient and nurse perceptions of an innovative TV wellness channel in an acute medical ward: a feasibility study

BackgroundThe Consultation Liaison Psychiatry service attends to the mental health needs of patients treated in a general hospital setting after referral by the treating team. Interventions may include psychoeducation and...

Investigation of risk of dementia diagnosis and death in patients in older people's secondary care mental health services.

ObjectivesPrevious studies have shown increased rates of death and dementia in older people in specific serious mental illnesses (SMI) such as bipolar disorder or depression. We examined the rates of death and dementia in older people referred into a secondary care psychiatric service across a range of SMIs.MethodsWe used an anonymised dataset across 6 consecutive years with 28,340 patients aged 65 years and older from a single secondary care psychiatric trust in the United Kingdom.We identified deaths and incident dementia in patients with bipolar disorder/mania, schizophrenia, recurrent depression and anxiety disorders. We compared mortality and dementia rates between these diagnostic groups and in different treatment settings. We also examined mortality rates and dementia rates compared with general population rates.ResultsPatients with schizophrenia showed the highest hazard rate for death compared to other groups with SMIs (hazard ratio, 1.58; 95% confidence interval (CI), 1.18–2.1, with anxiety group the reference). Survival was reduced in patients referred to liaison psychiatry services. There were no significant differences between the SMI groups in terms of rates of dementia. However, risks of death and dementia were significantly increased compared to the general population (standardized mortality rates with 95% CI, 2.6(2.0–3.3), 3.5(2.6–4.5), 2.5(2.0–3.0) and 1.8 (1.4–2.2) and standardized dementia incidence rates with 95% CI, 2.7(1.5–4.1), 2.9(1.5–4.7), 3.8(2.6–5.2) and 4.3 (3.0–5.7) for bipolar disorder/mania, schizophrenia, recurrent depression and anxiety disorders respectively.ConclusionsOlder adults referred into an old age psychiatry service show higher rates of dementia and death than those reported for the general population.

Time of referral to older adult liaison psychiatry service and other factors affecting length of stay in the general hospital.

To explore the relationship between social and clinical factors with (1) Time to referral to an older adult liaison psychiatry service, and (2) Length of stay (LOS), in a sample of older adults admitted to an acute general medical hospital receiving liaison psychiatry intervention, in London, United Kingdom, over a 3-year period. Information on patients referred to liaison psychiatry for older adults between January 2013 and December 2015 was collected using structured forms, with clinical diagnoses determined according to International Classification of Mental Disorders-10. The association of social and clinical factors with the time taken to refer to liaison psychiatry and LOS was assessed using Cox proportional hazards regression and zero-truncated Poisson regression, respectively. Compared with people who were diagnosed with depression, older adults with psychotic and alcohol use disorders had higher rates of referral to liaison psychiatry (adjusted hazard ratios [aHRs] 1.83 [95% CI: 1.30, 2.59] and aHR 1.69 [95% CI: 1.01, 2.83]) respectively. In adjusted models, LOS was increased in older adults with delusional disorders and shorter in people with alcohol use disorders, personality disorders and learning disabilities, compared to people with depressive diagnoses. Within this cohort, a new definite dementia diagnosis and longer time to refer to liaison psychiatry were both associated with a longer length of general hospital in-patient stay. In older adults admitted to general medical hospitals, and needing liaison psychiatry input, timely referral may be associated with a shorter LOS.

The early impact of COVID-19 on mental health and community physical health services and their patients’ mortality in Cambridgeshire and Peterborough, UK

BackgroundCOVID-19 has affected social interaction and healthcare worldwide. MethodsWe examined changes in presentations and referrals to the primary provider of mental health and community health services in Cambridgeshire and Peterborough, UK (population ~0·86 million), plus service activity and deaths. We conducted interrupted time series analyses with respect to the time of UK “lockdown”, which was shortly before the peak of COVID-19 infections in this area. We examined changes in standardized mortality ratio for those with and without severe mental illness (SMI). ResultsReferrals and presentations to nearly all mental and physical health services dropped at lockdown, with evidence for changes in both supply (service provision) and demand (help-seeking). This was followed by an increase in demand for some services. This pattern was seen for all major forms of presentation to liaison psychiatry services, except for eating disorders, for which there was no evidence of change. Inpatient numbers fell, but new detentions under the Mental Health Act were unchanged. Many services shifted from face-to-face to remote contacts. Excess mortality was primarily in the over-70s. There was a much greater increase in mortality for patients with SMI, which was not explained by ethnicity. ConclusionsCOVID-19 has been associated with a system-wide drop in the use of mental health services, with some subsequent return in activity. “Supply” changes may have reduced access to mental health services for some. “Demand” changes may reflect a genuine reduction of need or a lack of help-seeking with pent-up demand. There has been a disproportionate increase in death among those with SMI during the pandemic.

Understanding liaison psychiatry commissioning: an observational study

Purpose The purpose of this paper is to explore the challenges that are experienced by staff responsible for commissioning liaison psychiatry services and to establish if these are shared by other health professionals. Design/methodology/approach Using a mixed-methods design, the findings from a mental health commissioner workshop (n = 12) were used to construct a survey that was distributed to health care professionals using an opportunistic framework (n = 98). Findings Four key themes emerged from the workshop, which was tested using the survey. The importance of secure funding; a better understanding of health care systems and pathways; partnership working and co-production and; access to mental health clinical information in general hospitals. There was broad convergence between commissioners, mental health clinicians and managers, except in relation to gathering and sharing of data. This suggests that poor communication between professionals is of concern. Research limitations/implications There were a small number of survey respondents (n = 98). The sampling used an opportunistic framework that targeted commissioner and clinician forums. Using an opportunistic framework, the sample may not be representative. Additionally, multiple pairwise comparisons were conducted during the analysis of the survey responses, increasing the risk that significant results were found by chance. Practical implications A number of steps were identified that could be applied in practice. These mainly related to the importance of collecting and communicating data and co-production with commissioners in the design, development and monitoring of liaison psychiatry services. Originality/value This is the first study that has specifically considered the challenges associated with the commissioning of liaison psychiatry services.

The nature and activity of liaison mental services in acute hospital settings: a multi-site cross sectional study

BackgroundTo describe the clinical activity patterns and nature of interventions of hospital-based liaison psychiatry services in England.MethodsMulti-site, cross-sectional survey. 18 acute hospitals across England with a liaison psychiatry service. All liaison staff members, at each hospital site, recorded data on each patient they had face to face contact with, over a 7 day period. Data included location of referral, source of referral, main clinical problem, type of liaison intervention employed, staff professional group and grade, referral onto other services, and standard assessment measures.ResultsA total of 1475 face to face contacts from 18 hospitals were included in the analysis, of which approximately half were follow-up reviews. There was considerable variation across sites, related to the volume of Emergency Department (ED) attendances, number of hospital admissions, and work hours of the team but not to the size of the hospital (number of beds). The most common clinical problems were co-morbid physical and psychiatric symptoms, self-harm and cognitive impairment. The main types of intervention delivered were diagnosis/formulation, risk management and advice. There were differences in the type of clinical problems seen by the services between EDs and wards, and also differences between the work conducted by doctors and nurses. Almost half of the contacts were for continuing care, rather than assessment. Eight per cent of all referrals were offered follow up with the LP team, and approximately 37% were referred to community or other services.ConclusionsThe activity of LP services is related to the flow of patients through an acute hospital. In addition to initial assessments, services provide a wide range of differing interventions, with nurses and doctors carrying out distinctly different roles within the team. The results show the volume and diversity of LP work. While much clinical contact is acute and confined to the inpatient episode, the LP service is not defined solely by an assessment and discharge function; cases are often complex and nearly half were referred for follow up including liaison team follow up.

Long-term impact of the expansion of a hospital liaison psychiatry service on patient care and costs following emergency department attendances for self-harm.

In September 2014, as part of a national initiative to increase access to liaison psychiatry services, the liaison psychiatry services at Bristol Royal Infirmary received new investment of £250 000 per annum, expanding its availability from 40 to 98 h per week. The long-term impact on patient outcomes and costs, of patients presenting to the emergency department with self-harm, is unknown. To assess the long-term impact of the investment on patient care outcomes and costs, of patients presenting to the emergency department with self-harm. Monthly data for all self-harm emergency department attendances between 1 September 2011 and 30 September 2017 was modelled using Bayesian structural time series to estimate expected outcomes in the absence of expanded operating hours (the counterfactual). The difference between the observed and expected trends for each outcome were interpreted as the effects of the investment. Over the 3 years after service expansion, the mean number of self-harm attendances increased 13%. Median waiting time from arrival to psychosocial assessment was 2 h shorter (18.6% decrease, 95% Bayesian credible interval (BCI) -30.2% to -2.8%), there were 45 more referrals to other agencies (86.1% increase, 95% BCI 60.6% to 110.9%) and a small increase in the number of psychosocial assessments (11.7% increase, 95% BCI -3.4% to 28.5%) per month. Monthly mean net hospital costs were £34 more per episode (5.3% increase, 95% BCI -11.6% to 25.5%). Despite annual increases in emergency department attendances, investment was associated with reduced waiting times for psychosocial assessment and more referrals to other agencies, with only a small increase in cost per episode.