Ward Referrals Research Articles

Gender-specific differences in comorbidities, in-hospital complications and outcomes in emergency patients with ethanol intoxication with and without multisubstance use

To analyse gender-specific differences in comorbidities, multisubstance abuse, in-hospital complications, intensive care unit transfers and referrals to psychiatric wards of emergency department patients with ethanol intoxication. Several lines of evidence suggest an influence of gender differences on diagnostic and therapeutic approaches to various diseases. Over a period of 7 years, all patients with signs or symptoms of ethanol intoxication and a positive blood ethanol test admitted for the first time to the emergency department of a Swiss regional tertiary referral hospital were prospectively enrolled. Patients were categorised into two subgroups: patients without additional drug use were considered ethanol-only cases, whereas patients who had also ingested other substances (as determined from bystanders, physicians and urine drug screening) were considered multisubstance cases. A retrospective analysis of this database evaluated gender-specific differences in comorbidities, multisubstance abuse, in-hospital complications, intensive care unit transfers and referrals to psychiatric wards within these two subgroups. Statistical analysis included Fisher's exact test for categorical data and Wilcoxon rank sum test for continuous data. Of 409 enrolled patients, 236 cases were ethanol-only and 173 were multisubstance cases. The three most common comorbidities in multisubstance patients showed significant gender differences: psychiatric disorders (43% males vs 61% females; p = 0.022), chronic ethanol abuse (55% males vs 32% females; p = 0.002) and drug addiction (44% males vs 17% females; p = 0.001). Gender differences were also found for the most frequently co-ingested substances: benzodiazepines (35% males vs 43% females; p = 0.014), cannabis (45% males vs 24% females; p = 0.006) and cocaine (24% males vs 6% females; p = 0.001). Male and female ethanol-only patients were transferred to the intensive care unit in 8% of cases. In multisubstance cases, 32% of male and 43% of female patients were transferred to the intensive care unit (no significant gender difference). The psychiatric ward referral rate in male (30%) and female (48%) patients with multisubstance abuse was significantly different (p = 0.028). No significant gender difference in psychiatric ward referral rates was observed for ethanol-only patients (12% males, 17% females). Among emergency department patients admitted with ethanol intoxication, gender differences in comorbidities, substance use and psychiatric ward referrals were highly significant among patients who presented with multisubstance abuse. Rates of intensive care unit transfer for patients with ethanol intoxication are substantial for both genders, reflecting relevant disease burden and resource demand, as well as the need for further preventive efforts.

An Audit to Assess the Quality of Ward Referrals Sent to City Hospital Liaison Psychiatry Team From Inpatients Wards D15, D17and D27, Between July 2021 to September 2021

AimsLiaison psychiatry provides psychiatric care to medical patients. Patients include those attending emergency departments, general hospital inpatients and outpatients. Liaison teams work hand in hand with several general hospital teams to offer advice, review and manage these patients. Over the last few months, the Liaison service in City Hospital have been receiving many inappropriate referrals. Inappropriate referrals are defined as patients who are referred to services, with one of the following reasons: 1.Insufficient presenting complaint2.No documented Past psychiatric history3.Insufficient Mental state Examination (MSE)4.No risk assessment5.No documented Drug/alcohol history6.Patients having not consented to referral.7.If one or more of the above criteria is not metOur aim was to evaluate the appropriateness of the referrals received from D15, D17, D27 inpatients wards in City Hospital over a 3-month period from July to September 2021. These wards were chosen as they commonly refer patients to liaison services.MethodsWe collated data retrospectively on the nature of all referrals from D15, D17 and D27 ward over a 3-month period. The patient referral portal was used, and referral content of each patient was analysed. An audit tool was devised to assess whether the referrals followed the liaison referral pathway and guidelines set by NHS England for referral structure to liaison services.Results18 patients were referred to the Liaison psychiatry from the three wards over the three-month period. We observed 77.8% (n = 14) of the referrals having insufficient information for the presenting complaints, whilst 22.2% (n = 4) of them did not state past psychiatric history. Approximately 94.4%(n = 17) did not state sufficient details of MSE. In 83.3% (n = 15) of referrals appropriate detailed risk assessment was not done, 27.8% (n = 5) of them did not have alcohol/ drug use stated and 22.2% (n = 4) of patients referred did not consent to the referral being made.ConclusionThe results demonstrated that ward referrals lack quality and contain inadequate information to allow for safe screening of patients and for the implementation of appropriate actions by the liaison team. A possible reason for inappropriate referrals may be due an existing knowledge gap and lack of confidence taking detailed psychiatric histories, assessing risk, and performing MSE in non-psychiatric trainees making referrals to liaison services.

Psychiatric liaison service referral patterns during the UK COVID-19 pandemic: An observational study

Background and objectivesCOVID-19 has had a profound effect on mental health. Liaison psychiatry teams assess and treat people in mental health crises in emergency departments (EDs) and on hospital wards. During the first pandemic wave, new Mental Health Crisis Assessment Services (MHCAS) were created to divert people away from EDs. Our objective was to describe patterns in referrals to psychiatric liaison services across the North Central London care sector (NCL) and explore the impact of a new MHCAS. MethodsRetrospective study using routinely collected data (ED and ward referrals) from five liaison psychiatry services across NCL (total population 1.5 million people). We described referrals (per week and month) by individual liaison services and cross-sector, and patterns of activity (January 1st 2020 -September 31st 2020, weeks 1–39) compared with the same period in 2019. We calculated changes in the proportion of ED attendees (all-cause) referred to liaison psychiatry. ResultsFrom 2019–2020, total referrals decreased by 16.5% (12,265 to 10,247), a 16.4% decrease in ED referrals (9528 to 7965) and 16.6% decrease in ward referrals (2737 to 2282). There was a marked decrease in referrals during the first pandemic wave (March/April 2020), which increased after lockdown ended. The proportion of ED attendees referred to liaison psychiatry services increased compared to 2019. ConclusionsPeople in mental health crisis continued to seek help via ED/MHCAS and a higher proportion of people attending ED were referred to liaison psychiatry services just after the first pandemic wave. MHCAS absorbed some sector ED activity during the pandemic.

Integrating suitability for teaching into an electronic health record - A novel and versatile tool for medical education.

This article was migrated. The article was marked as recommended. The educational literature has noted the implications of electronic health records (EHR) for patient care and discussed various implications for the learner-teacher relationship but it has so far not viewed EHR as an educational tool. We wondered whether we could use EHR to facilitate undergraduate medical students' exposure to hospital in-patients with an interesting history or findings on clinical examination. As clinicians, we encounter such patients on a regular basis during ward rounds and referrals but students are often absent during these encounters, leading to a loss of learning opportunities. Our aim was therefore to harness the EHR and create an electronic "flag" that would, following consent, document suitable inpatients and thus maximise the students' exposure to patients who present learning opportunities. With help from our IT department we developed a simple add on to our existing EHR that allows any clinician to electronically highlight and document such patients during inpatient encounters. A member of the educational faculty can, whenever required, interrogate the EHR for the presence of inpatients with interesting findings on examination in the hospital and facilitate contact with our medical students. We report details of our approach, describe early experience and potential pitfalls and suggest future applications.

Integrating suitability for teaching into an electronic health record - A novel and versatile tool for medical education

This article was migrated. The article was not marked as recommended. The educational literature has noted the implications of electronic health records (EHR) for patient care and discussed various implications for the learner-teacher relationship but it has so far not viewed EHR as an educational tool. We wondered whether one could use EHR to facilitate undergraduate medical students' exposure to hospital in-patients with an interesting history or findings on clinical examination. As clinicians, we encounter such patients on a regular basis during ward rounds and referrals but students are often absent during these encounters, leading to a loss of learning opportunities. Our aim was therefore to harness the EHR and create an electronic "flag" that would, following verbal consent, document suitable inpatients and thus maximise the students' exposure to interesting findings on clinical examination. With help from our IT department we developed a simple add on to our existing EHR that allows any clinician to electronically highlight and document such patients during inpatient encounters. A member of the educational faculty can, whenever required, interrogate the EHR for the presence of inpatients with interesting findings on examination in the hospital and facilitate contact with our medical students. We report details of our approach, describe early experience and potential pitfalls and suggest future applications.

Neurologists' detection and recognition of mental disorder in a tertiary in-patient neurological unit.

A total of 129 ward referrals were identified; of these, 78 were from the regional in-patient neurological unit, which comprised 11.4% of the total of 679 admissions to that unit. Clinical implications A spectrum of neuropsychiatric conditions were recognised by neurologists, but overall rates of recognition were low. To address the problem of under-recognition, routine screening with validated assessment tools can represent a cost-effective and acceptable method to detect psychiatric disorders in an in-patient neurological setting. Declaration of Interest None.

An analysis of whether a working-age ward-based liaison psychiatry service requires the input of a liaison psychiatrist.

Aims and method This article presents a 12-month case series to determine the fraction of ward referrals of adults of working age who needed a liaison psychiatrist in a busy tertiary referral teaching hospital.Results The service received 344 referrals resulting in 1259 face-to-face contacts. Depression accounted for the most face-to-face contacts. We deemed the involvement of a liaison psychiatrist necessary in 241 (70.1%) referrals, with medication management as the most common reason.Clinical implications A substantial amount of liaison ward work involves the treatment and management of severe and complex mental health problems. Our analysis suggests that in the majority of cases the input of a liaison psychiatrist is required.

A retrospective review of the transfer of critically ill children to tertiary care in KwaZulu-Natal, South Africa

Background. Obtaining care for an acutely ill child in specialised paediatric services relies on referral from lower-level facilities. In South Africa, it is common practice for acutely ill children to be transported far distances by non-specialist teams with limited equipment, knowledge and skills. Objectives. To describe the transfer of these children and to determine whether they deteriorate from the time of referral to the time of arrival at a tertiary centre. Furthermore, we sought to identify modifiable factors that might improve outcomes during resuscitation and transfer. Methods. The study was a retrospective review of emergency referrals of children aged 1 month - 12 years to Grey’s Hospital paediatric ward or paediatric intensive care unit (PICU), from lower-level facilities in KwaZulu-Natal between January and June 2012. In conjunction with an assessment by the receiving clinician at Grey’s Hospital, Triage Early Warning Signs (TEWS) scores were obtained during telephonic referral and compared with the TEWS score on arrival in order to determine if a deterioration had occurred. Results. A total of 57 PICU referrals and 79 ward referrals were analysed. The mortality rate prior to transportation was 8.8%. Mean transfer distance was 131 km and mean transfer time 9 hours. Advanced life support teams undertook transportation in 76.7% of PICU and 25% of ward transfers and few adverse events were reported in transfer logs. However, 31.5% of PICU and 11.3% of ward referrals required immediate resuscitation on arrival. When the TEWS scoring system was applied 78.5% of PICU and 30.4% of ward referrals fell into the ‘very urgent’ and ‘emergency’ categories. Conclusion. Pretransport and in-transit care failed to stabilise children and this may reflect lack of skill of attending healthcare workers, transport delays or illness progression. Interventions to improve resuscitation and transfer are needed, and the use of retrieval teams should be investigated.

Consultant supervision of trainees seeing inpatient ward referrals – a cause for concern?

The adequate supervision of trainee doctors seeing ward referrals is critical to the quality of patient care and medical training. This survey assessed the level and nature of supervision of trainees in neurology and comparable specialities. 123 neurology specialty registrars from nine deaneries across the UK and 81 dermatology, rheumatology and infectious disease specialty registrars from the London deanery completed the survey. Only 11% of first year neurology and 21% of first year non-neurology registrars reported that the most common method of supervision when seeing ward referrals was for consultants to see ward referrals with them. The remaining first year neurology and non-neurology registrars reported being primarily supervised by discussing cases with consultant (62% and 37% respectively) or being asked to contact a consultant if help was needed (35% and 42% respectively). The lack of adequate supervision of junior trainees seeing ward referrals has significant implications for both patient safety and training.

Identification and prevalence of PTSD risk factors in ECMO patients: A single centre study

BackgroundExtracorporeal membrane oxygenation (ECMO) is one of the most invasive rescue therapies for acute heart and/or lung failure. Survivors have high rates of adverse mental health outcomes, such as post-traumatic stress symptoms (PTSS) and manifest post-traumatic stress disorder (PTSD). Yet no study to date has identified and explored PTSD risk factors in these patients. ObjectivesThe primary aim of this study was to determine and explore post-traumatic stress risk factors for patients treated with ECMO. It also aimed to provide a baseline profile for future hypothesis testing with respect to risk factor exposure, level of exposure and post-traumatic stress outcomes in these patients. Methods designRetrospective cohort study. SettingThe study was conducted at the Alfred Hospital Melbourne, Australia. ParticipantsPatients were selected in 2012 from an Intensive Care Unit (ICU) registry that prospectively included all patients admitted to ICU and treated with ECMO. Data extraction and analysisData were extracted from the ICU ECMO registry, ICU and ward charts, progress notes, referrals, drug charts and discharge letters. Data were descriptively analysed. ResultsPatients treated with ECMO are exposed to almost all investigated PTSD risk factors. These included psychiatric history (psychiatric comorbidities), admission to ICU and treatment (prolonged ventilation during prolonged ICU stay), and drug therapy (all patients treated with PTSD risk related drugs). ConclusionECMO patients are exposed to PTSD risk factors such as young age, mechanical ventilation, drug administration, delirium and agitation. Younger age, heterogeneous conditions, profound illness severity and prolonged ICU stay describe the case complexity of patients and may explain these findings. Patients in ICU are increasingly conscious during active treatment and this may have positive or negative psychological effects. “Awake” ECMO in which patients are conscious while on active life support may represent a unique PTSD risk factor in this perspective.

ARE NEUROLOGY TRAINEES ADEQUATELY SUPERVISED WHEN SEEING IN–PATIENT WARD REFERRALS?

ObjectivesTo investigate–1. How neurology speciality registrars are supervised when seeing in–patient ward referrals.2. To see if supervision differs in different regions within Great Britain.3. To compare the supervision of neurology...

VALIDATING THE GLASGOW-BLATCHFORD UPPER GI BLEEDING SCORING SYSTEM

IntroductionThe Glasgow Blatchford score is a risk scoring tool used to predict the need to treat patients presenting with upper gastrointestinal bleeding. NICE guidelines suggest patients with a score of...

Are admissions for gout preventable? An audit

The number of ward referrals due to gout has increased. Gout can result in a prolonged admission. Guidelines already exist for gout treatment [1]. The aim of the audit is:- 1. To identify preventable factors in admissions/hospital flares of gout. 2. To estimate length of stay due to gout.

Impact of an Intensivist-Led Multidisciplinary Extended Rapid Response Team on Hospital-Wide Cardiopulmonary Arrests and Mortality*

The effectiveness of rapid response teams remains controversial. However, many studied rapid response teams were not intensivist-led, had limited involvement beyond the initial activations, and did not provide post-ICU follow-up. The objective of this study was to examine the impact of implementing an intensivist-led multidisciplinary extended rapid response team on hospital-wide cardiopulmonary arrests and mortality. This was a pre-post rapid response team implementation study. : Tertiary care academic center in Saudi Arabia. A total of 98,391 patients in the 2-yr pre-rapid response team and 157,804 patients in the 3-yr post-rapid response team implementation were evaluated. The rapid response team was activated by any health care provider based on pre-defined criteria and a four-member intensivist-led multidisciplinary rapid response team responded to provide the necessary management and disposition. The rapid response team function was extended to provide follow-up until clinical stabilization. In addition, the rapid response team provided a mandatory post-ICU follow-up for a minimum of 48 hrs. The primary outcomes were cardiopulmonary arrests and mortality. After rapid response team implementation, non-ICU cardiopulmonary arrests decreased from 1.4 to 0.9 per 1,000 hospital admissions (relative risk, 0.68; 95% confidence interval, 0.53-0.86; p = 0.001) and total hospital mortality decreased from 22.5 to 20.2 per 1,000 hospital admissions (relative risk, 0.90; 95% confidence interval, 0.85-0.95; p < 0.0001). For patients who required admission to the ICU, there was a significant reduction in the Acute Physiology and Chronic Health Evaluation II scores after rapid response team implementation from 29.3 ± 9.3 to 26.9 ± 8.5 (p < 0.0001), with reduction in hospital mortality from 57.4% to 48.7% (relative risk, 0.85; 95% confidence interval, 0.78-0.92; p < 0.0001). Do-not-resuscitate orders for ward referrals increased from 0.7 to 1.7 per 1,000 hospital admissions (relative risk, 2.58; 95% confidence interval, 1.95-3.42; p < 0.0001) and decreased for patients admitted to ICU from the wards from 30.5% to 26.1% (relative risk, 0.86; 95% confidence interval, 0.74-0.99; p = 0.03). Additionally, ICU readmission rate decreased from 18.6 to 14.3 per 100 ICU alive discharges (relative risk, 0.77; 95% confidence interval, 0.66-0.89; p < 0.0001) and post-ICU hospital mortality from 18.2% to 14.8% (relative risk, 0.85; 95% confidence interval, 0.72-0.99; p = 0.04). The implementation of rapid response team was effective in reducing cardiopulmonary arrests and total hospital mortality for ward patients, improving the outcomes of patients who needed ICU admission and reduced readmissions and mortality of patients who were discharged from the ICU.

PTU-268 The impact of EWTD on gastroenterology training and the inpatient GI referral service at a district general hospital

IntroductionA Specialist Registrar's (SpR) weekly duties include two Consultant and one SpR ward round, two clinics, 1–2 endoscopy training lists along with on-calls for General Medicine (GIM). Ward referrals are...

PMO-025 Three-year review of local hepato-pancreatobiliary (HPB) cancer service & its impact on cancer detection in a non-tertiary centre in Mersey Region

IntroductionPatients with HPB cancer pose complex clinical problems requiring close liaison between primary, secondary & tertiary care. Reconfiguration of cancer services in the Mersey region has lead to standardisation of...

P01-266 - To assess the impact of an alcohol nurse specialist on alcohol related referrals to an irish liaison psychiatry service

IntroductionReferrals for advice regarding treatment of alcohol related disorders form a large component of the liaison psychiatry workload. This study aims to demonstrate whether the addition of an alcohol liaison nurse specialist would decrease the number of patients needed to be seen by psychiatrists.MethodsIn-patient ward referrals were examined over 2 nine month periods. The first nine month period examined all alcohol related referrals when there was no liaison alcohol nurse. In the second period, the nurse was present. Data was analysed using SPSSv15.ResultsA total of 243 referrals were examined over the 18 month period. The number of alcohol related referrals to psychiatrists dropped from 145 to 97 after the arrival of the alcohol nurse. This represented a 33% drop in the number of referrals. The alcohol nurse saw a total of 175 referrals. The psychiatrists saw a higher percentage of delirium tremens, 13.3% increased to 27.7%, p value .009. Also of note, the percentage of female referrals increased from 28.9% of all referrals to 44.3% of all referrals after the arrival of the alcohol nurse p=.027.ConclusionThe addition of an alcohol nurse specialist led to a substantial drop in the number of alcohol related referrals to psychiatrists allowing additional time to be devoted to other aspects of the liaison psychiatry workload. More patients with delirium tremens and more women are being seen since the introduction of the alcohol nurse. Medical teams have a lower threshold of referral and more hazardous and harmful drinking was identified. Earlier intervention can help decrease longer term morbidity from alcohol.

Inpatient use and usefulness of a district general hospital neurologist

The Association of British Neurologists (ABN) has suggested that neurologists “make a valuable contribution to the diagnosis and management of acute neurology through the medium of neurological ward referrals”.1 However,...

Suicide rate 22 years after parasuicide: cohort study

The rate of suicide for people who have had an episode of parasuicide is 100 times higher in the year following the episode than that of the general population.1 Providing...

Scabies management in the community.

Unidentified and undertreated cases of scabies are the source of continued spread. To evaluate management of scabies in the community. Eighty-six outpatient and ward referrals were reviewed. Fifty-six had previously applied scabicidal treatments (Group 1), whilst in 30 patients the diagnosis was made de novo (Group 2). Treatment failure was identified by a detailed questionnaire. In both groups, patients were reviewed at four to six weeks. Sixty-four per cent of Group 1 was initially correctly diagnosed. Seventy per cent of Group 1 patients had received verbal and written instruction as part of previous unsuccessful treatments. The clearance rate in the combined group treated according to protocol was 96%; 100% clearance was ultimately achieved. Inconsistency in diagnosis and treatment of patients is common. A treatment protocol should be made available to family practitioners.