Skip to main content Accessibility help
×
Home
Hostname: page-component-568f69f84b-klmjj Total loading time: 0.335 Render date: 2021-09-20T11:54:52.440Z Has data issue: true Feature Flags: { "shouldUseShareProductTool": true, "shouldUseHypothesis": true, "isUnsiloEnabled": true, "metricsAbstractViews": false, "figures": true, "newCiteModal": false, "newCitedByModal": true, "newEcommerce": true, "newUsageEvents": true }

Weekday and seasonal patterns in psychiatric referrals in three major London A&E departments, 2012–2014

Published online by Cambridge University Press:  30 January 2018

James Dove*
Affiliation:
Camden & Islington NHS Foundation Trust, London
Amit Mistry
Affiliation:
Barnet, Enfield & Haringey Mental Health Trust, London
Nomi Werbeloff
Affiliation:
Camden & Islington NHS Foundation Trust, London Division of Psychiatry, UCL
David Osborn
Affiliation:
Camden & Islington NHS Foundation Trust, London Division of Psychiatry, Faculty of Brain Sciences, UCL
Nora Turjanski
Affiliation:
Camden & Islington NHS Foundation Trust, London
*Corresponding
Correspondence to James Dove (james.dove@nhs.net)
Rights & Permissions[Opens in a new window]

Abstract

Aims and method

To identify temporal and demographic trends in referrals made to psychiatric liaison services. Routine clinical data from 16 105 individual referrals from three central London accident and emergency (A&E) departments to psychiatric liaison services from 2012 to 2014 were obtained and analysed using the Clinical Record Interactive Search (CRIS).

Results

Referrals from A&E to psychiatric liaison services increased 16% over the 3-year study period. There were fewer referrals to psychiatric liaison services in winter months compared with other seasons. There were fewer referrals to psychiatric liaison services over the weekend compared with weekdays (average 15.4 daily weekday referrals v. 13.2 weekend, z = 5.1, P < 0.001), and weekend referrals were slightly less likely to result in admission to psychiatric hospital (11.3% v. 12.8%, respectively, χ2 = 6.33, P = 0.01).

Clinical implications

Psychiatric staffing in A&E and inpatient psychiatric wards requires planning to meet temporal and regional variations in the pattern of demand.

Declaration of interest

None.

Type
Original Papers
Creative Commons
Creative Common License - CCCreative Common License - BY
This is an Open Access article, distributed under the terms of the Creative Commons Attribution licence (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted re-use, distribution, and reproduction in any medium, provided the original work is properly cited.
Copyright
© The Authors 2018

Accident and emergency (A&E) departments in the UK are getting busier, with an estimated 50% increase in demand over the past 10 years.Reference Aitken, Robens and Emmens 1 Approximately 5% of A&E attendances are for treatment of a mental disorder. 2 An estimated 8% of all A&E attendances are by ‘chronic repeat attenders’; the most common reason for frequent attendance is an untreated mental health problem.Reference Aitken, Robens and Emmens 1

The increased demands on A&E and the consequent impact on bed availability in acute trusts have been well studied, and a trend in peak pressures on A&E departments over the winter months has been established.Reference Fisher and Dorning 3 , 4 Although it is acknowledged that A&E attendances are generally lower in the winter months, patients are likely to be more unwell, requiring admission that can lead to longer hospital stays and long waiting times in A&E – the ‘winter pressures’.Reference Flory 5 This phenomenon has attracted injections of short-term funding of staff and resources in an attempt to encourage flow through the system – including to liaison mental health teams.

Public awareness of these pressures has led to a number of developments in recent years. These include the drive towards consultant-delivered care and, more recently, the ‘7-day National Health Service (NHS)’ proposals made by Bruce Keogh initially in 2013.Reference Freemantle, Daniel, McNulty, David, Bennett and Keogh 6 , 7 These initiatives are now supported by government policy following suggestions that, further to the pressures on NHS services, there may be a weekend effect in terms of increased morbidity and mortality. 8

A recent study by Patel et al Reference Patel, Chesney, Cullen, Tulloch, Broadbent and Stewart 9 investigated the mortality relating to psychiatric weekend admissions and found no correlation between weekend admission and increased mortality. However, the study identified that those admitted at the weekend had shorter admissions and higher readmission rates, leading to the suggestion that there is a different population who are more likely to be admitted at weekends. There is little or no work looking at the fluctuation in presentation at the gateways to psychiatric admissions – of which A&E attendance is a major source.

Anecdotally, it is said that ‘major’ mental illness, i.e. bipolar affective disorder and schizophreniform disorders, have bimodal peaks in presentation of spring and autumn;Reference Singh, Chavan, Priti and Ajeet 10 , Reference Licanin, Fisekovic and Babićo 11 it might be assumed, therefore, that these would be peak admission times for psychiatric patients.

Here, we describe a study that analyses 3 years of referral data from three central London A&E departments to their psychiatric liaison teams, looking at seasonal variation and variation in weekday/weekend referrals, as well as some limited analysis of the demographics of those patients referred.

Aims

The aim of this study is to describe referral rates from three central London A&E departments to their respective psychiatric liaison services, to explore whether patterns of referral are similar to trends reported regarding general attendance to A&E, including the weekend and ‘winter pressures’ models reported nationally. The secondary aim was to compare weekend v. weekday referral trends, and whether these referrals were more or less likely to result in admission to inpatient services. The tertiary aim was to assess those presenting frequently to A&E services (≥3 times during the study period), and determine whether these patterns were more pronounced in this group of patients.

Method

Routine clinical data for this study was obtained from Camden & Islington (C&I) NHS Foundation Trust using the Clinical Record Interactive Search (CRIS) tool. CRIS is an application developed to enable routinely collected electronic health records to be used in research, using an explicit deidentification process.Reference Fernandes, Cloete, Broadbent, Hayes, Chang and Jackson 12 C&I is a large mental health provider serving a geographic catchment area of two inner-city London boroughs, and approximately 440 000 residents. The database contains full but anonymised information from over 100 000 mental health patients.Reference Werbeloff, Markou, Hayes, Pitman and Osborn 13 Studies using CRIS received ethical approval from the National Research Ethics Service (NRES) Committee East of England – Cambridge Central (14/EE/0177).

We conducted a retrospective cohort study of all A&E referrals to psychiatric liaison services across three London teaching hospitals (Royal Free Hospital (RFH) and Whittington Hospital (WH) in North London, and University College London Hospital (UCLH) in Central London) over a 3-year period (2012–2014), deriving a complete data set of 16 105 individual psychiatric referrals. These 3 years were chosen since complete electronic record data was available for all three sites.

Data collection on the 16 105 referrals was limited to fields that are well recorded on CRIS and encompassed the following:

  • day and date of referral from A&E to psychiatric liaison service

  • demographic details of referee – age, gender, ethnicity

  • discharge destination of referral, i.e. admission or discharge

  • admission, i.e. informal or under a section of the Mental Health Act.

Data on diagnosis were not used for purposes of this study, as the majority of the patients referred to liaison teams are not allocated a recorded ICD-10 diagnosis, for instance, where no mental disorder is present after assessment.

Discharge destination of liaison referral being admission to psychiatric hospital was used as a ‘proxy of severity’ of presentation, in common with other similar studies.Reference Thinn, Kuswanto, Sum, Chai, Sok and Xu 14 Reference Unick, Kessell, Woodard, Leary, Dilley and Shumway 20

Number of presentations of individual patients during the time period was also recorded, and those presenting ≥3 times in the study period were identified as ‘frequent attenders’ and analysed as a separate cohort within the study in an attempt to identify any differences in patterns of referral for this group.

Statistical analysis

Number of referrals per year was expressed as a proportion of referrals from the total population in the C&I catchment area (426 463 according to the 2011 census). Z-tests were used to compare the proportion of referrals between the different study years, seasons and days of the week (weekday v. weekend).

Descriptive statistics of all patients referred over the study period were examined.

The chi-square test of independence (χ2) was used to compare the number of referrals across seasons and days of the week.

Multilevel logistic regressions were used to account for multiple referrals of one patient and to examine the association between patient characteristics (sex, age and ethnicity) and weekend referral.

Finally, frequent attenders were compared to non-frequent attenders using the χ2 test for categorical variables and independent samples t-test for continuous variables.

Results

In the years 2012–2014, there were a total of 16 105 referrals from A&E services to psychiatric liaison teams in the study area (RF: 4575, UCLH: 6440, WH: 5090). These referrals represent a total of 10 049 individual patients referred. The total number of referrals per patient varied from 1 to 49.

Description of cohort

The average age of patients referred was 38.8 years (SD = 15.6); 92.6% were under 65 years of age. 51.2% of the cohort were male. Ethnicity data were missing for 17% of the sample. Of those with complete data, the majority of patients were of White ethnic origin (69.5%).

Frequent attenders (≥3 referrals over study period, n = 1108) did not differ from the rest of the cohort with regard to gender and age distribution, although there was a slightly higher proportion of people of White ethnic origin.

Trend in referrals year on year

As can be seen in Table 1, there was an increase of 16% (z = 7.764 P < 0.001) in total referrals over the 3 years across the three sites (RF +36%, WH +7%, UCLH +12%).

Table 1 Total referrals to psychiatric liaison service from A&E by hospital site by year

Over the 3 years, 12.4% of referrals led to an inpatient psychiatric admission (n = 2003), 33.4% of those (n = 654) under a section of the Mental Health Act.

Seasonality of referrals

When the 16 105 referrals across the year were divided by season (defined as: winter, December to February; spring, March to May; Summer, June to August; Autumn, September to November) the only statistically significant finding was that, compared with all other seasons, the winter months saw fewer referrals (z = 4.8, P < 0.001; see Table 2 and Fig. 1). This matched with the lowest percentage overall of admissions from all seasons. Peak admissions were seen in the spring – 13.1% or 546 admissions over the 3 years – however, the percentage of referrals resulting in admission did not differ significantly by season (χ2 = 3.92, P = 0.27). Similarly, there was no statistically significant difference between the percentage of referrals resulting in admission under the Mental Health Act by season (χ2 = 0.30, P = 0.96).

Fig. 1 All referrals to psychiatric liaison services from A&E 2012–2014; comparison with subsequent admissions from those referrals, ‘informal’ and under a section of the Mental Health Act; grouped by season.

Table 2 Comparison of referrals to psychiatric liaison service from A&E and subsequent admissions, by season

Weekend referrals

Of the 16 105 referrals, there were fewer referrals to psychiatric liaison services at weekends compared with weekdays (0.48% v. 0.56% of the population; z = 5.1 P < 0.001).

Fewer weekend referrals resulted in inpatient admissions compared with weekday referrals (11.3% v. 12.8%, respectively, χ2 = 6.33, P = 0.01). Of the weekday referrals that resulted in admissions, 33.3% were under a section of the Mental Health Act. Of the weekend referrals that resulted in admissions, 30.6% were under a section. This difference is not statistically significant (χ2 = 1.20, P = 0.27).

Multilevel logistic regressions suggested that patients referred on weekends were more likely to be female, under the age of 65 and of White ethnic origin (Table 3).

Table 3 Comparison of demographic data of all referrals to psychiatric liaison services; weekend v. weekday attenders

a. Data on ethnicity missing for 1726 (17.2%) participants.

Discussion

Referrals to psychiatric liaison services between 2012 and 2014 within three central London A&E departments echoed the national figures for A&E attendances, with increased overall attendance year on year. Our results also showed a seasonal trend similar to the A&E data, with decreased absolute referrals in winter months. However, in contrast to the general hospital population, these referrals appear to be for people with a lower severity of illness in the winter months (using the proxy outcome measure of an admission to inpatient psychiatric services resulting from those referrals). Our data showed increased severity of presentations (increased admissions) occurring outside the winter months, but there was no statistically significant variation in number of patients admitted informally or under the Mental Health Act throughout the year.

Weekdays were slightly busier in terms of average numbers of psychiatric referrals and admissions than weekends, in terms of both numbers of referrals and numbers of admissions to psychiatric inpatient beds (11.3% v. 12.8%, respectively, χ2 = 6.33, P = 0.01).

There is only limited evidence from this data set to support the concept of a defined seasonal variation in psychiatric presentation; despite the academic position that ‘major’ mental illness – bipolar affective disorder and schizophreniform disorders – have bimodal peaks in presentation of spring and autumn.Reference Aitken, Robens and Emmens 1 This phenomenon might, however, be able to explain the trend seen in our data of a shift in severity of illness when comparing the psychiatric population with the general acute hospital intake, with a peak of admission rates from winter to spring; however, there were no reliable data in this study on diagnosis.

This study demonstrates an increased presentation of mental health problems to A&E, and increased severity of those presentations, during the week rather than at the weekend.

Key points and implications for A&E and psychiatric liaison services from this study are as follows.

  • There was a significant increase in number of referrals from A&E to psychiatric liaison services year on year.

  • Winter was significantly different from the three other seasons (with lower referrals).

  • There were significantly fewer referrals per day (on average) on weekend v. weekdays, but the absolute difference was only 1–2%.

Limitations

We looked at referrals to mental health liaison services, rather than totals for A&E mental health presentations. It is anticipated that a far higher proportion of patients with a primary psychiatric reason for presentation are managed by A&E staff and discharged without referral to mental health liaison services. It could be argued, therefore, that referral itself could be used as a proxy for severity of presentation.

This study looks at only one route of psychiatric presentation – through A&E – and does not include other routes of presentation, i.e. crisis teams, general practitioner, etc., and it is therefore not a comprehensive picture of fluctuation in need throughout the year.

Diagnosis was not reliably recorded in the data set and therefore not included in this study – a major limitation in discussion around seasonal variations in psychiatric illness presentation.

We have no data on timings of referrals and we are therefore unable to comment on ‘out of hours’ attendance other than weekday/weekend comparisons.

It is highly likely that there is a variety in threshold for referral between sites and at different times of year. For example, higher absolute summer referrals could possibly be accounted for by an influx of new doctors with lower thresholds for referral, resulting in an increase in summer referral rates but lower severity of presentation; however, we have used statistical tests in the data set in an attempt to mitigate the impact of these variables.

Use of psychiatric admission as a proxy for severity is not without its limitations: decisions to admit, particularly informally, may well be linked to bed pressures, abilities of home treatment teams locally, etc. The admissions under a section of the Mental Health Act should be less susceptible to these variables.

Although there are differences in the populations that the three hospitals serve, they are of similar size and location with equally diverse local populations, allowing for a good generalisability of the data. The e-record (RiO) is the only records system used by the psychiatric teams at all three sites and as such is a reliable representation of all patients seen.

About the authors

James Dove is an ST5 Psychiatric Trainee at Camden & Islington NHS Foundation Trust, London, UK. Amit Mistry is an ST5 Psychiatric Trainee at Barnet Enfield & Harringey Mental Health Trust, London, UK. Nomi Werbeloff is a PhD Research Associate at UCL, and Camden & Islington NHS Foundation Trust. David Osborn is a Professor of Psychiatric Epidemiology at Division of Psychiatry, Faculty of Brain Sciences, UCL and a Consultant Psychiatrist at Camden & Islington NHS Foundation Trust. Nora Turjanski is a Consultant Liaison Psychiatrist at Camden & Islington NHS Foundation Trust.

References

1 Aitken, P, Robens, S, Emmens, T (eds). Developing Models for Liaison Psychiatry Services – Guidance. Strategic Clinical Network for Mental Health, Dementia and Neurological Conditions South West. Devon Partnership NHS Trust, 2014 (http://mentalhealthpartnerships.com/resource/developing-models-for-liaison-psychiatry-services).Google Scholar
2 Joint Commissioning Panel for Mental Health. Guidance for Commissioners of Liaison Mental Health Services to Acute Hospitals. Volume Two: Practical Mental Health Commissioning. Royal College of Psychiatrists’ Joint Commissioning Panel for Mental Health, 2012 (http://www.jcpmh.info/good-services/liaison-mental-health-services/, accessed 14th December 2016).Google Scholar
3 Fisher, E, Dorning, H. Winter Pressures: What's Going on Behind the Scenes? Nuffield Trust and Health Foundation, 2016 (http://www.qualitywatch.org.uk/node/760, accessed 14th December 2016).Google Scholar
5 Flory, D. Winter Pressures (letter). Department of Health, 2011 (https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/215813/dh_123683.pdf, accessed 14th December 2016).Google Scholar
6 Freemantle, N, Daniel, R, McNulty, D, David, R, Bennett, S, Keogh, BE, et al. Increased mortality associated with weekend hospital admission: a case for expanded seven day services? BMJ 2015; 351: h4596.CrossRefGoogle ScholarPubMed
7 NHS England. NHS Services, Seven Days a Week Forum: Summary of Initial Findings. 2013. (http://www.england.nhs.uk/wp-content/uploads/2013/12/brd-dec-13.pdf, accessed 14th December 2016).Google Scholar
8 The Rt Hon Jeremy Hunt MP. Oral statement to Parliament NHS 7 day services and the junior doctors’ strike. Department of Health, 2016 (https://www.gov.uk/government/speeches/nhs-7-day-services-and-the-junior-doctors-strike, accessed 14th December 2016).Google Scholar
9 Patel, P, Chesney, E, Cullen, AE, Tulloch, AD, Broadbent, M, Stewart, R, et al. Clinical outcomes and mortality associated with weekend admission to psychiatric hospital. Br J Psychiatry 2016; 209(1): 2934.CrossRefGoogle ScholarPubMed
10 Singh, GP, Chavan, BS, Priti, A, Ajeet, S. Seasonal pattern of psychiatry service utilization in a tertiary care hospital. Indian J Psychiatry 2007; 49(2): 9195.CrossRefGoogle Scholar
11 Licanin, I, Fisekovic, S, Babićo, S. Admission rate of patients with most common psychiatric disorders in relation to seasons and climatic factors during 2010/2011. Mater Sociomed 2012; 24(2): 9499.CrossRefGoogle ScholarPubMed
12 Fernandes, AC, Cloete, D, Broadbent, MT, Hayes, RD, Chang, CK, Jackson, RG, et al. Development and evaluation of a de-identification procedure for a case register sourced from mental health electronic records. BMC Med Inform Decis Mak 2013; 13: 71.CrossRefGoogle ScholarPubMed
13 Werbeloff, N, Markou, M, Hayes, JF, Pitman, AL, Osborn, DP. Individual and area-level risk factors for suicidal ideation and attempt in people with severe depression. J Affect Disord 2016; 205: 387392.CrossRefGoogle ScholarPubMed
14 Thinn, DSS, Kuswanto, CN, Sum, MY, Chai, SB, Sok, HKD, Xu, C, et al. The 23-hour observation unit admissions within the emergency service at a national tertiary psychiatric hospital: clarifying clinical profiles, outcomes, and predictors of subsequent hospitalization. Prim Care Companion CNS Disord 2015; 17(4): doi:10.4088/PCC.15m01789.Google Scholar
15 Goldberg, JF, Ernst, CL, Bird, S. Predicting hospitalization versus discharge of suicidal patients presenting to a psychiatric emergency service. Psychiatr Serv 2007; 58(4): 561565.CrossRefGoogle ScholarPubMed
16 Lyons, JS, Stutesman, J, Neme, J, Vessey, JT, O'Mahoney, MT, Camper, HJ. Predicting psychiatric emergency admissions and hospital outcome. Med Care 1997; 35(8): 792800.CrossRefGoogle ScholarPubMed
17 Way, BB, Banks, S. Clinical factors related to admission and release decisions in psychiatric emergency services. Psychiatr Serv 2001; 52(2): 214218.CrossRefGoogle ScholarPubMed
18 Kunen, S, Prejean, C, Gladney, B, Harper, D, Mandry, CV. Disposition of emergency department patients with psychiatric comorbidity: results from the 2004 National Hospital Ambulatory Medical Care Survey. Emerg Med J 2006; 23(4): 274275.CrossRefGoogle ScholarPubMed
19 Rabinowitz, J, Massad, A, Fennig, S. Factors influencing disposition decisions for patients seen in a psychiatric emergency service. Psychiatr Serv 1995; 46(7): 712718.Google Scholar
20 Unick, GJ, Kessell, E, Woodard, EK, Leary, M, Dilley, JW, Shumway, M. Factors affecting psychiatric inpatient hospitalization from a psychiatric emergency service. Gen Hosp Psychiatry 2011; 33(6): 618625.CrossRefGoogle ScholarPubMed
Figure 0

Table 1 Total referrals to psychiatric liaison service from A&E by hospital site by year

Figure 1

Fig. 1 All referrals to psychiatric liaison services from A&E 2012–2014; comparison with subsequent admissions from those referrals, ‘informal’ and under a section of the Mental Health Act; grouped by season.

Figure 2

Table 2 Comparison of referrals to psychiatric liaison service from A&E and subsequent admissions, by season

Figure 3

Table 3 Comparison of demographic data of all referrals to psychiatric liaison services; weekend v. weekday attenders

Submit a response

eLetters

No eLetters have been published for this article.
You have Access
Open access
3
Cited by

Send article to Kindle

To send this article to your Kindle, first ensure no-reply@cambridge.org is added to your Approved Personal Document E-mail List under your Personal Document Settings on the Manage Your Content and Devices page of your Amazon account. Then enter the ‘name’ part of your Kindle email address below. Find out more about sending to your Kindle. Find out more about sending to your Kindle.

Note you can select to send to either the @free.kindle.com or @kindle.com variations. ‘@free.kindle.com’ emails are free but can only be sent to your device when it is connected to wi-fi. ‘@kindle.com’ emails can be delivered even when you are not connected to wi-fi, but note that service fees apply.

Find out more about the Kindle Personal Document Service.

Weekday and seasonal patterns in psychiatric referrals in three major London A&E departments, 2012–2014
Available formats
×

Send article to Dropbox

To send this article to your Dropbox account, please select one or more formats and confirm that you agree to abide by our usage policies. If this is the first time you use this feature, you will be asked to authorise Cambridge Core to connect with your <service> account. Find out more about sending content to Dropbox.

Weekday and seasonal patterns in psychiatric referrals in three major London A&E departments, 2012–2014
Available formats
×

Send article to Google Drive

To send this article to your Google Drive account, please select one or more formats and confirm that you agree to abide by our usage policies. If this is the first time you use this feature, you will be asked to authorise Cambridge Core to connect with your <service> account. Find out more about sending content to Google Drive.

Weekday and seasonal patterns in psychiatric referrals in three major London A&E departments, 2012–2014
Available formats
×
×

Reply to: Submit a response

Please enter your response.

Your details

Please enter a valid email address.

Conflicting interests

Do you have any conflicting interests? *