Evaluation of intensive community care services for young people with psychiatric emergencies: study protocol for a multi-centre parallel-group, single-blinded randomized controlled trial with an internal pilot phase.

BACKGROUND: Over 3000 young people under the age of 18 are admitted to Tier 4 Child and Adolescent Mental Health Services (CAMHS) inpatient units across the UK each year. The average length of hospital stay for young people across all psychiatric units in the UK is 120 days. Research is needed to identify the most effective and efficient ways to care for young people (YP) with psychiatric emergencies. This study aims to evaluate the clinical effectiveness and cost-effectiveness of intensive community care service (ICCS) compared to treatment as usual (TAU) for young people with psychiatric emergencies. METHODS: This is a multicentre two-arm randomized controlled trial (RCT) with an internal pilot phase. Young people aged 12 to < 18 considered for admission at participating NHS organizations across the UK will be randomized 1:1 to either TAU or ICCS. The primary outcome is the time to return to or start education, employment, or training (EET) at 6 months post-randomization. Secondary outcomes will include evaluations of mental health and overall well-being and patient satisfaction. Service use and costs and cost-effectiveness will also be explored. Intention-to-treat analysis will be adopted. The trial is expected to be completed within 42 months, with an internal pilot phase in the first 12 months to assess the recruitment feasibility. A process evaluation using visual semi-structured interviews will be conducted with 42 young people and 42 healthcare workers. DISCUSSION: This trial is the first well-powered randomized controlled trial evaluating the clinical and cost-effectiveness of ICCS compared to TAU for young people with psychiatric emergencies in Great Britain. TRIAL REGISTRATION: ISRCTN ISRCTN42999542, Registration on April 29, 2020.

Delay in the induction of labour process: a retrospective cohort study and computer simulation of maternity unit workload.

OBJECTIVES: Delay in the induction of labour (IOL) process is associated with poor patient experience and adverse perinatal outcome. Our objective was to identify factors associated with delay in the IOL process and develop interventions to reduce delay. DESIGN AND SETTINGS: We performed a retrospective cohort study of maternity unit workload in a large UK district general hospital. Electronic hospital records were used to quantify delay in the IOL process and linear regression analysis was performed to assess significant associations between delay and potential causative factors. A novel computer maternity unit simulation model, MUMSIM (Maternity Unit Management SIMulation), was developed using real-world data and interventions were tested to identify those associated with a reduction in delay. PARTICIPANTS: All women giving birth at Stoke Mandeville Hospital, Buckinghamshire National Health Service (NHS) Trust in 2018 (n=4932). PRIMARY OUTCOME MEASURE: Delay in the IOL process of more than 12 hours. RESULTS: The retrospective analysis of real-world maternity unit workload showed 30% of women had IOL and of these, 33% were delayed >12 hours with 20% delayed >24 hours, 10% delayed >48 hours and 1.3% delayed >72 hours. Delay was significantly associated with the total number of labouring women (p=0.008) and the number of booked IOL (p=0.009) but not emergency IOL, spontaneously labouring women or staffing shortfall. The MUMSIM computer simulation predicted that changing from slow release 24-hour prostaglandin to 6-hour prostaglandin for primiparous women would reduce delay by 4% (p<0.0001) and that additional staffing interventions could significantly reduce delay up to 17.9% (p<0.0001). CONCLUSIONS: Planned obstetric workload of booked IOL is associated with delay rather than the unpredictable workload of women in spontaneous labour or emergency IOL. We present a novel maternity unit computer simulation model, MUMSIM, which allows prediction of the impact of interventions to reduce delay.

ELECTIVIST: a novel system to improve elective caesarean section booking.

Elective caesarean sections (ELCS) vary widely in surgical complexity and are routinely performed between 39 and 40 weeks of pregnancy. Unselected ELCS lists may create clinical risk due to inappropriately complex case mixes and over-running theatre time, impacting on emergency care. Despite evidence that ELCS list over-run is a widespread concern for many units, there is a paucity of literature regarding effective ELCS booking systems. We designed a novel ELCS risk scoring system, ELECTIVIST, comprising a risk assessment by the booking clinician and allocation of a complexity score to each case from 1 to 6. The maximum risk score for any one patient was 6, with a maximum total score on any one ELCS list of 6 and a maximum of three cases per list. We performed a retrospective analysis of all ELCS performed in our unit in 2016 using existing booking information and theatre data to assess existing case mix complexity and theatre over-run. This showed that 36% of ELCS lists were overbooked with inappropriately complex case mix and 21% of lists over-ran with 6% impacting on emergency obstetric theatres. Assessment of the impact of ELECTIVIST on ELCS capacity prior to implementation showed that no additional capacity was required to accommodate existing complexity. At 6 months following implementation, theatre over-run was reduced to 10% and over-run impacting on emergency theatre to 1%. The requirement for extra ELCS lists to accommodate capacity reduced by 66%. ELECTIVIST is a novel system that improves ELCS booking using existing capacity and reduces theatre list over-run. It is transferable, cost neutral and could be widely applied in obstetric units.

Should junior doctors strike?

An impasse in negotiations between the Department of Health (DoH) and the British Medical Association in November this year led to an overwhelming vote for industrial action (IA) by junior doctors. At the time of writing, a last minute concession by DoH led to a deferment of IA to allow further negotiations mediated by the Advisory, Conciliation and Arbitration Service. However, IA by junior doctors remains a possibility if these negotiations stall again. Would the proposed action be ethically justifiable? Furthermore, is IA by doctors ever ethically defendable? Building on previous work, we explore important ethical considerations for doctors considering IA. The primary moral objection to doctors striking is often claimed to be risk of harm to patients. Other common arguments against IA by doctors include breaching their vocational responsibilities and possible damage to their relationship with patients and the public in general. These positions are in turn countered by claims of a greater long-term good and the legal and moral rights of employees to strike. Absolute restrictions appear to be hard to justify in the modern context, as does an unrestricted right to IA. We review these arguments, find that some common moral objections to doctors striking may be less relevant to the current situation, that a stronger contemporary objection to IA might be from a position of social justice and suggest criteria for ethically permissible doctor IA.

Paediatric bipolar disorder: international comparisons of hospital discharge rates 2000-2010.

BACKGROUND: Controversy surrounds the diagnosis and prevalence of paediatric bipolar disorder, with estimates varying considerably between countries. AIMS: To determine the international hospital discharge rates for paediatric bipolar disorder compared with all other psychiatric diagnoses. METHOD: We used national data-sets from 2000 to 2010 from England, Australia, New Zealand, the USA and Germany. RESULTS: For those aged under 20 years, the discharge rates for paediatric bipolar disorder per 100 000 population were: USA 95.6, Australia 11.7, New Zealand 6.3, Germany 1.5 and England 0.9. The most marked divergence in discharge rates was in 5- to 9-year-olds: USA 27, New Zealand 0.22, Australia 0.14, Germany 0.03 and England 0.00. CONCLUSIONS: The disparity between US and other discharge rates for paediatric bipolar disorder is markedly greater than the variation for child psychiatric discharge rates overall, and for adult rates of bipolar disorder. This suggests there may be differing diagnostic practices for paediatric bipolar disorder in the USA. DECLARATION OF INTEREST: None. COPYRIGHT AND USAGE: © 2015 The Royal College of Psychiatrists. This is an open access article distributed under the terms of the Creative Commons Non-Commercial, No Derivatives (CC BY-NC-ND) licence.

A comparison of American and English hospital discharge rates for pediatric bipolar disorder, 2000 to 2010.

OBJECTIVE: Controversy exists over the diagnosis and prevalence of pediatric bipolar disorder (PBD). Although several small surveys suggest that the rate of the PBD diagnosis in clinical settings is higher in the United States than in other countries, no comprehensive cross-national comparisons of clinical practice have been performed. Here, we used longitudinal national datasets from 2000 to 2010 to compare US and English hospital discharge rates for PBD in patients aged 1 to 19 years. METHOD: We used the English National Health Service (NHS) Hospital Episode Statistics (HES) dataset and the United States National Hospital Discharge Survey (NHDS) to compare US and English discharge rates for PBD (bipolar I disorder [BP-I], bipolar II disorder [BP-II], bipolar disorder not otherwise specified [BP-NOS], and cyclothymia). We also conducted cross-national comparisons for all other psychiatric diagnoses in youth and for adults with bipolar disorder (BD). RESULTS: There was a 72.1-fold difference in discharge rates for PBD in youth between the United States and England (United States, 100.9 per 100,000 population, 95% confidence interval = 98.1-103.8, versus England, 1.4 per 100,000 population, 95% CI = 1.4-1.5). After controlling for cross-national differences in length of stay, discharge rates for PBD remained 12.5 times higher in the United States than in England. For all other child psychiatric diagnoses, the discharge rate was 3.9-fold higher, and for adults with BD 7.2-fold higher, in the United States than in England. CONCLUSION: The disparity between US and English discharge rates for PBD is markedly greater than the disparity for child psychiatric discharge rates overall and for adult rates of BD. This suggests that the difference in discharge rates for PBD may be due to differing diagnostic practices for PBD in the United States versus in England.

Adolescent inpatient psychiatric admission rates and subsequent one-year mortality in England: 1998-2004.

BACKGROUND: Adolescence is a time of very rapid change not only in physical but also psychological development. During the teenage years there is a reported rise in the prevalence of psychiatric disorders. The aim of this study was to investigate age- and sex-specific National Health Service (NHS) hospital inpatient admission rates for psychiatric conditions in adolescents in England, and to examine their mortality within one year of discharge. METHOD: Using a record-linked NHS Hospital Episode Statistics (HES) dataset for England, and linked death certificates, age- and sex-specific admission rates and subsequent mortality rates were analysed by single year of age for people aged 10-19 years. RESULTS: There were similar numbers of admissions for males and females: 29,595 and 28,188 respectively. Admission rates increased substantially with increasing age, from .2 per 1000 population per year aged 10 years to 2.2 per 1000 aged 19 years. There was no appreciable difference in death rates for males and females in the year following discharge--males .23% (based on 68 deaths), females .18% (52 deaths). However, these death rates were significantly higher than those found in the general population of equivalent age: expressed as standardised mortality ratios (SMRs), setting the SMRs for males and females in the general population each as 100, the SMR in the psychiatric population were 518 (95% CI 402-657) for males and 937 (692-1225) for females. The diagnostic groups with the highest mortality were development disorders (SMR 3017, 95% CI 1757-4831), eating disorders (SMR 1103, 443-2272), and affective disorders (SMR 940, 589-1423). CONCLUSION: Adolescent psychiatric disorders represent a serious public health issue, with a steep rise in hospital admissions during the teenage years, and a six-fold increased death rate within one year of discharge compared to the general population of the same age.