Variation in Clinical Care Associated with Weekend Admission And
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BJPsych Open (2020) 6, e103, 1–6. doi: 10.1192/bjo.2020.88 Variation in clinical care associated with weekend admission and discharge in psychiatric in-patient units: retrospective case-note review Ryan Williams, Lorna Farquharson, Ellen Rhodes, Mary Dang, Natasha Lindsay, Alan Quirk, David S. Baldwin and Mike J. Crawford Background have a crisis plan in place (OR = 0.65, 95% CI 0.46–0.92) or to be – Questions have been raised regarding differences in the stan- given medication to take home (OR = 0.45, 95% CI 0.30 0.66). dards of care that patients receive when they are admitted to or They were also less likely to have been assessed using a vali- – discharged from in-patient units at weekends. dated outcome measure (OR = 0.70, 95% CI 0.50 0.97). Aims Conclusions To compare the quality of care received by patients with anxiety There is no evidence of a ‘weekend effect’ for patients admitted and depressive disorders who were admitted to or discharged to psychiatric hospital at weekends, but the quality of care from psychiatric hospital at weekends with those admitted or offered to those who were discharged at weekends was rela- discharged during the ‘working week’. tively poor, highlighting the need for improvement in this area. Method Keywords Retrospective case-note review of 3795 admissions to in-patient Depressive disorders; in-patient treatment; anxiety disorders; psychiatric wards in England. Quality of care received by people quality of care; weekend. with depressive or anxiety disorders was compared using mul- tivariable regression analyses. Copyright and usage Results © The Author(s), 2020. Published by Cambridge University Press In total, 795 (20.9%) patients were admitted at weekends and 157 on behalf of the Royal College of Psychiatrists. This is an Open (4.8%) were discharged at weekends. There were minimal dif- Access article, distributed under the terms of the Creative ferences in quality of care between those admitted at weekends Commons Attribution licence (http://creativecommons.org/ and those admitted during the week. Patients discharged at licenses/by/4.0/), which permits unrestricted re-use, distribu- weekends were less likely to be given sufficient notification (48 h) tion, and reproduction in any medium, provided the original work in advance of being discharged (OR = 0.55, 95% CI 0.39–0.78), to is properly cited. Concerns have been raised that the quality of in-patient care that to using this measure to evaluate quality of care.15 Another study people receive may vary according to the day of the week.1 reported shorter lengths of stay among those admitted at week- Clinical outcomes may be worse among patients who are admitted ends,16 but this was conducted within a single organisation; the – to2 7 and discharged from8 acute hospitals at the weekend com- impact of weekend admission and discharge across a range of ser- pared with those admitted and discharged during the ‘working vices has not been explored. week’. We therefore aimed to investigate whether weekend admission Reasons for this ‘weekend effect’ are unclear. Although it has or discharge from psychiatric hospital was associated with worse been suggested that increased mortality may be the result of lower clinical care for a specific patient cohort (those diagnosed with staffing levels or poorer access to pathology, radiology and other depressive illness, anxiety or stress-related disorders), using services, others have noted that the ‘threshold’ for hospital admis- primary outcome measures based on National Institute for Health – sion may be higher at weekends and argued that poorer outcomes and Care Excellence (NICE) guidance for in-patient services17 19 among those admitted over the weekend may be because their and the Royal College of Psychiatrists’ Standards for Inpatient health problems are more severe.9 However, a recent meta-analysis Mental Health Services.20 found evidence of a weekend effect even after accounting for sever- ity of disease.10 Studies to date have largely examined general hospitals provid- Method ing acute medical, surgical and obstetric care: little research has been carried out in psychiatric hospitals, where there are over 100 000 in- Setting and participants patient admissions per year in England alone.11 The lack of research Data were obtained from the National Clinical Audit of Anxiety and in this area is concerning, particularly as the periods immediately Depression (NCAAD) carried out by the Royal College of following admission and discharge have been identified as high- Psychiatrists (RCPsych) in England in 2017–2018. The method- risk windows for adverse incidents in psychiatric in-patient ology for the audit has already been published and is available units.12,13 online.21 All in-patient mental health facilities in England that One of the few studies in mental health services investigated receive funding from the National Health Service (NHS) and mortality due to suicide, and found a ‘reverse’ weekend effect, provide services to adults diagnosed with anxiety and/or depressive whereby in-patients who died by suicide during an admission disorders (54 trusts in total) were asked to take part. Restricting the were less likely to have been admitted at the weekend.14 However, sample to people with anxiety and depressive disorders reduced the suicide during admission is a rare event and there are limitations impact of a potential confounder, that individuals admitted or 1 Downloaded from https://www.cambridge.org/core. 30 Sep 2021 at 19:14:50, subject to the Cambridge Core terms of use. Williams et al discharged on weekends and on weekdays may have different clin- Exposure, outcome measures and covariates ical characteristics. ‘Weekend admission’ was defined as being admitted to hospital All services that took part in the audit were asked to supply an between 00:00 h and 23:59 h on a Saturday, Sunday or UK public anonymous register of eligible patients who had been admitted to holiday. ‘Weekend discharge’ was defined as the end of a hospital hospital during a sampling period from 1 April 2017 to 30 admission taking place within that same time frame. The primary September 2017. If a patient had been admitted more than once outcome measures were 23 items on quality of clinical care, based – during this sampling period, only the first admission was examined on NICE national guidelines17 19,22 and Standards for Inpatient for the audit. Mental Health Services as defined by the RCPsych’s College Patients were considered eligible for inclusion if they fulfilled Centre for Quality Improvement.20 ≥ the following criteria: age 16 years; and a recorded primary diag- These were: nosis of either an anxiety or a depressive disorder (as per ICD-10) at the point of discharge. (1) Did the (initial) assessment include details about the patient’s Patients were excluded if they had been given a primary diagno- past response to treatment? sis of bipolar affective disorder, cyclothymia, mania or any psychotic (2) Did the (initial) assessment consider whether the patient had disorder during the admission. Those who were subsequently a history of trauma? admitted to forensic or long-stay (e.g. rehabilitation) wards were (3) Was there a documented current BMI? also excluded. (4) Was there a documented current smoking status? If a service’s register included >100 eligible cases, the RCPsych (5) Was the identified family member, friend or carer provided audit team selected 100 of these at random for inclusion in the audit. with information about available support services and/or a support plan? (where an appropriate family member, friend or carer had been identified) Data collection (6) Was the identified family member, friend or carer offered a All organisations that had been invited to participate (representing carer’s assessment? (where an appropriate family member, services provided by 54 NHS trusts) submitted data for the audit. friend or carer had been identified) Staff from the audit department of each organisation were asked (7) Did the patient have a care plan? to review the case notes for each of their eligible patients and com- (8) Is there evidence that the care plan was jointly developed plete an online data collection tool, using data from clinical records between the patient and clinician? only. For each organisation, five of the sampled cases were selected (9) Was the patient given a copy of their care plan? at random for dual auditing (the tool was completed twice inde- (10) Was the patient referred to psychological therapy? pendently by separate auditors). For these cases, the two corre- (11) Was the patient given at least 24 h notice of discharge? sponding sets of results were then specifically examined by the (12) Was the identified family member, friend or carer given at RCPsych team to determine interrater reliability. Levels of interrater least 24 h notice of discharge? (where an appropriate family agreement were generally high, with 30% of items having complete member, friend or carer had been identified) agreement, 39% having substantial agreement and 31% having (13) Was the patient being prescribed psychotropic medication at moderate to low agreement. In addition, three organisations were the point of discharge? randomly selected for a quality assurance process that involved (14) Was the patient given verbal and/or written information the RCPsych team visiting, auditing a random selection of cases dir- about their medication prior to discharge? ectly and comparing these with the data that had been submitted – (15)