Improving the care of mentally ill patients in a tertiary emergency department: development of a psychiatric assessment and planning unit.

OBJECTIVE: The aim was to describe the Psychiatric Assessment and Planning Unit (PAPU), established at the Royal Melbourne Hospital (RMH) to improve access to psychiatric care for patients presenting via the Emergency Department (ED). METHOD: PAPU was opened in January 2007. Data was recorded from RMH ED databases to compare ED lengths of stay (LOS) prior to and after establishing PAPU. Interventions including requirement for one-to-one nursing (i.e. one nurse dedicated to the care and observation of one patient) and mechanical restraint and unarmed security threats are routinely documented and were compared before and after PAPU opened. Demographic data and inpatient LOS information was collected by clinicians in PAPU. RESULTS: During the 12 months of initial evaluation we found that PAPU assisted with reducing the number of patients waiting excessive LOS in the RMH ED essentially to zero, due to both expedient transfers from ED and increased direct admissions from the community. We were also able to demonstrate a reduction in mechanical restraint, security codes for unarmed threats and one-to-one nursing in the ED. CONCLUSIONS: The establishment of the PAPU at RMH has resulted in significant improvement in the care of patients with mental illness in the least restrictive environment, based on decreased LOS and need for interventions.

Outcome of index upper gastrointestinal endoscopy in patients presenting with dysphagia in a tertiary care hospital-A 10 years review.

BACKGROUND: Patients with malignant tumours of the upper gastrointestinal tract tumours exhibit important alarm symptoms such as dysphagia that warrant clinical investigations. An endoscopic examination of the upper gastrointestinal tract will be required in most cases. This study evaluates the diagnostic potential of index endoscopy in a random population of patients with dysphagia. METHODS: This is a retrospective analysis of prospectively collected data over 10 years. Patients with previous endoscopic evaluation or upper gastrointestinal pathology were excluded from the study. Data was analysed to see the number and frequency of abnormal findings in upper gastrointestinal tract, and their significance in relation to the presenting symptoms. RESULTS: Total number of index endoscopies was 13, 881. 913 patients were included in the study including 465 males (age range: 17-92 years, median: 55 years) and 448 females (age range: 18-100, median: 59 years), with male to female ratio of 1.04: 1. Oesophagus was abnormal in 678 cases (74%) and biopsies were taken in 428 patients (47%). Superficial oesophagitis, Barrett's oesophagus, oesophageal cancer, and oesophageal ulcer were main histological findings. Age more than 50 years and weight loss were significant predictors of oesophageal cancer (p < 0.0001). Male gender, heartburn, epigastric pain, weight loss and vomiting were significantly related to Barrett's oesophagus. A total of 486 gastric and 56 duodenal biopsies were also taken. There were 20 cases of gastric adenocarcinoma. CONCLUSION: OGD is an effective initial investigation to assess patients with dysphagia, especially males above the age of 50 years. Patients may be started on treatment or referred for further investigations, for example, a barium meal in the absence of any anatomical abnormality.

Chronic mental illness and community treatment resistance.

OBJECTIVES: The movement from institutional to community care has been a key component of national mental health reform in Australia. In Victoria, where a model of community care has been fully implemented, a specialized forensic hospital is the sole remaining stand-alone psychiatric inpatient facility and access to long-term inpatient beds is severely limited. Clinical experience suggests that some high-needs patients are not well serviced by this structure. These patients are placing an increasing burden on a wide range of community services outside mental health. This paper aims to define more clearly this patient group, explore the limitations of their management and outline potential pathways for service development. CONCLUSIONS: A population of complex patients with chronic mental illness are not effectively contained within a 'good enough' community-based mental health system. Active debate is required regarding the community's willingness to tolerate the risks and challenges that arise from the current approach. A collaborative care model involving case-based and incentive funding in combination with community-integrated complex care units may improve the care of these patients.

Early diagnosis of early gastric cancer.

The prognosis of gastric cancer is closely related to the stage of disease at diagnosis. Early gastric cancer, whereby disease is limited to mucosa and submucosa, confers a survival rate of greater than 90% in 5 years in many centres. Gastric cancer is still a major cause of cancer mortality worldwide. In high incidence areas such as Japan, screening of asymptomatic population has been advocated. However, in Western countries, mass screening is not cost-effective. Hence, strategy has been directed to screen symptomatic individuals who are at higher risk of gastric cancer. Most patients with early gastric cancer present with symptoms indistinguishable from benign peptic ulcer disease. Screening for this group of patients improves detection rate of early gastric cancer and therefore its prognosis. Endoscopy for surveillance of premalignant lesions has been explored with this objective in mind. Serology testing for biomarkers such as pepsinogen, anti-Helicobacter pylori antibody and gastrin has been studied as an alternative to endoscopy. There is compelling evidence for the role of H. pylori in the initiation of Correa's cascade (stepwise progression from chronic active gastritis, atrophic gastritis, intestinal metaplasia, dysplasia and finally adenocarcinoma). Regression of premalignant lesions has been demonstrated with H. pylori eradication. However, it is not known whether this might effectively prevent gastric cancer in either low or high-risk population.

Development of clinical guidelines for the pharmacological management of behavioural disturbance and aggression in people with psychosis.

OBJECTIVE: To describe the process underpinning the development of clinical guidelines for the management of behavioural disturbance in psychosis. METHOD: A structured process was followed, encompassing a literature review, focus groups with key staff, and pilot testing and monitoring of the guidelines in an acute psychiatric setting. RESULTS: The process was well accepted by staff and was found useful in monitoring outcomes in a naturalistic setting. The final guidelines proved safe and effective in the acute setting. CONCLUSIONS: The incorporation of a monitoring system for interventions for the management of behavioural disturbance in acute psychiatric settings is beneficial for staff and patients alike.

Improving outcomes in gastric cancer over 20 years.

BACKGROUND: Gastric cancer has in the past proven to be a difficult disease to cure. Surgery is the most effective treatment, although the extent of lymphadenectomy undertaken is controversial. This paper examines trends in the detection and treatment of gastric cancer, the move toward targeted surgery, and their impact on survival. METHODS: From 1982 to 2001, 430 patients with gastric cancer were under the care of a single surgeon at the same institution. Copies of the operation records, discharge summaries, and histology reports were retained and subsequently reviewed. RESULTS: Thirty-six patients were excluded from the analysis. Two hundred and five patients (52%) had potentially curative surgery for adenocarcinoma and 189 had incurable disease. During the 20-year period, overall 5-year survival increased significantly, from 15% to 41% (P < 0.01). The number of curative procedures also increased significantly, from 33% to 73% (P1 < 0.001) as disease was detected earlier, and 5-year survival in these patients increased from 26% to 46%. Eighty-seven D1, 92 D2, and 26 targeted procedures were performed, with 30-day mortalities of 5%, 9%, and 5%, respectively. The 5-year survival was 47% for D1, 42% for D2, and 66% for targeted surgery. CONCLUSION: This paper demonstrates an improvement in the stage at which disease was detected and improvement in long-term survival for patients with gastric cancer. The development of targeted surgery has shown promising early results.

The configuration of mental health services to facilitate care for people with schizophrenia.

In Australia, the configuration of public mental health services varies between States and Territories, but, overall, community-based services are increasingly integrated and responsive to people with schizophrenia. Community-based services include mobile crisis teams, providing home-based acute treatment, and case-management services for ongoing treatment. Service improvements have been uneven across Australia. Some people with schizophrenia in psychiatric crisis have had difficulty accessing either home-based acute psychiatric treatment or acute psychiatric beds. Social isolation and lack of meaningful occupation continue to be a problem for people with schizophrenia. Psychosocial interventions can enhance reintegration into the community. However, the number of community-based psychosocial rehabilitation programs is still inadequate.