De-institutionalisation, the advent of community care and development of psychotropic medicines are implicated in the reduction in hospital bed numbers and mean length of stay. There remains a huge variance in length of stay and outcomes across the UK and beyond (NHS Confederation, 2011).

Figures on length of stay and service configuration are difficult to obtain, but it’s often thought that short term admissions lead to improved outcomes and are better for individuals than long-term institutionalisation. However, shorter admissions are implicated in the perception that wards are now more acute (Baker et al, 2007), and there is a revolving door of patients discharged too quickly, leading to rising numbers of people detained in hospital (CQC, 2014)

The reviewers of a newly updated Cochrane review aimed to establish if there was evidence to support short/brief admissions versus longer or routine care.

Methods

A systematic literature review was conducted via the Cochrane group of MEDLINE, EMBASE, CINAHL & PsychINFO. Data was extracted and relative risks and 95% confidence intervals were calculated. Quality of evidence assessed by GRADE, and data imported to GRADEPRO.

Results

This was an update on the previous 2007 & 2010 reviews.

Six RCTs from between 1969 & 1980 were identified and included. Although analysis was often based on data from single studies.

There were no significant differences in:

• Death (RR 0.42, CI 0.1 to 1.83)
• Improvement in mental state (RR 3.39, CI 0.76 to 15.02)
• Readmission rates (RR 0.77, CI 0.34 to 1.77)

There was a significant difference in favour of:

• Short stay admissions and reduced delayed discharge (RR 0.54, CI 0.33 to 0.88)
• Improvement in general (social) functioning (RR 0.61, CI 0.5 to 0.76)

Author’s conclusions

We found limited low and very low quality data which were all over 30 years old. Outcomes …suggest that a planned short-stay policy does not encourage a ‘revolving door’ pattern of admission and disjointed care for people with serious mental illness.

Discussion

The latest study identified by the revised search was published in 1980 and all evidence was very low quality.  Yet, the plain language summary of this Cochrane review states that:

…people with mental illness coming into hospital … a short stay (of less than 28 days) means they are no more likely to be readmitted, to leave hospital abruptly, or to lose contact with services after leaving hospital than if they received long-stay care.

Since 1980 there have been considerable changes in inpatient mental health services, particularly in acute mental health wards and the re-introduction of rehabilitation wards in both the UK and USA. There is also 30 years of evidence which suggests negative experiences of being admitted to inpatient care which does not seem to have been considered in this review. Compared to other service provision in mental health the research into the effectiveness of acute, long-stay (rehabilitation) or psychiatric intensive care units is poor.

Studies of this kind are difficult to undertake and obtain funding for, there is a lack of consensus about service provision, and vast international differences in hospital and community care. Clearly, considerably more research is needed into inpatient care, as it is a costly component of mental health.

Links

Babalola O, Gormez V, Alwan NA, Johnstone P, Sampson S. Length of hospitalisation for people with severe mental illness. Cochrane Database of Systematic Reviews 2014, Issue 1. Art. No.: CD000384. DOI: 10.1002/14651858.CD000384.pub3.

Baker JA, Munro SL. (2007). Factors influencing acuity within inpatient mental health care. Journal of Psychiatric Intensive Care, 2 (2), 90-96. [Abstract]

Efficiency in mental health services: Supporting improvements in the acute care pathway (PDF). NHS Confederation briefing 214, Feb 2011.

Monitoring the Mental Health Act in 2012/13 (PDF). Care Quality Commission, Jan 2014.