Aims and method A retrospective evaluation was undertaken of the clinical and economic effectiveness of three in-patient rehabilitation units across one London National Health Service trust. Information on admission days and costs 2 years before and 2 years after the rehabilitation placement, length of rehabilitation placement and the discharge pathway was collected on 22 service users.Results There were statistically significant reductions in hospital admission days in the 2 years following rehabilitation compared with the 2 years before, further reflected in significantly lower bed costs. Longer length of rehabilitation placement was correlated with fewer admission days after the placement. A substantial proportion of the sample went into more independent living, some with no further admissions at follow-up.Clinical implications The findings suggest that in-patient rehabilitation is both clinically and cost effective: if benefits are sustained they will offset the cost of the rehabilitation placement.
Mr R was a 45-year-old man who had been diagnosed with hepatitis C, genotype 3a. He was commenced on a 16-week course of pegylated interferon-α2a 180 μg per week and ribavirin 400 mg twice daily. He was otherwise healthy and had recently completed the Boston marathon. During treatment the only complaints Mr R made were of sleep disturbance and weight loss as a result of reduced appetite which are recognized side effects of the treatment. Six days after completion of his treatment Mr R was picked up in the street by the police following several complaints from members of public. He was seen trying to damage parked cars and shouting repeatedly that he was God. He was agitated and had to be handcuffed by the police who escorted him to hospital. A physical examination was unremarkable except for a raised pulse rate of 120 beats per minute. There was no significant abnormality in his blood test results. He was placed on Section 2 of the Mental Health Act for assessment of a suspected mental illness. Mr R had neither a past psychiatric history nor any past family psychiatric history. On admission to the psychiatric ward he believed that he was being followed on CCTV and made sexually inappropriate comments to staff. As he continued to be highly agitated olanzapine 10 mg intramuscularly was administered. Over the next day Mr R remained elated in mood and irritable with paranoid thoughts. Mr R did not require further emergency intramuscular medications as he gradually became calmer and more cooperative. Three days after admission his mental state and behaviour began to show significant improvement. He had wished not to take oral olanzapine that was prescribed and hence no psychotropic medications were used following the initial olanzapine dose on admission. Mr R said that he had no recollection of being brought in by the police or his psychotic behaviour. He and his family denied that alcohol or illicit drugs had been used. He did recall that his sleep had been very poor, a common feature in mania, in the days before his admission. A computed tomography scan of his head was normal. Seven days after admission he was visited by his family and allowed leave off the ward as there were no remaining psychotic or manic symptoms. He was later discharged from the ward after uneventful leave at home and remained well 6 months on.
Aims and MethodWe hypothesised that the proportion of people referred to two outer London mental healthcare services for older people with cognitive impairment increased after the 2001 National Institute for Health and Clinical Excellence (NICE) guidelines for acetylcholinesterase (AChE) inhibitor use in Alzheimer's disease, but declined after the amended 2006 guidelines. We reviewed case notes for 546 individuals referred between 1999 and 2007.ResultsThe proportion of individuals with cognitive impairment referred increased between 1999 (56.1%) and 2005 (70.5%, χ2=5.4, P=0.02), as did the proportion prescribed AChE inhibitor (0.8% to 16.1%, χ2=27.5, P<0.001). There were no significant changes between 2005 and 2007.Clinical ImplicationsThe 2006 NICE amendment may have curbed the increase in psychiatric referrals and AChE inhibitor prescribing rates for people with cognitive impairment but so far these rates have not decreased.
Deliberate self-harm is one of the most frequent reasons for general hospital admission. It is estimated that about 150 000 cases present to accident and emergency departments in the UK annually (Hawton and Fagg, 1992; Hawton et al, 1998). Most cases are associated with a psychiatric disorder. A large proportion of cases involve an overdose of commonly available drugs such as aspirin, paracetamol, antidepressants and minor tranquillizers, often in conjunction with alcohol (Hawton et al, 2004). Selfharm is a high risk factor for future suicide. Individuals who have deliberately harmed themselves have a 100-fold greater risk of suicide than the general population (Hawton and Fagg, 1992). Hence it is essential that assessments are thorough and management is planned appropriately.
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