Psychiatric Quarterly

, Volume 89, Issue 1, pp 11–32 | Cite as

Frequent visitors at the psychiatric emergency room – A literature review

Open Access
Review Article

Abstract

Frequent visitors at the psychiatric emergency room (PER) constitute a small subgroup of patients, yet they are responsible for a disproportionate number of visits and thus claim considerable resources. Their needs are often left unmet and their repetitive visits reflect their dissatisfaction as well as that of PERs' staff. Motivated by these dilemmas, this study systematically reviews the literature about frequent visitors at PER and seeks to answer two questions: What characterizes frequent visitors at PER in the literature? and What characterizes PER in the literature? Based on 29 studies, this paper offers answers to the two questions based on a strength weakness opportunities and threats (SWOT) analysis. The results of the review and subsequent analysis of the literature revealed the multiplicity and complexity of frequent visitors' characteristics and how they appear to converge. Commonalities were more difficult to identify in PER characteristics. In some cases, this happened because the characteristics were poorly described or were context specific. As a result, it was not easy to compare the studies on PER. Based on SWOT and the findings of the analysis, the paper proposes new venues of research and suggests how the field of mental health might develop by taking into account its opportunities and threats.

Keywords

Frequent visitor Psychiatric emergency Review SWOT 

Introduction

Psychiatric emergency rooms (PER) have been changing as rapidly as the entire mental health care system. A strong impact on the change and development of PER had the initiation of the deinstitutionalization [1, 2] that started in the 1960s on a global scale. This soon resulted in fewer inpatient beds and outpatient services, more admissions, shorter stays, service gaps, as well as inadequate housing and community support services for those suffering from mental health problems; thus contributing to a growing number of mental health patients and a greater need for PER. In addition, an increase in substance abuse in general [3, 4], as well as the increasing occurrence of community social problems and decreasing tolerance for them [1] were additional reasons of the rapid evolution of PER. As an ultimate consequence of growing need and simultaneous cutbacks, PER have become an important gate keeper for providing care by use of triage [5]. PER are characterized by ongoing, chronic crisis management [2] while at the same time also attempting to provide specialized, high quality frontline care for patients when resources that are already scarce have to cover an increasing number of new and returning patients. For many who lack access to other sources of care or resources, PER have turned into safety nets [6, 7].

The social and economic burden of mental ill health is vast and continues to grow. Thus, in regard to PER, it becomes apparent that the growing discrepancy between patients’ needs and emergency resources [8, 9] contributes to both patients’ and staff members’ dissatisfaction which also could be a result of the lack of consensus concerning PER’s goals and resource allocation [9].

One could assume that persons visiting PER are a homogenous group or in Bachrachs words “faceless representations of a homogeneous group” [10] consisting of mainly those struggling with problems related to substance abuse or those who have been diagnosed with severe mental illnesses such as schizophrenia. However, visitors to PER are a very heterogeneous group of individuals with a wide spectrum of mental health issues [e.g. 11, 12, 13]: problems in living, social problems, and problems related to societal matters that are influenced by current events such as a terror attacks, wars or an influx of refugees. One distinct subgroup of patients in PER are frequent visitors [e.g. 3]. Even though they are a relatively small group, they account for a disproportionate high number of visits and thus claim a considerable amount of the already limited resources [5, 11, 13, 14, 15, 16]. Frequent visitors at PER are fragile and exposed and because of the psychiatric nature of their illness they have difficulties expressing and demanding their rights in terms of mastering life in general and tackling psychiatric care in particular. Due to their repetitive behavior, it can be concluded that their needs are complex and varying and are insufficiently met by PERs. In 1983, Bassuk had already concluded that overutilization of PER mirrors the gaps in the health care system [17]. PER are the context in which acute crisis situations are taken care of, which means that staff is pressed to make fast decisions of short-term relevance. While this orientation might be satisfactory for persons that visit a PER once or twice, the expectations and needs of frequent visitors might be different. The fact that they return to PER indicates that they might need to be provided with a long-term solution and continuity of care [18, 19] that would decrease or end their visits to PER. Further, it indicates that a long-term sustainable development of PER themselves is required. The fact that frequent visitors are often referred to as difficult patients [2, 20] or as hard to treat [18] is another indication why they need to be given more attention. Since PER are part of the human sector where people work with and for other people [21], humane condition should be the core element in PER so as to reduce patients suffering and provide sustainable working settings for staff.

Frequent visitors

The number of visits to PER are soaring not only due to deinstitutionalization but also due to increases in substance abuse [3] and in mental health problems in general. Previous studies have shown that PER are increasingly used by visitors with non-urgent needs [22, 23, 24], implying that the quality and availability of care for visitors suffering an acute crisis is being compromised [24]. These findings are in line with other studies that have pointed out that a number of visits of persons to PER have increased among those who do not represent “true” psychiatric emergencies but who use PER as a source of support [22, 23, 25]. Consequently, those non-urgent and frequent visits claim a disproportionate amount of PER’s resources [24] and put a substantial financial strain on PER [5]. Although PER represent a medical specialty, it can be concluded that they function as a “revolving door” for particularly persons who frequently visit PER [11, 26, 27] and who often have non-urgent mental health problems and needs [22].
  • Research question 1: What characterizes frequent visitors at PER in the literature?

Psychiatric emergency rooms

The field of health care and mental health care in particular have undergone significant changes over the past decades. As a consequence the same can be said about the development of PER and staff working in a psychiatric care setting that had to be adjusted in order to meet the new challenges.

PER is both time and staff-intensive [25]. Since the workload in PER is increasing [27] and utilization rates are soaring [28] it becomes more difficult for staff at PER to provide quality services. Central to the concept of psychiatric emergency is the subjective quality, the unpredictable nature of the emergencies, the wide range of diagnoses and symptoms of people visiting PER, lack of prior assessment or adequate planning, result uncertainty, severity, urgency etc. which puts many demands on staff at PER and makes PER a challenging workplace [29]. One consequence are inaccurate diagnoses that have shown to be associated with poor treatment outcomes and overuse of the most expensive types of services e.g. hospitalization [30].

Since the domain of PER is so far-reaching in terms of services that they provide and the variety of patients they serve, it is difficult to make a comprehensive evaluation of PER [1]. Since PER are the context where frequent visitors are comprehensively evaluated, their needs are assessed, and they are cared for, the characteristics and specific dimensions of PER are important to explore.
  • Research question 2: What characterizes PER in the literature?

The aim of this paper is to explore what characterizes frequent visitors to PER and PER themselves by critically evaluating previous studies and providing a systematic review by addressing the two main research questions. Given the changing nature of PER’s frequent visitors and PER, this study provides an insight into the development of both over time. For each question, and inspired by Jackson et al. [31], a SWOT 1 analysis will be performed to consider the strengths and weaknesses of the previous research as well as opportunities and threats in it. The latter two aspects will lay the ground for suggestions for future research.

Method

Literature review

The papers relevant for this review were identified by a computer-based search done in the Web of Science and PubMed databases. A key word search was conducted by combining the search term “psychiatric emergency” with terms associated with a repetitive behavior or high frequency (“frequent”, “return”, “multiple”, “repeat”,” recurrent”,” high” or” increase”). The key word search was limited to the titles of articles. No time restrictions were imposed in order to cover as broad a field of research as possible.

Inclusion criteria and selection process

The citations retrieved were scrutinized by reading the titles/abstracts/articles. The following inclusion criteria were used to identify studies to be included in the review; they had to be (1) published in a peer-reviewed journal in English; (2) based on original empirical data analysis; and (3) focused on frequent visitors in psychiatric emergency care settings.

Results

In total, 67 items were identified in the Web of Science database and 23 in the by PubMed database. After duplicates were excluded, the total number of studies was 65. An additional 36 were excluded because they did not meet the inclusion criteria. Table 1 lists the author(s), year, data's origin, method, sample size and data of the remaining 29 articles.
Table 1

Summary of articles included

No

Authors (year)

Data’s origin

Method

Sample

Data

1

Raphling, D. L., & Lion, J. (1970) [36]

USA

mixed

15

Observations on FV + register data

2

Steer, R. A., Diamond, H., Litwok, E., & Henry, M. (1979) [37]

USA

quant

442

Home visits

3

Munves, P. I., Trimboli, F., & North, A. J. (1983) [38]

USA

quant

3824

Patients with no previous record at PER

4

Pérez, E., Minoletti, A., Blouin, J., & Blouin, A. (1986) [39]

Canada

quant

913

913

Questionnaires on patient filled in by staff

Questionnaires filled in by patient

5

Surles, R. C., & McGurrin, M. C. (1987) [40]

USA

mixed

NM

27,899

35,250

Interviews with staff;

Register data

Register data (from other services)

6

Ellison, J. M., Blum, N. R., & Barsky, A. J. (1989) [41]

USA

quant

68

62

FV; Register data

NFV; Register data

7

Hansen, T. E., & Elliott, K. D. (1993) [42]

USA

 

1144

Register data

8

Sullivan, P. F., Bulik, C. M., Forman, S. D., & Mezzich, J. E. (1993) [43]

USA

quant

16,257

Register data

9

Klinkenberg, W. D., & Calsyn, R. J. (1997) [44]

USA

quant

319

Register data

10

Spooren, D. J., Van Heeringen, K., & Jannes, C. (1997) [45]

Belgium

quant

13,323

Register data

11

Saarento, O., Hakko, H., & Joukamaa, M. (1998) [15]

Finland

quant

537

Patients with no previous record at PER

12

Saarento, O., Kastrup, M., & Hansson, L. (1998) [46]

Denmark/Finland

quant

1055

Patients with no previous record at PER

13

Segal, S. P., Akutsu, P. D., & Watson, M. A. (1998) [47]

USA

quant

417

NM

Register data;

Brief questionnaire to staff

14

Arfken, C. L., Zeman, L. L., Yeager, L., Mischel, E., & Amirsadri, A. (2002) [3]

USA

quant

48

5722

Questionnaires with staff;

Register data

15

Segal, S. P., Akutsu, P. D., & Watson, M. A. (2002) [26]

USA

quant

See 13

 

16

Arfken, C. L., Zeman, L. L., Yeager, L., White, A., Mischel, E., & Amirsadri, A. (2004) [34]

USA

mixed

74

74

68

Interviews with FV; Register data

Interviews with NFV; Register data

Telephone interviews with family members

17

Bruffaerts, R., Sabbe, M., & Demyttenaere, K. (2005) [48]

Belgium

quant

531

Questionnaires filled in by staff about FV

18

Pasic, J., Russo, J., & Roy-Byrne, P. (2005) [16]

USA

quant

17,481

Register data

19

Ledoux, Y., & Minner, P. (2006) [11]

Belgium

quant

2470

Register data

20

Chaput, Y. J., & Lebel, M. J. (2007) [13]

Canada

quant

14,825

Register data

21

Chaput, Y. J., & Lebel, M. J. (2007) [5]

Canada

quant

19,740

Register data

22

Goldstein, A. B., Frosch, E., Davarya, S., & Leaf, P. J. (2007) [33]

USA

quant

509

Register data

23

Paradis, M., Woogh, C., Marcotte, D., & Chaput, Y. (2009) [49]

Canada

quant

4

PER

24

Boyer, L., Dassa, D., Belzeaux, R., Henry, J. M., Samuelian, J. C., Baumstarck-Barrau, K., & Lancon, C. (2011) [50]

France

quant

8860

Register data

25

Buus, N. (2011) [2]

Denmark

qual

11

Interviews with nursing staff

26

Aagaard, J., Aagaard, A., & Buus, N. (2014) [27]

Denmark

mixed

15

8034

15 interviews with FV;

Register data

27

Richard-Lepouriel, H., Weber, K., Baertschi, M., DiGiorgio, S., Sarasin, F., & Canuto, A. (2015) [51]

Switzer-land

quant

4322

Register data

28

Lincoln, A. K., Wallace, L., Kaminski, M. S., Lindeman, K., Aulier, L., & Delman, J. (2016) [35]

USA

mixed

16

NM

Interviews with FV;

Quantitative data

29

Nossel, I. R., Lee, R. J., Isaacs, A., Herman, D. B., Marcus, S. M., & Essock, S. M. (2016) [52]

USA

quant

97

Register data

FV frequent visitor

NFV non-frequent visitor

Description of findings

Of the articles included in the review, 13 were published before 2000 (1970 to 2000) and 16 after 2000 (2001 to 2016). The articles were mainly published in journals within the fields of health care sciences, public, environmental and occupational health and psychiatry with very few exceptions in nursing, social work or emergency medicine. The majority of articles (14) was published in Psychiatric Services, which before 1995 was called Hospital and Community Psychiatry. All the journals are ranked and have impact factors varying between 0.769 and 5.605, as reported in Web of Science for 2015. Data for 16 of the articles was collected in USA, 9 in Europe and 4 in Canada, showing the clear dominance of the American research community in this field.

Twenty of the studies included had a quantitative approach focusing on register data of patients. Three additional quantitative studies concentrated on psychiatric emergency services, one on staff members, and another one on an implementation of an intervention. Out of 29 studies, one had a qualitative approach, interviewing staff about their categorization process of frequent visitors [2].

Five studies used a mixed method approach, combining interviews (or observations) of patients/nurses with register data. Out of 29 studies, one focused on a patient group below 18 years [33], whereas the remainder of 28 focused on the adult population, though this was not explicitly stated in many of the articles. None of the studies included explicit organizational/economic perspectives.

The quantitative data was analyzed using statistical tests, mainly regression analysis. In the qualitative study, discourse analysis was used with an underlying social constructionist framework. Furthermore, one article was a case control study [34], and another was a community based participatory research study [35].

Research question 1: What characterizes frequent visitors at PER in the literature?

Table 2 is a summary of the definitions used in the literature reviewed, either as determined in the introduction or method section or as part of the results if some categorization was made there.
Table 2

Definition of frequent visitor from literature review

No

Examples of terms used

Conceptual definition of FV

Operationalization of the FV (examples of predictors of FV or FV are more likely to (be))

1

Patients with repeated admissions

NM

Attitude of helpless persons victimized by powerful external forces; place solution to their problems entirely in hands of physician; request for hospitalization and medication; demanding, provocative, and manipulative in communication with staff

2

Multiple visit; subsequent visits

NM

Displaying bizarre behavior during 1st visit; 92.2% receive same diagnosis as during 1st visit

3

Repeat patient visits

Return visit within 12 months after initial visit

Unemployed; need public assistance; have psychiatric history and/or, cognitive difficulties; severe primary diagnosis at initial visit

4

Non-repeaters

Repeat users

- > 0 visits preceding index visit

- > Group 1: 1 repeat visit within 6 months preceding index visit;

Group 2: 2 or more repeat visit within 6 months preceding index visit

Group 1: Self-referred; single; have previous and current psychiatric treatment; schizophrenic; personality disorder; younger

Group 2: Younger; unaccompanied; separated; comply more often with ambulatory follow-up; have poor rapport with staff in PER

(no sig. Differences in sociodem and socioecon characteristics between NR and group 1 and 2)

5

Heavy users

Three or more admissions per year

Resemble young adult chronic patients; male, 17–35 years; schizophrenic; refuse outpatient care

6

Frequent repeaters

6 or more visits

Resident of catchment area; homicidal; self-injured; intoxicated during visits; absence of psychotherapist; have anxiety; self-referred; schizophrenic; have diagnosis of alcohol and/or substance abuse; borderline personality; concurrent psychiatric treatment; referred to outpatient treatment (no sign. Differences in sociodem. And socioecon. Characteristics)

7

Frequent repeaters

Occasional repeaters

Non-repeaters

- > 4–12 visits in a year

- > 2–3 visits

- > single visit

Schizophrenic; less often referred to outpatient clinics; visits after 4:30 p.m. and on weekends

8

Repeat users

4 groups: 1 visit, 2–4 visits, 5–10 visits and 11–162 visits

Male; younger; schizophrenic; suffer from major depression;, non-white; unmarried, unemployed; co-morbidity with substance abuse as 1st 2nd or 3rd diagnosis

9

Repeat visit; return visits

Repeat visit after 18 months

Previous psychiatric hospitalization; currently receiving outpatient treatment and not receiving aftercare

10

Repeated psychiatric referrals

NM

Male; younger; previous hospitalization; substance abuse disorder; inpatient treatment at end of visit

11

Repeat users

3–24 visits during the last 2 years of the follow-up

Male; living alone;, suffering from more serious diagnosis

12

Repeat users

Patients belonging to the upper tenth percentile of the emergency outpatient contacts, which in this study indicates at least three emergency contacts during the l-year follow-up

Location 1: male; divorced or unmarried; living with their parents; without their own housing; unemployed; age 25–44

Location 2: no sig.; differences in sociodem. Characteristics

Have index contact with psychiatric services in outpatient care; self-referrals

13

Involuntary returnees and non-returnees

Return within 12 months

Spend more days in hospital after evaluation; psychotic disorder; more dangerous; less treatable; more insured; comply more with their referrals for treatment (no sign. Differences in sociodem. Characteristics),

14

Frequent visitors

Infrequent visitors

- > 6 and more visits per calendar year

- > 5 or less visits per calendar year

Motives for visits from staffs’ view: temporal pattern, weather, lunar variable

15

Involuntary returnees and non-returnees

Return within 12 months

See 13

16

Frequent visitors

6 or more visits in 12 months following index visit

Mon-adherent with treatment; admitted to inpatient hospital; homeless; rather drink than do drugs before visit; visit also other PER; have previous psychiatric hospitalization (no sign diff. in diagnosis)

In interviews: report PER’s convenient location, no need for appointment, shelter, medication

17

Patients with recurrent utilization, repeated referrals

Patients with a history of PER visits

Female, mean age 37.3; lives with family; unemployed; have substance use disorders, personality disorders; noncompliant with aftercare; previous outpatient treatment

18

High utilizers

Three definitions: 1-patients with visits at least two standard deviations above the mean number of visits (selected because standard deviation units are the most common measure of variability); 2-patients with 6 or more visits in a single year (selection on the basis of previous studies); and 3- patients with 4 or more visits in one quarter (selected on the basis of the definition by the county).

Male; unemployed; enrolled in public mental health system; developmental disability; homeless; living dependently; have previous psychiatric hospitalization; schizophrenic

19

Frequent repeaters

Occasional repeaters

- > 4 contacts or more during index period of 16 months

- > 2 to 3 contacts during index period of 16 months

Male; younger; mean age 37.5; socially disabled; have psychosis; suffer from grief; self-referrals; lower welfare status

20

Patients who make multiple visits, Multiple visit patients

4 groups: 1 visit, 2 visits, 3–10 visits, 11+ visits

Younger; schizophrenic; have co-morbid psychiatric diagnosis; less dual diagnosis with substance abuse; more frequently placed under observation or hospitalized; unemployed

21

Multiple visit patients

intermediate group: 4–10 visits; heavy user group: 11+ visits

4–10 visits: schizophrenic; substance abuse; use of multiple services

11+ visits: schizophrenic; bipolar disorders; shorter time intervals between visits; use of multiple services

22

Repeat visitors

Repeat visit within six months after index visit

African American, show disruptive behavior; previous psychiatric hospitalization; suffer from diagnostic co-morbidity

23

Increase in utilization; utilization rates

NM

PER

24

Frequent visitors

Occasional visitors

- > six or more visits in 6 years

- > 2–5 visits in 6 years

Younger; single; homeless;, have non-affective psychotic disorders, schizophrenic, diagnostic variability

25

Frequent visitors

By nurses as persons who did not profit from psychiatric treatment and who could not mobilize sufficient resources in their psychosocial network to find alternatives to ER visits

Successful visits: relatively rapid with core problems and needs clearly identified; experience of reciprocity and rapport

Difficult visits: nurses are not able to deal swiftly with visitor or/and visitor did not profit from treatment, discrepancies between assistance offered at PER and visitors’ own perception of their needs; not all FV were classified as difficult

26

Frequent visitor

5 visits or more per year

Schizophrenic; male; living in sheltering housing

In interviews: final resort for help in an unbearable situation; integrated and valued part of social network

27

Recurrent visits (frequent visitors)

3 visits or more per year

Personality disorder (no sociodemographic predictors were found)

28

Repeat use of PES, frequent users, high utilizers, non-frequent users

Repeat use within 90 days

In interviews: instability in domains like housing, employment, finances, interpersonal relationships, formal treatment services, use of medication, living with substance abuse etc.

29

Frequent users

3 visits or more in a year

Implementation of a model to decrease use of PER and increase use of outpatient services

FV Frequent visitors

NM not mentioned

NR Non-Repeater

Strengths

One strength of the literature is that most of the articles are based on large samples, which allows for generalization to the population. Several papers went beyond descriptive analysis and applied more sophisticated statistical techniques, such as logistic regression or linear regression analysis or both [e.g. 3, 5, 16, 27]. This leads to a more thorough understanding of the causal inference. Most of the studies used a longitudinal design, which showed how frequent visitors as a group change over time and allowed for better understanding of behavioral (proxied) patterns of that patient group. A few studies used new methodological approaches, e.g., mixed method designs [27, 34, 35, 36, 40]. This provides a better understanding for the complexity of frequent visitors as a group, no less from the perspective of significant others and nurses.

The descriptions of frequent visitors in the literature are another strength. On an operational level, frequent visitors were often described as being single [e.g. 39, 50], unmarried [e.g. 39, 43], homeless [e.g. 16, 34, 50], or living alone [e.g. 15, 16]. They were also found to have unreliable social support [e.g. 16] and be socially disabled [e.g. 11]. All these characteristics may be indicators of social isolation. Further, socioeconomic characteristics such as unemployment [e.g. 16, 39, 43] and economic impairment [e.g. 11, 48] have been found in the literature. Studies also have shown that the group mainly consists of men [e.g. 11, 15, 43] and persons of a young age [e.g. 11, 13, 43, 50]. Persons who frequently visit PER often suffer from a mental illness such as personality disorder [e.g. 16, 39, 46, 48] or schizophrenia [e.g. 5, 13, 39, 41] and substance abuse [e.g. 11, 41, 48]. They also are known for prior psychiatric hospitalization [e.g. 15, 16, 26, 33, 34, 39, 41, 44]. This substantial variation of characteristics indicates that this group has a rather heterogenic need profile, implying a complexity in supplying care for those persons. In summary, many variables are repetitive (e.g., diagnosis variables, which are found in almost all articles), whereas other variables are context-specific characteristics, like race or socioeconomic factors.

Weaknesses

One weakness of the literature is the lack of current data. Though six studies were published after 2010, the data used in them was relatively dated; the latest study was published in 2016 using data from February 2009 to April 2010 [52]. This has left a gap in the years covered and a need for studies using data more collected recently so as to understand current developments. In addition, majority of the studies used a quantitative approach based on register data, suggesting a stronger focus is needed on more qualitative or mixed method designs that provide an opportunity to gain an in-depth understanding about frequent visitors. Basing studies on register data also meant that they lacked the perspectives on non-patients, such as organizational and staff perspectives or from significant others. Especially the perspective of the frequent visitors of PER might be important to consider, yet it is rarely taken into account when quantitative methods are used. Majority of the studies did not report practical implications and thus lacked relevance for praxis. The studies used many different definitions and terms for frequent visitors, which unnecessarily complicates comparison of the studies.

Though the diagnoses of frequent visitors was mentioned in most articles, they were described and analyzed in different ways (e.g., three diagnoses are given per visit or the most common diagnosis is picked or articles mention the principle diagnosis or severe primary diagnosis). This creates diagnostic confusion particularly in the context of longitudinal studies, which most of the studies are, and thus they lack transparency.

Additionally, only in few quantitative studies a control group was used [e.g. 5, 16, 34], which could be seen as a methodological weakness.

Opportunities

One way of moving forward in the research area would be to develop the concept of frequent visitors further by conducting qualitative studies from which qualitative definitions of frequent visitors could be derived. This could allow for an in-depth understanding of frequent visitors and their needs, which would prepare the way for the development of effective interventions.

Another way forward would be to explore the different dimensions of the definition of frequent visitors, by exploring the views of different external actors. This might contribute to a more holistic definition because different perspectives would be taken into account.

Finally, one could study frequent visitors’ specific needs, life styles, behavior, and social networks in order to develop the interventions that are necessary and that could be implemented with a long-term perspective.

Threats

There is a danger of misinterpreting the results of the studies if the settings, definitions, and terms are so varied. Because the majority of studies were conducted in US, the findings lack a broader perspective. Further, most of the studies missed taking the findings to a higher theoretical level. They did not explain their results by using the underlying theoretical reasons, but instead were driven mainly by empirical aims. Thus, although the studies succeeded in identifying patterns and characteristics of frequent visitors, they did not provide reasons for the results. As a consequence, the situation of frequent visitors would not be improved based on these studies because knowing only about their patients’ patterns is not enough. More focus should be paid to practical implications in order to make a difference in frequent visitors’ situations.

Research question 2: What characterizes PER in the literature?

Categories “organizational context,” “geographical context,” “types of services and facilities, “processes and procedures,” “service usage,” “health care system,” and “staff” are shown below in Table 3. The characteristics of the PER were derived from the literature included in the review that were mainly described in the introduction and method sections of the articles.
Table 3

Characteristics of PER from literature review

No

Organizational context

Geographic context

Services and facilities

Processes and procedures

Service usage

Health Care System

Staff

1

General public hospital

Massachusetts

Walk-in clinic, admitted on unselected basis

Brief but thorough evaluation of psychiatric, social, and general medical conditions, follow up after discharge by other psychiatric facilities within hospital or by community agencies

NM

NM

NM

2

Home visiting team belong to general public hospital

NM

Mobile component of a 24 h a day

9-passenger station wagon with mobile telephone and pager system; description of primary and secondary goal; if protective environment needed court or voluntary commitment in accordance with law

Description of process, phone call, weapon involvement, police, reflection over violence and injury, description of intervention

NM

A psychiatric corpsman (trained by the navy) and a registered psychiatric nurse

3

University hospital

Dallas

24 h a day

Psychiatric interview record

NM

NM

Psychiatrist or psychiatric resident, a registered nurse, a clerk, and clinical psychology interns and medical students at specified times, under supervision

4

General hospital

Ottawa, catchment area 700.000

40 beds for psychiatry

Clinical assessment follows the guidelines of the initial evaluation form

NM

NM

NM

5

5 general hospitals, 1 private psychiatric hospital, 1 not affiliated with a hospital

7 PER in Philadelphia, in 5 different areas

24 h a day, provide 85% of PE care in the city

NM

NM

NM

NM

6

General hospital

Massachusetts

NM

NM

NM

NM

NM

7

NM

Portland

NM

NM

NM

NM

Nurse or resident daytime consultation Monday–Friday; otherwise, on-call resident

8

University hospital

Pittsburgh; socioeconomic status of pop varies

24 h a day; specialized sections

NM

NM

NM

NM

9

General public hospital

Metropolitan region of 2,000,000 inhabitants

24 h a day

 

Number of visits and admissions per year

NM

Mainly nurses, psychiatric residents, social workers

10

General public hospital

4 PER in large cities in Belgium

NM

NM

NM

NM

NM

11

NM

City with 100,000 inhabitants

Catchment: university and industrial town

24 h a day service

NM

NM

NM

NM

12

NM

A: Catchment: part of central city Copenhagen, 2.5 km from PER, population density

B: Catchment area: university and industrial town of Oulu, 30 km from PER, population density

Open referral system, 24 h day

NM

NM

A, B: socialized health care system

NM

13

NM

7 PER in San Francisco Bay area

NM

NM

NM

NM

NM

14

University hospital

City with 950,000 inhabitants, 82% African American

Does not provide crisis residential services

NM

Number of hospital admissions per year

NM

Psychiatrists, psychiatric residents, nurses, social workers, mental health technicians

15

See 13

      

16

NM

Located in disadvantaged areas in 10 largest cities in US; 82% African American

24 h a day

Part of hospital but not connected to MER

Number of visits per year

NM

Psychiatrists, psychiatric residents, nurses, social workers, mental health technicians

17

University hospital

City of Leuven with 100,000 inhabitants; catchment area of hospital 250,000 people; only hospital with PER

Comprehensive assessment and treatment and disposition plan for each patient; follow-up service

PER program started 1999,

automatic enrollment; provides a full range of emergency evaluation, intervention, referral and disposition services for adults in crisis; programs philosophy

NM

Public health care;

universal health insurance covering mental health and substance abuse treatment

PER team: 1 supervisor, 2 residents, 1 psychologist, 4 licensed nurses

18

NM

Seattle

24 h a day

NM

Number of visits per year

NM

Psychiatrists, psychiatric residents, nurse practitioners, nurses, social workers

19

General public hospital

City Brussels with 950.000

inhabitants

Special treatment units in total

120 beds, 6 for short-term stays

unrealistic to expect PER to use DSM-IV thoroughly

Number of visits to hospital and PER per year

 

NM

20

University hospital

A, B: Montreal

C, D: Canadian city

C: no observation area

Number of persons served

doubled within 2 years

 

NM

Specialized nurses and psychiatric staff on weekdays; evenings and weekends covered by regular staff, psychiatrists, or psychiatric residents (on call)

21

University hospital

Montreal

NM

NM

Number of visits per year

NM

NM

22

University hospital

Metropolitan region, state

and surrounding community

NM

Evaluation by psychiatric

residents, no overnight coverage, all evaluations by PR were discussed with child psychiatry attending physician during and before final disposition

Number of visits per year

NM

Psychiatric residents on call daily 8 am – 11 pm,

23

University hospitals

4 PER

A: Montreal, catchment area doubled to 180,000

B: Montreal

C and D: Kingston (city and metro), no catchment

A: self-contained, secure unit, short-stay observation beds

B: no prior medical triage, walk-in clinic, self-contained, secure unit, short-term observation beds, catchment stable C and D: city population increased by 4%; metro population by 10%

NM

NM

NM

NM

24

University hospital

Marseille, 1,000,000 people; description of region

NM

NM

NM

NM

NM

25

University hospital

Detroit

Open access; no formal referral needed; 10 beds short-term stays

NM

Number of visits per year

NM

Study population was staff, but no description beyond study population

26

University hospital

Aarhus, Caucasian,

low-wage, highly educated

inhabitants

Open access 24 h a day, beds available for short-term stays

NM

Number of visits and hospital admissions per year; self-referral

Public financed by taxes; visit without any charge

Staff is specialized, only works at PER, staff at PER has increased; shifts

27

University hospital

Geneva; catchment of

700,000 located on border

24 h a day

Evaluations and interventions, hospitalization or referral to outpatient service, private psychiatrists, or GP.

Initial screening by primary nurse via clinical interview to determine if further in-depth medical or psychiatric. Assessment is needed; description of evaluation

NM

NM

Multidisciplinary team of psychiatrists, nurses, administration staff

28

NM

Busy urban Boston

Different sections

NM

NM

NM

NM

29

University medical center

Large urban New York

NM

NM

Number of visits per year

NM

NM

NM not mentioned

Strengths

The studies’ strengths lay in their transparency concerning the location of the PER, its ownership, and the PER’s capacity. In the studies reviewed, the PER was often located at a university hospital or a public hospital; in one case the PER was community-based [40]. Some studies did not mention the ownership of the hospital, but almost all stated the name of the hospital or city. Most of the articles provided some sort of a description of the PER, such as having open access, 24 h 7 days a week, being available for everyone, or being combined with inpatient or outpatient services. In this way, some sort of context description was provided, which is important in order to correctly interpret and understand the results of the study.

Another strength is that several studies mentioned the total number of visits per year. Particular when provided in combination with number of inhabitants of the city or the catchment area of a PER, it gives a good insight about the size of the hospital and its capacity. In many studies, the number of visits per year was described in the results section, which could be one reason why it is not included in Table 3. One could also draw conclusions about the patients visiting a PER by knowing about the PER’s location, e.g., rural, suburban, or whether the PER is located in an economically disadvantaged area characterized by high unemployment rates or is in an area dominated by a certain ethnographic subgroup, which were mentioned a number of times.

Weaknesses

The primary weakness of the studies lays in the limited descriptions of organizational structure and processes within PER as well as incomplete descriptions of the local and national contexts in which PER were embedded. Only a limited number of studies mentioned the health care system and its specifics. None of the studies discussed organizational structures such as power and hierarchy or explored the relationship between those structures and the use of resources, be they tangible or intangible. Further, all but one study [33] focused on adult patients and thus excluded adolescents as a group. This is especially a weakness, given that a number of psychotic disorders can be detected at the early age [e.g. 53]. By diagnosing e.g. depression in adolescents, interventions could be implemented earlier and with a preventive purpose [54], which could be beneficial for the patient and increase the efficiency of the service provision.

A further weak point of the studies is that they seldom described the catchment areas, making it impossible to know the total number of visits in relation to population served. Few studies [e.g. 15, 46, 48] have addressed the dynamics within the population in terms of its growth, composition, density, or involvement with other special treatment units. Further, the studies have not addressed the infrastructural aspects such as transportation and accessibility of PER. Finally, the studies have limited discussions on the types of services PER offer, which makes it hard to compare PER across different studies.

Opportunities

One aspect that could enrich studies of PER would be exploring the team aspect of staff work. Studies in other health-related contexts with a focus on acute and intensive care settings have indicated that teamwork and the dynamics in health care teams are important, given that teams handle complex work assignments better than individuals [55, 56, 57]. The complexity of PER and its assignment might thus serve as a golden opportunity in exploring the potential importance of team work and its outcomes. These types of study would be of particular interest in contexts like Swedish PER units, where the staff works in teams with the help of the triage method. Another opportunity for learning more about PER would be to approach them from an organizational perspective, exploring their organizational structure, economic resources, hierarchical relationships between different categories of staff, and how the division of labor between these groups is organized. Exploring these aspects might allow for a more nuanced view of PER and their structuresas well as a better understanding of how those are related to PER’s organizational efficiency and performance. This could be of particular relevance since several studies mention how scarce resources at PER are [e.g. 5, 15]. Exploring staff members’ experiences of their working settings, lived world, and well-being could provide yet another opportunity to better understand how to motivate PER staff and consequently to improve the quality of their work and their level of work satisfaction. Finally, understanding the role of geography (i.e., location in urban or rural areas and communicational and transportation conditions) could shed light on PER’s functioning and the differences that appear between the studies.

Threats

Again, a threat can be seen in the dominance of the US-based studies, which results in a limited view on the context of PER and their patients. Further, the studies lack information on the methods used within psychiatric emergency care, e.g., in developing countries. Studies tend to focus on a medical/clinical perspective, which leads to a lack of multidisiplinarity. Putting more stress on the nursing/caring perspective within PER could be of importance because the nursing staff is highly involved and are the first to encounter the patient. Another threat is the lack of exploration of geographical aspects of patients vis à vis PER (e.g., rural area vs metropolitan area). The organizational and management structures within PER are also underexplored; knowing more about them could further the understanding of the role and functioning of PER.

Discussion and conclusion

This literature review posed two research questions: 1) What characterizes frequent visitors at PER in the literature? and 2) What characterizes PER in the literature? Both were explored by the means of a systematic review combined with a SWOT analysis. One aspect that emerged from the literature review is the inconsistent use of the terms “PER” and “frequent visitors.” The broad spectrum of differences in terms can be partly explained by the variation of definitions, variation in different health care settings and welfare systems, geographical and climate differences, and, not least, different populations served. The diversity of conceptualization of PER and frequent visitors represents a challenge. According to McArthur, even a common definition concerning how emergency psychiatric care defines itself needs to be found [8]. In addition, an accepted operational definition of frequent visitors has not yet been proposed [18]. This literature review attempted to provide a first step in developing accepted operational definitions for PER and frequent visitors by surveying the literature on both concepts: PER and frequent visitors. The two are interdependent and thus should both be acknowledged in future definitions of either concept. Though there has been some discussion about what a “true” psychiatric emergency constitute, the basis for all definitions should be found in the urgency of the visitors’ need for care, either as experienced by the person or by others.

In most of the papers, frequent visitors are quantified and objectified, with the studies dealing with frequent visitors at PER based on register data and archival data. There is a lack of qualitative studies investigating the perspective of persons in care in terms of their needs, their satisfaction with PER services, and their life style and living situation. Such studies are needed in order to provide appropriate support and help to frequent visitors and might identify whether the type of help needed could be offered outside of PER. The studies are empirically driven and do not seek to establish models or theories. One way forward would be to look at the findings of the studies and to try to further develop existing models and eventually create new ones. This would also allow for learning more about, e.g., frequent visitors’ attitudes and behaviors by applying existing models. One such model could be, e.g., the Tidal model [19, 58], which was developed for psychiatric care settings. Another possibility for seeking explanation for the results would be the application of existing theories, e.g., Giddens’ structuration theory that poses that society is based on social actions and should be understood in terms of agency (relationship with other people based on interactions) and structure (rules and resources). Agency and structure exist in duality (i.e., they involve reciprocity between actors and collectives) [59]. This review revealed that the studies focus mainly on the characteristics of the agent (the frequent visitors) and do not do enough to take into account the implications of PER and the challenges PER faces (structural aspects) when caring for frequent visitors. In order to understand the agency and the structure, one needs to study their interactive nature. Applied here, it means that future studies should focus on understanding the role of PER for frequent visitors and the role of frequent visitors for PER, which so far has not found its way into the literature [cf. 18].

The opportunity and threat discussions further revealed the need for studies that address person-centeredness. Person-centered frameworks have recognized the important role of the care environment with its hinders and facilitating roles [60], thus context needs to be considered more when investigating frequent visitors at PER. Such investigations should include physical setting, organizational systems, professional competencies, human relationships, and hierarchies [61], as well as the interpersonal context [20]. PER provides a unique context for caring processes to occur and for interactions between staff and patient. The first encounters between frequent visitors and staff and how staff interacts with and cares for them is part of the therapeutic relationship [e.g. 62, 63, 64, 65]. Concepts of transference and countertransference might need to be taken into account, in particular in this setting.

Further the literature has shown that frequent visitors psychological and service needs are complex, vary from patient to patient and between the contexts. Thus, understanding patients’ needs better would allow for better fitted and tailored interventions that also strive for continuity. The latter could only be achieved by collaboration with external actors.

In reviewing the literature, it became apparent that PER continue to face challenges, given their fast-paced environments, and insufficient time for staff to provide giving diagnoses and care while serving acutely ill, vulnerable persons that need interhuman and interpersonal interaction. Instead, the literature is in agreement when addressing PERs’ frequent visitors as ‘hard to treat’ and ‘difficult patients’ [20, 47, 66, 67, 68] or those that cannot profit from psychiatric treatment [2]. Little information is revealed about how frequent visitors could profit from the newly gained insights of the studies. Future research would benefit from applying the aforementioned theories or models or other person-centered frameworks that stress acknowledging the patient as an equal partner in the health care process. Such theories or models also conceptualize the context and the person(s) of the studies, which might lead to the development of the former and improved care for the latter.

Footnotes

  1. 1.

    SWOT is one of the most known approaches used for analysis of a company’s strategic position being the acronym for Strengths, Weaknesses, Opportunities and Threats. The idea of ensuring a fit between the external situation (threats and opportunities) and own internal qualities (strengths and weaknesses) has shown to be very popular ([32].Hill, T. and R. Westbrook, SWOT analysis: it’s time for a product recall. Long range planning, 1997. 30(1): p. 46–52.) not only in the field of business administration but also is widely being used for any kind of strategic planning or examination of projects, organizations, companies or other ventures.

Notes

Compliance with ethical standards

Conflict of interest

The author declares that she has no conflict of interest.

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Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made.

Authors and Affiliations

  1. 1.Department of NursingKristianstad UniversityKristianstadSweden
  2. 2.Department of Health SciencesLund UniversityLundSweden

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