PRÁCTICA FAMILIAR RURAL│Vol.5│No.1│Marzo 2020

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Parcon, M., Corripio, I., Marcet, J., Estebanez, M., Calvo, L. Observational Study of Complexity in a Psychiatric Hospital Unit. Práctica Familiar Rural. 2020 marzo; 5(1).

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ARTÍCULOS ORIGINALES (pre-print)

Observational Study of Complexity in a Psychiatric Hospital Unit

Mg. Melynn Parcon Bitanga [1]*   http://orcid.org/0000-0001-6292-7221
Dr. Iluminada Corripio Collado [2] http://orcid.org/0000-0003-2562-711X
Dr. Josep Marcet Bartra [2] http://orcid.org/0000-0002-4646-4076
Dr. Maria Jesus Estebanez Elguezaba [2] http://orcid.org/0000-0002-6422-9619
Dr. Laura Calvo Saiz [2] http://orcid.org/0000-0002-6426-7340

1. Universidad de Cantabria. Facultad de Medicina. Santander, España.
2. Hospital de la Santa Creu i Sant Pau. Departamento de Psiquiatría. Barcelona, España.

doi: https://doi.org/10.23936/pfr.v5i1.132

Recibido: 12/12/2019 Aprobado: 15/02/2020

ABSTRACT

Objectives: 1. Describe the possible variables that may be related to a psychiatric complex patient at the Acute Psychiatric Unit of Santa Creu i Sant Pau Hospital in Barcelona. 2. Determine the usefulness of the standard definition of chronic complex patient in a psychiatric patient.
Methods: A cross sectional, observational, and quantitative study was conducted at Hospital Santa Creu i Sant Pau. A total of 46 patients admitted at the Acute Psychiatric Ward from March to May 2018 were included in the study. The scales used are: EEAG, FAST, CGI, EQ-VAS and Zarit Burden. The number of extended stays in health institutions, previous admissions and duration of hospital stay are also evaluated.
Results: No difference was noted among the scales EEAG, FAST, CGI, EQ-VAS and Zarit Burden. Upon analysis of variables, factors such as previous hospitalization and days of hospitalization were associated with psychiatric chronic complex patients.
Conclusion: The standard definition of a Chronic Complex Patient does not fit the needs of complexity in a psychiatric patient. Factors such as previous hospitalization and days of hospitalization are associated with psychiatric chronic complex patients.

Keywords: quality of life, multimorbidity, caregiver, psychiatric

Estudio Observacional de Complejidad en la Unidad de Hospitalización de Psiquiatría

RESUMEN

Objetivos: 1. Describir posibles variables relacionadas con un paciente complejo psiquiátrico en la Unidad Psiquiatría Aguda del Hospital Santa Creu i Sant Pau en Barcelona. 2. Determinar la utilidad de la definición estándar de paciente complejo crónico en paciente psiquiátrico.
Métodos: Se realizaron estudios transversales, observacionales y cuantitativos en la Hospital de la Santa Creu i Sant Pau. Un total de 46 pacientes ingresados ​​en la sala de psiquiatría aguda desde marzo a mayo de 2018 fueron incluidos en el estudio. Las escalas utilizadas fueron: EEAG, FAST, CGI, EQ-VAS y Zarit burden. También se evaluó el número de estadías prolongadas en instituciones de salud, los ingresos previos y la duración de la estadía en el hospital.
Resultados: No se observó diferencias entre las escalas EEAG, FAST, CGI,  EQ-VAS y Zarit Burden. Tras el análisis de las variables, factores como la hospitalización previa y los días de hospitalización están asociados con pacientes psiquiátricos complejos crónicos.
Conclusión: La definición estándar de un paciente complejo crónico no se ajusta a las necesidades de complejidad en un paciente psiquiátrico. Factores como la hospitalización previa y los días de hospitalización están asociados con pacientes psiquiátricos complejos crónicos.

Palabras clave: calidad de vida, multimorbilidad, cuidador, psiquiátrico

 

INTRODUCTION

In order to remain true to the holistic meaning of health, keeping in mind the  physical, mental and social well-being of the human person, definitions of disease concepts are constantly challenged and changed in order to provide a better understanding of diseases, ultimately refining and improving health care services.  In recent years, changes were observed about the idea of complexity, which is generally defined as a patient who suffers from two or more chronic diseases or co-morbidity(1) and needs increased attention and health care cost(2).  In the mid-1990s, several surrogate terms for complexity emerged, explaining the different interactions and relationships between two or more diseases in one patient such as: comorbidity, multimorbidity, polypathology and multiple chronic (3), showing that the understanding about complexity is continuously changing and evolving in order to accurately identify and classify the medical situation of patients.

An established criteria of complexity does not exist in Psychiatry, thus, in the Psychiatric Department of the Hospital of Santa Creu I Sant Pau in Barcelona, the general definition of chronic complex patient is being applied in the Psychiatric department. The definition of chronic complex patient in the said hospital is:  a.) two or more hospital admissions in the past year and/or b.) suffers from the following pathology: diabetes mellitus, chronic obstructive pulmonary disease (COPD), dementia, cardiac insufficiency, cirrhosis, stroke and chronic renal insufficiency.

Although there are no established criteria of complexity in the psychiatric population, previous approaches imply aspects of economic burden (time of admission, polytherapy, and social support) and humanistic factors (subjective feeling of well-being, functionality, and burden of caregiver) as parameters related to complexity. (4) (5)

The aim of this study is to explore the variables implicated in a chronic complex patient in psychiatry and determine the usefulness of the standard concept of chronic complex patient as applied to psychiatric patients at the Hospital of Santa Creu i Sant Pau in order to pave the way for a personalized and holistic care.

METHODS

A cross sectional and observational study of quantitative type was conducted in Hospital of Santa Creu i Sant Pau, Barcelona amongst 46 patients admitted at the Acute Psychiatric Unit from March to May 2018.  Data were collected by psychiatrists amongst patients and their caregivers (if present) at the first visit, during hospitalization and discharge periods.

The variables of the study are 1.) Independent variable is the pathology of the patient 2.) Dependent variable is the presence of complexity.

In order to participate in the study, the subjects should complete a series of inclusion criteria which are: 1). patients hospitalized at the Acute Psychiatric Unit from March to May 2018. 2). age of 18 years or older 3).voluntary signature of informed consent.

On the other hand, patients who did not complete the inclusion criteria were not included in the study.

The study was carried out strictly following the international ethical recommendations for medical research in humans and conducted in accordance with the standards set out in the Declaration of Helsinki. Before including any subject in the study and obtaining the informed consent, the researcher or the person designated by the same, explained to the possible participant or their legal / family tutor, the objectives, methods and potential risks and inconvenience of the study.

The following scales were used in the study:

1. Global Assessment Functioning (EEAG – Escala de Evaluación de la actividad Global)

It is a numeric scale used by mental health clinicians and physicians to subjectively rate the social, occupational, and psychological functioning in adults. (6)

2. Clinical Global Impression (CGI)

The National Institute of Mental Health (NIMH) developed this scale for sponsored clinical trials in order to provide a brief, stand-alone assessment of the clinician's view of the patient's global functioning prior to and after initiating a  study medication.(7)

3. Functioning Assessment Short Test (FAST)

FAST  is  a  brief  instrument   designed  to  assess  the  main      functioning  problems experienced by psychiatric patients, particularly bipolar patients.(8)

4. EQ-VAS  

The EQ-VAS, which asks patients to indicate their overall health on a vertical visual analogue scale ranging from “worst possible” to “best possible” health(9)   

5.  Zarit Burden

This scale was developed to measure subjective burden among caregivers of adults with dementia (10)

RESULTS

Majority of the patients are caucasian, female and single with a median age of 46.3 (SD = 16.482). Majority lives with their family of origin, while a significant number of the respondents lives alone. A total of 13% receives pension, 76% has support group but only 15% receive social security support. As for the educational level, more than half had both secondary and bachillerato/BUP. Those who are employed and receive pension accounts for 24% of the population (Table 1).

Contrasting both chronic complex patients (CCP) (n=9) and non- chronic complex patients (non-CCP) (n=37), a significant difference was observed in the number of previous admissions and the number of days admitted. However, no significant difference was observed in Quality of life (QOL), FAST total, CGl, EEAG and caregiver burden (Table 3). Likewise, there is no significant difference in the need for social support for both CCP (11%) and non-CCP (18.9%). The quality of life is correlated with PANNS N.

DISCUSSION

The aim of this research study is to explore the variables that may be related to a psychiatric complex patient and to determine the usefulness of the standard concept of chronic complex patient in a psychiatric patient used at the Hospital of Santa Creu I Sant Pau in Barcelona.

Majority of patients (38 out of 46) do not have social support, which may be a contributing factor to the presence of psychiatric disorders; as mentioned in the study of Real et al., the lack of financial resources translates to higher incidence of mental health problems, as observed in times of job losses and financial difficulties (11).  Moreover, social network of friends and health care professionals, relates to better quality of life and prognosis of psychological disorders; as well as improvement in the level of functioning of patients with psychosis. (12) (13) (14)  

Comparing CCP (n=9) and non-CCP (n=37) (Table 3), significant differences or increased values were obtained in the variable “previous hospitalization” and “days of hospitalization”.  These two variables may be of good use for identifying a CCP as these are directly proportional to the health status of a patient.  A patient with more previous hospitalizations and has a prolonged hospital stay may have a worse prognosis or a more serious pathology than a patient who do not have these characteristics. In terms of quality of life, and FAST total, there is no significant difference between CCP and non-CCP which means that both group may have the same level of quality of life, need for social support and functionality.  This result is different from studies reviewed, asserting that CCP have a poorer health status, quality of life, functionality and  need more social support as compared to non-CCP. (1)(2)

It is suggested that family members hold an important role for CCP precisely because of the difficulties that these patients experience in accomplishing activities of daily living and fulfilling medical orders.(1) In this study, the difference between care giver burdens was studied; there was no statistically significant difference in the caregiver burden between CCP and non-CCP (Table 3), suggesting that the level of caregiving burden is the same for both groups. The authors Ampalam et al. (15) suggests that burden and stress are greater in caregivers of psychiatric patients than caregivers of patients with chronic medical illness.  

Further study about the topic is recommended as small number of patients with complexity was identified (9 out of 46).  Additional study is also suggested in order to diversify the sample as the population is composed mostly of women (27 out of 46) belonging to white race (44 out of 46).

CONCLUSION

The standard definition of a chronic complex patient used in the Hospital Santa Creu i Sant Pau does not fit the needs of complexity in a psychiatric patient. Factors such as previous hospitalization and days of hospitalization are associated with psychiatric chronic complex patients.

The results support studies that suggest the need for a better approach to the concept of psychiatric complexity in order to implement personalized and integrated treatments.

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