Research and Quality Improvement Activities in the Psychiatric Emergency Service
Ian C. Dawe
RESEARCH
In an effort to better understand the scope of previous research on psychiatric emergency services (PESs) as well as to identify areas of focus for future studies, Jennifer Field Brown, in a 2005 article in Psychiatric Quarterly, reviewed the PES literature published in a 10-year period between 1983 and 2003 (1). Her report revealed the methodologic limitations pervasive throughout the PES research literature, identified several dimensions of service that remained unexplored, and ended with a call to action on a systematic research agenda for the field.
Several years have now passed since this excellent article first appeared; unfortunately, not much has changed. Although many new articles have been published, there remain too many anecdotal descriptions of individual PES programs and little significant comparisons between programs. Without meaningful comparison data, no universal conclusions can truly be drawn to help policy makers, clinicians, funders, and, importantly, our clients identify the key, core elements of PES and to determine and address differences in the quantity and quality of services provided.
Methodologic Issues
Of the many systemic methodologic flaws identified in research review articles such as Brown’s, four key issues should be priorities for future PES researchers: (a) picking the appropriate study design, (b) the need to use standardized assessment tools, (c) ensuring a study has adequate sample size, and (d) the ethical consent issue.
STUDY DESIGN
A longitudinal study is a research design in which the same individuals are observed on more than one occasion. Longitudinal designs are useful to understand the fluctuating course of a particular symptom, the extent to which symptoms may remit, recur, or progress, and to identify prognostic factors predicting the future course of an illness.
Cross-sectional studies, on the other hand, are useful to determine the presence or absence of a symptom at a specific time and are usually conducted with a standardized questionnaire. These tend to be among the most frequent designs in current PES research.
Case-control studies provide a simple and cost-effective method of studying associations between risk factors and disease, whereas cohort studies follow individuals over time (either prospectively or retrospectively) to identify the onset of a particular point of interest.
Large-scale trials with more naturalistic designs, as opposed to classic randomized controlled trials with strict inclusion and exclusion criteria, are often advisable to obtain results that are more generalizable to daily clinical practice.
Each design has its advantages and its drawbacks. When conducting emergency research, clinicians are advised to invest time in carefully choosing the most appropriate design for the particular questions being asked.
STANDARDIZED ASSESSMENT TOOLS
Consensus about the use of standardized measurement scales and data collection in clinical trials is absolutely necessary for valid, reliable, and comparable research.
Much recent work in Canada has focused on the Emergency Screener for the Resident As-sessment Instrument in Mental Health (RAI-MH). The RAI is a standardized comprehensive clinical assessment tool that provides information to support care planning, outcome measurement, quality
management, and resource allocation and is now mandatory across all inpatient units in the province of Ontario. The RAI-ER assessment focuses on risk appraisal and safety (e.g., harm to self, others) and decision support for placement and bed utilization and has high validity and interrater reliability.
management, and resource allocation and is now mandatory across all inpatient units in the province of Ontario. The RAI-ER assessment focuses on risk appraisal and safety (e.g., harm to self, others) and decision support for placement and bed utilization and has high validity and interrater reliability.
Active in both the United States and Canada, the Psychiatric Emergency Research Collaboration (PERC) is a multicenter network of general medical and psychiatric emergency departments devoted to improving the management of psychiatric and behavioral emergencies in part by standardizing data collection across sites so as to guide future prospective research efforts and hypothesis generation for the field.
Large-scale, standardized activities such as these examples provide massive structured databases and greatly assist in our efforts to advance knowledge about the assessment, management, and outcomes of psychiatric emergencies in both medical and psychiatric emergency departments.
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