Process-related factors in the delivery of psychiatric care
In terms of process factors, effective triaging, use of SOPs, adherence to referral protocols,
provider-patient interaction, and observing patients’ rights and staff safety were demonstrated
to significantly affect the quality of mental health emergency care. The highest percentage
37% of the respondents perceived that the process for psychiatric emergency care was
moderate/average. However, a considerable percentage 31% and 18% scored the processing
system as low and very low respectively. This study indicated there was an effective triaging
of the patient in the outpatient department [p=.00]. This is in line with a study that found
mentally ill patients getting higher scores in triaging than the general patient (Atzema C. et al
2012). In addition use a triage scale has been proven to improve provider confidence and
ensures patient safety and better outcome (Broadbent . et al, 2002). However, in Australia,
study findings show that triage of general patients in the emergency department is well
established as opposed to the triage of patients with mental illness. (Broadbent .et al , 2007).
The study indicated that informed consent is sought during treatment; provider-patient
interaction was satisfactory 51%. Nevertheless, inadequate privacy was reported 65%. Over
half 59% of the respondents indicated that the rights of patients are upheld, significantly
affecting quality [p=.01]. Most believe that psychiatric emergency patients were handled with
respect by the staffs. Contrary to this study findings, another study indicated patients’ rights
are often violated during involuntary admission when they are retained in the hospital without
their opinion being sought (Svindseth, Nottestad & Dahl, 2010)
This study indicates patients experience long waiting hours, waiting time is not in line with
the service delivery charter according to this study. About half of the respondents 57%
pointed out that the waiting time for emergency mental health patients was in line with the
service delivery charter, which is up to 60 minutes. Contrary to this study, a study in Nigeria
reported waiting time to be between 3-21 hours. Average waiting time in the emergency
department in Ontario was found to be slightly shorter (10 minutes) for patients with severe
mental disorders as compared to the general patients, (Clare L., et al, 2012) In another study,
waiting time was found to be longer for patients with mental disorders as compared to those
without mental disorders (Waseem et al, 2010). Another study by American College of
Emergency Physician’s, reported patient waiting times of between 7 to 10 hours to be seen
(Health Care Finance 2016) Use of a mental health triage scale significantly reduced waiting
time and time of movement from the ED to the wards (Smart D., et al, 1999)
Care providers,(63%) perceive inadequate safety measures when attending to the patients
with emergency mental health according to this study, significantly affecting the quality of
care [p = .00]. This is in line with a study that indicated, assessing for risk should be a priority
when caring for the patient in order to minimize violence meted on care provides while
attending to these patients (Nazarian D.J., 2017)
The study indicated there is documentation of emergency mental health when they occur.
This is contrary to a report from Haris Health Systems in Los Angels, which reported poor
documentation of all aspects of mental health care (Tucci, et al, 2016). Occurrences of
emergency mental health when clearly and accurately documented allows for ease of
communication amongst the staff (Simon, 2011).
This study indicated that provider-patient interaction was satisfactory (51%). Contrary to this,
a study in Hong Kong showed that communication between provider-patient and the provider
was not effective, thus compromising the quality of care (Jack K.H. et al 2015). Provider-
patient interaction should not be just an interview for purposes of diagnosing, time should be
invested in the patient’s opportunity to ask questions to clear any doubts. Effective
communication skills reduce occupational stress amongst healthcare workers (Ghazavi G.,
2010). A study in Australia revealed that care providers are eager to learn more evidence-
based methods that will help them provide quality care (Manton,2013)
This study indicates standard operating procedures were adhered to (60%), and referral
protocol was used when providing psychiatric emergency care (55%). These significantly
affected quality of care [p = .00], [p = .001] respectively. Some healthcare providers felt that
the use of guidelines or protocols were user-friendly, facilitated the easy transfer of patients
and were important in patient care (Bhugra, 2013)
Most reported there was monitoring of psychiatric emergency patients who are secluded.
Patients who are secluded require regular monitoring (Chang, 2010). Health care providers
must be vigilant when a patient is restrained, and be on the lookout for injuries (Secure
Rooms and Seclusion Standards and Guidelines 2012).
Significantly perceived to be affecting quality is safety measures in place, and safety when
providing care. In this study majority (63%) perceived insufficient provider safety measures
when attending to psychiatric emergency patients [p = 0.001]. Similarly, most indicated that
they do not feel safe when attending to a patient presenting with mental health emergency [p
= 0.05]. Anderson A. et al (2005), indicated in their study violence against healthcare
personnel is on the increase, commonly occurring early in the career. This may be attributed
to less experience on the lookout for risk factors. Similarly, threats and assault were
increasingly experienced by a considerable number of health care workers. Those with more
experience were advantaged, but that did not rule out assault completely. (Pellegrini,
2014)More than half indicated inadequate treatment of mental health emergency patients. The
study indicated that less than 2% of the aggregate wellbeing spending plan has led to scarce
resources, resulting in inadequate treatment.
However, most (86%) of the respondents were documenting the psychiatric emergency
occurrences and 75% indicated the documentation was done consistently. This is contrary to
what was found a study by Tucci V. et al (2016) indicating that there is generally very poor
documentation of psychiatric examination by health care providers in the event of a mental
health emergency.
The study shows there is no de-escalation before patient restraint. Chemical restraint (54%)
and physical restraints (45%) are the commonly used methods of managing patients.
However, it has no significance in quality of care. This is perceived to affect the quality of
care [p = 0.00] A study carried out on service users indicated the use of seclusion as a
convenient option for the care provider, rather than a therapeutic measure (Mayers P, et al,
2010)
The study looked at factors which are known to affect quality of care. The testing hypothesis
was performed between all the factors (structural, process and care outcome) against level of
satisfaction with quality of mental health emergency care provided. There was a significant
relationship between process and outcome. Those who scored moderate and high in process
index are more likely to perceive care as quality [p = 0.000]. Same applies to
those who scored moderate in outcome index are likely to perceive care as quality [p =
0.003]
The H0 = There is no relationship between structural factors, process factors, outcome
factors and quality of mental health emergency care at Mathari Hospital was not
supported.
There is a statistically significant relationship between process factors, outcome
factors and quality of psychiatric emergency care at Mathari Hospital.
