Audit in practice Referrals to the emergency assessment clinic, Whitchurch Hospital, Cardiff

A series of papers looking at the work of the walk-in psychiatric emergency service based at the Maudsley Hospital have been reported in the literature (Lim, 1983; Mindham et al, 1973; Brothwood, 1965). This clinic was established in 1952 and is one of the oldest in Europe. A similar clinic the Emergency Assessment Clinic (EAC) was introduced to Whitchurch Hospital, Cardiff in 1970. The EAC provides a 24 hour, seven day a week assessment facility and is staffed by the duty senior house officer/registrar who is supervised by a senior registrar and/or consultant. Whenever possible a member of nursing staff accompanies the junior doctor during an assessment. Clerical backup is provided during working hours by the Medical Records Department. The role of the EAC is similar to that of the Maudsley clinic as described by Brothwood in 1965-"the assessment of the need for admission and other urgent treatment, the correct allocation of patients to available services and prompt assumption of clinical responsibility of the patient".

A series of papers looking at the work of the walk-in psychiatric emergency service based at the Maudsley Hospital have been reported in the literature (Lim, 1983;Mindham et al, 1973;Brothwood, 1965). This clinic was established in 1952 and is one of the oldest in Europe. A similar clinic the Emergency Assessment Clinic (EAC) was introduced to Whitchurch Hospital, Cardiff in 1970.
The EAC provides a 24 hour, seven day a week assessment facility and is staffed by the duty senior house officer/registrar who is supervised by a senior registrar and/or consultant. Whenever possible a member of nursing staff accompanies the junior doctor during an assessment. Clerical backup is provided during working hours by the Medical Records Department.
The role of the EAC is similar to that of the Maudsley clinic as described by Brothwood in 1965-"the assessment of the need for admission and other urgent treatment, the correct allocation of patients to available services and prompt assumption of clinical responsibility of the patient".

The study
Information was gathered from the EAC log-book which contains brief details of each consultation recorded at the time of interview by the doctor and when necessary the case notes of those admitted were examined. The following data were obtained: (a) referral source: when multiple agencies were involved only the primary motivating agent was recorded (b) diagnosis: diagnoses were recorded using ICD-9 (WHO, 1978) (c) management: when more than one course of action was recorded the immediate action was chosen in order of preference -admit, day patient attendance, out-patient attendance, GP referral, etc. (d) demographic data: the referrals were divided by sex and into six equal age groups.

Findings
During the study period 720 people made 808 visits to the clinic, which led to 410 admissions. In the analysis each consultation was treated separately.
Sources of referral: for both sexes the primary source was the general practitioner (65% of males, 75% of females) and secondly the police (10% of males, 7% of females). Other significant sources included selfreferral, Doctors' Deputising Service and other medical/surgical units. There was no source recorded on 23 (2.8%) consultations.
Initial diagnosis: there were significant differences in the initial diagnosis made between the group of patients subsequently admitted and the group who were not. For those admitted the commonest was psychosis (56%) whereas in the other group two diagnoses were equally common, neuroses and alcohol/drug abuse (18.5% each).
Disposal: admission to hospital accounted for 50% of the outcomes in both male and female referrals. Another 21% were offered some form of psychiatric follow-up including out-patients, day patient attend ance etc. Only 11% of the consultations led to 'home with no follow-up' and 4.5% to a referral to their general practitioner.
Age distribution of those admitted: for males admitted the peak age group was 26-35 years old and for females two peaks were observed 36-45 years and 65 years plus. This may be explained when the commonest diagnoses on discharge from hospital received by the two sex groups are compared. For males this was schizophrenia (17.5%) and for females manic depressive psychosis (13.5%).

Comment
We acknowledge that there are considerable method ological difficulties in this retrospective study and it is difficult to assess the consistency with which the log book was completed. A number of patients known to the services may have bypassed the clinic and been admitted straight to the wards. There is also the issue of reliability of the diagnoses made in the clinic for those not admitted as some of the SHOs may have had as little as two months experience in psychiatry. Despite these difficulties we still feel that the infor mation gathered is of relevance since it reflects actual clinical practice. The commonest source of referral to the EAC was theGP(70% of all referrals) which is consistent with similar surveys in Scotland (Hall & Hunter, 1970) and at the Maudsley Hospital. The determinants of a GP's decision to refer a patient to the psychiatric services include the clinical condition of the patient, demographic characteristics and lastly the character istics of the GP themselves. Over 50% of these were already known to the psychiatric services and from the whole of this group 75% were admitted.
Consistent with previous studies, the commonest diagnosis of those admitted from the EAC was psy chosis (58%), followed by neurosis then alcohol or drug abuse. This contrasts with those not admitted in whom psychosis and neurosis were diagnosed equally. The commonest admitting diagnosis for males was schizophrenia but in the females three diagnoses were equally common: manic-depressive psychosis depressed type, schizophrenia, and manic-depressive psychosis manic type.
In the log-book the doctor is asked to state whether he/she regarded the referral as appropriate.

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The majority were felt to be appropriate but for those considered not to be the main reasons given were: being too intoxicated for assessment, suffering from primary medical disorders, e.g. pneumonia, over doses, and those who could have been managed adequately by referral to an out-patient clinic.
The EAC provides a quick and readily available service to professionals dealing with mental illness. Its main usage is for the assessment and management of acute and chronic psychoses.