JMIR RESEARCH PROTOCOLS Rodriguez-Jimenez et al Protocol Structure and Functioning of Acute Inpatient Psychiatric Units in Spain: Qualitative Study Roberto Rodriguez-Jimenez1,2,3, MD, PhD; Iluminada Corripio4, PhD; Ricardo Campos5, PhD; Mario Páramo6, MD; Manuel Franco-Martin7,8, MD, PhD; Estefanía Segura9; Sergio González10,11, MD; José Martínez-Raga12, MD, PhD 1 Department of Psychiatry, Instituto de Investigación Sanitaria Hospital 12 de Octubre (imas12), Madrid, Spain 2 Biomedical Research Networking Centre in Mental Health (CIBERSAM), Madrid, Spain 3 Faculty of Medicine, Universidad Complutense de Madrid, Madrid, Spain 4 Department of Psychiatry, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain 5 Department of Psychiatry, Hospital Clínico Universitario Lozano Blesa, Zaragoza, Spain 6 Department of Psychiatry, Hospital de Conxo, Universidad de Santiago, Santiago de Compostela, Spain 7 Department of Psychiatry, Jefe del servicio de psiquiatría del Hospital Universitario Rio Hortega de Valladolid, Valladolid, Spain 8 Department of Psychiatry, Complejo Asistencial de Zamora, Zamora, Spain 9 Department of Psychiatry, Hospital General Universitario de Ciudad Real, Ciudad Real, Spain 10 Department of Psychiatry, Hospital Universitario Virgen Macarena, Sevilla, Spain 11 Department of Psychiatry, Faculty of Medicine, University of Seville, Sevilla, Spain 12 Department of Psychiatry, Hospital Universitario Doctor Peset, Valencia, Spain Corresponding Author: Roberto Rodriguez-Jimenez, MD, PhD Department of Psychiatry Instituto de Investigación Sanitaria Hospital 12 de Octubre (imas12) Av de Córdoba km 5,400 Madrid, 28041 Spain Phone: 34 91 390 85 36 Email: roberto.rodriguez.jimenez@gmail.com Abstract Background: As a consequence of the decentralization of health care provision to the different Regions (called Autonomous Communities) in Spain, different health care models and resources have been developed for psychiatric patients. It would be very useful to obtain comprehensive and comparative data on health care models, resources, and activity of acute inpatient psychiatric units (AIPUs) as a key part of mental health systems. Objective: The aim of this study was to determine the current state of AIPUs in Spain through a national scorecard that allows the current situation to be visualized in terms of resources, processes, and outputs. Methods: A 104-item online questionnaire was sent to all the AIPUs of the different Regions in Spain. It was divided into 11 sections, including data on the resources, processes, and outputs of the AIPUs plus general data, an indicator dashboard, and good practices. Results: The questionnaire was completed by 60.0% (117/195) of the AIPUs invited to participate. The information collected has allowed us to obtain a detailed snapshot of the current situation of AIPUs in Spain at the levels of infrastructure and material resources, staffing, organization and activity of the units, coordination with other units, guidelines, processes and protocols used, participation and communication with patients and their families, teaching activity, and research linked to the units. Conclusions: This project aimed to help understand the general situation of AIPUs in Spain and its different Regions, contribute to enhancing the benchmarking and harmonization among Spanish Regions, and provide data for future comparisons with other countries. International Registered Report Identifier (IRRID): RR1-10.2196/26214 (JMIR Res Protoc 2021;10(4):e26214) doi: 10.2196/26214 https://www.researchprotocols.org/2021/4/e26214 JMIR Res Protoc 2021 | vol. 10 | iss. 4 | e26214 | p. 1 (page number not for citation purposes) XSL• FO RenderX JMIR RESEARCH PROTOCOLS Rodriguez-Jimenez et al KEYWORDS acute inpatient psychiatric units; organization; resources; scorecard; Spain results of this study could provide data for future comparisons Introduction with other countries. In Spain, as a consequence of the decentralization set out in the An AIPU is defined as the hospital unit where psychiatric Spanish Constitution of 1978, the jurisdiction for health care treatments are administered that require short-term inpatient provision was transferred to each of the 17 Regions in Spain admission (in general, less than 1 month). Admission of a patient (known as Autonomous Communities) to constitute regional to an AIPU is indicated in situations where it is not possible to health care services. These act as the administrative managerial provide outpatient care for an acute psychiatric process or for structure that integrates all the health centers, services, and the exacerbation of a chronic process [2]. In line with this, the establishments of each Region, as well as the provincial and 1983 Mental Health Act for England and Wales defines short city councils and any other interregional territorial hospital stays as those that are less than 28 days [3]. The World administration. Health Organization Mental Health Atlas 2017 [4] defines Thus, since 1981, health care functions and services have been psychiatric hospital rooms in general hospitals as units that transferred from the central government to the different Spanish provide hospital health care for the management of patients Regions. The first Region to have these functions transferred with acute mental problems and the period of stay is generally was Catalonia in 1981, followed by Andalucía in 1984, and short (weeks to months). eventually the Region of Madrid, where the transfer process was finalized in 2002. As a result, despite sharing a model and Methods common guideline, there are differences both in terms of structure as well as the way in which the different health care Questionnaire systems function within each Region. A Scientific Committee comprised of professionals who understand the functioning of the AIPU in the different This decentralization of health care services over 2 decades has representative Spanish Regions was appointed. A questionnaire resulted in the coexistence of different models within the Public consisting of 104 questions was designed to be answered online Health Care System, despite the fact that the Spanish General by the staff member responsible for the AIPU in the different Health Law defines common guidelines. Thus, in practice, the Regions. As a basis for its design, a literature review was carried transfer process has introduced its own characteristics and out to identify the main resources, processes, and results differential traits in the implementation of this law in each indicators for AIPUs in Spain and at the international level. The Region. In this regard, in 1987, the Interterritorial Board of the search in PubMed was performed using the terms: “acute Spanish National Health Care System was created, to represent inpatient psychiatric units” AND [“quality” OR “indicators” and coordinate the services provided by all the Regional Health OR “mental health services” OR “measuring” OR Care Services. This Board was defined as the “permanent body “improvement”]. Indicators and scorecards for results of coordination, cooperation, communication, and information monitoring and assessment included in the mental health plans of Health Services” between each other and with the State of the different Spanish Regions, clinical management plans Administration, with the aim of “promot[ing] the cohesion of and activity reports of psychiatry services, and recommendations the [Spanish] Health System through an effective guarantee of and specialized publications on management systems were also the rights of citizens throughout the country” [1]. reviewed. Based on the results of this review [5-26], a first draft The specialty of psychiatry has not been unaffected by these of the survey was drawn up using the scorecards and indicators changes, and currently there are inter-Regional differences in of resources, processes, and results in AIPUs. Finally, this first the structure and care of psychiatric patients. This fact is draft was reviewed by the Scientific Committee, who selected understood by psychiatry professionals in Spain, who have what they considered to be the more important variables and stated in different forums and meetings that there is interest in indicators. The final questionnaire was included in the 123 Form generating a comprehensive overview of psychiatric care models Builder online survey platform [27]. The online version was and the performance of acute inpatient psychiatric units (AIPUs) also reviewed by the Scientific Committee to ensure that it was in Spain, integrating the different operating models in the easy to understand and complete. various Spanish Regions. Data Collection The present study was therefore proposed with the aim of The data collection period was open for more than 6 months, understanding the current state of AIPUs in Spain through a between July 2018 and January 2019. At beginning of this scorecard that allows the current situation to be visualized in period, emails were sent out to all the designated heads of the terms of resources, processes, and outputs. It will permit intra- AIPUs to introduce the study and to provide access to a link to and inter-Regional analysis of unmet needs, taking into the questionnaire. In order to obtain the most complete responses consideration the idiosyncrasies of each Region. Moreover, by possible, both in terms of the participating centers as well as comparing the strengths and weaknesses among Regions, the percentage of questions answered per questionnaire, a total benchmarking and therefore harmonization regarding Spanish of 10 general reminders were sent out via email to the units that AIPUs could be proposed to health care planners. Finally, the had not started or completed the questionnaire. After 4 weeks, https://www.researchprotocols.org/2021/4/e26214 JMIR Res Protoc 2021 | vol. 10 | iss. 4 | e26214 | p. 2 (page number not for citation purposes) XSL• FO RenderX JMIR RESEARCH PROTOCOLS Rodriguez-Jimenez et al personalized emails were sent out to the person in charge of the including data on the resources, processes, and results of the unit whenever a response was not obtained. AIPU, plus a General section asking for general and complementary information about the AIPU, with the aim of The online questionnaire sent out to the inpatient units of the collecting, in a structured manner, the most complete set of different Spanish Regions was divided into 11 sections, information on the units (see Table 1). Table 1. Survey sections and number of questions. Section Description Number of questions 1. Number of beds The number of beds available per 100,000 inhabitants 2 2. Multidisciplinary team of the AIPUa The number of staff available in each AIPU 9 3. Infrastructure and AIPU models The architectural structure, resources and the AIPU model: locked or nonlocked 19 4. Profiles of patients admitted to AIPUs Age, patients over 65 years old, patients with cognitive impairment, and patients under 8 18 years old 5. Access Organization of Care The route of referral to the AIPU, patient distribution, use of scales, questionnaires, 14 clinical guidelines, and standardized operating procedures 6. Specific interventions offered by the Specific interventions such as: medical interdisciplinary consultations, electroconvulsive 5 AIPU therapy, or transcranial magnetic stimulation 7. Integration and coordination of the AIPU The integration and coordination between the professionals that make up the AIPU and 1 also with other hospital services, as well as other levels of care 8. Participation of people with mental health The participation of the patients and their relatives in the decision processes and the use 5 problems and their relatives of satisfaction questionnaires for patients and relatives 9. Activity of the AIPU Markers of activity such as total admissions per 100,000 inhabitants, ratio of total planned 6 vs emergency admissions, ratio of voluntary vs nonvoluntary admissions, percentage of admissions per diagnostic group, mean stay, readmissions (at 7 and 30 days), voluntary discharges 10. Training Number of staff taking part in teaching activities, as well as the number of medical and 3 nursing students 11. Research The participation of the AIPU in public and private research, development, and innovation 4 General and complementary information Hospital type, participant profile, quality indicators, and best practices 28 a AIPU: acute inpatient psychiatric unit. The survey included a combination of dichotomous (yes/no) Processes and Outputs and multiple-choice questions, questions asking for specific To obtain the profiles of patients admitted to AIPUs [25], data data or figures, and open questions requiring free-text responses. were collected on patient age, percentage of patients over 65 The results of the survey are presented as mean and standard years old, percentage of patients with cognitive impairment, deviation for quantitative results and as percentages in the case and the percentage of patients under 18 years old. of qualitative variables. Data for Spain as a whole and for each Spanish Region are presented. Regarding access and organization of care [16,17], the following were analyzed: the route of referral to the AIPU (emergency Variables Collected Through the Questionnaire services, mental health center, other services, outpatient clinics, AIPU Resources primary care, other), criteria used by AIPU staff to distribute patients who are admitted, use of validated scales and The number of beds available per 100,000 inhabitants was questionnaires in the patient assessment, use of clinical collected [5]. To assess the multidisciplinary team of the AIPU guidelines, and application of standardized operating procedures [10], the number of staff available in each AIPU to attend to (such as suicide risk prevention, immobilization, inpatient patients with mental health problems during their hospital stay admission process, electroconvulsive therapy, prevention of was analyzed. The teams that make up the AIPU were usually unplanned departure from inpatient care, treatment with professionals from psychiatry, nursing, psychology, social work, clozapine). and occupational therapy. Full-time equivalent data were studied, corresponding to full-time staff. In addition to the treatment of inpatients, we collected information on the specific interventions offered by the AIPU Regarding the infrastructure and AIPU models [22], the [13-15]: medical interdisciplinary consultations for hospitalized architectural structure was studied: availability of individual or patients, electroconvulsive therapy, and transcranial magnetic shared rooms; square meterage; and availability of meeting stimulation. Data on access to different pharmacological options rooms, cafeterias, and visiting room. The AIPU model was also for the control of agitation were also collected, as well as access collected: locked or nonlocked units. https://www.researchprotocols.org/2021/4/e26214 JMIR Res Protoc 2021 | vol. 10 | iss. 4 | e26214 | p. 3 (page number not for citation purposes) XSL• FO RenderX JMIR RESEARCH PROTOCOLS Rodriguez-Jimenez et al to different extended-release antipsychotic drugs for treatment Regarding training [17,19,25], data on the number of staff, as during hospitalization. well as the number of medical and nursing students, taking part in teaching activities were collected. The integration and coordination between the professionals that make up the AIPU [11,20], as well as the possible forms of To assess research [17,19,25], participation of the AIPU in communication, were studied (face-to-face meetings, clinical Research, Development and Innovation (R&D&i) projects and sessions, telephone, email, electronic health records, the type of funding were analyzed. We also examined the videoconference, others). Information was noted on the number of staff from the AIPU who are integrated in established coordination with other hospital services (eg, internal medicine, research structures such as the Carlos III Health Institute, neurology, anesthesiology), as well as other levels of care, such Biomedical Research Networking Center for Mental Health as mental health centers, medium-to-long stay units, outpatient Network (CIBERSAM), and Network of Research on Addictive hospitals, drug-dependency care networks, and primary care. Disorders (Red de Investigación en Trastornos Adictivos). Finally, data on referrals at discharge were also collected. Finally, the different lines of research carried out by the AIPU were collected. The existence of official tools for the participation of the relatives or guardians of patients with mental health issues admitted to the AIPU [6-9], such as personal interviews, Results informed consent, and written material specifically for good A total of 195 AIPUs were identified in the 17 regions. The communication with relatives or guardians as well as the patient, designated person in charge of each unit was informed and was collected. Data on the use of satisfaction questionnaires for invited to participate in the study. Finally, information was patients and relatives were also compiled. obtained from 117 AIPUs throughout Spain, providing relevant The following activity markers of the AIPU [16-19,21-25] were data on resources and activity; this indicates participation by collected: total admissions to AIPU per 100,000 inhabitants, 60.0% of the identified units. This general response rate, at a ratio of total planned vs emergency admissions, ratio of 95% confidence level, had a margin of error or confidence voluntary vs nonvoluntary admissions, percentage of admissions interval of 6%. A representation of units from all Regions was per diagnostic group, mean length of stay, adjusted mean stay achieved (see Figure 1). index, readmissions to the AIPU (at 7 and 30 days), and voluntary discharges. Figure 1. Distribution of the contacted acute inpatient psychiatric units (AIPUs) and participation rates per Region. In most cases, the contact and request for participation were the center, 83.8% (98/117) were in public hospitals. Last, with made through the heads of psychiatry services or departments regards to the hospital size, it should be noted that, although and coordinators of the AIPU; in 70.8% (83/117) of cases, the the majority of participating units (54/117, 46%) were located person who filled out the questionnaire was the coordinator of in medium-size hospitals (from 201 to 500 beds, known as group the AIPU. 2 in Spain), the questionnaire was completed by units of hospitals with less than 200 beds (group 1), accounting for 17% According to the functional purpose of the hospital where they (20/117) of all units, and units belonging to hospitals with are located, 87.2% (102/117) of the participating AIPUs were 500-1000 beds (group 3), accounting for 32% (37/117) of all located in general hospitals, while 12.8% (15/117) belonged to units. Only 5% (6/117) of the participating units were found in psychiatric hospitals. In terms of the functional dependency of hospitals with more than 1000 beds (group 4; see Figure 2). https://www.researchprotocols.org/2021/4/e26214 JMIR Res Protoc 2021 | vol. 10 | iss. 4 | e26214 | p. 4 (page number not for citation purposes) XSL• FO RenderX JMIR RESEARCH PROTOCOLS Rodriguez-Jimenez et al Figure 2. Profile of the units that completed the acute inpatient psychiatric unit (AIPU) questionnaire. centers, both general and specialized hospitals, and the Discussion participation of hospitals with different numbers of beds. The aim of this study was to understand the current state of These findings will allow us to present the ways in which AIPUs AIPUs in Spain through a scorecard that allows the current in Spain function and to examine the structural and functional situation to be visualized in terms of resources, processes, and differences among the different Spanish Regions (and could outputs in the different Spanish Regions. It will permit intra- also allow comparison with other countries). Analysis of these and inter-Regional analysis and could provide data for future results will allow areas of improvement to be identified for comparisons with other countries. which possible actions may be designed in response and whose We estimate that 60.0% (117/195) of all Spanish AIPUs implementation will have a positive impact on the working of provided data to this study, which means that the results obtained the AIPU. At the same time, it will also enable us to lay down in the different areas studied are quite representative of the the foundations for a continuous monitoring system that will reality of the situation of these units in Spain. This is also allow the measurement of said impact. Accordingly, we hope supported by the participation of AIPUs from all Regions, as that our findings will enable us to draw conclusions to help us well as a high level of participation of AIPUs from public achieve excellence in the planning of health care for mental health patients and their families and friends. Acknowledgments This work was possible thanks to the invaluable collaboration of the professionals from the 117 AIPUs that have collaborated, contributing data to the comparative analysis of units. We especially want to thank you for your time and dedication to the project. This project had the support of the Otsuka-Lundbeck Alliance, consisting of companies that fund this vision and approach to mental health. Conflicts of Interest Author RR-J has been a consultant for, spoken in activities of, or received grants from Instituto de Salud Carlos III, Fondo de Investigación Sanitaria (FIS), Centro de Investigación Biomédica en Red de Salud Mental (CIBERSAM), Madrid Regional Government (S2010/ BMD-2422 AGES; S2017/BMD-3740), JanssenCilag, Lundbeck, Otsuka, Pfizer, Ferrer, Juste, Takeda, Exeltis, Angelini, and Casen-Recordati. Author MF-M is involved in clinical trials and research projects funded by Janssen, Otsuka, Lundbeck, Roche, Acadia, Pfizer, Exeltis, and Servier. None of the other authors have any conflicts of interest. References https://www.researchprotocols.org/2021/4/e26214 JMIR Res Protoc 2021 | vol. 10 | iss. 4 | e26214 | p. 5 (page number not for citation purposes) XSL• FO RenderX JMIR RESEARCH PROTOCOLS Rodriguez-Jimenez et al 1. Act 16/2003 on the Cohesion and Quality of the National Health System. Ministerio de Sanidad. 2003 May 28. 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URL: https://www.123formbuilder.com/es [accessed 2021-03-21] Abbreviations AIPU: acute inpatient psychiatric unit Edited by G Eysenbach; submitted 03.12.20; peer-reviewed by M Alvarez de Mon, MA Bahrami; comments to author 28.01.21; revised version received 11.03.21; accepted 17.03.21; published 07.04.21 Please cite as: Rodriguez-Jimenez R, Corripio I, Campos R, Páramo M, Franco-Martin M, Segura E, González S, Martínez-Raga J Structure and Functioning of Acute Inpatient Psychiatric Units in Spain: Qualitative Study JMIR Res Protoc 2021;10(4):e26214 URL: https://www.researchprotocols.org/2021/4/e26214 doi: 10.2196/26214 PMID: 33729167 ©Roberto Rodriguez-Jimenez, Iluminada Corripio, Ricardo Campos, Mario Páramo, Manuel Franco-Martin, Estefanía Segura, Sergio González, José Martínez-Raga. Originally published in JMIR Research Protocols (http://www.researchprotocols.org), 07.04.2021. 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