Implementation of the Crisis Resolution Team model in adult mental health settings: a systematic review

Characteristics and results of comparison studies of two CRT models are summarised in Table 1. Of the five quantitative studies comparing two different CRT models, one [35] reported an association between the presence of a psychiatrist within the CRT and reduced hospital admissions (admissions reduced 40% (from 105 to 62), p < .0005). Harrison and colleagues [34] reported an association between extending direct referrals to primary care and a reduction in the proportion of CRT service users with severe and enduring mental illness and the mean duration of CRT care episodes (after introduction of primary care referrals, the percentage of people treated who had complex care needs reduced from 70% to 39%, p < 0.001). However the impact of this change in referral criteria on client or service outcomes was not evaluated. Three studies found no clear or significant difference between outcomes of the different CRT models regarding: organisational changes within the same team [31]; team opening times (9 am-5 pm versus 24-hours) [32]; and assessments by trainee psychiatrist versus by nurse practitioner [33].

Full results from studies comparing CRTs with TAU (standard care not including a CRT) are provided in Additional file 5: Table DS11. Of the 16 studies, 13 used hospital admission as an outcome. Nine out of these 13 studies found reduced hospital admissions with CRT care. Four out of 12 studies looking at bed days found reduced bed days with CRT care; a further study found a significantly lower number of bed days in CRT group than for standard care at six weeks but not maintained at six months; and another reported reduced bed days but with no significance value. Of the five studies measuring service user satisfaction, two did not find greater satisfaction for service users using CRT services, whilst three found significantly higher satisfaction rates for CRT service users than those accessing treatment as usual or another service.

Additional file 5: Table DS12 provides full details of the characteristics of services in studies comparing CRTs with TAU. Data extraction regarding CRT characteristics remained incomplete, despite efforts to contact authors in order to fill in gaps in information. From the available data, at least 16 of the 20 CRTs provided medical cover including a psychiatrist within the team, 14 functioned with a gatekeeping role, 13 ran a 24 hour service, 13 were multi-disciplinary, nine facilitated early discharge and five had staff ratios of at least 14 per 150,000. Table 2 below summarises study outcomes and the characteristics of services in studies with positive results and those without.

There was no obvious difference in study quality between studies reporting positive results and those not finding significant advantages to CRT care (median MMAT score of 3 for both). With the exception of staffing levels, where there was considerable missing data, in most studies the CRT was adhering to key elements of the original CRT model [2]. However, in the absence of any quantitative data synthesis, significant differences between effective and ineffective CRT services cannot be identified. No characteristic was consistently associated exclusively with better outcome or with no effect. The range of outcomes assessed was limited, with for example symptoms and quality of life not measured in most studies.

An English CRT survey [7] reported that CRTs which offered a 24 hour service were more effective in reducing hospital admissions than those only operating reduced hours (83% of primary care trusts with a CRT with 24-hours service showed a fall in total admissions, compared with 60% of trusts with no team and 74% of trusts with a CRT without a 24-hour service). However, a secondary analysis of this data [14] casts some doubt on whether CRTs were effective in reducing admissions and suggested that it was not possible to isolate the impact of CRTs independent of co-occurring local reductions in inpatient beds. A Norwegian CRT survey [19] provided inferential evidence in support of CRTs operating with extended opening hours and accepting self-referrals if they sought to focus on working with acutely unwell people (CRTs with extended opening hours accepted more severely ill service users (HoNOS score p < 0.001) than those operating office hours only). CRTs with longer opening hours accepted more severely unwell service users, while accepted service users who had self-referred were as severely unwell as those referred by health professionals (see Additional file 3: Table DS4). A study investigating the same cohort reported that a team focus on out-of-office contact (unstandardized multivariate regression coefficients 2.502, p = 0.016) and longer treatment times (unstandardized multivariate regression coefficients 0.068, p < 0.001) were predictors of favourable outcomes of crises [48].

Findings from surveys, interviews, focus groups and quantitative questionnaires are fully reported and displayed thematically in the table in Additional file 5: Table DS13. The characteristics most frequently identified by service users, carers and staff as important elements influencing CRT service quality are summarised in Table 3.

Additional file 5: Table DS14 reports the themes found in guidance and recommendations for CRTs in England. Documents included government and expert guidance publications, some of which are based on stakeholder groups such as NICE guidelines and reviews. Key elements of a CRT model which were specified in the original government mandatory guidelines regarding CRTs in England [2] were referenced in the documents, including: 24-hour, seven-day-a-week service; gatekeeping role; multidisciplinary teams; length of treatment; and staff numbers. The most common recommendations from CRT guidance are summarised in Table 4.

Other less frequent recommendations related to themes of medication management within the CRT; service user age and presentation to be served by the CRT; central location of the CRT; rapid assessment and acceptance of referrals from multiple sources; the role of medication, assessment, skilled staff, a team approach, short-term duration, location in the home and suitable referral to other services; content and process of care including risk, training and supervision, service user and carer involvement in care, and working with other services; risk policies and shared responsibilities; the extent of training and supervision of CRT staff; evaluation and monitoring to be carried out by the CRT; and joint working with other services. There was a high level of overlap and congruence between recommendations reported by statutory and by non-statutory organisations.