1 For relatively predictable trajectories of care ICPs can be effective in supporting proactive care management and ensuring that patients receive relevant clinical interventions and/or assessments in a timely manner. This can lead to improvements in service quality and service efficiency without adverse consequences for patients. 2 ICPs are an effective mechanism for promoting adherence to guidelines or treatment protocols thereby reducing variation in practice. 3 ICPs can be effective in improving documentation of treatment goals, documentation of communication with patients, carers and health professionals. 4 ICPs can be effective in improving physician agreement about treatment options. 5 ICPs can be effective in supporting decision-making when they incorporate a decision-aide. 6 The evidence considered in this review indicates that ICPs may be particularly effective in changing professional behaviours in the desired direction, where there is scope for improvement or where roles are new. 7 Even in contexts in which health professionals are already experienced with a particular pathway, ICP use brings additional beneficial effects in directing professional practice in the desired direction. 8 ICPs may be less effective in bringing about service quality and efficiency gains in variable patient trajectories. 9 ICPs may be less effective in bringing about quality improvements in circumstances in which services are already based on best evidence and multidisciplinary working is well established. 10 Depending on their purpose, the benefits of ICPs may be greater for certain patient subgroups than others. 11 We do not know whether the costs of ICP development and implementation are justified by any of their reported benefits. 12 ICPs may need supporting mechanisms to underpin their implementation and ensure their adoption in practice, particularly in circumstances in which ICP use is a significant change in organisational culture. 13 ICP documentation can introduce scope for new kinds of error. Conclusions  ICPs are most effective in contexts where patient care trajectories are predictable. Their value in settings in which recovery pathways are more variable is less clear. ICPs are most effective in bringing about behavioural changes where there are identified deficiencies in services; their value in contexts where inter-professional working is well established is less certain. None of the studies reviewed included an economic evaluation and thus it is not known whether their benefits justify the costs of their implementation.

1 In order to reduce anxiety, it is likely that patients will benefit psychologically from having the opportunity to listen to music in the immediate pre-procedural period. 2 Patients do not appear to experience any alteration in physiological status as a result of listening to music. 3 Further research is indicated in order to replicate existing studies, to strengthen the evidence to support such interventions and to establish intervention parameters. 4 Further research is needed analysing the physiological mechanisms by which music listening is believed to reduce state anxiety and the contribution of the automated and other nervous systems to this reduction.

BackgroundInpatient child and adolescent mental health services are one part of a complex system, and exist to meet the needs of young people with the greatest mental health difficulties.ObjectivesThe research question was ‘What is known about the identification, assessment and management of risk (where “risk” is broadly conceived) in young people (aged 11–18 years) with complex mental health needs entering, using and exiting inpatient child and adolescent mental health services in the UK?’Data sourcesThe two-phase Evidence for Policy and Practice Information and Co-ordinating Centre approach was used. In phase 1, scoping searches were made using two databases with an end date of March 2013. Phase 2 centred on the search for citations relating to the risks to young people of ‘dislocation’ and ‘contagion’. Searches were made using 17 databases, with time limits from 1995 to September 2013. Websites were searched, a call for evidence circulated and references of included citations reviewed.Review methodsPriority risk areas for phase 2 were decided in collaboration with stakeholders including through consultations with young people and the mother of a child who had been in hospital. All types of evidence relating to outcomes, views and experiences, costs and cost-effectiveness, policies, and service and practice responses in the areas of ‘dislocation’ and ‘contagion’ for young people (11–18 years) using inpatient mental health services were considered. A staged approach to screening was used. Data were extracted into tables following guidance from the Centre for Reviews and Dissemination or tables developed for the review. Quality was assessed using appraisal checklists from the Effective Public Health Practice Project or the Critical Skills Appraisal Programme or devised by previous reviewers. No papers were excluded on the grounds of quality, and all materials identified were narratively synthesised.ResultsIn phase 1, 4539 citations were found and 124 included. Most were concerned with clinical risks. In phase 2, 15,662 citations were found and 40 addressing the less obvious risks of ‘dislocation’ and ‘contagion’ were included, supplemented by 20 policy and guidance documents. These were synthesised using these categories: Dislocation: Normal Life; Dislocation: Identity; Dislocation: Friends; Dislocation: Stigma; Dislocation: Education; Dislocation: Families; and Contagion. No studies included an economic analysis or economic evaluation. The importance to stakeholders of these less obvious risks contrasted with the limited quantity and quality of research capable of informing policy, services and practice in these areas.LimitationsIncluded studies were of variable quality. Data derived could not be used to inform an economic modelling of NHS costs or to analyse cost-effectiveness. Other limitations were the search for only English-language materials and the use of umbrella concepts (‘dislocation’ and ‘contagion’).ConclusionsThe less obvious risks are important, but little evidence exists to support their identification, assessment and management. This has implications for services, and a programme of research is recommended to generate new knowledge.FundingThe National Institute for Health Research Health Services and Delivery Research programme.

BackgroundYoung people with complex or severe mental health needs sometimes require care and treatment in inpatient settings. There are risks for young people in this care context, and this study addressed the question: ‘What is known about the identification, assessment and management of risk in young people (aged 11–18) with complex mental health needs entering, using and exiting inpatient child and adolescent mental health services in the UK?’MethodsIn phase 1 a scoping search of two electronic databases (MEDLINE and PsychINFO) was undertaken. Items included were themed and presented to members of a stakeholder advisory group, who were asked to help prioritise the focus for phase 2. In phase 2, 17 electronic databases (EconLit; ASSIA; BNI; Cochrane Library; CINAHL; ERIC; EMBASE; HMIC; MEDLINE; PsycINFO; Scopus; Social Care Online; Social Services Abstracts; Sociological Abstracts; OpenGrey; TRiP; and Web of Science) were searched. Websites were explored and a call for evidence was circulated to locate items related to the risks to young people in mental health hospitals relating to ‘dislocation’ and ‘contagion’. All types of evidence including research, policies and service and practice responses relating to outcomes, views and experiences, costs and cost-effectiveness were considered. Materials identified were narratively synthesised.ResultsIn phase 1, 4539 citations were found and 124 items included. Most were concerned with clinical risks. In phase 2, 15,662 citations were found, and 40 addressing the risks of ‘dislocation’ and ‘contagion’ were included supplemented by 20 policy and guidance documents. The quality of studies varied. Materials were synthesised using the categories: Dislocation: Normal Life; Dislocation: Identity; Dislocation: Friends; Dislocation: Stigma; Dislocation: Education; Dislocation: Families; and Contagion. No studies included an economic analysis. Although we found evidence of consideration of risk to young people in these areas we found little evidence to improve practice and services.ConclusionsThe importance to stakeholders of the risks of ‘dislocation’ and ‘contagion’ contrasted with the limited quantity and quality of evidence to inform policy, services and practice. The risks of dislocation and contagion are important, but new research is needed to inform how staff might identify, assess and manage them.

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