Background: Seclusion (the isolation of a patient in a locked room) and transfer to a psychiatric intensive care unit (PICU; a specialised higher-security ward with higher staffing levels) are two common methods for the management of disturbed patient behaviour within acute psychiatric hospitals. Some hospitals do not have seclusion rooms or easy access to an on-site PICU. It is not known how these differences affect patient management and outcomes.
Psychiatric Intensive Care
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Objectives: To (1) assess the factors associated with the use of seclusion and PICU care, (2) estimate the consequences of the use of these on subsequent violence and costs (study 1) and (3) describe differences in the management of disturbed patient behaviour related to differential availability (study 2).
Results: Patients subject to seclusion or held in a PICU were more likely than those who were not to be aggressive afterwards, and costs of care were higher, but this was probably because of selection bias. We could not derive satisfactory estimates of the causal effect of either intervention, but it appeared that it would be feasible to do so for seclusion based on an enriched sample of untreated controls (study 1). Hospitals without seclusion rooms used more rapid tranquillisation, nursing of the patient in a side room accompanied by staff and seclusion using an ordinary room (study 2). Staff at hospitals without seclusion rated it as less acceptable and were slower to initiate manual restraint. Hospitals without an on-site PICU used more seclusion, de-escalation and within-eyesight observation.
Our goal is to stabilize patients and minimize the risk of harm to themselves and others, while helping our community healthcare providers place their patients in facilities with the most appropriate and effective level of treatment.
Psychiatric intensive care units (PICUs) were designed to create a safe and controlled environment for the management of acutely disturbed psychiatric patients on a short-term basis, with high staffing levels and a limited number of beds. Admission and discharge criteria are usually clearly defined and the majority have locked doors. The average length of stay ranges from 2.6 days to 30 days, although there have been cases where approximately 20% of patients stayed for over 2 months.
The majority of PICUs reported in the literature provide care and treatment for non-offender patients with mental illness who cannot be managed in open wards. In the UK, intensive care for mentally disordered offenders is provided by the secure psychiatric services. Problems in the movement of patients through different levels of security, however, has led to the development of PICUs in some medium secure facilities.
Apart from the obvious need for medical treatment mainly with antipsychotic agents, it has been made very clear that anger management appears to be effective, as intensive, non punitive, and ability enhancing behavioural interventions can eliminate chronic violent behaviours even while psychotic symptoms, diverted sexuality and/or personality disorders remain. It is clear that anger management in conjunction with other interventions, within an already therapeutic milieu can make a significant contribution to the patients problematic behaviours. It is possible to pilot a continuous cycle of anger management sessions within a PICU with promising results .
b) Time: It is important to consider that many aggressive patients are presented to PICU from custodial or secure environments and as such many will struggle to adapt to the intensive pace of the PICU and group work. Therefore, tasks may take longer to complete and there may be some unwillingness to plan ahead. Knowing this possible effect and working with it within treatment is imperative to aid in the transition of each patient to the intensive and short term treatment plan of a PICU unit.
This study aims to validate the HIC monitor as a model-fidelity scale to the High and Intensive Care (HIC) model, a recently developed model for acute psychiatric wards. To assess the psychometric properties of the HIC monitor, 37 audits were held on closed inpatient wards at 20 psychiatric hospitals in the Netherlands. Interrater reliability, construct validity and content validity were examined. Our results suggest that the HIC monitor has good psychometric properties. It can be used as a tool for assessing the implementation of the HIC model on acute psychiatric wards in the Netherlands, and for quality assessment and improvement.
Quality of care in acute psychiatry is a subject of international debate. There are three main issues of concern: (1) prevention of coercion, especially seclusion (Huckshorn 2006; Noorthoorn et al. 2016; Steinert and Lepping 2009; Voskes et al. 2013); (2) improvement of continuity of care, particularly between in- and outpatient care (Bachrach 1981); and (3) fostering collaboration between mental healthcare professionals, patient, and relatives (Malm et al. 2015). In the Netherlands, patients are generally treated by ambulatory care teams, such as Active Community Treatment teams (ACT), Flexible Active Community Treatment teams (FACT), and by Intensive Home Treatment teams. Admissions to a psychiatric ward can be arranged by these teams, by the police or by psychiatric emergency services. Patients can be admitted to either an open ward or a closed ward in a psychiatric hospital. Currently, the number of beds on closed wards is declining and many open wards have already been closed, thereby increasing the pressure on the remaining wards and the need for quality standards. Over recent years, the High and Intensive Care (HIC) model has been developed to improve the quality of mental health care, specifically inpatient care. Representing a new approach to care, and also new material conditions (van Mierlo et al. 2013), the HIC model has been received with growing enthusiasm. By late 2016, 79% of mental healthcare institutions with closed acute admission wards had adopted it and had joined the HIC foundation to start implementing the model.
Data was collected on closed acute admission wards for adult psychiatric patients (aged 18 and older) in various mental healthcare institutions in the Netherlands. Patients admitted to these wards were in acute psychiatric crisis situations, many of whom were admitted involuntarily. The participating mental healthcare institutions all provided both inpatient and outpatient services. Although some larger mental healthcare institutions with bigger catchment areas have multiple acute admission wards, no other separate intensive inpatient units in acute psychiatric care for adults, such as PICU, exist in the Netherlands. The selection of wards was done by mental healthcare institutions that participated in the development and implementation of the HIC model. Each participating institution was asked to select two acute closed wards for adult patients in which they could implement the HIC model. As institutions implemented the HIC model at different times and in different phases, levels of implementation also differed.
Per audit, two auditors visited the ward simultaneously. Before the audit, the manager of the ward had used a questionnaire to collect basic information on team structure and the organization of care. At the ward, the auditors observed a multidisciplinary meeting in which staff discussed care for individual patients. They then interviewed nurses, medical staff, managers and one patient, and used a checklist to examine the health records. After the audit, each auditor independently filled in the score sheet for the HIC monitor, and sent it to the researchers. To ensure that inter-rater reliability was assessed correctly, the two auditors were not allowed to discuss the scores they gave.
Twenty-five large mental healthcare institutions in the Netherlands were asked to participate in this study. Twenty-one (84%) agreed, representing 79% of the total number of closed beds in acute psychiatric hospitals in the Netherlands. One institution was excluded, as it offered to participate with a single ward that specialized in addiction care. One ward at another institution was excluded from analysis, as it turned out to specialize in long-stay care rather than acute care. As 17 institutions participated with two wards, and three participated with one ward, the 20 institutions included represented a total of 37 wards. Twelve of these institutions provided one auditor, and five provided more than one. The audit team consisted of nurses, managers, psychiatrists, and policy officers. All auditors had clinical or managerial experience with acute psychiatric care.
Regarding the construct validity, our results showed that the HIC monitor can distinguish between the two groups of institutions, thereby demonstrating a measure of the level of implementation of the HIC model. As there are no other instruments to measure this level of implementation, this was the only way to obtain construct validity. As far as we know, the HIC monitor is the first instrument to assess implementation of a model for acute psychiatric wards. This means that there is no gold standard with which it can be compared.
The study had three main limitations. First, the wards where audits took place were selected by the participating mental healthcare institutions. Since the institutions differed in terms of the number of wards and of the extent to which the HIC model had been developed, they may have selected wards on which the implementation of the HIC model was best established, thus leaving worse performing wards out of the picture. If so, this might have given a more positive view of the development of the HIC model within those institutions. This does not affect the validation of the HIC monitor, even though both early and late implementing institutions may have chosen their best wards.
In conclusion, as a useful tool for assessing the level of implementation of the HIC model on acute psychiatric wards, the HIC monitor can be used for quality assessment and improvement. Our study shows that the HIC monitor has reasonably good psychometric properties. Due to the consensus that was sought during its development and validation, it is an instrument that corresponds closely to daily practice, and may thus benefit the implementation of the HIC model on acute psychiatric wards. As it can be used to study the associations between the components and outcomes of the HIC model (use of coercion, patient satisfaction), it can contribute to the improvement of quality of care for acute psychiatric patients. 2ff7e9595c
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