[DGPPN recommendations on quality indicators for schizophrenia]

Preventing, reducing, and attenuating restraint: A prospective controlled trial of the implementation of peer support in acute psychiatry

Introduction

The use of restraint as a means of managing patients is considered a critical factor that interferes with recovery. Strategies to create a less restrictive environment within psychiatric facilities are therefore eagerly sought. Peer support workers (PSWs) are increasingly employed in mental health settings. The prevailing theory is that PSWs have the potential to contribute to conflict and restraint prevention efforts in acute psychiatric wards. However, to date, research in support of this claim remains limited.

Objective

The present study aimed at assessing the effectiveness of employing peer support workers with regard to reducing the use of restraint.

Methods

This prospective controlled pre-post study sought to evaluate the implementation of peer support in one locked ward compared to treatment as usual (TAU) with no implementation of peer support in a second locked ward of a psychiatry department in Berlin, Germany. The pre-post comparison was planned to consist of two assessment periods of 3 months each, taking place directly before and after peer support implementation or TAU. Both assessments were extended to a period of 6 months, before and after the initially planned 12-month implementation process, in order to balance the effects of disruptions and of the COVID-19 pandemic. Using routine data, the proportion, frequency, and duration of mechanical restraint, forced medication as well as mechanical restraint in combination with forced medication, were evaluated.

Results

In the control group, an increase in the proportion of patients subjected to measures of restraint was found between pre- and post-assessment, which was accompanied by a further increase in the mean number of events of restraint per patient within this group. In the intervention group, no significant change in the application of restraint was observed during the study period.

Discussion

There is some indication that peer support may be protective with regard to restraint in acute wards. However, our study faced major challenges during the implementation process and the post-assessment period, such as COVID-19 and staff reorganization. This may have led to peer support not reaching its full potential. The relationship between the implementation of peer support and the use of restraint therefore merits further investigation.

[Experience-based items of quality in psychiatric treatment: A first multivariate construct]

In the context of psychiatric care, user-generated measurement instruments may contribute to quality development and assurance. An explorative construct of experience-related quality components was developed in participative-collaborative cooperation that grasps the users' experiences of psychiatric care. After developing the components using a grounded theory methodology, they were quantified, and their interrelations were investigated using a multidimensional scaling method to explore their internal cohesion. The construct makes it possible to separate structural from interpersonal requirements of the quality components. It further indicated which components are more feasible for the home treatment setting, and which ones for an institutional setting. The components and the construct may be perceived as first steps towards the development of user-generated quality indicators; however, further validation steps are necessary.

[Biometric properties of QUALIFY: a tool for assessing quality indicators]

INTRODUCTION

Accurate health care evaluation using quality indicators (QIs) is of vital clinical importance for a quality-oriented health care system. The QUALIFY tool is the current research standard for assessing QIs of health care; however, its biometric properties in psychiatry have not yet been evaluated empirically. Our aim was to evaluate the internal consistency and structure of QUALIFY.

METHODS

This study applies a literature-based post-hoc analytical design to a sample of 289 QIs of mental health care. First, the indicators were assessed on the basis of nineteen ordinal QUALIFY criteria as a single measuring tool. Second, using Cronbach's alpha the internal consistency of the measuring tool was evaluated and the structure of QUALIFY using an explorative principal component analysis was tested.

RESULTS AND DISCUSSION

The tool showed an acceptable internal consistency (Cronbach's α=0.75), with three criteria (consideration of potential risks/side effects when using the indicator, implementation barriers taken into account, and the ability to influence the indicator) being inconsistent with the full scale. If these three criteria were not taken into account, the tool had a good internal consistency (Cronbach's α=0.81). The QUALIFY structural matrix comprises three components, one of which reflected six from eight original quality criteria of the scientific category. The other two components represent the semiotic structure of the QIs.

CONCLUSION

QUALIFY is an internally inconsistent instrument, which may be useful to assess mental health care QIs. The information about the structure of QUALIFY can be applied for the purposes of research planning as well as the interpretation and development of QIs.

Forensische Modelle zur Gewaltprävention an der Schnittstelle zur Allgemeinpsychiatrie: der forensisch-psychiatrische Konsildienst

Obwohl bei einer Untergruppe psychisch kranker Menschen ein erhöhtes Gewaltrisiko verortet werden kann und Patienten der Maßregelvollzugskliniken in der Regel eine allgemeinpsychiatrische Vorgeschichte haben, existieren bislang nur vereinzelt präventiv ausgerichtete Behandlungsmodelle an der Schnittstelle zwischen forensischer und allgemeiner Psychiatrie. Im vorliegenden Artikel werden unterschiedliche Ansätze einer interdisziplinären Zusammenarbeit vorgestellt und das Angebot des forensisch-psychiatrischen Konsildiensts der Fachstelle Forensic Assessment & Risk Management (FFA) der Klinik für Forensische Psychiatrie (KFP) der Psychiatrischen Universitätsklinik Zürich (PUK) beschrieben.

[Revised S3 guidelines on schizophrenia : Developmental process and selected recommendations]

Schizophrenia is one of the most severe mental diseases and leads to significant personal and social impairments for affected persons. The illness is characterized by frequent relapses, results in increased mortality and is associated with the highest socioeconomic costs of all diseases. Moreover, patients with schizophrenia are often stigmatized in everyday life and also in most treatment settings. In 1998 the first German schizophrenia guidelines were published, followed by the first S3 guidelines for schizophrenia in 2006. The revision process started in 2012 coordinated by the German Association for Psychiatry, Psychotherapy and Psychosomatics (DGPPN) and the revised guidelines were published in 2019. The target group for the revised S3 guidelines includes all persons involved in the care of patients with schizophrenia in all sectors of the German healthcare system, including decision makers and insurance funds. Starting with an introduction of the biological, clinical and epidemiological basis of the disorder, recommendations for the diagnostics of schizophrenia, the detection of comorbidities, the use of antipsychotic medication and other somatic procedures, for psychotherapy, psychosocial interventions, handling of special treatment conditions and rehabilitation are made. Finally, recommendations for an evidence-based and optimal coordination within the healthcare system are made, followed by a discussion of the cost-effectiveness of treatment and presentation of strategies for improved quality management. The most important aspect of the revised S3 guidelines on schizophrenia is the multiprofessional cooperation in all phases of the disorder and an empathic and respectful therapeutic alliance.

[Staffing levels and patient-related outcomes : Systematic literature review on international evidence]

The objective of this study was to systematically review the international literature with respect to significant links between staffing levels or qualification on the one hand and patient-related outcomes on the other. Of the initial 7778 abstracts identified by means of a complex search strand in PubMed and CINAHL, 51 could finally be included in a qualitative synthesis. A total of nine different patient-related outcome categories with significant associations on an at least ordinally scaled level were distinguished. None of the studies included had a (quasi-)experimental research design. Despite, in some instances, high numbers of cases at multiple sites and efforts to control obvious confounding variables by regression analysis, no evidence-based conclusions for health policy or clinical practice can be drawn from the available observational studies. There is therefore a considerable need for prospective randomized or at least quasi-experimental studies also as accompanying research on novel models of financing.

[Frequency of coercive measures as a quality indicator for psychiatric hospitals?]

BACKGROUND

The percentage of patients subjected to coercive measures has been proposed as 1 of 10 quality indicators for psychiatric inpatient treatment by the German Association of Psychiatry, Psychotherapy and Psychosomatics (DGPPN). Internationally, there are similar recommendations and corresponding reporting systems.

METHODS

The registry of coercive measures of psychiatric hospitals in Baden-Württemberg that was established in 2015, yields the possibility to examine the appropriateness of this indicator, based on raw data of 108,863 cases in 2016. This study investigated how the indicator is influenced by patient variables and characteristics of hospital structure.

RESULTS

The percentage of cases exposed to coercive measures was strongly (r = 0.6) correlated with the percentage of involuntarily treated cases. With respect to the latter, hospitals varied widely with a range from 0.7% up to 24.1%. Specialized wards serving patients outside the catchment area with a high number of coercive measures also had a strong influence on the results of a benchmarking comparison.

CONCLUSION

The indicator is a good instrument for longitudinal evaluation of an institution; however, due to a high number of known and unknown confounding factors, it is inappropriate for the purpose of comparing psychiatric hospitals.