High and Intensive Care in Psychiatry: Validating the HIC Monitor as a Tool for Assessing the Quality of Psychiatric Intensive Care Units

An Integrative Review on Psychiatric Intensive Care

Psychiatric intensive care units (PICUs) provide care and treatment when psychiatric symptoms and behaviors exceed general inpatient resources. This integrative review aimed to synthesize PICU research published over the past 5 years. A comprehensive search in MEDLINE, PsycINFO, PubMed and Scopus identified 47 recent articles on PICU care delivery, populations, environments, and models. Research continues describing patient demographics, and high rates of challenging behaviors, self-harm, and aggression continue being reported. Research on relatives was minimal. Patients describe restrictive practices incongruent with recovery philosophies, including controlling approaches and sensory deprivation. Some initiatives promote greater patient autonomy and responsibility in shaping recovery, yet full emancipatory integration remains limited within PICU environments. Multidisciplinary collaboration is needed to holistically advance patient-centered, equitable, and integrative PICU care. This review reveals the complex tensions between clinical risk management and emancipatory values in contemporary PICU settings. Ongoing reporting of controlling practices counters the recovery movement progressing in wider mental healthcare contexts. However, care innovations centered on patient empowerment and humane environments provide hope for continued evolution toward more liberation-focused PICU approaches that uphold both patient and provider perspectives.

Nurses' and Patients' Perceptions about Psychiatric Intensive Care-An Integrative Literature Review

This integrative literature review describes nurses's and patients' perceptions of care in psychiatric intensive care units (PICU). The database search was conducted in April 2020. PRISMA checklist and Mixed Method Appraisal Tool guided the identification and evaluation of the studies (n = 21). Data was analyzed with qualitative content analysis. Nurses perceived PICU as a challenging work environment where their primary task was to ensure the unit's safety. Patients views on their treatment varied from positive to negative. Patients wished to have more privacy and supportive interaction. Findings can be used as a basis in developing care practices and staff's further education in PICUs.

The Active Recovery Triad monitor: evaluation of a model fidelity scale for recovery-oriented care in long-term mental health care settings

OBJECTIVE

The Active Recovery Triad (ART) model is a recently developed care model for people who are admitted to an institutional setting for several years and receive 24-h mental health care and support. This study focuses on the ART monitor, a model fidelity scale that measures the degree of compliance with the ART model. Our aim is to evaluate the psychometric properties of the ART monitor and to further improve the instrument.

METHODS

Fifteen teams at the start (n = 7, group 1) or in the process (6 months to three years) of implementing care according to the ART model (n = 8, group 2) were audited using the ART monitor. Auditors were trained care workers, peer workers, and family peer workers. Auditors and team members provided feedback on the instrument. The content validity, construct validity and inter-rater reliability of the ART monitor were investigated. Based on the outcomes of these psychometric properties, the ART monitor was finalized.

RESULTS

Regarding content validity, auditors and teams indicated that they perceived the ART monitor to be a useful instrument. In terms of construct validity, a significant difference (t(13) = 2.53, p < 0.05) was found between teams at the start of the implementation process (group 1, average score of 2.42 (SD = 0.44)) and teams with a longer duration of implementation (group 2, average score of 2.95 (SD = 0.37)). When allowing for a one-point difference in scores, 88% of the items had an inter-rater agreement over 65%. Items with a relatively low inter-rater reliability, in combination with feedback from auditors and teams regarding content validity, provided direction for further improvement and revision of the instrument.

CONCLUSIONS

We concluded that the revised ART monitor is feasible and useful in mental health care practice. However, further evaluation of its psychometric properties will be needed.

Protocol for the Lovisenberg Open Acute Door Study (LOADS): a pragmatic randomised controlled trial to compare safety and coercion between open-door policy and usual-care services in acute psychiatric inpatients

INTRODUCTION

The reduction of coercion in psychiatry is a high priority for both the WHO and many member countries. Open-door policy (ODP) is a service model for psychiatric ward treatment that prioritises collaborative and motivational measures to better achieve acute psychiatric safety - and treatment objectives. Keeping the ward main door open is one such measure. Evidence on the impact of ODP on coercion and violent events is mixed, and only one randomised controlled trial (RCT) has previously compared ODP to standard practice. The main objectives of the Lovisenberg Open Acute Door Study (LOADS) are to implement and evaluate a Nordic version of ODP for acute psychiatric inpatient services. The evaluation is designed as a pragmatic RCT with treatment-as-usual (TAU) control followed by a 4-year observational period.

METHODS AND ANALYSIS

In this 12-month pragmatic randomised trial, all patients referred to acute ward care will be randomly allocated to either TAU or ODP wards. The primary outcome is the proportion of patient stays with one or more coercive measures. Secondary outcomes include adverse events involving patients and/or staff, substance use and users' experiences of the treatment environment and of coercion. The main hypothesis is that ODP services will not be inferior to state-of-the art psychiatric treatment. ODP and TAU wards are determined via ward-level randomisation. Following conclusion of the RCT, a longitudinal observational phase begins designed to monitor any long-term effects of ODP.

ETHICS AND DISSEMINATION

The trial has been approved by the Regional Committees for Medical and Health Research Ethics (REC) in Norway (REC South East #29238), who granted LOADS exemption from consent requirements for all eligible, admitted patients. Data are considered highly sensitive but can be made available on request. Results will be published in peer-reviewed journals and presented at scientific conferences and meetings.

TRIAL REGISTRATION NUMBER

ISRCTN16876467.

PROTOCOL VERSION

1.4, 21 December 2021.

The Forensic High and Intensive Care Monitor: Measurement Properties of a Model Fidelity Scale for Contact-Based Care in Forensic Psychiatry

Forensic High and Intensive Care (FHIC) has recently been developed as a new care model in Dutch forensic psychiatry. FHIC aims to provide contact-based care. To support Dutch forensic care institutions in the implementation of the model, a model fidelity scale was developed called the FHIC monitor. The aim of this study was to assess the inter-rater reliability, content validity, and construct validity of the FHIC monitor. A multi-methods design was used, combining qualitative and quantitative research. To collect data, audits and focus group meetings were organized to score care at individual wards with the monitor and get feedback from auditors and audit receiving teams about the quality of the monitor. In total, fifteen forensic mental healthcare institutions participated. The instrument showed acceptable inter-rater reliability and content validity, and a significant difference between expected high and low scoring institutions, supporting construct validity. The instrument can be used as a valid instrument to measure the level of implementation of the FHIC model on forensic psychiatric wards in the Netherlands.

"Disruptive Behavior" or "Expected Benefit" Are Rationales of Seclusion Without Prior Aggression

OBJECTIVE

In the Netherlands, seclusion of patients with a psychiatric disorder is a last-resort measure to be used only in the event of (imminent) severe danger or harm. Although aggressive behavior is often involved, seclusions not preceded by aggression also seem to occur. We sought insight into the non-aggressive reasons underlying seclusion and investigated the factors associated with it.

METHOD

We included all patients admitted to a Dutch psychiatric hospital in 2008 and 2009. Seclusions had been registered on Argus-forms, and aggression incidents had been registered on the Staff Observation Aggression Scale-Revised (SOAS-R), inspectorate forms and/or patient files. Determinants of seclusion with vs. without prior aggression were analyzed using logistic regression. Reasons for seclusion without prior aggression were evaluated qualitatively and grouped into main themes.

RESULTS

Of 1,106 admitted patients, 184 (17%) were secluded at some time during admission. Twenty-one (11.4%) were excluded because information on their seclusion was lacking. In 23 cases (14%), neither SOAS-R, inspectorate forms nor individual patient files indicated any aggression. Univariable and multivariable regression both showed seclusion without preceding aggression to be negatively associated with daytime and the first day of hospitalization. In other words, seclusion related to aggression occurred more on the first day, and during daytime, while seclusion for non-aggressive reasons occurred relatively more after the first day, and during nighttime. Our qualitative findings showed two main themes of non-aggressive reasons for seclusion: "disruptive behavior" and "beneficial to patient."

CONCLUSION

Awareness of the different reasons for seclusion may improve interventions on reducing its use. Thorough examination of different sources showed that few seclusions had not been preceded by aggression. The use of seclusion would be considerably reduced through interventions that prevent aggression or handle aggression incidents in other ways than seclusion. However, attention should also be paid to the remaining reasons for seclusion, such as handling disruptive behavior and focusing on the beneficial effects of reduced stimuli. Future research on interventions to reduce the use of seclusion should not only aim to reduce seclusion but should also establish whether seclusions preceded by aggression decrease different from seclusions that are not preceded by aggression.

Measuring Seclusion in Psychiatric Intensive Care: Development and Measurement Properties of the Clinical Seclusion Checklist

Background: Acute psychiatric units in general hospitals must ensure that acutely disturbed patients do not harm themselves or others, and simultaneously provide care and treatment and help patients regain control of their behavior. This led to the development of strategies for the seclusion of a patient in this state within a particular area separated from other patients in the ward. While versions of this practice have been used in different countries and settings, a systematic framework for describing the various parameters and types of seclusion interventions has not been available. The aims of the project were to develop and test a valid and reliable checklist for characterizing seclusion in inpatient psychiatric care. Methods: Development and testing of the checklist were accomplished in five stages. Staff in psychiatric units completed detailed descriptions of seclusion episodes. Elements of seclusion were identified by thematic analysis of this material, and consensus regarding these elements was achieved through a Delphi process comprising two rounds. Good content validity was ensured through the sample of seclusion episodes and the representative participants in the Delphi process. The first draft of the checklist was revised based on testing by clinicians assessing seclusion episodes. The revised checklist with six reasons for and 10 elements of seclusion was tested with different response scales, and acceptable interrater reliability was achieved. Results: The Clinical Seclusion Checklist is a brief and feasible tool measuring six reasons for seclusion, 10 elements of seclusion, and four contextual factors. It was developed through a transparent process and exhibited good content validity and acceptable interrater reliability. Conclusion: The checklist is a step toward achieving valid and clinically relevant measurements of seclusion. Its use in psychiatric units may contribute to quality assurance, more reliable statistics and comparisons across sites and periods, improved research on patients' experiences of seclusion and its effects, reduction of negative consequences of seclusion, and improvement of psychiatric intensive care.

Communities of Practice in Acute and Forensic Psychiatry: Lessons Learned and Perceived Effects

In the Netherlands, two new approaches have been developed for acute and forensic psychiatry, called High and Intensive Care (HIC) and Forensic High and Intensive Care (FHIC). The models provide standards for temporary high-quality clinical care for patients in crisis and combine practices to reduce seclusion. To support the implementation of these approaches, Communities of Practice (CoPs) were created, including peer providers, mental health nurses, psychiatrists and managers. CoPs are increasingly used in healthcare. However, CoPs vary greatly in form and objective, and more insight is needed in the organisation and facilitation of CoPs. Therefore, the aim of this study is to gain insight into the lessons learned and perceived effects of the CoPs. A qualitative approach was used. Data were collected through focus groups (n = 3) with participants in the CoPs, feedback meetings with teams implementing HIC (n = 78) or FHIC (n = 23), and observations by the researchers. Data were analysed thematically. Lessons learned are: 1) create an ambassador role for CoP participants, 2) organize concrete activities, 3) take care of a multidisciplinary composition, and 4) foster shared responsibility and work on sustainability. Perceived effects of the CoPs were: 1) support of HIC and FHIC implementation, 2) creation of a national movement, and 3) further development of the HIC and FHIC approaches. The audits served as an important vehicle to activate the CoPs, and stimulated the implementation of HIC and FHIC. The findings may help others in creating a CoP when it comes to the implementation of best practices and improving healthcare.

Implementation of High and Intensive Care (HIC) in the Netherlands: a Process Evaluation

The High and Intensive Care model (HIC) was developed to reduce coercion and improve the quality of acute mental health care in the Netherlands. This study aimed to identify drivers of change which motivate professionals and management to implement HIC, and to identify facilitators and barriers to the implementation process. 41 interviews were conducted with multiple disciplines on 29 closed acute admission wards for adult psychiatric patients of 21 mental healthcare institutions in the Netherlands. The interviews were analysed by means of thematic analysis, consisting of the steps of open coding, axial coding and selective coding. Findings reveal three major drivers of change: the combination of existing interventions in one overall approach to reduce coercion, the focus on contact and cooperation and the alignment with recovery oriented care. Facilitators to implementation of HIC were leadership, involving staff, making choices about what to implement first, using positive feedback and celebrating successes, training and reflection, and providing operationalizable goals. Barriers included the lack of formal organizational support, resistance to change, shortage of staff and use of flex workers, time restraints and costs, lack of knowledge, lack of facilities, and envisaged shortcomings of the HIC standards. Drivers of change motivate staff to implement HIC. In the process of implementation, attention to facilitators and barriers on the level of culture, structure and practice is needed.

High and Intensive Care in Psychiatry: A New Model for Acute Inpatient Care

In response to three reforms in Dutch mental health care, an organizational framework, including methods and interventions, was developed as part of a new model for acute inpatient care. Core elements of high and intensive care (HIC) include preventing seclusion by means of a stepped-care principle; a six-step process of admission, treatment, and care; combining medical and recovery approaches; combining professional and experiential knowledge; and providing a healing environment. The HIC model differs from the utilization of psychiatric intensive care units in that it focuses on collaboration with outpatient care; establishing contact between staff, patients, and relatives; and minimizing coercion.

Dealing with care disruption in High and Intensive Care wards: From difficult patients to difficult situations

High and Intensive Care is a relatively new care model in Dutch mental health care for clinical admissions. One of the goals is to keep the admission short. For some patients, this goal is not realized, which results in a long-term admission. Often, this is experienced as a disruption. Disruptions in care processes are frequently defined in terms of patient characteristics. Yet, it may be that other factors play a role. The aim of this study is to gain better insight into the perceptions of care professionals of what is characteristic for disruptions at High and Intensive Care wards and how professionals can deal with these. Qualitative research was performed by means of semi-structured interviews and a focus group with professionals. Results show that a focus on patient characteristics is too narrow and that other factors also play an important role. These factors include challenges in the relation between professionals and the patient, a divided team, and a lack of collaboration with ambulatory care. In order to deal with these factors, professionals should invest in the relationship with the patient, identify destructive team processes early, and improve communication with ambulatory care. It is recommended to develop a monitoring tool that includes all these factors. Another recommendation is to organize structured reflection on dilemmas experienced in care. In conclusion, this study shows the importance of going beyond patient characteristics in order to better understand, identify, and deal with disruption at High and Intensive Care wards.

The Compulsory Care Act: Early Observations and Expectations of In- or Outpatient Involuntary Treatment

BACKGROUND

On January 1, 2020, the Dutch Compulsory Care Act (WvGGZ) replaced the Special Admissions Act (BOPZ). While the old law only allowed compulsory treatment in hospitals, the new law allows it both inside and outside the hospital. Moreover, the new law prioritizes the patient's own opinion on coercive measures. By following patients' own choices, the Compulsory Care Act is hoped to lead to fewer admission days and less inpatient compulsory treatment in involuntarily admitted patients.

METHODS

We studied the seclusion and enforced-medication events before and after January 1, 2020, using coercive measures monitoring data in a Mental Health Trust. Trends in hours of seclusion and the number of enforced-medication events per month from 2012 to 2019 were compared with 2020. We used generalized linear models to perform time series analysis. Logistic regression analyses and generalized linear models were performed to investigate whether patient compilation determined some of the observed changes in seclusion use or enforced-medication events.

RESULTS

The mean number of hours of seclusion between 2012 and 2019 was 27,124 per year, decreasing from 48,542 in 2012 to 21,133 in 2019 to 3,844 h in 2020. The mean incidence of enforced-medication events between 2012 and 2019 was 167, increasing from 90 in 2012 to 361 in 2019 and then fell to 294 in 2020. In 2020, we observed 3,844 h of seclusion and 294 enforced-medication events. Near to no outpatient coercion was reported, even though it was warranted. The time series analysis showed a significant effect of the year 2020 on seclusion hours (β = -1.867; Exp(β) = 0.155, Wald = 27.22, p = 0.001), but not on enforced-medication events [β = 0.48; Exp(β) = 1.616, Wald = 2.33, p = 0.13].

DISCUSSION

There was a reduction in the number of seclusion hours after the introduction of the Compulsory Care Act. The number of enforced-medication events also increased from a very low baseline, but from 2017 onwards. To see whether these findings are consistent over time, they need to be replicated in the near future.

CONCLUSION

We observed a significant increase in enforced-medication use and a decrease in seclusion hours. The year 2020 predicted seclusion hours, but not enforced-medication events.

Does high and intensive care reduce coercion? Association of HIC model fidelity to seclusion use in the Netherlands

BACKGROUND

A new inpatient care model has been developed in the Netherlands: High and Intensive Care (HIC). The purpose of HIC is to improve quality of inpatient mental healthcare and to reduce coercion.

METHODS

In 2014, audits were held at 32 closed acute admission wards for adult patients throughout the Netherlands. The audits were done by trained auditors, who were professionals of the participating institutes, using the HIC monitor, a model fidelity scale to assess implementation of the HIC model. The HIC model fidelity scale (67 items) encompasses 11 domains including for example team structure, team processes, diagnostics and treatment, and building environment. Data on seclusion and forced medication was collected using the Argus rating scale. The association between HIC monitor scores and the use of seclusion and forced medication was analyzed, corrected for patient characteristics.

RESULTS

Results showed that wards having a relatively high HIC monitor total score, indicating a high level of implementation of the model as compared to wards scoring lower on the monitor, had lower seclusion hours per admission hours (2.58 versus 4.20) and less forced medication events per admission days (0.0162 versus 0.0207). The HIC model fidelity scores explained 27% of the variance in seclusion rates (p < 0.001). Adding patient characteristics to HIC items in the regression model showed an increase of the explained variance to 40%.

CONCLUSIONS

This study showed that higher HIC model fidelity was associated with less seclusion and less forced medication at acute closed psychiatric wards in the Netherlands.

Changes over time of the diagnostic and therapeutic characteristics of patients of a psychiatric intensive care unit in Austria

OBJECTIVE

The aim of this repeated cross-sectional study was to compare patients from a psychiatric intensive care unit (PICU) over ≫30 years regarding their diagnostic and therapeutic characteristics.

METHOD

Three samples including 100 consecutive inpatients each from the Viennese PICU were submitted to a chart review: sample no. 1 from the years 1985/86, no. 2 from 1995/96 and no. 3 from 2007/08.

RESULTS

Changes in referral modes were associated with a decrease of patients with substance induced disorders and an increase of patients with affective disorders over time. The rate of admissions after accidents and suicides was stable. The use of cranial MRI increased, while intravenous psychopharmacotherapy and parenteral nutrition decreased. Involuntary admission occurred in 43% and in 37% of patients physical restraints were necessary. We saw a shift from tricyclic antidepressants to SSRIs and SNRIs from sample 1 to 3. Likewise, we observed the emergence of atypical antipsychotics and a reduction of use of typical neuroleptics mainly from sample 2 to 3. The percentage of patients receiving benzodiazepines increased over time, while the mean dosage of benzodiazepines decreased. 7% of patients received electroconvulsive therapy.

CONCLUSIONS

The changes over time in our samples reflect the medical progress made during the last decades. Future studies should focus on evaluation of efficacy of psychiatric intensive care using standardized measurements.

Text Analysis of Electronic Medical Records to Predict Seclusion in Psychiatric Wards: Proof of Concept

Aim: With the introduction of "Electronic Medical Record" (EMR) a wealth of digital data has become available. This provides a unique opportunity for exploring precedents for seclusion. This study explored the feasibility of text mining analysis in the EMR to eventually help reduce the use of seclusion in psychiatry. Methods: The texts in notes and reports of the EMR during 5 years on an acute and non-acute psychiatric ward were analyzed using a text mining application. A period of 14 days was selected before seclusion or for non-secluded patients, before discharge. The resulting concepts were analyzed using chi-square tests to assess which concepts had a significant higher or lower frequency than expected in the "seclusion" and "non-seclusion" categories. Results: Text mining led to an overview of 1,500 meaningful concepts. In the 14 day period prior to the event, 115 of these concepts had a significantly higher frequency in the seclusion category and 49 in the non-seclusion category. Analysis of the concepts from days 14 to 7 resulted in 54 concepts with a significantly higher frequency in the seclusion-category and 14 in the non-seclusion category. Conclusions: The resulting significant concepts are comparable to reasons for seclusion in literature. These results are "proof of concept". Analyzing text of reports in the EMR seems therefore promising as contribution to tools available for the prediction of seclusion. The next step is to build, train and test a model, before text mining can be part of an evidence-based clinical decision making tool.