Characteristics of acute wards associated with the presence of a psychiatric intensive care unit, and transfers of patients to it

Comparing Attitudes to Containment Measures of Patients, Health Care Professionals and Next of Kin

Background: In clinical psychiatric practice, health care professionals (HCP) must decide in exceptional circumstances after the weighing of interests, which, if any, containment measures including coercion are to be used. Here, the risk for patients, staff, and third parties, in addition to therapeutic considerations, factor into the decision. Patients' preference and the inclusion of relatives in these decisions are important; therefore, an understanding of how patients and next of kin (NOK) experience different coercive measures is crucial for clinical decision making. The aim of this study is to compare how patients, HCP, and NOK assess commonly used coercive measures. Methods: A sample of 435 patients, 372 HCP, and 230 NOK completed the Attitudes to Containment Measures Questionnaire (ACMQ). This standardized self-rating questionnaire assessed the degree of acceptance or rejection of 11 coercive measures. Results: In general, HCPs rated the coercive measures as more acceptable than did NOK and patients. The largest discrepancy in the ratings was found in regard to the application of coercive intramuscular injection of medication (effect size: 1.0 HCP vs. patients). However, the ratings by NOK were significantly closer to the patients' ratings compared to patients and HCP. The only exception was the acceptance of treatment in a closed acute psychiatric ward, which was deemed significantly more acceptable by NOK than by patients. Also, patients who had experienced coercive measures themselves more strongly refused other measures. Conclusion: Patients most firmly rejected intramuscular injections, and the authors agree that these should only be used with reservation considering a high threshold. This knowledge about the discrepancy of the ratings should therefore be incorporated into professional training of HCP.

Seclusion and Psychiatric Intensive Care Evaluation Study (SPICES): combined qualitative and quantitative approaches to the uses and outcomes of coercive practices in mental health services

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.

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).

Design

The electronic patient record system at one trust was used to compare outcomes for patients who were and were not subject to seclusion or a PICU, controlling for variables, including recent behaviours. A cost-effectiveness analysis was performed (study 1). Nursing staff at eight hospitals with differing access to seclusion and a PICU completed attitudinal measures, a video test on restraint-use timing and an interview about the escalation pathway for the management of disturbed behaviour at their hospital. Analyses examined how results differed by access to PICU and seclusion (study 2).

Participants

Patients on acute wards or PICUs in one NHS trust during the period 2008–13 (study 1) and nursing staff at eight randomly selected hospitals in England, with varying access to seclusion and to a PICU (study 2).

Main outcome measures

Aggression, violence and cost (study 1), and utilisation, speed of use and attitudes to the full range of containment methods (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.

Limitations

Official record systems may be subject to recording biases and crucial variables may not be recorded (study 1). Interviews were complex, difficult, constrained by the need for standardisation and collected in small numbers at each hospital (study 2).

Conclusions

Closing seclusion rooms and/or restricting PICU access does not appear to reduce the overall levels of containment, as substitution of other methods occurs. Services considering expanding access to seclusion or to a PICU should do so with caution. More evaluative research using stronger designs is required.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

Acceptability and use of coercive methods across differing service configurations with and without seclusion and/or psychiatric intensive care units

Aims

The aim of this study was to compare across different service configurations the acceptability of containment methods to acute ward staff and the speed of initiation of manual restraint.

Background

One of the primary remits of acute inpatient psychiatric care is the reduction in risks. Where risks are higher than normal, patients can be transferred to a psychiatric intensive care unit or placed in seclusion. The abolition or reduction in these two containment methods in some hospitals may trigger compensatory increases in other forms of containment which have potential risks. How staff members manage risk without access to these facilities has not been systematically studied.

Design

The study applied a cross‐sectional design.

Methods

Data were collected from 207 staff at eight hospital sites in England between 2013 ‐ 2014. Participants completed two measures; the first assessing the acceptability of different forms of containment for disturbed behaviour and the second assessing decision‐making in relation to the need for manual restraint of an aggressive patient.

Results

In service configurations with access to seclusion, staff rated seclusion as more acceptable and reported greater use of it. Psychiatric intensive care unit acceptability and use were not associated with its provision. Where there was no access to seclusion, staff were slower to initiate restraint. There was no relationship between acceptability of manual restraint and its initiation.

Conclusion

Tolerance of higher risk before initiating restraint was evident in wards without seclusion units. Ease of access to psychiatric intensive care units makes little difference to restraint thresholds or judgements of containment acceptability.

Safewards: the empirical basis of the model and a critical appraisal

ACCESSIBLE SUMMARY

In the previous paper we described a model explaining differences in rates of conflict and containment between wards, grouping causal factors into six domains: the staff team, the physical environment, outside hospital, the patient community, patient characteristics and the regulatory framework. This paper reviews and evaluates the evidence for the model from previously published research. The model is supported, but the evidence is not very strong. More research using more rigorous methods is required in order to confirm or improve this model.

ABSTRACT

In a previous paper, we described a proposed model explaining differences in rates of conflict (aggression, absconding, self-harm, etc.) and containment (seclusion, special observation, manual restraint, etc.). The Safewards Model identified six originating domains as sources of conflict and containment: the patient community, patient characteristics, the regulatory framework, the staff team, the physical environment, and outside hospital. In this paper, we assemble the evidence underpinning the inclusion of these six domains, drawing upon a wide ranging review of the literature across all conflict and containment items; our own programme of research; and reasoned thinking. There is good evidence that the six domains are important in conflict and containment generation. Specific claims about single items within those domains are more difficult to support with convincing evidence, although the weight of evidence does vary between items and between different types of conflict behaviour or containment method. The Safewards Model is supported by the evidence, but that evidence is not particularly strong. There is a dearth of rigorous outcome studies and trials in this area, and an excess of descriptive studies. The model allows the generation of a number of different interventions in order to reduce rates of conflict and containment, and properly conducted trials are now needed to test its validity.