Five-year review of absconding in three acute psychiatric inpatient wards in Australia

Elopement: Evidence-based mitigation and management

BACKGROUND

Elopement jeopardizes patient safety, affects the hospital's reputation, and results in financial ramifications. In an academic community hospital, executive leadership approached a team of nurse leaders for expertise following the elopement of a vulnerable patient.

AIM OF THE INITIATIVE

The team's goal was to identify evidence-based strategies to mitigate future elopement events. Following an extensive literature review and gap analysis, the organization recognized opportunities pertaining to elopement management, including patient assessment, prevention strategies, and facility-wide response when events occur. The nurse leader team thoroughly searched current literature to answer the Population, Intervention, Comparison, and Outcome (i.e., PICO) questions of interest. Following a critical appraisal of 55 articles, 26 were utilized to make practice change recommendations. The body of evidence included a variety of age groups and diagnoses.

IMPLEMENTATION PLAN

After the synthesis of the literature, the team provided recommendations to the organization. These recommendations included the assessment of patient-specific risks and the implementation of elopement prevention measures as fundamental elements for incidence reduction. The team partnered with multidisciplinary stakeholders for the revision of policies, processes, and electronic medical record documentation.

OUTCOMES

The organization monitored elopement events and the duration of each event throughout the phases of implementation. Pre-implementation data, collected from January to June 2021, demonstrated 34 individual elopement cases lasting an average of 118 min each. In comparison, post-implementation data collected during the same time frame in 2022 found only 12 events lasting an average of 24 min each.

IMPLICATIONS FOR PRACTICE

The organization implemented evidence-based recommendations to standardize the facility's approach to elopement. With structured assessment, precautions, and response, the organization demonstrated a notable decline in the number and duration of elopement events. Hardwiring processes, analyzing data, and adjusting expectations within an evidence-based framework should assist the organization's drive to further enhance patient safety surrounding elopement events.

Prevalence and Risk Factors for Absconding from an Open-Door, No-Restraint Inpatient Psychiatric Unit: A Single-Center Study in Italy

Absconding from inpatient psychiatric services has been associated with poor outcomes, putting the patient and community at risk and prolonging the recovery process. A retrospective study investigated the absconding rates and risk factors among patients admitted to an open-door, no-restraint inpatient psychiatric unit. Overall, the absconding rate was 4.5%, and the relative risk of absconding was higher for male, younger, and non-Caucasian patients as well as for those who had already absconded, were unknown to health services, compulsorily admitted, admitted for substance abuse, and in the first days of hospitalization. The findings of this study may have important public health implications.

Reconsidering the ethics of compulsive treatment in light of clinical psychiatry: A selective review of literature

The ethics of compulsive treatment (CT) is a medical, social and legal discussion that reemerged after the ratification by 181 countries of the 2007 United Nations Convention on the Rights of Persons with Disabilities (UN-CRPD). The optional protocol of the UN-CRPD was ratified by 86 countries aiming to promote, protect and ensure the full and equal enjoyment of all human rights. It also determined the need to review mental health laws as under this light treatment of persons with disabilities, particularly those with mental disorders, cannot accept the use of CT. This selective review of literature aims to clarify inputs from clinical psychiatry adding evidence to the multi-disciplinary discussion. It provides contradictory evidence on how patients experience CT and its impact on their mental health and treatment programs, also which are main reasons for the use of CT and what efforts in psychiatry have been made to reduce, replace and refine it.

Reconsidering the ethics of compulsive treatment under the light of clinical psychiatry

The ethics of compulsive treatment (CT) is a medical, social and legal discussion that reemerged after the ratification by 181 countries of the 2007 United Nations Convention on the Rights of Persons with Disabilities (UN-CRPD). The optional protocol of the UN-CRPD was ratified by 86 countries aiming to promote, protect and ensure the full and equal enjoyment of all human rights. It also determined the need to review mental health laws as under this light treatment of persons with disabilities, particularly those with mental disorders, cannot accept the use of CT. This selective review of literature aims to clarify inputs from clinical psychiatry adding evidence to the multi-disciplinary discussion. It focuses on how patients experience CT and its impact on their mental health and treatment programs, the reasons for the use of CT versus voluntary treatment and what efforts have been made to reduce, replace and refine the presence of CT in psychiatry.

Reconsidering the ethics of compulsive treatment in light of clinical psychiatry: A selective review of literature

The ethics of compulsive treatment (CT) is a medical, social and legal discussion that reemerged after the ratification by 181 countries of the 2007 United Nations Convention on the Rights of Persons with Disabilities (UN-CRPD). The optional protocol of the UN-CRPD was ratified by 86 countries aiming to promote, protect and ensure the full and equal enjoyment of all human rights. It also determined the need to review mental health laws as under this light treatment of persons with disabilities, particularly those with mental disorders, cannot accept the use of CT. This selective review of literature aims to clarify inputs from clinical psychiatry adding evidence to the multi-disciplinary discussion. It provides contradictory evidence on how patients experience CT and its impact on their mental health and treatment programs, also which are main reasons for the use of CT and what efforts in psychiatry have been made to reduce, replace and refine it.

Absconding: A qualitative perspective of patients leaving inpatient psychiatric care

Absconding from inpatient psychiatric care is a complex problem with significant and broad ranging effects for patients, staff, family/carers, and the broader community. Absconding includes leaving the ward without permission and failing to return from leave at an agreed time. This study is a retrospective chart audit of a data set of absconding events from 11 psychiatric wards in a metropolitan Australian city. The data set included both quantitative and qualitative data. The focus of this study is analysis of the qualitative data documenting what happened during events, with quantitative data provided to contextualize the qualitative analysis. A total of 995 absconding events by 488 patients were reported between January 2016 and June 2018, representing a rate of 1.6 per 100 admissions. Two themes were identified in the qualitative analysis. 'Having things to do' encompassed opportunistic absconding and volitional absconding. 'Something changed' represented predisposing events that affected the absconding behaviour, such as being stepped down in care (moving from a more acute to a less acute psychiatric unit), receiving bad news, or interpersonal conflict either between patients or between nursing staff and patients. Results highlight the importance of harm minimization strategies to reduce the incidence of absconding.

The reasons why patients abscond from public hospitals in southeastern Iran: a qualitative study

BACKGROUND

Patient absconding from hospital is one of the permanent issues the hospitals face, which poses many risks and challenges to the patient, hospital, and society. The present study aimed to identify the reasons for patient absconding behavior for public hospitals in southeastern Iran.

METHODS

The present study is a qualitative study which was conducted at three public hospitals in southeastern Iran using purposive sampling through semi-structured interviews with 63 informants involved in patient treatment process. Data were analyzed using Colaizzi content analysis (CCA) method.

RESULTS

Three main themes of economic, social factors, and factors related to the hospital covering 15 subthemes were identified to explain the reasons for patients absconding behavior.

CONCLUSION

There are many reasons for reducing patients absconding from hospitals, and one of the main reasons is the patients' economic and social problems. The absconding behavior can lead to harm and problems for patients, and some emotional and occupational consequences for the employees and nurses. Paying attention to this issue and considering some courses of action to prevent patient absconding might lead to a considerable promotion of public trust and eliminate many problems for hospitals.

Escape and absconding among offenders with schizophrenia spectrum disorder - an explorative analysis of characteristics

BACKGROUND

Escape and absconding, especially in forensic settings, can have serious consequences for patients, staff and institutions. Several characteristics of affected patients could be identified so far, albeit based on heterogeneous patient populations, a limited number of possible factors and basal statistical analyses. The aim of this study was to determine the most important characteristics among a large number of possible variables and to describe the best statistical model using machine learning in a homogeneous group of offender patients with schizophrenia spectrum disorder.

METHODS

A database of 370 offender patients suffering from schizophrenia spectrum disorder and 507 possible predictor variables was explored by machine learning. To counteract overfitting, the database was divided into training and validation set and a nested validation procedure was used on the training set. The best model was tested on the validation set and the most important variables were extracted.

RESULTS

The final model resulted in a balanced accuracy of 71.1% (95% CI = [58.5, 83.1]) and an AUC of 0.75 (95% CI = [0.63, 0.87]). The variables identified as relevant and related to absconding/ escape listed from most important to least important were: more frequent forbidden intake of drugs during current hospitalization, more index offences, higher neuroleptic medication, more frequent rule breaking behavior during current hospitalization, higher PANSS Score at discharge, lower age at admission, more frequent dissocial behavior during current hospitalization, shorter time spent in current hospitalization and higher PANSS Score at admission.

CONCLUSIONS

For the first time a detailed statistical model could be built for this topic. The results indicate the presence of a particularly problematic subgroup within the group of offenders with schizophrenic spectrum disorder who also tend to escape or abscond. Early identification and tailored treatment of these patients could be of clinical benefit.

Absconding from Public Mental Health Inpatient Units - Who Does it, and why?

Patients who abscond from acute inpatient psychiatric wards put themselves and others at risks of variable nature and severity. There is a limited understanding of what motivates them to do so. The research in this area is limited and predominantly outdated. To better understand the characteristics, patterns and predictors of people who abscond from hospital, this study compared absconding and non-absconding patients in a tertiary public hospital. Demographic and clinical characteristics were audited for patients who absconded (n = 159) and who did not abscond (n = 100) throughout a 2-year period. Patients who absconded in the public settings were more likely to be male, have suffered from a psychotic illness, had an increased number of psychiatric comorbidities, had a history of aggression, and used greater numbers of substances. They also had experienced homelessness, were case managed, and were managed as involuntary patients. Predictors were similar, and included involuntary legal status, greater number of substances used, greater numbers of comorbid psychiatric illnesses, polysubstance use, an absence of self-harm history, shorter duration of admission and male sex. This study has implications for the identification of those who are at greater risk of absconding from an inpatient unit. Through enhanced understanding, greater measures can be taken to minimise absconding and its associated risks.

Characteristics and outcomes of Aboriginal and Torres Strait Islander patients with dialysis-dependent kidney disease in Australian Intensive Care Units

BACKGROUND

In Australia, 531 people per million population have dialysis-dependent Chronic Kidney Disease (CKD5D). The incidence is four times higher for Aboriginal and Torres Strait Islander (Indigenous) people compared to non-Indigenous Australians. CKD5D increases the risk of hospitalisation, admission to the Intensive Care Unit (ICU) and mortality compared to patients without CKD5D. There is limited literature describing short-term outcomes of patients with CKD5D who are admitted to ICU, comparing Indigenous and non-Indigenous patients.

AIMS

This registry-based retrospective cohort analysis compared demographic and clinical data between Indigenous and non-Indigenous patients with CKD5D and tested whether Indigenous status predicted short-term outcomes independently of other contributing factors. Adjusted hospital mortality was the primary outcome measure.

METHODS

Data were from the Australian and New Zealand Intensive Care Society's Centre for Outcome and Resource Evaluation Adult Patient Database. Australian ICU admissions between 2010 and 2017 were included. Data from 173 ICUs (2,136 beds) include 1,051,697 ICU admissions of which 23,793 had a pre-existing diagnosis of CKD5D.

RESULTS

Indigenous patients comprised 11.9% of CKD5D patients in ICU. CKD5D was prevalent among 4.9% of Indigenous and 2.9% of non-Indigenous ICU admissions. Indigenous patients were 13.5 years younger, had fewer comorbidities and lower crude mortality despite equivalent calculated mortality risk. After adjusting for age, remoteness and severity of illness, Indigenous status did not predict mortality.

CONCLUSIONS

Socioeconomic disadvantage contributes to earlier development of CKD5D and the over representation in ICU of Indigenous people. Mortality is equivalent once correcting for confounders, but addressing inequality requires strengthening preventative care. This article is protected by copyright. All rights reserved.

Absconding During Inpatient Care from a Tertiary Psychiatric Hospital: A Comparative Study

BACKGROUND

Absconding from psychiatric hospitals is of great concern for patients and caregivers. Absconding affects not only the treatment and safety of these patients but also patient's caregivers and the community. Further investigation is needed to examine the pattern of this event and the characteristics of patients who abscond. Hence, our study was aimed to examine the sociodemographic and clinical profiles of inpatients who absconded from a psychiatric hospital in five years and to compare them with matched controls.

METHODS

A retrospective chart review of inpatients who absconded and matched control inpatients during the specified period of five years from January 2014 to December 2018 was done at a psychiatric hospital. Each control was matched with a corresponding absconding case on the following order: (a) admission ward, (b) admission period, (c) diagnosis, and (d) age. Results: Among 20,052 adult admissions during the specified period, 38 patients absconded, with a rate of 1.8 per 1,000 admissions. Most of them were male, from a younger age group, diagnosed with schizophrenia or mood disorder, and having comorbid substance use disorder, irritable affect, impaired judgment, and absent insight. Most of the events occurred within the first two weeks of admission. About 11% of them had a history of prior absconding from the hospital.

CONCLUSION

Knowledge about the associated sociodemographic and clinical profile would help clinicians and mental health care professionals to prevent absconding. Further risk assessment using a patient's profile would help to reduce absconding events from psychiatric hospitals in the future.

Seeking freedom: A systematic review and thematic synthesis of the literature on patients' experience of absconding from hospital

WHAT IS KNOWN ON THE SUBJECT?: Absconding refers to patients leaving psychiatric hospitals in an unexpected and/or unauthorized way and is often recognized as a form of challenging behaviour. There is some research about the rates of absconding, risks associated with it and interventions to try and reduce it; however, relatively little is known about the experience from the perspective of patients and this evidence has not previously been systematically reviewed. WHAT THIS PAPER ADDS TO EXISTING KNOWLEDGE?: Patients abscond to find relief, to regain power and control over their lives and/or to address unmet needs. Absconding can therefore be viewed as a means of seeking freedom. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: Nurses need to be aware that absconding is a positive act from the patient perspective and work collaboratively with them to reduce factors which motivate this behaviour. From the point of admission, nurses have an important role to play in reducing the sense of fear, isolation and powerlessness which motivates patients to abscond. Practical interventions such as giving patients the time and information necessary to be involved in decision-making, or asking about their responsibilities and commitments outside of hospital, may have a significant impact on the experience of admission and reduce the risk of absconding. Abstract Introduction Absconding from psychiatric hospitals is associated with significant risks, but is difficult to assess. It is often considered a form of challenging behaviour for mental health nurses, yet there is little evidence considering the behaviour from the patient perspective. Aim To identify and review evidence pertaining to the experience of patients who abscond from hospital, paying particular attention to their reasons for doing so. Method A systematic review and thematic synthesis of eight peer-reviewed studies. Results The meaning patients associated with absconding is best characterized as an act of seeking freedom. Within this, four sub-themes were identified: 1) seeking freedom to find relief, 2) to regain power and control over their lives, 3) to address unmet needs and 4) opportunistically. Discussion Perspectives on absconding are markedly different between nurses and patients. Nurses may view absconding as challenging or deviant behaviour, whilst patients understand it as a positive experience. This is because the hospital environment is not meeting their needs. Implications for practice Patients decide to abscond from hospital for valid and rational reasons. Mental health nurses are in a position to understand and address the issues underpinning them with a view to reducing absconding. Further research on absconding from hospital, taking the patient's perspective, is needed.

Development of a checklist to aid in the assessment of 'failure to return' from approved leave by acute inpatients

Better assessment of consumer behaviour and intentions prior to the granting of approved leave may reduce failure to return from such episodes of leave. The aims of this study were (i) to gain consensus on the factors associated with failure to return, and (ii) use these factors to construct a checklist to aid in assessment of consumers prior to being granted leave. Following a review of the literature a pool of 36 factors was identified. These were then assessed for relevance to absconding from approved leave using a modified Delphi approach. After two Delphi rounds, 10 factors were retained and these were collapsed under 6 domains; history of absconding, current substance use, behaviour cues, verbal cues, lack of engagement, and changes in mental state. While staff reactions to the checklist were positive, further testing of its effectiveness in the clinical setting is required.

Perceptions of nurses working with psychiatric consumers regarding the elimination of seclusion and restraint in psychiatric inpatient settings and emergency departments: An Australian survey

Seclusion and restraint continue to be used across psychiatric inpatient and emergency settings, despite calls for elimination and demonstrated efficacy of reduction initiatives. This study investigated nurses' perceptions regarding reducing and eliminating the use of these containment methods with psychiatric consumers. Nurses (n = 512) across Australia completed an online survey examining their views on the possibility of elimination of seclusion, physical restraint, and mechanical restraint as well as perceptions of these practices and factors influencing their use. Nurses reported working in units where physical restraint, seclusion, and, to a lesser extent, mechanical restraint were used. These were viewed as necessary last resort methods to maintain staff and consumer safety, and nurses tended to disagree that containment methods could be eliminated from practice. Seclusion was considered significantly more favourably than mechanical restraint with the elimination of mechanical restraint seen as more of a possibility than seclusion or physical restraint. Respondents accepted that use of these methods was deleterious to relationships with consumers. They also felt that containment use was a function of a lack of resources. Factors perceived to reduce the likelihood of seclusion/restraint included empathy and rapport between staff and consumers and utilizing trauma-informed care principles. Nurses were faced with threatening situations and felt only moderately safe at work, but believed they were able to use their clinical skills to maintain safety. The study suggests that initiatives at multiple levels are needed to help nurses to maintain safety and move towards realizing directives to reduce and, where possible, eliminate restraint use.

Empathic processes during nurse-consumer conflict situations in psychiatric inpatient units: A qualitative study

Empathy is a central component of nurse-consumer relationships. In the present study, we investigated how empathy is developed and maintained when there is conflict between nurses and consumers, and the ways in which empathy can be used to achieve positive outcomes. Through semistructured interviews, mental health nurses (n = 13) and consumers in recovery (n = 7) reflected on a specific conflict situation where they had experienced empathy, as well as how empathy contributed more generally to working with nurses/consumers. Thematic analysis was used to analyse the data, utilizing a framework that conceptualizes empathy experiences as involving antecedents, processes, and outcomes. The central theme identified was 'my role as a nurse - the role of my nurse'. Within this theme, nurses focussed on how their role in managing risk and safety determined empathy experienced towards consumers; consumers saw the importance of nurse empathy both in conflict situations and for their general hospitalization experience. Empathy involved nurses trying to understand the consumer's perspective and feeling for the consumer, and was perceived by consumers to involve nurses 'being there'. Empathic relationships built on trust and rapport could withstand a conflict situation, with empathy a core component in consumer satisfaction regarding conflict resolution and care. Empathy allows the maintenance of therapeutic relationships during conflict, and influences the satisfaction of nurses and consumers, even in problematic situations. Nurse education and mentoring should focus on nurse self-reflection and building empathy skills in managing conflict.

Safety in psychiatric inpatient care: The impact of risk management culture on mental health nursing practice

The discourse of safety has informed the care of individuals with mental illness through institutionalization and into modern psychiatric nursing practices. Confinement arose from safety: out of both societal stigma and fear for public safety, as well as benevolently paternalistic aims to protect individuals from self‐harm. In this paper, we argue that within current psychiatric inpatient environments, safety is maintained as the predominant value, and risk management is the cornerstone of nursing care. Practices that accord with this value are legitimized and perpetuated through the safety discourse, despite evidence refuting their efficacy, and patient perspectives demonstrating harm. To illustrate this growing concern in mental health nursing care, we provide four exemplars of risk management strategies utilized in psychiatric inpatient settings: close observations, seclusion, door locking and defensive nursing practice. The use of these strategies demonstrates the necessity to shift perspectives on safety and risk in nursing care. We suggest that to re‐centre meaningful support and treatment of clients, nurses should provide individualized, flexible care that incorporates safety measures while also fundamentally re‐evaluating the risk management culture that gives rise to and legitimizes harmful practices.

Critical Incidents During Leave From an Australian Security Hospital - A 12 Year Audit

All critical incidents between 2003 and 2015 relating to leave episodes from the High Security Inpatient Services, Brisbane, Australia were audited. The audit found that since March 2003, when the High Security Inpatient Service opened, there was a very small number of critical incidents related to over 46,000 leave episodes. Of the 17 patients who went absent without permission over the 12-year study period, only 2 patients re-offended and 1 patient deliberately self-harmed during a leave episode. One patient assaulted his escort nurse during a leave and four patients attempted unsuccessfully to flee their escort nurses during escorted off-ground leave. No patient committed a serious violent offence and no patient committed suicide during an absence from leave. Only 4 of the 17 patients who went absent during leave between 2003 and 2015 remain as inpatients in the High Security Inpatient Service.

Suicide after absconding from inpatient care in England: an exploration of mental health professionals' experiences

BACKGROUND

Absconding from inpatient care is associated with suicide risk in psychiatric populations. However, little is known about the real world context of suicide after absconding from a psychiatric ward or the experiences of clinical staff caring for these patients.

AIMS

To identify the characteristics of inpatients who died by suicide after absconding and to explore these and further key issues related to suicide risk from the perspective of clinical staff.

METHODS

A mixed-methods study using quantitative data of all patient suicides in England between 1997 and 2011 and a thematic analysis of semi-structured interviews with 21 clinical staff.

RESULTS

Four themes were identified as areas of concern for clinicians: problems with ward design, staffing problems, difficulties in assessing risk, and patient specific factors.

CONCLUSIONS

Results suggest that inpatients who died by suicide after absconding may have more complex and severe illness along with difficult life events, such as homelessness. Closer monitoring of inpatients and access points, and improved risk assessments are important to reduce suicide in this patient group.

The impact of structured decision making on absconding by forensic psychiatric patients: results from an A-B design study

BACKGROUND

Few studies have investigated absconding from forensic hospitals and there are no published studies of interventions aimed at reducing these incidents in forensic settings. We present a study of the impact of a new policy using structured professional judgment and an interdisciplinary team-based approach to granting privileges to forensic patients. We assess the impact of this policy on the rate and type of absconding from a metropolitan forensic facility.

METHODS

Following concern about the rate of absconding at our hospital, a new policy was implemented to guide the process of granting hospital grounds and community access privileges. Employing an A-B design, we investigated the rate, characteristics, and motivations of absconding events in the 18 months prior to, and 18 months following, implementation of this policy to assess its effectiveness.

RESULTS

Eighty-six patients were responsible for 188 incidents of absconding during the 42-month study window. The rate of absconding decreased progressively from 17.8% of all patients at risk prior to implementation of the new policy, to 13.8% during implementation, and further to 12.0% following implementation. There was a differential impact of the policy on absconding events, in that the greatest reduction was witnessed in absconsions occurring from unaccompanied passes; this was offset, to some extent, by an increase in absconding occurring from within hospital units or from staff accompanied outings. Seven of the absconding events included incidents of minor violence, and two included the commission of other illegal behaviors. The most common reported motive for absconding across the time periods studied was a sense of boredom or frustration. Discharge rate from hospital was 22.9% prior to the implementation of the policy to 22.7% after its introduction, indicating no change in the rate of patients' eventual community reintegration.

CONCLUSIONS

A structured and team-based approach to decision making regarding hospital grounds and community access privileges appeared to reduce the overall rate of absconding without slowing community reintegration of forensic patients.