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Quinn M, Jutkowitz E, Primack J, Lenger K, Rudolph J, Trikalinos T, Rickard T, Mai HJ, Balk E, Konnyu K. Protocols to reduce seclusion in inpatient mental health units. Int J Ment Health Nurs 2024; 33:600-615. [PMID: 38193620 DOI: 10.1111/inm.13277] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2023] [Accepted: 12/04/2023] [Indexed: 01/10/2024]
Abstract
The use of seclusion to manage conflict behaviours in psychiatric inpatient settings is increasingly viewed as an intervention of last resort. Many protocols have, thus, been developed to reduce the practice. We conducted a systematic review to determine the effectiveness of protocols to reduce seclusion on process outcomes (e.g., seclusion, restraint), patient outcomes (e.g., injuries, aggressive incidents, satisfaction), and staff outcomes (e.g., injuries, satisfaction). We searched Medline, Embase, the Cochrane Register of Clinical Trials, PsycINFO, CINAHL, cairn.info, and ClinicalTrials.gov for protocols to reduce seclusion practices for adult patients on inpatient mental health units (from inception to September 6, 2022). We summarised and categorised reported elements of the protocols designed to reduce seclusion using the Behaviour Change Wheel Intervention Functions and resources needed to implement the protocol in psychiatric units. We assessed risk of bias and determined certainty of evidence using GRADE. Forty-eight reports addressed five approaches to reduce seclusion: hospital/unit restructuring (N = 4), staff education/training (N = 3), sensory modulation rooms (N = 7), risk assessment and management protocols (N = 7), and comprehensive/mixed interventions (N = 22; N = 6 without empirical data). The relationship between the various protocols and outcomes was mixed. Psychiatric units that implement architecturally positive designs, sensory rooms, the Brøset Violence Checklist, and various multi-component comprehensive interventions may reduce seclusion events, though our certainty in these findings is low due to studies' methodological limitations. Future research and practice may benefit from standardised reporting of process and outcome measures and analyses that account for confounders.
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Affiliation(s)
- McKenzie Quinn
- Evidence Synthesis Program Center Providence VA Medical Center, Providence, Rhode Island, USA
| | - Eric Jutkowitz
- Evidence Synthesis Program Center Providence VA Medical Center, Providence, Rhode Island, USA
- Center of Innovation in Long-Term Services and Supports, Providence VA Medical Center, Providence, Rhode Island, USA
- Department of Health Services, Policy & Practice, Brown University, Providence, Rhode Island, USA
| | - Jennifer Primack
- Center of Innovation in Long-Term Services and Supports, Providence VA Medical Center, Providence, Rhode Island, USA
- Department of Psychiatry and Human Behavior, Warren Alpert School of Medicine, Brown University, Providence, Rhode Island, USA
| | - Katherine Lenger
- Evidence Synthesis Program Center Providence VA Medical Center, Providence, Rhode Island, USA
| | - James Rudolph
- Evidence Synthesis Program Center Providence VA Medical Center, Providence, Rhode Island, USA
- Center of Innovation in Long-Term Services and Supports, Providence VA Medical Center, Providence, Rhode Island, USA
| | - Thomas Trikalinos
- Evidence Synthesis Program Center Providence VA Medical Center, Providence, Rhode Island, USA
- Department of Health Services, Policy & Practice, Brown University, Providence, Rhode Island, USA
- Center for Evidence Synthesis in Health, Brown University, Providence, Rhode Island, USA
| | - Taylor Rickard
- Evidence Synthesis Program Center Providence VA Medical Center, Providence, Rhode Island, USA
| | - Htun Ja Mai
- Center for Evidence Synthesis in Health, Brown University, Providence, Rhode Island, USA
| | - Ethan Balk
- Evidence Synthesis Program Center Providence VA Medical Center, Providence, Rhode Island, USA
- Department of Health Services, Policy & Practice, Brown University, Providence, Rhode Island, USA
- Center for Evidence Synthesis in Health, Brown University, Providence, Rhode Island, USA
| | - Kristin Konnyu
- Department of Health Services, Policy & Practice, Brown University, Providence, Rhode Island, USA
- Center for Evidence Synthesis in Health, Brown University, Providence, Rhode Island, USA
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
- Institute of Applied Health Sciences, School of Medicine, Medical Sciences and Nutrition, University of Aberdeen, Aberdeen, UK
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Rogers JP, Lewis G, Lobo M, Wyke C, Meaburn A, Harding F, Garvey R, Irvine J, Yahya AS, Kornblum D, Cullen AE, Mirfin D, Lewis G. Identifying predictors of adverse outcomes after termination of seclusion in psychiatric intensive care units. BJPsych Open 2024; 10:e120. [PMID: 38773812 DOI: 10.1192/bjo.2024.710] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/24/2024] Open
Abstract
BACKGROUND Seclusion is a restrictive practice that many healthcare services are trying to reduce. Previous studies have sought to identify predictors of seclusion initiation, but few have investigated factors associated with adverse outcomes after seclusion termination. AIMS To assess the factors that predict an adverse outcome within 24 h of seclusion termination. METHOD In a cohort study of individuals secluded in psychiatric intensive care units, we investigated factors associated with any of the following outcomes: actual violence, attempted violence, or reinitiation of seclusion within 24 h of seclusion termination. Among the seclusion episodes that were initiated between 29 March 2018 and 4 March 2019, we investigated the exposures of medication cooperation, seclusion duration, termination out of working hours, involvement of medical staff in the final seclusion review, lack of insight, and agitation or irritability. In a mixed-effects logistic regression model, associations between each exposure and the outcome were calculated. Odds ratios were calculated unadjusted and adjusted for demographic and clinical variables. RESULTS We identified 254 seclusion episodes from 122 individuals (40 female, 82 male), of which 106 (41.7%) had an adverse outcome within 24 h of seclusion termination. Agitation or irritability was associated with an adverse outcome, odds ratio 1.92 (95% CI 1.03 to 3.56, P = 0.04), but there was no statistically significant association with any of the other exposures, although confidence intervals were broad. CONCLUSIONS Agitation or irritability in the hours preceding termination of seclusion may predict an adverse outcome. The study was not powered to detect other potentially clinically significant factors.
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Affiliation(s)
| | | | - Maria Lobo
- South London and Maudsley NHS Foundation Trust, London, UK
| | | | | | - Fiona Harding
- South London and Maudsley NHS Foundation Trust, London, UK
| | - Rebecca Garvey
- South London and Maudsley NHS Foundation Trust, London, UK
| | - Jenny Irvine
- South London and Maudsley NHS Foundation Trust, London, UK
| | | | - Daisy Kornblum
- South London and Maudsley NHS Foundation Trust, London, UK
| | - Alexis E Cullen
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
- Department of Psychosis Studies, Institute of Psychiatry, Psychology and Neuroscience, King's College London, UK
| | - David Mirfin
- South London and Maudsley NHS Foundation Trust, London, UK
| | - Glyn Lewis
- Division of Psychiatry, University College London, UK
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Savage MK, Lepping P, Newton-Howes G, Arnold R, Staggs VS, Kisely S, Hasegawa T, Reid KS, Noorthoorn EO. Comparison of coercive practices in worldwide mental healthcare: overcoming difficulties resulting from variations in monitoring strategies. BJPsych Open 2024; 10:e26. [PMID: 38205597 PMCID: PMC10790218 DOI: 10.1192/bjo.2023.613] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2023] [Revised: 10/13/2023] [Accepted: 10/18/2023] [Indexed: 01/12/2024] Open
Abstract
BACKGROUND Coercive or restrictive practices such as compulsory admission, involuntary medication, seclusion and restraint impinge on individual autonomy. International consensus mandates reduction or elimination of restrictive practices in mental healthcare. To achieve this requires knowledge of the extent of these practices. AIMS We determined rates of coercive practices and compared them across countries. METHOD We identified nine country- or region-wide data-sets of rates and durations of restrictive practices in Australia, England, Germany, Ireland, Japan, New Zealand, The Netherlands, the USA and Wales. We compared the data-sets with each other and with mental healthcare indicators in World Health Organization and Organisation for Economic Cooperation and Development reports. RESULTS The types and definitions of reported coercive practices varied considerably. Reported rates were highly variable, poorly reported and tracked using a diverse array of measures. However, we were able to combine duration measures to examine numbers of restrictive practices per year per 100 000 population for each country. The rates and durations of seclusion and restraint differed by factors of more than 100 between countries, with Japan showing a particularly high number of restraints. CONCLUSIONS We recommend a common set of international measures, so that finer comparisons within and between countries can be made, and monitoring of trends to see whether alternatives to restraint are successful. These measurements should include information about the total numbers, durations and rates of coercive measures. We urge the World Health Organization to include these measures in their Mental Health Atlas.
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Affiliation(s)
- Martha K. Savage
- School of Geography, Environment and Earth Sciences, Victoria University of Wellington, Wellington, New Zealand
| | - Peter Lepping
- Centre for Mental Health and Society, Wrexham Academic Unit, Bangor University, Bangor, UK
| | | | - Richard Arnold
- School of Mathematics and Statistics, Victoria University of Wellington, Wellington, New Zealand
| | - Vincent S. Staggs
- University of Missouri-Kansas City and Children's Mercy Research Institute, Kansas City, Missouri, USA (now at IDDI Inc, Raleigh, North Carolina, USA)
| | | | - Toshio Hasegawa
- Department of Occupational Therapy, Faculty of Health Sciences, Kyorin University, Mitaka, Japan
| | - Keith S. Reid
- Health and Life Sciences, Northumbria University, Newcastle upon Tyne, UK; and Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Eric O. Noorthoorn
- Radboud University Nijmegen, Nijmegen, the Netherlands; and Ggnet Mental Health Trust Warnsveld, Warnsveld, The Netherlands
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Luccarelli J, Sacks CA, Snydeman C, Luccarelli C, Smith F, Beach SR, McCoy TH. Coding for Physical Restraint Status Among Hospitalized Patients: a 2019 National Inpatient Sample Analysis. J Gen Intern Med 2023; 38:2461-2469. [PMID: 37002459 PMCID: PMC10064960 DOI: 10.1007/s11606-023-08179-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2022] [Accepted: 03/17/2023] [Indexed: 04/04/2023]
Abstract
BACKGROUND The reduction of physical restraint utilization in the hospital setting is a key goal of high-quality care, but little is known about the rate of restraint use in general hospitals in the USA. OBJECTIVE This study reports the rate of physical restraint coding among acute care hospital discharges in the USA and explores associated demographic and diagnostic factors. DESIGN The National Inpatient Sample, a de-identified all-payors database of acute care hospital discharges in the USA, was queried for patients aged 18 and older with a diagnosis code for physical restraint status in 2019. PARTICIPANTS Hospitalized patients aged 18 and older. MAIN MEASURES Demographics, discharge diagnoses, in-hospital mortality, length of stay, total hospital charges. KEY RESULTS In total, 220,470 (95% CI: 208,114 to 232,826) hospitalizations, or 0.7% of overall hospitalizations, included a discharge code for physical restraint status. There was a 700-fold difference in coding for restraint utilization based on diagnosis, with 7.4% of patients with encephalitis receiving restraint diagnosis codes compared to < 0.01% of patients with uncomplicated diabetes. In an adjusted model, male sex was associated with an odds ratio of 1.4 (95% CI: 1.4 to 1.5) for restraint utilization coding, and Black race was associated with an odds ratio of 1.3 (95% CI: 1.2 to 1.4) relative to white race. CONCLUSIONS In the general hospital setting, there is variability in physical restraint coding by sex, race, and clinical diagnosis. More research is needed into the appropriate utilization of restraints in the hospital setting and possible inequities in restraint utilization.
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Affiliation(s)
- James Luccarelli
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA.
- Harvard Medical School, Boston, MA, USA.
| | - Chana A Sacks
- Harvard Medical School, Boston, MA, USA
- Division of General Internal Medicine and Mongan Institute, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Colleen Snydeman
- Patient Care Services Office of Quality & Safety, Massachusetts General Hospital, Boston, MA, USA
| | - Christopher Luccarelli
- Department of Medicine and Department of Psychiatry and Behavioral Sciences, Duke University School of Medicine, Durham, NC, USA
| | - Felicia Smith
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Scott R Beach
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Thomas H McCoy
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
- Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
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Shields MC, Hollander MAG, Busch AB, Kantawala Z, Rosenthal MB. Patient-centered inpatient psychiatry is associated with outcomes, ownership, and national quality measures. HEALTH AFFAIRS SCHOLAR 2023; 1:qxad017. [PMID: 38756837 PMCID: PMC10986256 DOI: 10.1093/haschl/qxad017] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 02/15/2023] [Revised: 04/24/2023] [Accepted: 05/16/2023] [Indexed: 05/18/2024]
Abstract
Following discharge from inpatient psychiatry, patients experience elevated suicide risk, unplanned readmission, and lack of outpatient follow-up visits. These negative outcomes might relate to patient-centered care (PCC) experiences while hospitalized. We surveyed 739 former patients of inpatient psychiatric settings to understand the relationship between PCC and changes in patients' trust, willingness to engage in care, and self-reported 30-day follow-up visits. We also linked PCC measures to facility-level quality measures in the Inpatient Psychiatric Facility Quality Reporting program. Relative to patients discharged from facilities in the top quartile of PCC, those discharged from facilities in the bottom quartile were more likely to experience reduced trust (predicted probability [PP] = 0.77 vs 0.46; P < .001), reduced willingness to go to the hospital voluntarily (PP = 0.99 vs 0.01; P < .001), and a lower likelihood of a 30-day follow-up (PP = 0.71 vs 0.92; P < .001). PCC was lower among patients discharged from for-profits, was positively associated with facility-level quality measures of 7- and 30-day follow-up and medication continuation, and was inversely associated with restraint use. Findings underscore the need to introduce systematic measurement and improvement of PCC in this setting.
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Affiliation(s)
- Morgan C Shields
- Brown School, Washington University in St. Louis, St. Louis, MO 63130, United States
| | - Mara A G Hollander
- Department of Public Health Sciences, University of North Carolina at Charlotte, Charlotte, NC 28223, United States
| | - Alisa B Busch
- Department of Health Care Policy, Harvard University, Harvard Medical School, Boston, MA 02115, United States
- McLean Hospital, Belmont, MA 02478, United States
| | - Zohra Kantawala
- Brown School, Washington University in St. Louis, St. Louis, MO 63130, United States
| | - Meredith B Rosenthal
- Department of Health Policy and Management, Harvard University, Harvard T. H. Chan School of Public Health, Boston, MA 02115, United States
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Shields MC, Hollander MA. Complaints, Restraint, and Seclusion in Massachusetts Inpatient Psychiatric Facilities, 2008-2018. J Patient Exp 2023; 10:23743735231179072. [PMID: 37323757 PMCID: PMC10265359 DOI: 10.1177/23743735231179072] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/17/2023] Open
Abstract
There has been limited research on the quality of inpatient psychiatry, yet policies to expand access have increased, such as the use of Medicaid Section 1115 waivers for treatment in "Institutions for Mental Disease" (IMD). Using data from public records requests, we evaluated complaints, restraint, and seclusion from inpatient psychiatric facilities in Massachusetts occurring from 2008 to 2018, and compared differences in the rates of these events by IMD status. There were 17,962 total complaints, with 48.9% related to safety and 19.9% related to abuse (sexual, physical, verbal), and 92,670 episodes of restraint and seclusion. On average, for every 30 census days in a given facility, restraint, and seclusion occurred 7.47 and 1.81 times, respectively, and a complaint was filed 0.94 times. IMDs had 47.8%, 68.3%, 276.9%, 284.8%, 183.6%, and 236.1% greater rates of restraint, seclusion, overall complaints, substantiated complaints, safety-related complaints, and abuse-related complaints, respectively, compared to non-IMDs. This is the first known study to describe complaints from United States inpatient psychiatric facilities. Policies should strengthen the implementation of patients' rights and patient-centeredness, as well as external critical-incident-reporting systems.
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Affiliation(s)
| | - Mara A.G. Hollander
- Department of Public Health Sciences, University of North Carolina Charlotte, Charlotte, USA
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Pértega E, Holmberg C. A systematic mapping review identifying key features of restraint research in inpatient pediatric psychiatry: A human rights perspective. INTERNATIONAL JOURNAL OF LAW AND PSYCHIATRY 2023; 88:101894. [PMID: 37244128 DOI: 10.1016/j.ijlp.2023.101894] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/21/2022] [Revised: 04/30/2023] [Accepted: 05/02/2023] [Indexed: 05/29/2023]
Abstract
INTRODUCTION Restraints, a highly regulated and contentious measure in pediatric psychiatry, have significant negative impacts on children. The application of international human rights standards, such as the Convention of the Rights of the Child (CRC) and the Convention of the Rights of Persons with Disabilities (CRPD), has spurred global efforts to reduce or eliminate the use of restraints. However, a lack of consensus on definitions and terminology, as well as quality indicators in this field, hinders the ability to compare studies and evaluate interventions consistently. AIM To systematically map existing literature on restraints imposed upon children in inpatient pediatric psychiatry against a human rights perspective. Specifically, to identify and clarify gaps in literature in terms of publication trends, research approaches, study contexts, study participants, definitions and concepts being used, and legal aspects. These aspects are central to assess whether published research is contributing to achieve the CRPD and the CRC in terms of interpersonal, contextual, operational, and legal requirements of restraints. METHODS A systematic mapping review based on PRISMA guidelines was conducted, adopting a descriptive-configurative approach to map the distribution of available research and gaps in the literature about restraints in inpatient pediatric psychiatry. Six databases were searched for literature reviews and empirical studies of all study designs published between each database's inception and March 24, 2021, manually updated on November 25, 2022. RESULTS The search yielded 114 English-language publications, with a majority (76%) comprising quantitative studies that relied primarily on institutional records. Contextual information about the research setting was provided in less than half of the studies, and there was an unequal representation of the three main stakeholder groups: patients, family, and professionals. The studies also exhibited inconsistencies in the terms, definitions, and measurements used to examine restraints, with a general lack of attention given to human rights considerations. Additionally, all studies were conducted in high-income countries and mainly focused on intrinsic factors such as age and psychiatric diagnosis of the children, while contextual factors and the impact of restraints were not adequately explored. Legal and ethical aspects were largely absent, with only one study (0.9%) explicitly referencing human rights values. CONCLUSIONS Research on restraints of children in psychiatric units is increasing; however, inconsistent reporting practices hinder the understanding of the meaning and frequency of restraints. The exclusion of crucial features, such as the physical and social environment, facility type, and family involvement, indicates inadequate incorporation of the CRPD. Additionally, the lack of references to parents suggests insufficient consideration of the CRC. The shortage of quantitative studies focusing on factors beyond patient-related aspects, and the general absence of qualitative studies exploring the perspectives of children and adolescents regarding restraints, suggest that the social model of disability proposed by the CRPD has not yet fully penetrated the scientific research on this topic.
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Affiliation(s)
- Elvira Pértega
- Faculty of Law, University of Technology Sydney, Sydney, Australia; Child and Adolescens Mental Health Department, Hospital Lucus augusti, Lugo, Spain.
| | - Christopher Holmberg
- Department of Psychotic Disorders, Sahlgrenska University Hospital, Gothenburg, Sweden; Institute of Health and Care Science, University of Gothenburg, Gothenburg, Sweden
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Li L, Kruger M, Kim N, Ong S, Riley S, Cameron K, Koslosky K, Rhodes D. A Novel Approach to Delivering Evidence-based, High-quality Care in Psychiatry Through an Electronic Integrated Care Pathway (eICP) Pilot. Psychiatr Q 2023:10.1007/s11126-023-10016-z. [PMID: 36840898 PMCID: PMC9959944 DOI: 10.1007/s11126-023-10016-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/02/2023] [Indexed: 02/26/2023]
Abstract
Integrated care pathways (ICPs) are evidence-based decision support tools intended to reduce variation and improve quality of care. Historically, adoption of ICPs has been difficult to measure, as the pathways were outside of the electronic health record (EHR), where care delivery documentation and orders were completed. This Technology Column describes the innovative development and implementation of a diagnosis specific electronic ICP that directly embeds pathway steps into an EHR to facilitate order sets, clinical decision-making, and usage tracking. The pathway was implemented at a seven-hospital academic medical center, and details the technology, team structure, early adoption results, and future directions. As such, the importance of investing and organizing resources to create an eICP (e.g., time, technology, and specialized teams) to provide a user-friendly experience to support early adoption is underscored. Preliminary findings show that the eICP had consistent use in the first year of implementation. This manuscript is intended to serve as a practical guide to build eICPs within behavioral health service areas across institutions.
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Affiliation(s)
- Luming Li
- Yale School of Medicine, New Haven, CT, USA.
- Baylor School of Medicine, Houston, TX, USA.
- University of Texas McGovern School of Medicine, Houston, TX, USA.
- The Harris Center for Mental Health and IDD, Houston, TX, USA.
| | | | - Nancy Kim
- Yale School of Medicine, New Haven, CT, USA
- Yale New Haven Health System, New Haven, CT, USA
| | - Shawn Ong
- Yale School of Medicine, New Haven, CT, USA
- Yale New Haven Health System, New Haven, CT, USA
| | - Sarah Riley
- Yale School of Medicine, New Haven, CT, USA
- Yale New Haven Health System, New Haven, CT, USA
| | | | | | - Deborah Rhodes
- Yale School of Medicine, New Haven, CT, USA
- Yale New Haven Health System, New Haven, CT, USA
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Steinert T, Hirsch S, Flammer E. [Monitoring of coercive measures and compulsory treatment in Germany]. DER NERVENARZT 2022; 93:1105-1111. [PMID: 35819484 DOI: 10.1007/s00115-022-01349-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 06/21/2022] [Indexed: 11/30/2022]
Abstract
Epidemiological registers on the burden of disease and adverse events (deaths, serious side effects, etc.) play an important role in the management, evaluation, and improvement of healthcare treatment for the population. This also applies to coercive measures in the psychiatric healthcare system. Such registers only became feasible on a broad basis due to the availability of electronic medical records and steadily increasing computing capacities; however, in most German states, registers have not been implemented. Data protection problems must be taken into account in the collation of person-related data but can be solved by appropriate pseudonymization procedures taking the prerequisites of data parsimony into account. Extensive data are now available from the Baden-Wuerttemberg register for coercive measures, which has been in existence since 2015 and which enabled, for instance, evaluating the consequences of the changes to the law following the 2018 ruling of the Federal Constitutional Court on mechanical restraint and the consequences of the coronavirus pandemic. In the meantime, there are also state-wide data collections in some other German states; however, unlike in Baden-Wuerttemberg, these registers do not include measures under guardianship law. A nationwide register for coercive measures, compulsory treatment and involuntary detention has justifiably repeatedly been demanded for a long time. A major obstacle is the historically developed separation between the responsibility of the German states for the detention regulated by public law and the Federal State for the scope of application of the guardianship law.
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Affiliation(s)
- Tilman Steinert
- Klinik für Psychiatrie und Psychotherapie I, Universität Ulm (Weissenau), Ulm (Weissenau), Deutschland. .,Zentren für Psychiatrie Südwürttemberg, Ravensburg, Weingartshofer Str. 2, 88214, Ravensburg, Deutschland. .,Klinik für Psychiatrie und Psychotherapie, Universität Tübingen, Tübingen, Deutschland.
| | - Sophie Hirsch
- Klinik für Psychiatrie und Psychotherapie I, Universität Ulm (Weissenau), Ulm (Weissenau), Deutschland.,Zentren für Psychiatrie Südwürttemberg, Ravensburg, Weingartshofer Str. 2, 88214, Ravensburg, Deutschland., Zentren für Psychiatrie Südwürttemberg, Biberach, Deutschland
| | - Erich Flammer
- Klinik für Psychiatrie und Psychotherapie I, Universität Ulm (Weissenau), Ulm (Weissenau), Deutschland.,Zentren für Psychiatrie Südwürttemberg, Ravensburg, Weingartshofer Str. 2, 88214, Ravensburg, Deutschland
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Ruud T, Haugom EW, Pincus HA, Hynnekleiv T. Measuring Seclusion in Psychiatric Intensive Care: Development and Measurement Properties of the Clinical Seclusion Checklist. Front Psychiatry 2021; 12:768500. [PMID: 35002798 PMCID: PMC8733687 DOI: 10.3389/fpsyt.2021.768500] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2021] [Accepted: 11/23/2021] [Indexed: 11/13/2022] Open
Abstract
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.
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Affiliation(s)
- Torleif Ruud
- Mental Health Services, Akershus University Hospital, Lørenskog, Norway
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Espen Woldsengen Haugom
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
- Department of Acute Psychiatry and Psychosis Treatment, Sanderud, Division of Mental Health, Innlandet Hospital Trust, Ottestad, Norway
| | - Harold Alan Pincus
- Department of Psychiatry and Irving Institute for Clinical and Translational Research, Columbia University, New York City, NY, United States
- New York State Psychiatric Institute, New York City, NY, United States
| | - Torfinn Hynnekleiv
- Department of Acute Psychiatry and Psychosis Treatment, Division of Mental Health, Innlandet Hospital Trust, Reinsvoll, Norway
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A Visual Dashboard to Monitor Restraint Use in Hospitalized Psychiatry Patients. Jt Comm J Qual Patient Saf 2021; 47:282-287. [PMID: 33648859 DOI: 10.1016/j.jcjq.2021.01.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2020] [Revised: 01/12/2021] [Accepted: 01/13/2021] [Indexed: 11/23/2022]
Abstract
BACKGROUND Restraint events are tracked using a duration rate as part of a national psychiatry quality reporting program and tracked annually. Visual dashboards can help track metrics in near real time but are not routinely used in psychiatric settings. METHODS This observational study sought to characterize restraint events by extracting electronic medical record data on restraint episodes between January 1, 2017, and December 31, 2019, in five inpatient units in one academic medical center. The data were also used to build a visual dashboard and calculate restraint metrics (duration and frequency) across locations and time. RESULTS A total of 540 distinct restraint events occurred during the study period. Highest restraint episode counts occurred during evening shift (54.8%), compared to daytime (37.2%) and nighttime (8.0%) shifts. Highest episode duration rates occurred in an adult unit (61.3% of total hours spent in restraints across all units), while highest episode counts occurred in the adolescent unit (48.3% of all restraint episodes). A visual dashboard with two views (summary and detailed) was created. The summary view integrates patient volume data (total patient hours per month) with total duration and number of episodes per month. The detailed view displays event frequency by hour of day, nursing shift, weekday, and patient length of stay at the time of restraint. CONCLUSIONS Visual dashboards can provide timely and efficient access to granular data elements and metrics related to restraint events, beyond the reporting requirement of a national quality program. Visual dashboards can reveal variations in restraint use and yield important opportunities for clinical quality improvement.
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Li L, Mathis WS. Nationally Advancing Quality Improvement in Restraint and Seclusion Measures. Psychiatr Serv 2020; 71:1322-1323. [PMID: 33256532 DOI: 10.1176/appi.ps.202000461] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Luming Li
- Department of Psychiatry, Yale School of Medicine, New Haven, Connecticut (Li, Mathis); Yale New Haven Psychiatric Hospital, New Haven (Li); Connecticut Mental Health Center, New Haven (Mathis)
| | - Walter S Mathis
- Department of Psychiatry, Yale School of Medicine, New Haven, Connecticut (Li, Mathis); Yale New Haven Psychiatric Hospital, New Haven (Li); Connecticut Mental Health Center, New Haven (Mathis)
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