Aggressive incidents on a psychiatric intensive care unit

Aggression on the psychiatric ward: Prevalence and risk factors. A systematic review of the literature

INTRODUCTION

On psychiatric wards, aggressive behaviour displayed by patients is common and problematic. Understanding factors associated with the development of aggression offers possibilities for prevention and targeted interventions. This review discusses factors that contribute to the development of aggression on psychiatric wards.

METHOD

In Pubmed and Embase, a search was performed aimed at: prevalence data, ward characteristics, patient and staff factors that are associated with aggressive behaviour and from this search 146 studies were included.

RESULTS

The prevalence of aggressive behaviour on psychiatric wards varied (8-76%). Explanatory factors of aggressive behaviour were subdivided into patient, staff and ward factors. Patient risk factors were diagnosis of psychotic disorder or bipolar disorder, substance abuse, a history of aggression, younger age. Staff risk factors included male gender, unqualified or temporary staff, job strain, dissatisfaction with the job or management, burn-out and quality of the interaction between patients and staff. Staff protective factors were a good functioning team, good leadership and being involved in treatment decisions. Significant ward risk factors were a higher bed occupancy, busy places on the ward, walking rounds, an unsafe environment, a restrictive environment, lack of structure in the day, smoking and lack of privacy.

CONCLUSION

Despite a lack of prospective quantitative data, results did show that aggression arises from a combination of patient factors, staff factors and ward factors. Patient factors were studied most often, however, besides treatment, offering the least possibilities in prevention of aggression development. Future studies should focus more on the earlier stages of aggression such as agitation and on factors that are better suited for preventing aggression such as ward and staff factors. Management and clinicians could adapt staffing and ward in line with these results.

Rapid tranquillisation of acutely disturbed and violent patients: a retrospective cohort examination of 24 patients on a psychiatric intensive care unit

The prevalence of violent behaviour within acute psychiatric services is about 10%.

Aim

To identify the pharmacological management of acutely disturbed behaviour in patients requiring rapid tranquillisation (RT) on a psychiatric intensive care unit (PICU). Socio-demographic and clinical characteristics were also identified in these patients.

Method and objectives

A retrospective cohort examination was carried out of 24 patients receiving RT, average age of 38.8 years (7 women and 17 men), admitted to the PICU between 1 January 2011 and 31 December 2011. Patient records and hospital incident reporting system were used to obtain relevant data for analysis.

Results

The majority of patients were detained (95%); suffering from schizophrenia (45.8%); bipolar disorder (25%) and substance misuse disorders (12.5%). Verbal aggression (58.3%) and threatening behaviour (29.2%) were the most common factors leading to RT. Fourteen patients (58.3%) were medicated with a combination of haloperidol and lorazepam; nine (37.5%) with zuclopenthixol acetate only; and one (4.2%) with a combination of zuclopenthixol and promethazine.

Conclusion

Haloperidol in combination with lorazepam was the most common medication utilised for RT. Nevertheless, zuclopenthixol acetate alone, or combined with other drugs, was used in over 40% of cases. This finding is in considerable variation with recommended guidelines.

Prevalence and Risk Factors of Violence by Psychiatric Acute Inpatients: A Systematic Review and Meta-Analysis

Background

Violence in acute psychiatric wards affects the safety of other patients and the effectiveness of treatment. However, there is a wide variation in reported rates of violence in acute psychiatric wards.

Objectives

To use meta-analysis to estimate the pooled rate of violence in published studies, and examine the characteristics of the participants, and aspects of the studies themselves that might explain the variation in the reported rates of violence (moderators).

Method

Systematic meta-analysis of studies published between January 1995 and December 2014, which reported rates of violence in acute psychiatric wards of general or psychiatric hospitals in high-income countries.

Results

Of the 23,972 inpatients described in 35 studies, the pooled proportion of patients who committed at least one act of violence was 17% (95% confidence interval (CI) 14–20%). Studies with higher proportions of male patients, involuntary patients, patients with schizophrenia and patients with alcohol use disorder reported higher rates of inpatient violence.

Conclusion

The findings of this study suggest that almost 1 in 5 patients admitted to acute psychiatric units may commit an act of violence. Factors associated with levels of violence in psychiatric units are similar to factors that are associated with violence among individual patients (male gender, diagnosis of schizophrenia, substance use and lifetime history of violence).