Differences in seclusion rates between admission wards: does patient compilation explain?

Comparison of seclusion figures between wards in Dutch psychiatric hospitals showed substantial differences in number and duration of seclusions. In the opinion of nurses and ward managers, these differences may predominantly be explained by differences in patient characteristics, as these are expected to have a large impact on these seclusion rates. Nurses assume more admissions of severely ill patients are related to higher seclusion rates. In order to test this hypothesis, we investigated differences in patient and background characteristics of 718 secluded patients over 5,097 admissions on 29 different admission wards over seven Dutch psychiatric hospitals. We performed an extreme group analysis to explore the relationship between patient and ward characteristics and the wards' number of seclusion hours per 1,000 admission hours. In a multivariate and a multilevel analysis, various characteristics turned out to be related to the number of seclusion hours per 1,000 admission hours as well as to the likelihood of a patient being secluded, confirming the nurses assumptions. The extreme group analysis showed that seclusion rates depended on both patient and ward characteristics. A multivariate and multilevel analyses revealed that differences in seclusion hours between wards could partially be explained by ward size next to patient characteristics. However, the largest deal of the difference between wards in seclusion rates could not be explained by characteristics measured in this study. We concluded ward policy and adequate staffing may, in particular on smaller wards, be key issues in reduction of seclusion.

Impact of the physical environment of psychiatric wards on the use of seclusion

BACKGROUND

The physical environment is presumed to have an effect on aggression and also on the use of seclusion on psychiatric wards. Multicentre studies that include a broad variety of design features found on psychiatric wards and that control for patient, staff and general ward characteristics are scarce.

AIMS

To explore the effect of design features on the risk of being secluded, the number of seclusion incidents and the time in seclusion, for patients admitted to locked wards for intensive psychiatric care.

METHOD

Data on the building quality and safety of psychiatric as well as forensic wards (n = 199) were combined with data on the frequency and type of coercive measures per admission (n = 23 868 admissions of n = 14 834 patients) on these wards, over a 12-month period. We used non-linear principal components analysis (CATPCA) to reduce the observed design features into a smaller number of uncorrelated principal components. Two-level multilevel (logistic) regression analyses were used to explore the relationship with seclusion. Admission was the first level in the analyses and ward was the second level.

RESULTS

Overall, 14 design features had a significant effect on the risk of being secluded during admission. The 'presence of an outdoor space', 'special safety measures' and a large 'number of patients in the building' increased the risk of being secluded. Design features such as more 'total private space per patient', a higher 'level of comfort' and greater 'visibility on the ward', decreased the risk of being secluded.

CONCLUSIONS

A number of design features had an effect on the use of seclusion and restraint. The study highlighted the need for a greater focus on the impact of the physical environment on patients, as, along with other interventions, this can reduce the need for seclusion and restraint.

Methodological issues in monitoring the use of coercive measures

PURPOSE

In many European countries, initiatives have emerged to reduce the use of seclusion and restraint in psychiatric institutions. To study the effects of these initiatives at a national and international level, consensus on definitions of coercive measures, assessment methods and calculation procedures of these coercive measures are required. The aim of this article is to identify problems in defining and recording coercive measures. The study contributes to the development of consistent comparable measurements definitions and provides recommendations for meaningful data-analyses illustrating the relevance of the proposed framework.

METHODS

Relevant literature was reviewed to identify various definitions and calculation modalities used to measure coercive measures in psychiatric inpatient care. Figures on the coercive measures and epidemiological ratios were calculated in a standardized way. To illustrate how research in clinical practice on coercive measures can be conducted, data from a large multicenter study on seclusion patterns in the Netherlands were used.

RESULTS

Twelve Dutch mental health institutes serving a population of 6.57 million inhabitants provided their comprehensive coercion measure data sets. In total 37 hospitals and 227 wards containing 6812 beds were included in the study. Overall seclusion and restraint data in a sample of 31,594 admissions in 20,934 patients were analyzed. Considerable variation in ward and patient characteristics was identified in this study. The chance to be exposed to seclusion per capita inhabitants of the institute's catchment areas varied between 0.31 and 1.6 per 100.000. Between mental health institutions, the duration in seclusion hours per 1000 inpatient hours varied from less than 1 up to 18h. The number of seclusion incidents per 1000 admissions varied between 79 up to 745. The mean duration of seclusion incidents of nearly 184h may be seen as high in an international perspective.

CONCLUSION

Coercive measures can be reliably assessed in a standardized and comparable way under the condition of using clear joint definitions. Methodological consensus between researchers and mental health professionals on these definitions is necessary to allow comparisons of seclusion and restraint rates. The study contributes to the development of international standards on gathering coercion related data and the consistent calculation of relevant outcome parameters.

Antiserum-agar plate method for simultaneous detection and direct isolation of Legionella species in clinical and environmental specimens

Colonies of Legionella pneumophila serotypes 1 through 6, L. micdadei, L. bozemanii, L. dumoffii, and L. gormanii, which were developed on filtered yeast extract agar containing polyvalent antiserum, were surrounded by distinct, specific precipitin rings.

Murine model for study of cell-mediated immunity: protection against death from fully virulent Francisella tularensis infection

To assess cell-mediated immunity in terms of host protection, an experimental model was developed in which passively transferred spleen cells from immunized AKR/J mice enabled nonimmume syngeneic recipients to survive an otherwise fatal infection with fully virulent Francisella tularensis. Donor immunization was achieved by administering live attenuted tularemia vaccine and, subsequently, the virulent streptomycin-sensitive SCHU S4 strain of F. tularensis. At selected intervals after immunization, donor spleen cells were transferred to streptomycin-treated recipients challenged subcutaneously, intravenously, or intraperitoneally with 25 to 50 minimal lethal doses of virulent streptomycin-resistant F. tularensis SCHU S5. The protection afforded by immune spleen cells was maximal (essentially 100%) 12 days after the SCHU S4 secondary immunization.

Plague bacillus: survival within host phagocytes

Pasteurella pestis within nelutrophiles and macrophages removed from the peritoneal cavity of guinea pigs dutring experimental plague were shown to be viable by direct microscopic observation of the infected phagocytes incubating in sutitable bacteriologic media. The time-honored hypothesis that the major determinanit of the virulence of the plague bacillius is its ability to resist ingestion by phagocytes mutst be reevaluated.

Morphology, physiology, and serology of a Pasteurella species pathogenic for white perch. (Roccus americanus)

The Pasteurella species implicated as the etiologic agent of a massive white perch mortality in the Chesapeake Bay and first described by S. F. Snieszko et al. has been characterized further in our laboratory. The general morphology and physiology of this organism is similar to that of the pasteurellae and several known fish pathogens. There are enough dissimilarities, however, to rule out its identification with any established species. The organism is obligately halophilic and grows in a temperature range between 17 and 31 C on ordinary media containing 1% NaCl. It has a relatively narrow range of pH, temperature, and salinity tolerance, and a very short survival time in spent media or brackish water, in contrast to Pasteurella pestis and P. pseudotuberculosis. Serological tests also indicate that this organism is distinct from other species which it resembles. On the basis of classic morphological and physiological criteria, this organism fits best in the genus Pasteurella; the species name piscicida (L. noun piscis, a fish; L.v.L.adj. suffix-cidus, to kill; M.L. noun piscicida, fish killer) is proposed.

Fish: serologic evidence of infection with human pathogens

Specific antibodies to several bacteria pathogenic to humans were detected in the serums of white perch from surface waters adjacent to heavily populated areas on Chesapeake Bay. White perch from surface waters adjacent to sparsely populated areas were free of such antibodies. We suggest that fish may become actively infected with human pathogens by exposure to contaminated water and may constitute a hazard to public health.

Pesticins. 3. Expression of coagulase and mechanism of fibrinolysis

Mutational loss of pesticin I, a bacteriocin-like substance produced by Pasteurella pestis, is known to result in concomitant loss of a coagulase and fibrinolytic factor. No relationship was detected between pesticinogeny and other tested properties either associated with virulence or peculiar to P. pestis. Pesticin I was distinguished from the coagulase and fibrinolytic activities on the basis of anatomical distribution, behavior during gel filtration, and sensitivity to heat. Coagulase and the fibrinolytic factor were not differentiated by these criteria. Spontaneous suppressor mutations causing reversion to pesticinogeny were not detected, nor were such mutants obtained by treatment with ultraviolet light or 2-aminopurine. Attempts to demonstrate a common activator of pesticin I, coagulase, or the fibrinolytic factor in extracts of pesticinogenic cells were not successful. These results are in accord with the hypothesis that at least two structural genes for the three activities reside on a replicon distinct from the chromosome proper. Fibrinolytic activity was significantly reduced in the presence of 0.003 m epsilon-aminocaproic acid and was nonexistent on fibrin films freed from endogenous plasminogen by treatment with heat. Fibrinolytic activity on heated films could be restored by addition of plasma or serum from six mammalian species. Accordingly, the plague fibrinolytic factor, like staphylokinase or urokinase, promotes the conversion of plasminogen to plasmin.