Acute Psychiatric Inpatient Facilities Research Articles

PTSD, subsequent violence, and increased focus on trauma-informed care

PTSD, subsequent violence, and increased focus on trauma-informed care

Increased violence and aggression levels during the SARS-Cov-2 pandemic; data from three London acute psychiatric inpatient facilities.

IntroductionThe COVID-19 pandemic has significantly impacted mental health services, with the literature reporting an increase in the incidence of psychiatric admissions.ObjectivesThe aim of this study was to assess the impact of the pandemic on clinical presentations, characteristics of admission and incidents occurring in three acute inpatient mental health facilities in the UK.MethodsThis was a retrospective study comparing data from the first and third UK lockdown to the five years prior to the pandemic. Data was acquired from electronic clinical records and addressed two acute psychiatric inpatient wards and one psychiatric intensive care unit. Key outcomes of comparison were clinical presentations, number of admissions, length of hospital stay, number of incidents and characteristics of incidents.ResultsCompared to the previous 5 years, a higher number of incidents characterized by violence and aggression were reported during the first (56.8% vs 44.3%, x2=16.56, df=1, p<0.001) and third lockdown (100.0% vs 86.2%, x2=36.40, df=1, p<0.001). An increase in non-psychotic disorders was observed in the first lockdown (20.0% vs 13.1%, x2=4.76, df=1, p=0.029), whilst increased first episode psychosis (19.7% vs 11.3%, x2=8.1, df=1, p=0.004) and schizophrenia spectrum disorders (74.4% vs 57.2%, x2= 7.6, df=1, p=0.006) were diagnosed during the third lockdown. There were no significant changes in the diagnosis of mood disorders in both lockdowns compared to previously. The median length of inpatient stay significantly reduced during the first lockdown (28 days vs 36 days, x2= 7.66, df=1, p=0.006).ConclusionsIncreased inpatient incidents may be explained by the impact of the pandemic on staffing levels and resources, combined with increased emotional distress amongst patients in the face of uncertainty. The pandemic may have increased substance misuse potentially linked with the increased incidence of first episode psychosis.Disclosure of InterestS. Bonaccorso: None Declared, O. Ajnakina: None Declared, A. Ricciardi: None Declared, S. Ouabbou: None Declared, J. Wilson: None Declared, C. Theleritis: None Declared, M. Badhan: None Declared, A. Metastasio: None Declared, N. Stewart: None Declared, M. Barczyck: None Declared, F. Johansson: None Declared, T. Tharmaraja: None Declared, F. Schifano Speakers bureau of: Prof. Fabrizio Schifano is a member of the European Medical Agency

Establishing safe transfers between acute medical and psychiatric inpatient facilities

To improve the communication between two NHS trusts at the pre-transfer phase thereby ensuring safe transfer of medically fit individuals to a psychiatric hospital. A questionnaire was submitted to all doctors working within the psychiatric department to elicit what issues were experienced in patient transfers and what markers would be considered essential in any transfer checklist. The results of the questionnaire were followed by the introduction of a pre-transfer medical checklist. …

Predictors of length of stay in an acute psychiatric inpatient facility in a general hospital: a prospective study

Objective:There have been significant reductions in numbers of psychiatric beds and length of stay (LOS) worldwide, making LOS in psychiatric beds an interesting outcome. The objective of this study was to find factors measurable on admission that would predict LOS in the acute psychiatric setting.Methods:This was a prospective, observational study.Results:Overall, 385 subjects were included. The median LOS was 25 days. In the final model, six variables explained 14.6% of the variation in LOS: not having own income, psychiatric admissions in the preceding 2 years, high Clinical Global Impression and Brief Psychiatric Rating Scale scores, diagnosis of schizophrenia, and history of attempted suicide. All variables were associated with longer LOS, apart from history of attempted suicide.Conclusions:Identifying patients who will need to stay longer in psychiatric beds remains a challenge. Improving knowledge about determinants of LOS could lead to improvements in the quality of care in hospital psychiatry.

Oppositional Defiant Disorder Symptoms in Relation to Psychopathic Traits and Aggression Among Psychiatrically Hospitalized Children: ADHD Symptoms as a Potential Moderator

Oppositional defiant disorder (ODD) is associated with elevated rates of psychopathic traits and aggression. However, it remains unclear if attention-deficit/hyperactivity disorder (ADHD) symptoms exacerbate these relations, particularly in samples of children who are severely clinically distressed. The purpose of the present study was to test ADHD symptoms as a potential moderator of the relations of ODD symptoms to psychopathic traits (i.e., callous-unemotional [CU] traits, narcissism) and to aggressive subtypes (i.e., proactive, reactive aggression) in a large sample of children in an acute psychiatric inpatient facility (n = 699; ages 6-12). Multiple regression analyses indicated that, after controlling for child demographic variables, ADHD symptoms marginally exacerbated the relation between ODD symptoms and CU traits. Both ODD and ADHD symptoms had an additive, but not a multiplicative effect, in predicting narcissism. In addition, for a subset of the full sample for whom data were available (n =351), ADHD symptoms exacerbated the relation between ODD symptoms and both reactive and proactive aggression. These results suggest that ADHD symptoms tend to have a negative effect on the relation between ODD symptoms and markers of antisociality among children receiving acute psychiatric care.

Factors associated with length of stay and the risk of readmission in an acute psychiatric inpatient facility: a retrospective study.

ObjectiveThis study was to investigate factors influencing the length of stay and predictors for the risk of readmission at an acute psychiatric inpatient unit.MethodTwo comparative studies were embedded in a retrospective cross-sectional clinical file audit. A randomly selected 226 episodes of admissions including 178 patients during a twelve-month period were reviewed. A total of 286 variables were collected and analysed. A case control study was employed in the study of length of stay. A retrospective cohort study was used to investigate the predictors for the risk of readmission.ResultsLogistic regression analyses showed that 10 variables were associated with length of stay. Seclusion during the index admission, accommodation problems and living in an area lacking community services predicted longer stay. During the follow-up period 82 patients (46%) were readmitted. Cox regression analyses showed 9 variables were related to the risk of readmission. Six of these variables increased the risk of readmission, including history of previous frequent admission, risk to others at the time of the index admission and alcohol intoxication. More active and assertive treatment in the community post-discharge decreased the risk of readmission.ConclusionsLength of stay is multifactorially determined. Behavioural manifestations of illness and lack of social support structures predicted prolonged length of stay. Good clinical practice did not necessarily translate to a shorter length of stay. Therefore, length of stay is predictable, but not readily modifiable within the clinical domain. Good clinical practice within the community following discharge likely reduces the risk of readmission. Quality of inpatient care does not influence the risk of readmission, which therefore raises a question about the validity of using the rate of readmission as an outcome measure of psychiatric inpatient care.

A Naturalistic Inquiry of Registered Nurses' Perspectives and Expectations of Psychodynamic Therapeutic Care in Acute Psychiatric Inpatient Facilities

Within contemporary inpatient mental health nursing practice, the psychodynamic model of care considered previously to be central to the nurse-patient relationship now seems a radical concept. It appears to exist only within primary care facilities and public health care practice settings. This naturalistic inquiry aimed to explicate mental health nurses' perspectives and expectations of providing psychodynamic therapeutic care in acute inpatient psychiatric facilities. Ten registered nurses working in acute inpatient mental health facilities were interviewed. Five themes emerged: a career for life, relating in a psychodynamic manner, swimming against the current, adopting a position of difference, and hopeful expectancy.

First-ever admitted psychiatric inpatients in Italy: Clinical characteristics and reasons contributing to admission: Findings from a national survey

The aim of this study was to describe the sociodemographic, clinical and treatment-related characteristics of patients admitted to any acute psychiatric inpatient facilities in Italy for the first time in their life, and to identify reasons contributing to admission. Data from the PROGRES-Acute Project, a national survey on facilities admitting acute psychiatric patients in Italy, were used. A cluster analysis was carried out in order to identify patients' groups sharing similar sociodemographic and clinical characteristics. Among patients admitted during the index period, 337 were at their first-ever admission. Median age at admission was 40, and about 46% of patients were not receiving any treatment in the month prior to admission. Social/work functioning problems, social withdrawal and conflict with family members were the most common reasons contributing to admission. Cluster analysis yielded four patient groups: two groups of younger subjects, differentiating each other for frequency of antisocial behaviors, compulsory admissions, treatment at time of admission and family support; two groups of older subjects, with high rates of affective disorders, who showed remarkable differences with regard to their living situation and family support. Our study shows that first-ever admitted patients represent a highly heterogeneous group. Early intervention research should take this sociodemographic and clinical diversity into account, in order to better allocate resources and develop special intervention programs.

Violent Behavior in Acute Psychiatric Inpatient Facilities

Violence committed by acute psychiatric inpatients represents an important and challenging problem in clinical practice. Sociodemographic, clinical, and treatment information were collected for 1324 patients (677 men and 647 women) admitted to Italian public and private acute psychiatric inpatient facilities during an index period in 2004, and the sample divided into 3 groups: nonhostile patients (no episodes of violent behavior during hospitalization), hostile patients (verbal aggression or violent acts against objects), and violent patients (authors of physical assault). Ten percent (N = 129) of patients showed hostile behavior during hospitalization and 3% (N = 37) physically assaulted other patients or staff members. Variables associated with violent behavior were: male gender, <24 years of age, unmarried status, receiving a disability pension, having a secondary school degree, compulsory admission, hostile attitude at admission, and a diagnosis of schizophrenia, bipolar disorder, personality disorder, mental retardation, organic brain disorder or substance/alcohol abuse. Violent behavior during hospitalization was a predictive factor for higher Brief Psychiatric Rating Scale scores and for lower Personal and Social Performance scale scores at discharge. Despite the low percentage of violent and hostile behavior observed in Italian acute inpatient units, this study shed light on a need for the careful assessment of clinical and treatment variables, and greater effort aimed at improving specific prevention and treatment programs of violent behavior.

Executive-Level Reviews of Seclusion and Restraint Promote Interdisciplinary Collaboration and Innovation

Elimination of seclusion and restraint requires support at all levels of an organization, especially from leaders who visibly champion and communicate their vision. Nurses, physicians, educators, and administrators at New Hampshire Hospital, an acute psychiatric inpatient facility, have established a standard meeting time and place for an executive-level review of every episode of seclusion and restraint. The standing meeting demonstrates the organization's commitment to caring for both patients and staff. The daily meetings foster a spirit of interdisciplinary collaboration, where direct care staff have the opportunity to tell their stories and share their ideas and concerns in an environment that is caring, supportive, and devoid of criticism or blame. Narrative descriptions of emergency interventions, including what was learned from debriefings with patients and staff involved, provide data about factors that may contribute to the use of seclusion or restraint. This forum provides visible administrative and clinical support that promotes creative thinking, collaborative problem solving, and the exploration of new ideas recommended by those directly involved in providing patient care. It has fostered exploration and development of strategies that have minimized episodes of aggressive behavior as well as seclusion and restraint.

Patterns of care in patients discharged from acute psychiatric inpatient facilities

To analyze the characteristics of patients scheduled for discharge from acute psychiatric inpatient facilities in Italy, and their pattern of care. Socio-demographic and clinical characteristics, and patterns of care of 1,330 patients discharged from public and private inpatient facilities in Italy were assessed with a standardized methodology during an index period in the year 2004. About one half of the sample had schizophrenia or bipolar disorder. However, the case-mix differed between public and private facilities, where in-patients had more frequently mood and anxiety disorders. The use of two or more drugs was very common, involving more than 90% of patients and including typically benzodiazepines and antipsychotics. Structured psychosocial treatments were rarely initiated during the hospital stay. Increasing age, male gender, long stay in the facility (>60 days), personality disorder and type of facility were associated with a higher likelihood of being discharged to a community residential facility. Predictors of discharge to another psychiatric facility were increasing age, being single, schizophrenia, personality disorder and organic mental disorder. Families were not involved in decisions about patients' discharge in a significant proportion of cases. University psychiatric clinics and private facilities were less coordinated with the community system of care than General Hospital Psychiatric Units. Referral of patients with substance use disorder to drug addiction services occurred in just 30% of subjects. This study provides information on the characteristics and the pattern of care of patients discharged from inpatient facilities in a country that has closed down all its mental hospitals. This information may be relevant for those countries that are affording now the downsizing of MHs, and the expansion of community-based models of care.

Focus on Mental Health Care Reforms in Europe: A One-Day Census of Acute Psychiatric Inpatient Facilities in Italy: Findings From the PROGRES-Acute Project

On May 8, 2003, a survey was conducted of all inpatients at 369 psychiatric facilities for adult acute patients in all Italian regions except Sicily. The estimated point prevalence rate of admissions was 18.3 per 100,000 adult population. There were 305 involuntarily admitted patients (3.8%, or .70 per 100,000 population). Large differences between public and private facilities were found in age and gender distribution: the proportion of men age under age 35 was larger in public facilities, and the proportion of women age 65 and older was larger in private facilities. In Italy, monitoring and evaluation of community services, at both the local and national levels, is essential for policy development, implementation, and evaluation.

Focus on Mental Health Care Reforms in Europe: A One-Day Census of Acute Psychiatric Inpatient Facilities in Italy: Findings From the PROGRES-Acute Project

On May 8, 2003, a survey was conducted of all inpatients at 369 psychiatric facilities for adult acute patients in all Italian regions except Sicily. The estimated point prevalence rate of admissions was 18.3 per 100,000 adult population. There were 305 involuntarily admitted patients (3.8%, or .70 per 100,000 population). Large differences between public and private facilities were found in age and gender distribution: the proportion of men age under age 35 was larger in public facilities, and the proportion of women age 65 and older was larger in private facilities. In Italy, monitoring and evaluation of community services, at both the local and national levels, is essential for policy development, implementation, and evaluation.

Patterns of admission to acute psychiatric in-patient facilities: a national survey in Italy

A proper understanding of patterns of care represents a crucial step in improving clinical decision making and enhancing service provision. Only a few studies, however, have explored global patterns of psychiatric admissions nationwide, and none have been undertaken in Italy. Sociodemographic, clinical and treatment-related information was collected for 1577 patients admitted to 130 public and 36 private in-patient facilities in Italy during an index period in the year 2004. All patients were also rated using the 24-item Brief Psychiatric Rating Scale (BPRS) and the Personal and Social Performance (PSP) rating scales. Non-affective psychoses (36%) were the most common diagnoses and accounted to a large extent for compulsory admissions. Private facilities were more likely to admit patients with organic mental disorders and substance abuse/dependence and less likely to admit patients with non-affective psychoses. Overall, 77.8% of patients had been receiving treatment by a mental health professional in the month prior to admission. In 54% of cases, the admission was solicited by patients' family members. The main factors preceding admission were impairment in work or social functioning, social withdrawal, and conflict with family members. Agitation, delusions and/or hallucinations, and the presence of multiple problems were associated with compulsory admissions, whereas depressive and anxiety symptoms were associated with voluntary admissions. In a mixed, public-private psychiatric care system, like the Italian one, public and private facilities admit patients with widely different clinical characteristics and needs. Family support represents an important resource for most patients, and interventions specifically addressed to relieving family burden are warranted.

Child internalizing and externalizing behavior as predictors of age at first admission and risk for repeat admission to a child inpatient facility.

Gaining a better understanding of the types of child symptomatology that predict age at first admission and risk for readmission to a child psychiatric inpatient facility could help to inform the focus of intervention. Accordingly, the current study examined whether internalizing and externalizing behavior problems, alone or in combination, were associated with age at first admission and risk for repeat admission. Analyses were based on a sample of 372 children (M = 9.13 years, SD = 1.91) admitted to an acute psychiatric inpatient facility. Internalizing behavior was associated with a later age at admission, but unrelated to repeat admission. Externalizing behavior was associated with an earlier age at admission and increased risk for repeat admission. Co-occurring internalizing and externalizing behavior problems were associated with increased risk for repeat admission, but were unrelated to age at first admission. Implications for findings are discussed.

Initiation and Use of Public Mental Health Services by Persons With Severe Mental Illness and Limited English Proficiency

Initiation and Use of Public Mental Health Services by Persons With Severe Mental Illness and Limited English Proficiency

Characteristics and activities of acute psychiatric in-patient facilities: national survey in Italy

Legislation in 1978 led to the gradual replacement of mental hospitals in Italy with a full range of community-based services, including facilities for acute in-patient care. To survey the main characteristics of Italian public and private in-patient facilities for acute psychiatric disorders. Structured interviews were conducted with each facility's head psychiatrist in all Italian regions, with the exception of Sicily. Overall, Italy (except Sicily) has a total of 4108 public in-patient beds in 319 facilities, with 0.78 beds for every 10,000 inhabitants, and 4862 beds in 54 private in-patient facilities, with 0.94 beds per 10,000 inhabitants. In 2001 the rates of psychiatric admissions and admitted patients per 10,000 inhabitants were 26.7 and 17.8 respectively. In the same year the percentage of involuntary admissions was 12.9%, for a total of 114,570 hospital days. Many in-patient facilities showed significant limitations in terms of architectural and logistic characteristics. Staffing showed a great variability among facilities. The overall number of acute beds per 10,000 inhabitants is one of the lowest in Europe. The survey has provided evidence of two parallel systems of in-patient care, a public one and a private one, which are not fully interchangeable.

'Something always comes up': nurse-patient interaction in an acute psychiatric setting.

In this study, 10 nurses and 10 patients were interviewed to explore factors influencing nurse-patient interactions in an acute psychiatric inpatient facility. The six themes that emerged from the nursing interviews were; environment, something always comes up, nurses' attributes, patient factors, instrumental support and focus of nursing. The four themes from the patient interviews were; nurses' attributes, role perceptions, clinical care, and time. These findings have implications for clinical practice, the nurses' role and nursing education.

Factors influencing nurse-patient interaction in the acute psychiatric setting: an exploratory investigation.

Nurse-patient interaction in acute psychiatric in-patient facilities has been the subject of much discussion in the literature and remains a contentious issue. How and why nurses interact with patients in the acute care setting requires definition within the current dynamic environment of mental health service provision. Factors which impact on the manner in which nurses care for patients also require investigation. This article presents the findings of a collaborative research study that investigates factors that influence nurse-patient interaction in the acute psychiatric setting. Ten nurses on the study ward were given opportunity, through semi-structured interviews, to outline and describe the factors perceived to influence nurse-patient interaction. Factors identified as influencing interaction included the ward environment, something always comes up, nurses' attributes, patient factors, instrumental support and focus of nursing. Issues which emerged from the study provide managers and clinical nurses with an opportunity for generating new possibilities for nurse-patient interaction. However, these issues must be addressed in a sensitive way that takes into account the complex and dynamic nature of acute care settings.

Predicting length of stay in an acute psychiatric hospital.

Multivariate statistical methods were used to identify patient-related variables that predicted length of stay in a single psychiatric facility. The study investigated whether these variables remained stable over time and could be used to provide individual physicians with data on length of stay adjusted for differences in clinical caseloads and to detect trends in the physicians' practice patterns. Data on all patients discharged over two six-month periods were collected at an acute psychiatric inpatient facility. Stepwise multiple regression analyses were conducted on the two datasets. The results from both analyses revealed that five variables significantly predicted length of stay and were stable over time. They were a primary diagnosis of schizophrenia, the number of previous admissions, a primary diagnosis of a mood disorder, age, and a secondary diagnosis of an alcohol- or other drug-related disorder. For some physicians, the mean length of stay of their patients differed significantly from the length predicted by the regression model--generally, it was shorter. The results demonstrate that patient-related predictors of length of stay in a single psychiatric hospital can be identified using relatively simple statistical procedures and can be consistent across a large dataset and over time.