Acute Inpatient Psychiatric Services Research Articles

Improving Women's Sexual and Reproductive Health in Acute Inpatient Psychiatric Services – A Quality Improvement Project

Improving Women's Sexual and Reproductive Health in Acute Inpatient Psychiatric Services – A Quality Improvement Project

Predictors of high intensity use of acute psychiatric inpatient services

ABSTRACT Objective High Intensity Users (HIUs) represent a small group of individuals accounting for a large proportion of inpatient resources. The paper aims to identify risk factors for becoming a High Intensity User of acute inpatient services and to understand the impact of different operationalisations of HIU. Method Participants were eligible admissions from 2016 to 2022 in an outer London NHS Trust. Retrospective case files were accessed to retrieve data. Regression models were used to identify predictors of HIU, operationalised using three binary and one continuous measure (3+ admissions in one year; 4+ in 5 years; 3+ ever; and percentage of adulthood in hospital). Results Being of Black ethnicity or younger when first admitted was associated with greater high intensity use, however defined. Risk of 3+ admissions in a year increased with age and was higher for those with personality disorders, previous admissions, those who had been placed in care during childhood, and those with historical cannabis use. Individuals whose first admission was due to a suicide attempt were at lower risk. Different operationalisations of HIU altered the factors that predicted risk. Discussion The study highlights the need for a consensus HIU definition to help progress the research and clinical efforts to support this group. Identifying and targeting support for those at greater risk for frequent readmission is needed to help reduce readmission and improve outcomes.

Perceptions of racism in a children's psychiatric inpatient unit: A qualitative study of entrenching and uprooting factors.

We describe a systematic and orderly way to identify factors that contribute to entrenching racism as the status quo or that help to uproot it. By incorporating a racial equity lens, we can better understand daily racism and inform the optimal antiracist actions most relevant to an inpatient psychiatric setting. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: Our two-domain/six-theme model may serve as a rubric for individuals to engage in structured self-reflection, for organizations in auditing or programmatic evaluation, or as scaffolding for difficult but frequently elided conversations. The unique strengths of a mental health environment can be harnessed toward the elimination of racism and racist practices in clinical care and in the workplace ABSTRACT: INTRODUCTION: It is well documented that racism plays a role in health care access and outcomes. However, discussions about racism in the inpatient psychiatric workplace are generally avoided. To address this gap, we incorporated a racial equity perspective into a qualitative study to better understand daily racism, its impact on patients and staff, and to inform optimal antiracist actions most relevant to inpatient psychiatric settings. We sought to identify factors that may contribute to or deter from racism to inform interventions to sustain a psychologically supportive environment for patients and staff. We conducted semistructured interviews using a purposive sample of 22 individuals in an acute child psychiatric inpatient service. We analysed transcripts using thematic analysis guided by a constructivist grounded theory conceptual framework. We identified two countervailing processes: (1) Entrenching-factors that sustain or increase racism: Predisposing, Precipitating, and Perpetuating and (2) Uprooting-factors that rectify or reduce racism: Preventing, Punctuating, and Prohibiting. We organized each of the elements into a '6P' model along a temporal sequence around sentinel racist events. For each of the six components we describe: Contributing Factors, Emotional Reactions, and Behavioural Responses as reported by participants. Identifying factors that entrench or uproot racism can inform specific steps to improve the care of all children and families on an inpatient child psychiatry unit. The two-domain/six-theme model we developed can serve as a rubric for individuals or milieu-based inpatient settings serving patients of any age to engage in structured self-reflection, auditing, program evaluation, or as scaffolding for difficult but frequently elided conversations.

Psychiatrist and trainee moral injury during the organisational long COVID of Australian acute psychiatric inpatient services.

This paper provides a commentary on the risk of moral injury amongst psychiatrists and trainees working in the acute psychiatric hospital sector, during the third winter of the COVID-19 pandemic. Moral injuries arise from observing, causing or failing to prevent adverse outcomes that transgress core ethical and moral values. Potentially, morally injurious events (PMIEs) are more prevalent and potent while demand on acute hospitals is heightened with the emergence of highly infectious SARS-CoV-2-Omicron subvariants (BA.4 and BA.5). Acute hospital inpatient services were already facing extraordinary stresses in the context of increasingly depleted infrastructure and staffing related to the pandemic. These stresses have a high potential to be morally injurious. It is essential to immediately fund additional staff and resources and address workplace health and safety, to seek to arrest a spiral of moral injury and burnout amongst psychiatrists and trainees. We discuss recommended support strategies.

Protocol for the Lovisenberg Open Acute Door Study (LOADS): a pragmatic randomised controlled trial to compare safety and coercion between open-door policy and usual-care services in acute psychiatric inpatients

IntroductionThe reduction of coercion in psychiatry is a high priority for both the WHO and many member countries. Open-door policy (ODP) is a service model for psychiatric ward treatment that...

Factors associated with length of stay and readmission in acute psychiatric inpatient services in Portugal.

Assessing the factors that influence duration and number of hospitalizations may support mental health services planning and delivery. This study examines the factors associated with length of stay and readmission in Portuguese psychiatric inpatient services during 2002, 2007 and 2012.Data from all admissions were extracted from clinical files. Logistic regression models estimated the association between length of stay (<17 vs ≥17 days) and number of admissions per year (1 vs >1 admission) with sociodemographic, clinical, and contextual factors.Older age, a diagnosis of psychosis, and compulsory admission were associated with higher odds of longer length of stay. Being married, secondary education, suicide attempt, a diagnosis of substance use and “other mental disorders”, being admitted in 2012, and two of the psychiatric inpatient services associated with lower odds of longer length of stay.Being retired (or others), a diagnosis of psychosis, compulsory admission, and psychiatric service were associated with increased odds of readmission. Older age, and secondary and higher education were associated with lower odds of readmission.The findings indicate that multiple factors influence length of stay and readmission. Identifying these factors provides useful evidence for clinicians and policy makers to design more targeted and cost-effective interventions.

Negative symptom severity at discharge from an index hospitalization and subsequent use of psychiatric care resources: A retrospective 1-year follow-up study on 450 patients with schizophrenia spectrum disorders

Negative symptoms of schizophrenia have a great impact on patients' functioning and are among the most important contributors to subject's disability. However, few studies have assessed the role of type and severity of symptomatology of schizophrenia on the psychiatric care resource utilization.We investigated if the clinical profile of patients at discharge from an index hospitalization might be associated with a different use of psychiatric care resources in the subsequent 1-year period in a large population of patients with schizophrenia spectrum disorders.Clinical records of 450 patients with schizophrenia spectrum disorders admitted in an acute psychiatric inpatient service and subsequently followed in the outpatient services of the same Department were reviewed.Patients with more severe negative symptoms at discharge from hospital showed a higher number and duration of hospitalizations in the 1-year follow-up, as well as a higher number of rehabilitative residential admissions than patients with milder severity of negative symptoms. The same was true for patients with predominant negative symptoms. A global resource utilization index indicated a higher use of psychiatric resources in patients with higher severity of negative symptoms.In conclusion, showing moderate to severe negative symptoms versus positive symptoms at discharge from a hospitalization for an acute exacerbation of schizophrenia spectrum disorder does predict a higher use of psychiatric care resources. This underlines the importance of relieving negative symptoms even in the acute phase of treatment and the need to develop more effective treatments for this symptom dimension.

Methamphetamine use in patients presenting to emergency departments and psychiatric inpatient facilities: what are the service implications?

The aim of this study is to understand better the service implications of patients presenting to an inner city Australian Emergency Department (ED) and Acute Psychiatric Inpatient Service (AIS) with a history of recent crystal methamphetamine use. An audit was taken of all patients with recent crystal methamphetamine use presenting to St Vincent's Hospital Melbourne ED and AIS over the month of September 2017. Recorded information included patient demographics, diagnosis, aggressive episodes, restrictive interventions and other risk incidents. Methamphetamine was related to 21.7% of AIS admissions. Of these individuals, half were involved in aggression towards staff. In the ED, 65.7% of patients with amphetamine use were aggressive to staff and 50% were aggressive towards other patients. There were high rates of physical (69.2%) and mechanical restraint (61.5%) in the ED setting. Methamphetamine use in the AIS was commonly associated with enduring psychotic disorders, whilst those managed exclusively in the ED were most commonly in an acute intoxicated state. Methamphetamine use presents a significant challenge to EDs and acute mental health services. Additional resources are required to manage these patients and their impact on the health system needs to be factored into future service planning.

Unlocking an acute psychiatric ward: The impact on unauthorised absences, assaults and seclusions

Aims and method The acute psychiatric in-patient service in Christchurch, New Zealand, recently changed from two locked and two unlocked wards to four open wards. This provided the opportunity to evaluate whether shifting to an unlocked environment was associated with higher rates of adverse events, including unauthorised absences, violent incidents and seclusion. We compared long-term adverse event data before and after ward configuration change.Results Rates of unauthorised absences increased by 58% after the change in ward configuration (P = 0.005), but seclusion hours dropped by 53% (P = 0.001). A small increase in violent incidents was recorded but this was not statistically significant.Clinical implications Although unauthorised absences increased, the absence of statistically significant changes for violent incidents and a reduction in seclusion hours suggest that the change to a less restrictive environment may have some positive effects.

Factors associated with use of psychiatric intensive care and seclusion in adult inpatient mental health services.

Within acute psychiatric inpatient services, patients exhibiting severely disturbed behaviour can be transferred to a psychiatric intensive care unit (PICU) and/or secluded in order to manage the risks posed to the patient and others. However, whether specific patient groups are more likely to be subjected to these coercive measures is unclear. Using robust methodological and statistical techniques, we aimed to determine the demographic, clinical and behavioural predictors of both PICU and seclusion. Data were extracted from an anonymised database comprising the electronic medical records of patients within a large South London mental health trust. Two cohorts were derived, (1) a PICU cohort comprising all patients transferred from general adult acute wards to a non-forensic PICU ward between April 2008 and April 2013 (N = 986) and a randomly selected group of patients admitted to general adult wards within this period who were not transferred to PICU (N = 994), and (2) a seclusion cohort comprising all seclusion episodes occurring in non-forensic PICU wards within the study period (N = 990) and a randomly selected group of patients treated in these wards who were not secluded (N = 1032). Demographic and clinical factors (age, sex, ethnicity, diagnosis, admission status and time since admission) and behavioural precursors (potentially relevant behaviours occurring in the 3 days preceding PICU transfer/seclusion or random sample date) were extracted from electronic medical records. Mixed effects, multivariable logistic regression analyses were performed with all variables included as predictors. PICU cases were significantly more likely to be younger in age, have a diagnosis of bipolar disorder and to be held on a formal section compared with patients who were not transferred to PICU; female sex and longer time since admission were associated with lower odds of transfer. With regard to behavioural precursors, the strongest predictors of PICU transfer were incidents of physical aggression towards others or objects and absconding or attempts to abscond. Secluded patients were also more likely to be younger and legally detained relative to non-secluded patients; however, female sex increased the odds of seclusion. Likelihood of seclusion also decreased with time since admission. Seclusion was significantly associated with a range of behavioural precursors with the strongest associations observed for incidents involving restraint or shouting. Whilst recent behaviour is an important determinant, patient age, sex, admission status and time since admission also contribute to risk of PICU transfer and seclusion. Alternative, less coercive strategies must meet the needs of patients with these characteristics.

The Role of Gender as a Moderator of the Alliance‐Outcome Link in Acute Inpatient Treatment of Severely Disturbed Youth

Research is needed to further examine the role of treatment alliance or engagement among child and adolescent patients in inpatient psychiatric settings. In this study, 72 newly admitted patients on an inpatient adolescent psychiatric unit completed measures of symptom severity and treatment alliance. Female patients showed greater symptom severity at both admission and discharge. Residualized gain score analysis showed that male gender predicted greater symptom reduction. Treatment alliance also predicted greater symptom reduction, but only among women. These results suggest that alliance or engagement with acute inpatient psychiatric services may play a more important role among women than men in predicting symptomatic change in severely disturbed adolescents. Copyright © 2016 John Wiley & Sons, Ltd.

Psychiatric admissions fall following the Christchurch earthquakes: an audit of inpatient data.

Following the devastating earthquake in Christchurch, New Zealand, there was the widespread perception that the demand for inpatient mental health services would increase. However, our clinical observation was to the contrary, with substantial reductions in inpatient utilisation being noted. We therefore examined psychiatric bed occupancy and admission data to improve understanding of the impact of the disaster on mental health services. We audited acute psychiatric bed occupancy and admission rates prior to and following a major earthquake. After the earthquake, total bed occupancy reduced from an average of 93% to 79%. Daily admissions also reduced by 20.2% for the 30 days following the earthquake. All diagnostic groups, with the exception of the 'Schizophrenia, schizotypal and delusional disorders' category, contributed to the reduction. No rebound to increased occupancy or admissions was seen over the study period. The study confirmed our clinical observation that demand for acute inpatient psychiatric services were markedly reduced after the February 2011 earthquake.

Validation of the Chinese version of Perception of Care in an acute psychiatric ward in Hong Kong

This study aimed to validate and culturally adapt the Perception of Care (PoC) for patients receiving acute psychiatric inpatient services in Hong Kong. The PoC was translated and culturally adapted into a written Chinese version (C-PoC). Subjects completed C-PoC, Chinese version of Admission Experience Survey (C-AES) and World Health Organization Quality of Life Measure (WHOQOL-BREF). They were then rated by assessors with Brief Psychiatric Rating Scale (BPRS), Hamilton Rating Scale for Depression, Hamilton Rating Scale for Anxiety and Extrapyramidal Symptom Rating Scale. Explorative factor analysis and correlation between C-PoC, WHOQOL-BREF and C-AES served as the theoretical basis of construct validity. Multivariate analysis was used to identify predictors of satisfaction. The C-PoC has a four-factor structure that resembles the original scale with demonstrating satisfactory construct validity and test-re-test reliability. Psychiatric symptom ratings did not predict any satisfaction ratings. Extrapyramidal symptoms predicted poorer satisfaction. Younger patients with affective diagnoses had better satisfaction. The C-PoC is a psychometrically sound translation of the original scale. The current study paves the way for further studies among Chinese-speaking communities on the determinants and implications of patients' satisfaction by offering a psychometrically sound and yet concise instrument.

Implementing successful residential alternatives to acute in-patient psychiatric services: lessons from a multi-centre study of alternatives in England

Standard acute psychiatric care in the UK is costly but problematic. Alternatives to standard in-patient wards exist, but little is known about their effectiveness, implementation and sustainability. This paper explores successful features and limitations of five residential alternative services in England and factors that facilitate or impede their initial and sustained implementation and success. Semi-structured interviews about the functioning of six alternative services were conducted with 36 mental health professionals with good working knowledge of, and various connections with these services. A group interview with study researchers was also conducted. Data were analysed using thematic analysis. One service did not show evidence of operating as an alternative and was excluded from further analysis. The remaining five alternatives are valued for providing a more holistic style of care than standard services that confers many perceived benefits. However, they are seen as less appropriate for compulsorily detained or highly disturbed patients, and as providing less comprehensive treatment packages than hospital settings. Factors identified as important to successful implementation and sustainability are: responding to known shortcomings in local acute care systems; balancing role clarity and adaptability; integration with other services; and awareness of the alternative among relevant local health-care providers. Residential alternatives can play an important role in managing mental health crises. Their successful implementation and endurance depend on establishing and maintaining a valued position within local service systems. Findings contribute to bridging the gap between research evidence on the problems of standard acute care and delivering improved crisis management services.

Depression and cognitive deficits in geriatric schizophrenia

ObjectivePast reports have found patients with comorbid depression and schizophrenia spectrum disorders exhibit greater deficits in memory and attention compared to schizophrenia spectrum disorder patients without depressive symptoms. However, in contrast to younger schizophrenia patients, the few past studies using cognitive screens to examine the relationship between depression and cognition in inpatient geriatric schizophrenia have found that depressive symptomatology was associated with relatively enhanced cognitive performance. In the current study we examined the relationship between depressive symptoms and cognitive deficits in geriatric schizophrenia spectrum disorder patients (n=71; mean age=63.7) on an acute psychiatric inpatient service. MethodPatients completed a battery of cognitive tests assessing memory, attention and global cognition. Symptom severity was assessed via the PANSS and Calgary Depression Scale for Schizophrenia. ResultsResults revealed that geriatric patients' depression severity predicted enhancement of their attentional and verbal memory performance. Patients' global cognitive functioning and adaptive functioning were not associated with their depression severity. ConclusionContrary to patterns typically seen in younger patients and non-patient groups, increasing depression severity is associated with enhancement of memory and attention in geriatric schizophrenia spectrum disorder patients. Also, diverging from younger samples, depression severity was unassociated with patients adaptive and global cognitive functioning.

Implementing successful residential alternatives to acute in-patient psychiatric services: what can we learn from professional stakeholders' perspectives?

Implementing successful residential alternatives to acute in-patient psychiatric services: what can we learn from professional stakeholders' perspectives?

Admissions to acute adolescent psychiatric units: a prospective study of clinical severity and outcome.

BackgroundSeveral countries have established or are planning acute psychiatric in-patient services that accept around-the-clock emergency admission of adolescents. Our aim was to investigate the characteristics and clinical outcomes of a cohort of patients at four Norwegian units.MethodsWe used a prospective pre-post observational design. Four units implemented a clinician-rated outcome measure, the Health of the Nation Outcome Scales for Children and Adolescents (HoNOSCA), which measures mental health problems and their severity. We collected also data about the diagnoses, suicidal problems, family situations, and the involvement of the Child Protection Service. Predictions of outcome (change in HoNOSCA total score) were analysed with a regression model.ResultsThe sample comprised 192 adolescents admitted during one year (response rate 87%). Mean age was 15.7 years (range 10-18) and 70% were girls. Fifty-eight per cent had suicidal problems at intake and the mean intake HoNOSCA total score was 18.5 (SD 6.4). The largest groups of main diagnostic conditions were affective (28%) and externalizing (26%) disorders. Diagnoses and other patient characteristics at intake did not differ between units. Clinical psychiatric disorders and developmental disorders were associated with severity (on HoNOSCA) at intake but not with outcome. Of adolescents ≥ 16 years, 33% were compulsorily admitted. Median length of stay was 8.5 days and 75% of patients stayed less than a month. Compulsory admissions and length of stay varied between units. Mean change (improvement) in the HoNOSCA total score was 5.1 (SD 6.2), with considerable variation between units. Mean discharge score was close to the often-reported outpatient level, and self-injury and emotional symptoms were the most reduced symptoms during the stay. In a regression model, unit, high HoNOSCA total score at intake, or involvement of the Child Protection Service predicted improvement during admission.ConclusionsAcute psychiatric in-patient units for adolescents effectively meet important needs for young people with suicidal risks or other severe mental health problems. These units may act in suicide prevention, stabilizing symptom severity at a lower level within a short stay. It is important to explore the differences in outcome, compulsory admissions, and length of stay between units.

P03-14 - A quasi-experimental controlled intervention to reduce violence on an acute psychiatric ward

IntroductionViolence and aggression are a major concern in acute inpatient psychiatric wards. Hard outcome data on the impact of service change are scarce. This poster presents the outcomes of service changes designed to improve the acute ward environment and patient experience.Aims and objectivesTo implement changes to the delivery of acute inpatient psychiatric services and to measure the outcome of these changes in objective verifiable form.MethodSignificant changes were introduced to an acute psychiatric inpatient service. These included introducing a dedicated inpatient psychiatrist “hospitalist”, replacing weekly ward rounds with daily multidisciplinary care and discharge planning meetings and promoting increased roles for nursing staff in decision-making and patient contact. Outcomes measured included routinely recorded incidents of violence with and without injury, use of restraint for medication and use of constant nursing observation. The control group was a similar service in the same hospital subject to the same general policies and admitting patients demographically comparable, but that did not at the time undergo the interventions implemented in the trial service. All data was recorded by staff who were unaware of this study or even that any analysis of the data would occur.Results and conclusionsViolent incidents in the intervention ward dropped by 34% per patient (p=&lt; 0.02) whilst increasing by 3% in the control ward; restraints decreased by 28% (p=ns) whilst increasing by 12% in the control ward; with an overall reduction in constant observation. The intervention was highly effective in reducing violent incidents.

P03-189 Is the brief psychotic disorder a distinct nosologic entity?: A longitudinal study of 80 patients

Introduction:The DSM-IV-TR category “brief psychotic disorder” includes different concepts that have been defined before like bouffée délirante, cycloid psychosis and “acute and transient psychosis” in the last ICD-10. Limited prospective studies have been done, and they all show a marked diagnostic instability during follow-up. According to that, its independent nosologic entity is still uncertain.Aims:To determine the diagnostic stability of the brief psychotic disorders as well as their distinct clinical features.Method:Observational, retrospective, longitudinal study of 80 consecutive patients admitted at the acute psychiatric inpatient service of a general hospital between 2000 and 2006. at discharge, all of them fulfilled diagnostic criteria for “brief psychotic disorder” according to DSM-IV. Demographic and psychopathological data were analysed.Results:Mean age (SD) was 31.3 (9.5), most of them women (63%). the most frequent previous stressor was related to labour, while up to 45% didn't report any. 51% had no psychiatric family history. 15 (19%) patients previously had a brief psychotic episode. Psychopathological disturbances identified were: thought disorder 69%, anxiety 66.6%, insomnia 57.7%, suspiciousness 53.5%, rapidly changing delusions 53.3% (paranoid contents 75.3%), perplexity 46.5%, auditory hallucinations 45.1%, mood lability 36.6%, elation 23.9%, depressed mood 22.5% and irritability 12.7%. in the 24 month follow-up, 32.5% changed diagnosis to schizophrenia, 3"9% to schizoaffective, 10% to bipolar disorder and 16.9% achieved clinical remission. 28.5% were lost to follow-up.Conclusion:“Brief psychotic disorder” category is still uncertain and more data may be necessary to clarify if it should remain as a distinct nosologic entity.

The challenges of developing dual diagnosis capabilities for acute inpatient staff

Dual diagnosis poses particular challenges for inpatient mental health services. Workers have low levels of training, clinical experience and support to deliver integrated care that combines mental health and substance use interventions. In addition, inpatient workers have to balance being therapeutic with ensuring that illicit substance use does not occur on the wards. This often leads to confrontation and poor engagement.In order to improve the capabilities of the workers to deliver more effective interventions for this group of service users, dual diagnosis training should be a high priority for acute inpatient services. However, there are a number of challenges in the implementation of this including lack of resources to fund training and specialist roles, lack of time to attend training (and supervision), and lack of time to implement learning in routine care.This paper will describe the policy drivers for the improvement of dual diagnosis care in acute psychiatric inpatient services, and how two initiatives in London are overcoming some of the obstacles and showing some promising initial outcomes. This paper will make recommendations for future research and developments.