Adult Inpatient Units Research Articles

INFANTS AT RISK

Although most research on medical error has been conducted on adult inpatient units, the few studies conducted in pediatric settings suggest that errors occur more frequently in neonatal intensive care units (NICUs) than in other inpatient units. The effects of fatigue, due to long work hours, working at night, and insufficient sleep, are often underestimated. This article reviews basic information about fatigue and sleep and includes examples drawn from data provided by 6 NICU nurses who participated in a recent study to highlight the relationship between fatigue and error. These case studies reinforce the concept that NICU nurses need to be alert enough to provide safe care for their patients, as well as alert enough to detect and correct the errors made by others. Employing good sleep habits, minimizing shift rotations and excessive work hours, and using strategic naps can reduce the adverse effects of fatigue that could potentially put patients, especially the most vulnerable ones, at risk.

Factitious disorder on an inpatient psychiatry ward.

The authors present 6 cases of factitious disorder seen on a general adult inpatient psychiatry unit of a university hospital. They review the clinical features of this disorder and suggest that factitious disorder is much more prevalent among psychiatric inpatients than is commonly recognized. Strategies to assist in the diagnosis and management this disorder are detailed.

Prevalence and Severity of Intimate Partner Violence and Associations With Family Functioning and Alcohol Abuse in Psychiatric Inpatients With Suicidal Intent

Many medical settings have conducted screenings for domestic violence, but no study has assessed the prevalence and frequency of intimate partner violence (IPV) within the acute psychiatric inpatient population. This descriptive, cross-sectional study was conducted in adult inpatient acute care units at a psychiatric hospital. Participants completed questionnaire-based assessments of recent and lifetime history of IPV, family functioning, and alcohol use. Recruited patients were aged between 18 and 65 years, were English-fluent and literate, had suicidal ideation, and had been living with an intimate partner for at least the past 6 months. Acutely psychotic patients and patients who were too agitated to complete the questionnaires were excluded. 110 patients completed the assessments. Interpersonal violence was assessed using the Revised Conflict Tactics Scale (CTS2), family functioning was measured using the Family Assessment Device, and alcohol use was assessed with the Alcohol Use Disorders Identification Test. Data were gathered from August 2004 through February 2005. Over 90% of suicidal inpatients reported IPV perpetration and victimization in their relationships in the past year, with the overwhelming majority reporting severe IPV. Male and female patients did not differ significantly on any CTS2 violence perpetration or victimization subscale (all p values >.05). Poor family functioning predicted physical violence victimization in both male and female suicidal inpatients, even after controlling for alcohol use and demographic characteristics. Psychiatric inpatients with suicidal ideation or intent would benefit from screening for IPV. Information about IPV and treatment options should be made available to psychiatric inpatients with suicidal intent. Attention to the family functioning of these patients is recommended.

Reducing the incidence of vancomycin-resistant Enterococci (VRE): A 12-month outcome on an adult inpatient oncology unit

ISSUE: Oncology patients are at increased risk for acquiring resistant bacteria due to multiple antibiotic therapies, frequent and prolonged hospitalizations, and immunosuppression secondary to disease and treatment. Over the summer of 2003, an increased incidence of VRE and corresponding utilization of infection control precautions was noted on the adult oncology unit. PROJECT: A multidisciplinary team met to identify and outline interventions to reduce factors contributing to horizontal transmission of antibiotic resistant pathogens in this patient population. The team's purpose was to provide a safer environment through the promotion of basic infection control practices, including standard precautions; promote early identification and isolation of patients with drug-resistant organisms; and educate staff, patients, and families regarding the importance of basic infection control practices and active surveillance screening cultures for drug-resistant organisms. Education and observational studies were done by the department of epidemiology to increase staff knowledge and awareness of current infection control practices. Routine cleaning needs were identified, cleaning responsibilities clarified, and storage of shared patient equipment was improved. Scripts were developed to assist staff in discussing the importance of screening with patients and families. Patient letters were developed to outline the unit's plan and the importance of hand hygiene for patients and visitors. All oncology patients were screened for VRE on admission and weekly thereafter. Patients identified as VRE positive were placed on drug-resistant organism (DRO) precautions, an enhanced contact precaution that required gowns and gloves for entry into the patient room. Precautions days were tracked monthly. Bimonthly team meetings were held to discuss and address issues and provide real time data for review and analysis. RESULTS: Through a multidisciplinary collaborative effort, we were able to initiate and sustain a greater than 50% reduction in the number of new cases of VRE. Fewer patients on infection control precautions impacted nursing care time, increasing both patient and staff satisfaction. LESSONS LEARNED: Active surveillance screening cultures and prompt isolation, in conjunction with basic infection control measures, can promote a safer patient environment and reduce the risk of horizontal transmission in a high-risk patient population.

Does a limited nurse triage service reduce junior doctor psychiatric on-call workload?

Aims and MethodTo investigate whether nurse triage might reduce junior doctors' on-call workloads in a general adult psychiatry in-patient unit, we measured changes in workload after the introduction of a limited (overnight and weekend mornings) nurse triage service on the unit, comparing pre-triage work levels with levels 1 year later. This time frame allowed the new service to settle in, and controlled for seasonal variations in workload.ResultsThe number of ‘work episodes' went up, especially during the night shifts, but the average length of each episode went down (both statistically significant, P < 0.001). The net result was a slight increase in workload in terms of total time spent dealing with episodes, most notably at night.Clinical ImplicationsA limited overnight nurse triage service was ineffective on its own as a means of reducing the out-of-hours workload of junior doctors, and even slightly increased it. A more comprehensive triage service, with a greater range of alternatives to admission, might have had a different result.

Managing sexual behavior on adult acute care inpatient psychiatric units.

Protecting and safeguarding persons with impaired decisional capacity are among the critical functions of a psychiatric hospital. The objective of this study was to investigate the elements of these functions as they relate to sexual behavior on an adult acute care inpatient psychiatric unit and to develop a policy to prevent or at least manage such behavior. The authors undertook an extensive literature review of articles and legal cases. The review was presented at numerous meetings of staff and interdisciplinary teams on the adult teaching unit at Bellevue Hospital in New York City. The findings from the review and the results of staff discussions were used in creating the policy. In the acute care setting, it may be both reasonable and prudent to prevent all sexual interactions between patients, especially given the potential risks of such behavior. Concerns include the transmission of sexually transmitted disease, reproductive issues, and the legal implications of nonconsensual activity. Despite these concerns, adult psychiatric inpatients should be granted as many rights as are possible without having an adverse effect on their treatment or recovery. There is currently no standard for a sexual behavior policy for psychiatric inpatients. Thus ward staff are left with minimal guidance and potential confusion in the event that sexual incidents do occur, and there is a greater likelihood of arbitrary responses. The policy developed through this study is an example of how individual institutions can enforce a structured protocol when dealing with an ambiguous and difficult issue.

Staff survey results and characteristics that predict assault and injury to personnel working in mental health facilities

AbstractThe purpose of this study was to complete a mental health staff opinion survey to identify patient and staff characteristics associated with staff assault and injury in psychiatric treatment settings and to develop a model of prediction for staff assault and injury utilizing these survey variables. The data consisted of opinion surveys sent to staff of 15 child, adolescent, and adult psychiatry inpatient units in the United States. Multivariate logistic regression was used to determine the level of assault and staff‐reported injury prediction that could be obtained from the staff‐completed opinion survey. Responses indicated a high prevalence of reported aggression, with 62.3% of staff endorsing verbal and physical aggression, property destruction, and self‐injurious behavior as being prevalent at their site, whereas only 4.1% rated none of these as prevalent. Staff working with children and adolescents in settings with high rates of psychiatric diagnoses reported increased frequency of assault and injury compared with those working with adults. Younger, less experienced staff reported higher rates of assault and injury. Staff working with female patients reported similar rates of assault and injury to those working with males. A logistic regression analysis using staff‐reported survey results of both staff and patient characteristics predicted assault correctly 73.7% of the time and injury 66.1% of the time. Resources for violence prevention and staff training programs in violence prevention are needed in child and adolescent psychiatry wards. Results are consistent with theories emphasizing the importance of negative emotions and affects, impulsivity, and frustration in goal‐directed activities in human aggression. Aggr. Behav. 29:31–40, 2003. © 2003 Wiley‐Liss, Inc.

Medication study supports registered nurses' competence for single checking.

In 1999, a review of medication policies and practices for The Geelong Hospital, a Victorian regional acute care hospital, was conducted under the leadership and direction of the Executive Nursing Director. The findings of the review suggested that a study be conducted to examine the safety of single-person (registered nurse division 1) checking of a designated group of medications that had previously been double-checked. The present study was conducted as a descriptive study in adult inpatient units and speciality and midwifery services of The Geelong Hospital, and included the monitoring of medication errors for the designated group of medications under a single-person checking protocol for a 7-month period. A similar number of medication errors were reported when compared with a similar time-frame in which double-person checking was standard practice. At the completion of the study, a convenience sample of 129 nurses from the participating units and services completed questionnaires. The majority of the nurses appreciated the increased autonomy the change to single-person checking of medications provided. They also identified benefits for patients, including that they were able to be more responsive to patient needs.

Integration of inpatient and outpatient services in an acute care transplant unit

Creating an ambulatory outpatient service for transplant recipients in an inpatient care unit allows several goals to be met: decreased inpatient length of stay, decreased cost per case, and increased patient satisfaction. By using 6 inpatient beds for ambulatory outpatient procedures, the leadership staff of an adult inpatient care unit in Mount Sinai Medical Center consolidated adult transplant services into a single area promoting quality transplant care.

Drugs and syringe drivers: a survey of adult specialist palliative care practice in the United Kingdom and Eire.

Subcutaneous delivery of drugs using a syringe driver is common practice within specialist palliative care units. There is, however, little documented information regarding clinical practice. A survey performed in 1992 reported that at least 28 drugs were used in combination with others in a single syringe driver. The aim of the present study was to reassess practice in this field and to enquire more specifically about newer drugs. Postal questionnaires were sent to all adult specialist palliative care in-patient units in the UK and Eire (n = 208). One hundred and sixty-five units (79%) responded. The most common syringe driver in use was the Graseby 26 (61% of responding units). Most units delivered the contents of the syringe over 24 h, and water was usually used as the diluent in 90% of cases. The maximum number of drugs that respondents were prepared to mix in a single syringe was usually three (51%) or four (35%). In the UK, all units used diamorphine in doses from 2.5 mg/24 h upwards. All respondents also used haloperidol, in doses from 0.5 to 60 mg/24 h. A total of 28 different drugs were used in syringe drivers. The most common combinations were diamorphine and midazolam (37%), diamorphine and levomepromazine (35%), diamorphine and haloperidol (33%), and diamorphine and cyclizine (31%). In conclusion, there is much in common with regard to the way in which drugs are delivered in syringe drivers. However, a wide variety of drugs and drug combinations are still in use.

Integration of Inpatient and Outpatient Services in an Acute Care Transplant Unit

Creating an ambulatory outpatient service for transplant recipients in an inpatient care unit allows several goals to be met: decreased inpatient length of stay, decreased cost per case, and increased patient satisfaction. By using 6 inpatient beds for ambulatory outpatient procedures, the leadership staff of an adult inpatient care unit in Mount Sinai Medical Center consolidated adult transplant services into a single area promoting quality transplant care.

P03.338 Experiences with the open-door-system in a adult inpatient psychiatric unit in a German general hospital

P03.338 Experiences with the open-door-system in a adult inpatient psychiatric unit in a German general hospital

How is psychiatry taught to Australian and New Zealand medical students?

This study aimed to describe the amount, format and content of psychiatry teaching programs in all 12 Australian and New Zealand medical schools. A structured questionnaire which included definitions and coding instructions was completed by class coordinators for the years of 1995 or 1996. Missing and inconsistent data were checked by coordinators and results were confirmed by heads of department. Most departments of psychiatry taught throughout the undergraduate course. Only three made no contribution to pre-clinical teaching. The time devoted to clinical tuition ranged from 279 to 454 h per university with a mean of 353 h. Clinical attachments occupied most time (mean = 70%), followed by small group teaching (mean = 19%) and lectures (mean = 11%). Medical schools varied greatly in the attention given to history taking and mental state examination, psychological therapies and the sub-specialties of child and aged psychiatry. Clinical attachments were mostly to adult inpatient units. Private psychiatric hospitals and clinics were used infrequently as were consultation-liaison psychiatry services and primary care. There is a need to broaden the clinical experience of students to better equip them for future medical practice. There appears to be a serious mis-match between the settings in which most students are taught and the settings in which most will work later as non-psychiatric practitioners. It was disappointing that psychological therapies received so little attention given the central place of counselling in modern medical practice.

Caffeine and Nicotine Use in an Addicted Population

ABSTRACT This study was undertaken to examine differences in caffeine and nicotine use between the psychiatric population and the addicted population in a private psychiatric inpatient facility. Eighty-six patients on an adult addictive disease inpatient unit and 80 patients on an adult psychiatry unit in a private psychiatric hospital were interviewed with regard to their use of nicotine and caffeine. In addition, demographic information and primary diagnoses were obtained from the psychiatric admission assessment in the medical record as listed by the admitting psychiatrist. Although there was little difference in psychiatric patients vs. chemically dependent patients with regard to the percentage of caffeine users, the chemically dependent individuals drank more coffee, soft drinks, and tea. A much greater percentage of the chemically dependent individuals also smoked cigarettes, although not in a greater amount than the psychiatric patients who smoked. Because group assignment was not random, ordinary least squares (OLS) regression analyses were conducted to determine the independent associations of age, sex, education, and treatment population in predicting levels of caffeine and tobacco use. Even after controlling for demographic differences between the two samples, chemically dependent patients still reported higher levels of daily caffeine and tobacco use than patients on the general psychiatric unit.

The Crawford Long Hospital of Emory University Experience

To identify which of three pain intensity measurement scales is most appropriate for use with patients admitted to the inpatient units of the study hospital. The following questions were addressed: Is one of the scales easier for most patients? Is the choice of scales influenced by nursing unit, age, education, race, SES, diagnosis, or type of pain experienced? Do patients perceive that a rating scale helps them describe their pain more effectively? 267 patients admitted over a 3-week period completed a four-page questionnaire and demographic form distributed on admission. The primary admitting diagnosis for 39.5% of the sample reflected acute pain, 40.3% chronic pain, and 20.2 no pain. Three pain rating scales were presented: two visual analogues (one contained a 100 mm line; the other contained six faces depicting graduated levels of distress); and a cognitive number rating scale. Each scale used a 0 (no pain) to 10 (worst pain possible) rating format. Patients completed the questionnaire by rating the intensity of pain experienced using each of the three scales once over the next 24 hours. The last page contained questions related to which of the scales was easiest to use, whether the scale was helpful or needed further explanation, and work and education information. The demographic form was completed from information contained in the patient record. The scale selected most frequently was the visual analogue containing faces (48.6%), followed by the number (35.3%) and line scales (16.1%). None of the demographic information was found to significantly influence choice of preferred scale. A majority (85.8%) indicated a rating scale as helpful; only 13.6% indicated a need for further explanation. The means for pain intensity ranged from 5.09 to 5.75. The interval between pain ratings for the majority (> 71%) was less than 2 hours. Patients tended to tell the nurse about their pain when the intensity exceeded the midpoint on the scales. A reliability coefficient for the three scales was computed at alpha = 0.88. The use of rating scales for pain assessment in adult inpatient units was viewed positively by patients. Recommendations for incorporating self-ratings of pain intensity are set forth. Involving both patients and providers in the process is essential to improving both our processes and the outcomes achieved.

Influences on fit between psychiatric patients' psychosocial needs and their hospital discharge plan.

The study examined factors that help determine a good or poor fit between the psychosocial support needs of hospitalized patients and the hospital's discharge plan. The Mount Sinai Discharge Planning Inventory was completed weekly for 494 consecutive admissions to the hospital's adult inpatient psychiatric units. The resources that patients brought with them into the hospitalization in the areas of housing, entitlements, daily activities, and psychiatric treatment were recorded as well as the resources that would constitute an optimal discharge plan. Good or poor fit was operationally defined by the match between the optimal, first-choice plan and the implemented discharge plan. One-third of admissions were found to have an optimal fit on admission in all resource categories studied. For patients who entered the hospital with suboptimal resources, discharge planing was significantly more likely to establish clinically relevant psychiatric treatment options and to strengthen daily living activities than to change housing resources. Certain diagnoses and a history of drug abuse, criminality, violence, and treatment noncompliance were associated with poorer fits with first-choice disposition options. The Mount Sinai Discharge Planning Inventory provides a method to systematically evaluate discharge planning by tracking progress toward securing relevant posthospital care and support.

Seasons and depression: The influence of cigarette smoking

The seasonality of depressive illness has been documented since antiquity. A review of 611 patients, who were consecutively admitted to the adult inpatient psychiatric unit of a mid-Michigan general hospital, examined the influence of cigarette smoking and psychiatric diagnosis upon the seasonal variation of admissions. Among the smokers, admissions for depressive disorders ( n = 151) peaked in the springtime ( z = 2.1, p < .05) and declined in summer. Admissions for the nonsmokers failed to demonstrate a substantial seasonal rhythm. Admissions for smokers and nonsmokers in other diagnostic groups did not show any seasonal variation. These findings parallel numerous studies regarding the influence of seasons upon rates of hospitalization for depressive disorder, and completed suicide. Therapeutic implications related to the bidirectional relationship between cigarette smoking and depression are discussed.

Factors influencing registered nurses teaching breast self-examination to female clients.

A university hospital-based study was conducted to explore factors that influence nurses teaching breast self-examination (BSE) to female clients, using the PRECEDE (Predisposing, Reinforcing, and Enabling factors in Educational Diagnosis and Evaluation) model as an organizing framework. Female registered nurses (N = 140) from adult inpatient and outpatient units completed a questionnaire that included items about frequency of BSE, knowledge of breast cancer screening and BSE technique, health motivation, confidence and competence in performing BSE, and teaching BSE. Data analysis compared the characteristics of nurses who reported teaching BSE with nurses who did not teach. Nurses in the teaching group had more work experience in nursing and were more likely to have a friend with breast cancer than were those in the nonteaching group. The teaching group had more knowledge about breast cancer screening and BSE technique and reported more confidence and competence in performing BSE.

Effects of a smoke-free policy on an inpatient psychiatric unit

Objective - To evaluate prospectively the effects of a smoke-free policy on the behavioural functioning of patients in a locked adult inpatient psychiatric unit and on staff attitudes towards the policy. Methods - Data were collected on patient medication use and behavioural indices three months before and three months after policy implementation. Addition ally, unit staff completed a survey six months before and six months after policy implementation. Results -The smoke-free policy pro duced significantly fewer adverse effects than the staff had anticipated. Staff atti tudes also changed to favour a smoke free environment. Results of a follow up interview indicated that hospital admission in a smoke-free environment did not appear to alter the long term smoking behaviour of patients. Conclusions - Successful implementa tion of a smoke-free policy in a psy chiatric unit can be achieved with careful planning. (Tobacco Control 1995; 4: 372-379)

Cost-effective communication skills training for state hospital employees

This study evaluated the cost-benefits of a staff communications training program designed to improve patient management skills and relieve staff stress. The interpersonal communications program, based on the Carkhuff model, was specially designed for mental health settings. The training program focused on developing accurate empathy by teaching staff members to use appropriate cognitive and emotional components of interpersonal communication. Staff on a short-stay adult inpatient recidivist unit received the training, while those on a matched unit served as a quasi-control group. Data from routine reports from six months before and six months after training were analyzed. The main cost-benefit variables of interest were improved staff retention and patient outcomes. The trained unit had less staff turnover, and staff members on that unit used less sick and annual leave. Fewer patients' rights complaints were filed, and fewer assaults on staff were reported. The cost-benefit analysis revealed substantial savings for the trained unit and increased expenditures for the control unit. The results suggested that training in empathic communication skills for direct care staff is a promising proactive, cost-effective approach to coping with staff stress and turnover and may also improve patient outcomes.