Psychiatric Emergency Unit Research Articles

Hospital Employee Assault Rates Before and After Enactment of the California Hospital Safety and Security Act

This study examines changes in violent event rates to hospital employees before and after enactment of the California Hospital Safety and Security Act in 1995. We compared pre- and post-initiative employee assault rates in California (n = 116) emergency departments and psychiatric units with those in New Jersey (n = 50), where statewide workplace violence initiatives do not exist. Poisson regression with generalized estimating equations was used to compare assault rates between a 3-year pre-enactment period (1993-1995) and a 6-year post-enactment period (1996-2001) using New Jersey hospitals as a temporal control. Assault rates among emergency department employees decreased 48% in California post-enactment, compared with emergency department employee assault rates in New Jersey (rate ratio [RR] = 0.52, 95% confidence interval [CI]: 0.31, 0.90). Emergency department employee assault rates decreased in smaller facilities (RR = 0.46, 95% CI: 0.21, 0.96) and for-profit-controlled hospitals (RR = 0.39, 95% CI: 0.19, 0.79) post-enactment. Among psychiatric units, for-profit-controlled hospitals (RR = 0.41, 95% CI: 0.19, 0.85) and hospitals located in smaller communities (RR = 0.44, 95% CI: 0.21, 0.92) experienced decreased assault rates post-enactment. Policy may be an effective method to increase safety to health care workers.

Human-Biometeorological Effects on Sleep Disturbances in Athens, Greece: A Preliminary Evaluation

The aim of this study was to examine the effects of the daily minimum air temperature and human-biometeorological variables, as well as their day-to-day changes, on sleep disturbances (SD) in the inhabitants of Athens, Greece. The SD dataset used for the analysis included the daily records of the psychiatric emergency unit of the Athens University Medical School for the years 1989 (with mild thermal load) and 1994 (with heavy thermal load). The meteorological variables for the estimation of the thermal indices were recorded by the meteorological station of Hellenikon, which is located at the headquarters of the Hellenic National Weather Service. The mean radiant temperature ( T mrt) and the thermal indices predicted mean vote (PMV), physiologically equivalent temperature (PET) and standard effective temperature (SET*) have been analyzed. The first step was to assess the SD frequencies as a function of the meteorological and human-biometeorological variables on the basis of 10-day intervals to determine the influence of the examined variables on SD. The daily SD records were included as Poisson random variables in the applied Generalized Linear Models (GLM). The extracted results suggested that a considerable increase in SD existed in 1994 compared to 1989. This was due to the many consecutive days with heavy thermal load (PET >35°C and Tmin >23°C) in 1994 compared to the lack of such days in 1989. Furthermore, statistically significant ( p<0.01) positive relationships were found between minimum air temperature, all thermal indices and SD.

Innovation in Our Nation's Public Hospitals: Interview with Five CEOs and Medical Directors

What quality improvement strategies are the leaders of our nation's prominent public hospitals following at this critical time of American health care change? Even more burdened than community hospitals with care for the uninsured and immigrant populations and with scarcer resources, how can they prosper, let alone survive? At the Spring 2007 annual meeting of the National Association of Public Hospitals in Boston, we talked with five leaders (Table 1) and found surprising and hopeful answers, and offer this conversation so that we can learn from them and follow their lead. Table 1 The participants The Permanente Journal (TPJ): Please briefly introduce yourself, your position, and give a brief description of your hospital health system. Sandral Hullett, MD (SH): Cooper Green Mercy Hospital is a small community hospital in the medical center affiliated with the University of Alabama at Birmingham, so we are a teaching facility. About 70% of the patients are uninsured; the other 30% are Medicaid, Medicare, and third party. We are a service provider for a large number of disadvantaged people. Fifty percent of our funding is from an indigent county tax. We've been there since 1972 and have been primarily a source for acute care though we are changing our image through more community-based work. Gene Marie O'Connell, RN, MS (GO): San Francisco General Hospital (SFGH) is the only trauma center in the city, with a full array of services in the acute care hospital as well as primary care and specialties, and the only psychiatric emergency unit in the city with the most psychiatric and mental health services of any area hospital. We have a total of 550 beds. Through an affiliation with University of California, San Francisco, we provide a third of all the teaching for the university. Last year we saw over 100,000 unduplicated clients. John W Buford, III (JB): Truman Medical Center (TMC)—a 501-C3, nonprofit entity that was originally the city hospital—is a two-hospital system that includes a long-term care facility, as well as a major behavioral health offering, and we oversee the Jackson County Public Health Department. Alan D Aviles (AA): The New York City Health and Hospitals Corporation is the largest municipal health system in the country. We serve about 1.3 million New Yorkers every year, including about 400,000 uninsured. The system includes 11 acute care facilities and 4 long-term care facilities and more than 80 community-based primary care sites. We have 4500 acute care beds and another 3000 long-term care beds. We provide 5 million outpatient visits per year and 1 million emergency room visits per year. We also run a very large Medicaid-managed care plan with more than 275,000 enrollees.

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

Letter

Back to table of contents Previous article Next article LetterFull AccessLetterKotaro Hatta M.D., Ph.D.Hisashi Kurosawa M.D., Ph.D.Heii Arai M.D., Ph.D.Kotaro Hatta M.D., Ph.D.Search for more papers by this authorHisashi Kurosawa M.D., Ph.D.Search for more papers by this authorHeii Arai M.D., Ph.D.Search for more papers by this authorPublished Online:1 Nov 2007https://doi.org/10.1176/ps.2007.58.11.1502AboutSectionsPDF/EPUB ToolsAdd to favoritesDownload CitationsTrack Citations ShareShare onFacebookTwitterLinked InEmail Hospitalization for Medical Comorbidities Among Psychiatric Patients in TokyoThe purpose of this prospective cohort study was to clarify the incidence and kinds of medical comorbidity for which psychiatric patients should be hospitalized. Gathering such epidemiological data in Tokyo, which has approximately 12 million inhabitants, might inform public policy not only in Japan but also in other countries.The study was conducted throughout Tokyo from April 1 to May 31, 2007. Participating in the study were 21 of Tokyo's 28 general hospital psychiatric units (75%), all three general hospital psychiatric emergency units, and all 11 general hospital psychiatric units specializing in medical comorbidity. Because these three types of general hospital psychiatric units are responsible for treating severe medical illness among psychiatric patients in Tokyo, the study was designed to capture all psychiatric patients admitted for primary medical diagnoses. Information was collected about demographic and clinical characteristics of patients who were admitted and those who were not admitted because no beds were available. The study protocol was approved by an institutional review board. In the two-month period 326 patients were admitted to one of these units for a primary medical diagnosis: 174 to general hospital psychiatric units, ten to general hospital psychiatric emergency units, and 142 to general hospital psychiatric units specializing in medical comorbidity. The mean±SD age of these patients was 61.7±16.2 years, and 150 patients (46%) were male. Of the 326 patients, 194 (60%) were medical cases and the remaining 132 patients (40%) were surgical. Respiratory diseases were the most frequent (61 patients, or 19%), followed by diseases requiring orthopedic surgery (42 patients, or 13%), diseases requiring abdominal surgery (32 patients, or 10%), and gastrointestinal and hepatic diseases (32 patients, or 10%). At discharge 130 patients (40%) had ICD-10 psychiatric diagnoses in the F2 category (schizophrenia and schizotypal and delusional disorders), 91 patients (28%) had ICD-10 F0 diagnoses (organic mental disorders, including symptomatic disorders), and 149 patients (15%) had ICD-10 F3 diagnoses (mood disorders). Among the patients with F0 diagnoses were 59 patients (18%) with dementia and organic amnesic syndrome (F00–F04) and 32 patients (10%) with delirium and other disorders (F05–F07). A total of 88 patients could not be admitted to general hospital psychiatric units because there were no available beds. On the basis of the number of patients who were admitted to general hospital psychiatric units (174 patients) and the participation rate for that type of unit in the study (75%), the estimated total number of patients admitted to that type of unit during the study is 232. Also, on the basis of the number of patients who weren't able to be admitted to that type of unit (88 patients) and the participation rate (75%), the estimated total number of patients who could not be admitted to that type of unit during the study is 117. The numbers of patients admitted to general hospital psychiatric emergency units and general hospital psychiatric units specializing in medical comorbidity were ten and 142, respectively. The participation rates for both of these types of unit were 100%, and there were no patients who were not able to be admitted.Thus a total of 501 patients needed admission over the study period, which suggests an annual total of 3,006 patients. Thus with approximately 12 million inhabitants, the incidence of medical comorbidity for which psychiatric patients should be hospitalized appears to be at least 25 per 100,000 inhabitants in Tokyo. Although previous studies have examined comorbid medical conditions among psychiatric inpatients ( 1 , 2 ), these studies looked at hospitals only and did not use population-based designs ( 1 , 2 ). One population-based study focused only on mortality among psychiatric outpatients ( 3 ). Thus few cohort studies about hospitalization for medical comorbidities among patients with severe mental illness have been conducted. One strength of our study is that it included all psychiatric patients who lived in a defined area during the study period. A limitation is that our findings may be representative only of patients in Tokyo. Acknowledgments and disclosuresThis work was supported by grant H-19-009 from the Ministry of Health, Welfare, and Labor of Japanese Government.The authors report no competing interests.Dr. Hatta and Dr. Arai are with the Department of Psychiatry, Juntendo University School of Medicine, Tokyo. Dr. Kurosawa is with the Nippon Medical School in Tokyo.

Facteurs prédictifs de la récidive du comportement suicidaire chez des patients souffrant d’un trouble de personnalité borderline

The high prevalence of suicidal behavior (SB) in patients with borderline personality disorder (BPD) raises clinical questions in terms of screening and prevention, particularly for an emergency psychiatric department. The purpose of this prospective study was to determine the risk factors of the recurrence of SB during a one year follow-up in BPD patients consulting the emergency unit of the University Hospitals of Geneva (HUG) following a suicide attempt. All subjects included in the study (age 18-65) had been diagnosed with BPD according to DSM IV criteria. Furthermore, they all consulted the emergency psychiatric unit after a suicide attempt. The exclusion criteria were the presence of cognitive, bipolar or psychotic disorders. Almost all SB patients from the Canton of Geneva (350 000 inhabitants) are directed to the HUG emergency department. After one year, 95 subjects were included in the study, while the total number of emergency psychiatric consultations was of about 10 000. During the emergency consultations, the clinicians checked the DSM IV criteria for BPD and current Major Depressive Episode, following the usual guidelines, independently of the study. The clinicians were specifically trained to set up the diagnosis of BPD by means of the International Personality Disorder Examination (IPDE). The gravity of depressive disorders was assessed with the Hamilton Depression Rating Scale (HDRS). The recurrence of SB was recorded for every patient during one year. Among the 95 patients included in the study, 34 patients (36%) were re-admitted to the emergency unit for one or several SB during the first year after inclusion. The recurrence of the SB was significantly higher in women (OR=9.8), in patients with past history of SB (OR=8.9) and in patients living alone (OR=2.5). Interestingly, the presence of a farewell letter seems to be a protective factor (OR=0.1) for SB. Furthermore, low economic status appears to be associated with a higher recurrence risk, but the trend is not statistically significant. Recurrence and intensity (HDRS) of the major depressive episode, drug addiction, and other disorders on axis I of DSM IV did not differ statistically in patients with or without SB recurrence. In this preliminary study, we tried to identify patients at risk for SB, relating to early secondary prevention, starting from the first assessment at the emergency unit.

L'accueil d'urgence en psychiatrie de l'enfant et de l'adolescent : évolution sur 20 ans dans un site hospitalo-universitaire

Because of the close relationship between child and adolescents with their environment, Psychiatric emergencies in this population are very specific. Situations seen and their management are different from psychiatric adult emergencies. Beside real psychiatric emergencies, we often see situations characterised by psychological distress with an important social component. Our retrospective study compares two populations of youth people seen in the outpatient psychiatric emergency unit of the Pitié-Salpêtrière hospital in Paris. We analyse 196 cases seen during 1992 and 314 seen during 2002. The purpose is to evaluate the evolution of demographic and clinical characteristics of these two populations. The results are completed by a previous study conducted in 1981. Main demographic results are: 1) a dramatic increase of the number of patients seen; 2) a significant decrease of the mean age of consultation (13.6 yo in 1992 vs 12.3 yo in 2002); 3) sex-ratio stay the same, with more girls among old ages and more boys among young ages; 4) families themselves ask for consultation more and more often (58% in 2002). Clinical results are: 1) main reason of consultation stays acting-out disorders, especially in boys (50% in 1992 and 2002); 2) a greater proportion of patients has a psychiatric follow-up at the time of the consultation (38.2% in 1992; 55.4% in 2002); 3) major depression is the first diagnosis in 1992 (24.2%) and 2002 (35.8%); 4) psychiatric hospitalisation occurs in 34.2% in 1992 vs 19.8% in 2002, but absolute numbers remains stable. These results might be useful for the public health system in order to improve our answers for these requests more and more numerous for patients younger and younger.

Panic attacks: Weather and season sensitivity

The recent publication of the article about seasonal changes in panic disorder patients by Ohtani et al. from Nagoya underlines the neglected fact of sensitivity to seasonal changes among panic disorder patients.1 Because seasonality is a complex variable we consider it important to complement these results with some parallel findings. In the 1950s seasonal changes were classified by De Rudder2 and more recently modified by San Gil et al. as: (i) true seasonality, conditions influenced by specific climatic conditions such as rain, wind and sunlight; (ii) pseudo-seasonality, when a condition appears predominantly during a certain season; and (iii) indirect seasonality, conditions influenced by factors that change because of the season such as clothing, food intake and physical activity (e.g. more sexual assaults in summer coinciding with more alcohol abuse and less dress3,4).3 This classification has not been sustained. A more specific useful description is proposed: seasonal sensitivity, when conditions occur during a certain season; and weather sensitivity, when conditions are influenced by climatic conditions. Of course, these overlap because certain climatic conditions are more prevalent in certain seasons. Panic patients tend to express high sensitivity to weather conditions and there are also seasonal peaks for symptom re-occurrence. To study this we examined cases of anxiety attended to in the psychiatric emergency unit of a general hospital in Barcelona and classified them as panic and non-panic anxiety, assessing for associations with weather conditions.5 The results indicate different trends for panic and non-panic anxiety. Panic anxiety was found to be more frequent during days with the warm western-origin poniente wind and during autumn, and less frequent during rainfall. Non-panic anxiety exhibited autumn and summer seasonality. In terms of specific seasonal peaks, these results differ from those published by Ohtani et al. However, they coincide in that there are seasonal and climate-related changes (i.e. relation to overcast weather) in the course of panic symptoms. There are methodological differences between both studies that could explain differences in results, mainly the use of a self-rating seasonal pattern assessment questionnaire versus using number of emergencies due to anxiety to correlate with weather conditions. Also, differences of seasonal sensitivity could be attributed to geographic climate differences such as those related to the latitude of the area. Findings are irregular but there is an obvious relationship between weather and anxiety. It would be interesting to examine panic attack meteorological sensitivity prospectively.

Co-morbidity: Psychiatric Disorders and Substance Misuse in a Psychiatric Emergency Unit in Brazil—An Exploratory Study

The aim of the study is to examine the prevalence rate of psychiatric disorders and substance misuse in patients admitted to the psychiatric emergency unit in Ribeirao Preto, Sao Paulo, Brazil. The data was obtained from SAME (Servico de Arquivo Medico e Estatistico) and the method used in this study is an examination of 500 patients admitted to the emergency psychiatric unit in the year 2000. The data was from the Service of Medical and Statistical Unit of the Hospital Clinic of Ribeirao Preto. The findings show that the prevalence rate of dual diagnosis for first time admissions and re-admissions was 32.6% and 33.8% respectively. The highest rate of admissions is observed in the 20 to 39 age range (55.3% of the total admissions) which is predominantly male. The majority of patients admitted were diagnosed with the co-existence of alcohol and psychiatric disorders (59%). About 42% had alcohol dependence syndrome and 30% of those admitted were suffering from abstinence or withdrawal syndrome as a result o...

A systematic intervention to improve patient information routines and satisfaction in a psychiatric emergency unit

Patients admitted to acute psychiatric hospitalization often report that they are being subject to coercion, irrespective of their official legal status. This experience may be related to a feeling of process exclusion and insufficient information about legal rights. Still, little systematic research has been performed to find effective ways of improving the quality of information presented to the patients and to increase patient satisfaction in a routine clinical setting. The purpose of our study was to systematically record measures of patient satisfaction before, during and after an intervention to improve the information procedures during patient admission. Based on a total of 763 consecutive admissions in an emergency psychiatric ward, 433 completed patient questionnaires were returned, indicating measures of patient satisfaction and factual knowledge in 30 different questions. The patients’ general satisfaction scores increased only slightly during and after the intervention, but a robust and sustained improvement of the patients’ satisfaction with the information received was recorded. Furthermore, the patients also reported an increased knowledge about specific legal issues related to their hospitalization. As this is an important aspect of patients’ rights, we advocate the use of systematic procedures to increase patients’ awareness of their legal status and knowledge about procedures in connection with hospitalization.

Dissociative disorders in the psychiatric emergency ward

Objective The aim of this study was to determine the prevalence of dissociative disorders among emergency psychiatric admissions. Method Forty-three of the 97 consecutive outpatients admitted to the psychiatric emergency unit of a university hospital were screened using the Dissociative Experiences Scale (DES). Seventeen (39.5% of the 43 evaluated) patients with a DES score above 25.0 were then interviewed with the Dissociative Disorders Interview Schedule and the Structured Clinical Interview for Dissociative Disorders. Results Fifteen emergency unit patients (34.9% of the 43 evaluated participants) were diagnosed as having a dissociative disorder. Six (14.0%) patients had dissociative identity disorder, 6 (14.0%) had dissociative disorder not otherwise specified, and 3 (7.0%) had dissociative amnesia. The average DES score of dissociative patients was 43.7. A majority of them had comorbid major depression, somatization disorder, and borderline personality disorder. Most of the patients with dissociative disorder reported auditory hallucinations, symptoms associated with psychogenic amnesia, flashback experiences, and childhood abuse and/or neglect. Conclusions Dissociative disorders constitute one of the diagnostic groups with high relevance in emergency psychiatry.

Diagnostic variability for schizophrenia and major depression in a large public mental health care system dataset

Administrative datasets can provide information about mental health treatment in real world settings; however, an important limitation in using these datasets is the uncertainty regarding psychiatric diagnosis. To better understand the psychiatric diagnoses, we investigated the diagnostic variability of schizophrenia and major depression in a large public mental health system. Using schizophrenia and major depression as the two comparison diagnoses, we compared the variability of diagnoses assigned to patients with one recorded diagnosis of schizophrenia or major depression. In addition, for both of these diagnoses, the diagnostic variability was compared across seven types of treatment settings. Statistical analyses were conducted using t tests for continuous data and chi-square tests for categorical data. We found that schizophrenia had greater diagnostic variability than major depression (31% vs. 43%). For both schizophrenia and major depression, variability was significantly higher in jail and the emergency psychiatric unit than in inpatient or outpatient settings. These findings demonstrate that the variability of psychiatric diagnoses recorded in the administrative dataset of a large public mental health system varies by diagnosis and by treatment setting. Further research is needed to clarify the relationship between psychiatric diagnosis, diagnostic variability and treatment setting.

Behavior therapy in dissociative convulsions disorder.

To compare the remission in symptoms achieved with behavior therapy and routine clinical care to that with routine clinical care given alone to patients having dissociative disorder. A randomized controlled trial. Psychiatry Unit, Lady Reading Hospital, Peshawar from April 2004 to September 2004. A total sample of 100 patients was recruited through Psychiatric OPD and Emergency unit. Patients were randomly allocated to the intervention or control group. The number of fits were recorded each day during admission. The patients were followed-up for four weeks after discharge. Hospital anxiety and depression scale and clinical global impression scales were applied. The two-sample Kolmogorov-Smirnov test was used to show the differences in relative frequencies of fits between the two groups. There were no statistically significant differences in sociodemographic and clinical variables in the intervention and control groups at baseline. There was a highly significant difference between the two groups in frequency of fits at discharge, on the first follow-up and on the fourth follow-up (p=0.000). Similarly, patients in the intervention group showed more improvement on hospital anxiety and depression scale compared to the control group, (p=0.000) at the end of four weeks. Behavioral intervention in the management of conversion disorder is more effective than the methods applied in our daily practice.

Troubles dépressifs majeurs et urgences psychiatriques: Une étude naturaliste concernant la place des interventions de crise

This retrospective study aimed to evaluate the impact of introducing crisis intervention patterns in the emergency unit of a general hospital on the number of admissions and outpatient follow-ups for patients with major depressive disorder. The study included all patients with major depressive disorder (DSM-IV criteria) who visited the psychiatric emergency unit in a general hospital during two 8-month periods: before (425 patients) and after (436 patients) crisis interventions were introduced. After crisis interventions were introduced, the voluntary admission rate decreased significantly (from 17.9% to 12.4%), while the number of outpatient follow-ups increased (from 82.1% to 86.2%). Borderline personality disorder was associated with a significant reduction of the admission rate (27.8% against 38.2%), while the admission rate for patients with depressive disorder with psychotic features did not decline after crisis interventions. Crisis interventions were more effective on women. These outcomes suggest the relevance of crisis intervention in psychiatric emergency settings to improve the management of patients with major depressive disorder. Crisis intervention fosters outpatient multimodal follow-up rather than admission in a psychiatric setting.

Economic impact of crisis intervention in emergency psychiatry: a naturalistic study

Objective. – This is a naturalistic study comparing the outcomes of all emergency psychiatric interventions in the Hospital Center of Luxemburg during two periods of six months each, before and after the introduction of a crisis intervention program. The aim of the study was to investigate the clinical and economic impact of crisis intervention on psychiatric emergency admissions. Methods. – All subjects admitted to the emergency psychiatric unit during the two study periods were considered for participation. Data were collected retrospectively and comparisons were made between patients before (September 1, 2001 to February 28, 2002) and after (September 1, 2002 to February 28, 2003) crisis intervention programs were established. Results. – A comparison between the two patient groups demonstrated a significant decrease in the rate of voluntary hospitalizations after crisis intervention, and a significant increase in the number of patients with subsequent outpatient consultations. The cost increase due to ambulatory follow-ups was widely compensated for by the cost decrease due to hospitalization avoidance. Conclusions. – These preliminary findings suggest that crisis intervention leads to a shift from hospitalization to outpatient psychotherapeutic management in emergency psychiatric services, which has a significant economic impact.

Facteurs sociodémographiques et construction de l’alliance thérapeutique aux urgences psychiatriques

Therapeutic alliance is a clinical concept considering the non-specific aspects and the common factors of the therapeutic relationship. In emergency, the therapeutic alliance seems to be one of the essential elements of crisis management, as the first stage of therapeutic framework. The aim of this study was to investigate the influence of sociodemographic factors in the constitution of the therapeutic alliance between patient and psychiatrist at the emergency psychiatric unit of a university general hospital. The study concerned 140 patients, requiring during workdays an urgent psychiatric intervention. Data were collected during four months. The exclusion criteria were the acute psychotic disorders, mania, delirium and dementia, situations interfering with the understanding of the study and with the patients' informed consent. The level of therapeutic alliance was estimated by means of the French translated questionnaire of “Helping Alliance” of Luborsky, completed separately by psychiatrists and patients. The results show a relatively limited influence of socio-demographic factors on the therapeutic alliance. The patients' age is a factor influencing alliance only for the psychiatrists, with a better alliance for the less than 25-year-old patients and more than 45 years. The patients with a lower instruction level have a better type I alliance. The scores of alliance with the French-speaking psychiatrists do not differ for the immigrant patients and the native French-speaking patients. Further than the epidemiological interest, this preliminary study suggests the interest of the consideration of the emergency time, in the construction of the therapeutic alliance.

CUIDAR A LOS CUIDADORES: ATENCIÓN FAMILIAR.

The primary care of a psychiatric patient represents a real challenge for the family environment, this situation causes that many of the families that play the caregiver role experience stressing and overwhelming feelings that can directly evoke physical and mental problems causing several types of emotional distress. In this communication named “Taking care of the caregivers: Family Care” we will make reference to the situation that emerges after the hospitalization of one of the family members in a psychiatric emergency unit and a thought about the actions that the psychiatrical nurses can and should take. This family atention includes a series of actions with a common goal: to be with the family in the disease process, to inform about the cares that have to be given to the patient, to clarify the doubts and adjust their expectances among a warm and kind family-nurse realtionship. The principal objective is the aproaching to the patient family as the primary attention focus by means of instruments that can help this aproach, the knowledge of the family structure, the most probable stressing factors and definitely to treat the whole family in a hospital scenario in order to detect the posible disfunctions.

Nurses' intention to report child abuse in Taiwan: A test of the theory of planned behavior

The purposes of this study were to identify factors associated with nurses' intention to report suspected child abuse in Taiwan, and to determine the empirical adequacy of the extended theory of planned behavior (TPB) to explain nurses' intention to report child abuse. A stratified quota sampling technique was used to select registered nurses in emergency rooms, psychiatric units, and pediatric units in Taiwan. A total of 1,362 questionnaires from 1,617 nurses were used for the analyses. Structural equation modeling demonstrated that nurses' attitudes toward reporting child abuse, perceived behavioral control, subjective norms, and knowledge of the child abuse and reporting law explained 85% to 91% of the variance in nurses' intention to report child abuse for the less severe and severe child abuse cases in vignettes, respectively. The findings support the use of the extended TPB in identifying factors associated with nurses' intention to report child abuse in Taiwan.

Pratique de la contention dans un service d’urgences psychiatriques

The practice of physical restraint is relatively frequent in medical emergency and geriatric units. Its use in psychiatry is controversial. Although distinct, it is often associated with seclusion, as a response to or prevention of agitated mentally ill patients'behavior. A detailed review of the literature shows the scarceness of work defining the exclusive use of restraint without seclusion. We report a naturalistic study over 6 Months, covering 76 cases having required restraint. The study of the international literature concerns nursing care, geriatric, child-adolescent psychiatric and adult psychiatric reviews. The restraint is a usual practice in general care like emergency, intensive care or geriatric units in order to prevent the patients from falling or to administrate certain care. Legal action has been reported as a consequence of lack of information or agreement of the family. The psychiatric use of restraint is conceived as an additional measure to seclusion, which is a controversial procedure from a therapeutic point of view as well as because of its long duration of application. The practice of restraint described in French literature, from Pinel (in to Daumézon and from French hospital regulations to "transparency forms", seems to be more easily accepted for its short duration and its careful prescription in order to maintain relations with the patients, including agitated children. We made a 6 Months retrospective study in a Parisian psychiatric emergency unit receiving an average of 30 patients a day. The rate of restraint is 1.4%. The objective was to describe the main clinical, epidemiological and situational characteristics and to define quality criteria concerning restraint regarding to the existing standards. We had at our disposal a restraint protocol in order to avoid its prescription as a punishment or for the comfort or the convenience of an insufficient staff. The decision of the restraint is directly prescribed by a physician or decided in emergency by the nurses and then rapidly confirmed by medical prescription. In short, most restrained patients are male, the average age is 32 Years old, and the diagnoses associated with restraint in order of frequency are schizophrenia, personality disorders, acute psychotic episodes, manic episodes and toxic abuses. The main early-warning signs are aggressiveness, delusions, opposition, paranoiac thoughts and distrust. The average duration is 2 hours with continuous clinical supervision and a relational contact maintained. Our study confirms the notion of cumulate restraint days. Actually, 43% of the restraints happen on the same day as others do. The high rate on those days could be as Fischer hypothesized the result of instinctive, aggressive and sexual release of the staff, as well as the consequence of an increase in anxiety and agitation of the other patients. The legal framework is more the duty of assistance to a person in danger than constrained hospitalization, which is not systematically pronounced. No injury or somatic complication occurred during restraint. Neither complaint from the patient or his family nor sick leave of staff was recorded. The specific use of restraint can be compared to the existing standards for using the seclusion room. Among those standards only 1 of 23 criteria was not verified. The others was applicable or without object. The therapeutic use of restraint requires the development of specific quality standards, and the existing criteria concerning seclusion represent a necessary but insufficient answer. We emphasize the need to take into account the early warning signs, a response to the cumulative restraint days, as well as a satisfaction study on patients and the feasibility of such a study in an emergency service.

Patterns of Public Mental Health Service Use by Age in Patients With Schizophrenia

Objective Authors examined the relationship between age and use of public mental health services by adults with schizophrenia in a large mental health care system. Methods The study sample included 4,975 patients treated for schizophrenia in San Diego County's Adult Mental Health Services (AMHS) during fiscal year 1999–2000. They compared three age-groups: 18–44 years (young adults), 45–64 (middle-aged), and 65-or-older (elderly) on 1) the number of individuals treated for schizophrenia per 10,000 people in the county, and 2) the use of six different types of public mental health services, including hospitalization, emergency psychiatric unit, crisis house, outpatient clinic, day treatment, and case management. Results Elderly patients with schizophrenia were underrepresented among AMHS users with a diagnosis of schizophrenia. The use of hospitalization, emergency room, crisis house, and day treatment was highest among young-adult patients and decreased with age. Outpatient treatment use was similar for young-adult and middle-aged patients and lower for elderly patients. The only type of service use that seemed to increase with age was case management. Even after controlling for gender, ethnicity, living situation, substance use disorder, and insurance status, most of the above-mentioned age-related differences in service use persisted. Conclusion Among patients with schizophrenia in a public mental health system, old age was associated with significantly lower use of all mental health services except case management. Research is needed to explore reasons for this differential use of services across age-groups. Authors examined the relationship between age and use of public mental health services by adults with schizophrenia in a large mental health care system. The study sample included 4,975 patients treated for schizophrenia in San Diego County's Adult Mental Health Services (AMHS) during fiscal year 1999–2000. They compared three age-groups: 18–44 years (young adults), 45–64 (middle-aged), and 65-or-older (elderly) on 1) the number of individuals treated for schizophrenia per 10,000 people in the county, and 2) the use of six different types of public mental health services, including hospitalization, emergency psychiatric unit, crisis house, outpatient clinic, day treatment, and case management. Elderly patients with schizophrenia were underrepresented among AMHS users with a diagnosis of schizophrenia. The use of hospitalization, emergency room, crisis house, and day treatment was highest among young-adult patients and decreased with age. Outpatient treatment use was similar for young-adult and middle-aged patients and lower for elderly patients. The only type of service use that seemed to increase with age was case management. Even after controlling for gender, ethnicity, living situation, substance use disorder, and insurance status, most of the above-mentioned age-related differences in service use persisted. Among patients with schizophrenia in a public mental health system, old age was associated with significantly lower use of all mental health services except case management. Research is needed to explore reasons for this differential use of services across age-groups.