Inpatient Psychiatric Unit Research Articles

Trends in Acute Care Use for Mental Health Conditions Among Youth During the COVID-19 Pandemic

Understanding how children's utilization of acute mental health care changed during the COVID-19 pandemic is critical for directing resources. To examine youth acute mental health care use (emergency department [ED], boarding, and subsequent inpatient care) during the second year of the COVID-19 pandemic. This cross-sectional analysis of national, deidentified commercial health insurance claims of youth mental health ED and hospital care took place between March 2019 and February 2022. Among 4.1 million commercial insurance enrollees aged 5 to 17 years, 17 614 and 16 815 youth had at least 1 mental health ED visit in the baseline year (March 2019-February 2020) and pandemic year 2 (March 2021-February 2022), respectively. The COVID-19 pandemic. The relative change from baseline to pandemic year 2 was determined in (1) fraction of youth with 1 or more mental health ED visits; (2) percentage of mental health ED visits resulting in inpatient psychiatry admission; (3) mean length of inpatient psychiatric stay following ED visit; and (4) frequency of prolonged boarding (≥2 midnights) in the ED or a medical unit before admission to an inpatient psychiatric unit. Of 4.1 million enrollees, 51% were males and 41% were aged 13 to 17 years (vs 5-12 years) with 88 665 mental health ED visits. Comparing baseline to pandemic year 2, there was a 6.7% increase in youth with any mental health ED visits (95% CI, 4.7%-8.8%). Among adolescent females, there was a larger increase (22.1%; 95% CI, 19.2%-24.9%). The fraction of ED visits that resulted in a psychiatric admission increased by 8.4% (95% CI, 5.5%-11.2%). Mean length of inpatient psychiatric stay increased 3.8% (95% CI, 1.8%-5.7%). The fraction of episodes with prolonged boarding increased 76.4% (95% CI, 71.0%-81.0%). Into the second year of the pandemic, mental health ED visits increased notably among adolescent females, and there was an increase in prolonged boarding of youth awaiting inpatient psychiatric care. Interventions are needed to increase inpatient child psychiatry capacity and reduce strain on the acute mental health care system.

Psychiatric Boarding Patterns Among Publicly Insured Youths Evaluated by Mobile Crisis Teams Before and During the COVID-19 Pandemic

Psychiatric boarding occurs when patients needing intensive psychiatric services who are already under clinical supervision experience delays in their admission to psychiatric facilities. Initial reports have suggested that the US had a psychiatric boarding crisis during the COVID-19 pandemic; however, little is known about the consequences of this crisis for publicly insured youths. To estimate pandemic-associated changes in psychiatric boarding rates and discharge modalities for people aged 4 to 20 years who accessed psychiatric emergency services (PES) through a mobile crisis team (MCT) evaluation and were covered by Medicaid or health safety net programs. This retrospective cross-sectional study used data from the MCT encounters of a multichannel PES program in Massachusetts. A total of 7625 MCT-initiated PES encounters with publicly insured youths who lived in Massachusetts between January 1, 2018, and August 31, 2021, were assessed. Encounter-level outcomes (psychiatric boarding status, repeat visits, and discharge disposition) during a prepandemic period (January 1, 2018, to March 9, 2020) were compared with outcomes during a pandemic period (March 10, 2020, to August 31, 2021). Descriptive statistics and multivariate regression analysis were used. Among 7625 MCT-initiated PES encounters, the mean (SD) age of publicly insured youths was 13.6 (3.7) years; most youths identified as male (3656 [47.9%]), were of Black race (2725 [35.7%]) or Hispanic ethnicity (2708 [35.5%]), and spoke English (6941 [91.0%]). During the pandemic period, the mean monthly boarding encounter rate was 25.3 percentage points higher than the prepandemic period. After adjustment for covariates, the odds of an encounter resulting in boarding doubled during the pandemic (adjusted odds ratio [AOR], 2.03; 95% CI, 1.82-2.26; P < .001), and boarding youths were 64% less likely to be discharged to inpatient psychiatric care (AOR, 0.36; 95% CI, 0.31-0.43; P < .001). Publicly insured youths who boarded during the pandemic had significantly higher rates of 30-day readmissions (incidence rate ratio, 2.17; 95% CI, 1.88-2.50; P < .001). Boarding encounters during the pandemic were significantly less likely to end in discharge to inpatient psychiatric units (AOR, 0.36; 95% CI, 0.31-0.43; P < .001) or community-based acute treatment facilities (AOR, 0.70; 95% CI, 0.55-0.90; P = .005). In this cross-sectional study, publicly insured youths were more likely to experience psychiatric boarding during the COVID-19 pandemic and, if boarding, were less likely to transfer to a 24-hour level of care. These findings suggest that psychiatric service programs for youths were not prepared to support the levels of acuity and demand that emerged from the pandemic.

Kynanthropic and vampirism delusions: a case report and review of the literature.

Zooanthropy (delusional beliefs of turning into an animal) is a rare but well recognised psychiatric phenomenon. This case describes the presence of kynanthropic delusions (delusional beliefs of turning into a dog). Multiple other psychotic symptoms were also evident including unusually the additional presence of delusions of vampirism. Delusional beliefs in this case were associated with behavioural changes including growling and barking, and less commonly an expressed craving for biting people's necks to suck human blood. Symptom intensity was associated with increased psychosocial stressors for this patient, with some benefit noted from very high doses of anti-psychotic medications. Brief admissions to the acute psychiatric inpatient unit and thus removal from environmental stressors has been associated with an amelioration in symptomatology.

Quality Improvement Project to Improve the Implementation of Mental Health Act Code of Practice Guiding Principles and Patient Knowledge About MHA in In-Patient Psychiatric Unit

AimsTo improve the efficiency of MHA documentation, patient education on MHA and implementation of guidelines of Code of Practice in in-patient unit. We also aimed to involve patients at some stages of the QI project to ensure they remain updated about the legal framework and associated documents and their voice remains central.MethodsThe QI Project was started after an initial audit was conducted which included MHA documentation on admission and during the length of stay, patients’ legal rights, section-17 leaves, capacity and treatment forms, tribunal reports, section-117 meetings and arrangement of independent managers hearings prior to Section Renewals. Using 5-Why QI methodology, the medical team and the MHA administrator reviewed the gaps in the initial audit. Using the QI “theory of change” model, three primary drivers of “Responsible Clinician and MHA Administration Liaison”, “Patient Education on MHA” and “Policies and Guidelines Implementation” were established. Secondary drivers for “RC and MHA Administration Liaison” required inputs from doctors, secretaries, nurses and MHA Admin. Change ideas of introducing weekly email template for required MHA actions, section paper scrutiny template made for approval by MHA Admin/ RC prior to patient's admission, Introduction of MHA relevant actions section in the morning handover and patient's review record form.Secondary drivers and change ideas for “Patient Education on MHA” included discussions with MDT, easy- language information leaflets, discussion slots with pharmacists about medications before consenting for treatment forms, discussion slots with the key nurse and RC about MHA related decisions and going through statutory reports together to understand the nature and degree of illness, and risks necessitating the renewal of admission.Secondary drivers and change ideas for “Policies and Guidelines Implementation” included teaching sessions for nurses on report writing, giving evidence at tribunals, and how to inform patients about legal rights, and liaison with medical management QI committee to ensure capacity and treatment certificates are up to date and filed in the medical folders. The initial audit tool was repeated on quarterly basis in addition to the PDSAs to measure results.ResultsResults showed 100% score in capacity assessments, treatment certificates and timely reports. There was still improvement needed in organising managers hearing prior to section renewal, likely section renewals left till late. A pre-and-post intervention score on patients’ knowledge of rights and MHA showed an improvement of 68%.ConclusionThe QI-project helped in implementing MHA code of practice guiding principles and patients’ knowledge about MHA and their rights.

Coexistence of different delusional misidentification syndromes in clinical practice: A case series

ObjectiveThe objective of this study is to analyse the coexistence of several delusional misidentification syndromes in a clinical sample. MethodsOver one year, a sample of six patients presenting two or more types of delusional misidentification syndromes was selected. All these patients were admitted to the psychiatric inpatient unit of a Spanish hospital. ResultsDespite the different diagnoses, the patients included presented different types of delusional misidentification syndromes, both hyperidentification and hypoidentification. Antipsychotic treatment was not very effective against these delusional misidentification syndromes. ConclusionsThe coexistence of several delusional misidentification syndromes indicates that the aetiopathogenesis of the different types is similar. It is a field with important clinical implications, due to the poor response to treatment, as well as the possible medico-legal implications.

Avoiding the Chill Pill- Results from a Simulation-Based Verbal De-escalation Training for Psychiatry Residents in a Community Mental Health Center

Background: Potentially dangerous encounters with uncooperative, belligerent, or even violent patients in the Emergency Department and Psychiatric Inpatient Units require skilled responses and timely management of episodes of acute agitation. Lack of training and knowledge in these scenarios could compromise the safety of both staff and patients. There have been improvements in knowledge and comfort when dealing with acutely agitated patients documented in previous studies that have used simulation training for junior psychiatry residents. Objectives: Understand the existing knowledge and skill gap and attempt to address it through simulation training. Methods: This is an IRB exempt quality improvement project, supported with funds from the Committee of Interns and Residents. The study was conducted over 3 years (2019-2022). All psychiatry residents (N=36) participated in an online module (4hrs, JCAHO and OMH accredited) and simulation training with 3 standardized patients (actors). All residents were blind to the clinical scenarios and observed by faculty. Each incoming class (2019-2022) has been trained yearly since. Pre and post intervention surveys asked questions about knowledge, comfort, perceived competence, prior training, verbal de-escalation skills (APSP-agitated patient simulation project survey) and the validated Management of Aggression and Violence Attitude Scale (MAVAS). Results: Data from pre- and post- intervention APSP responses were analyzed using the student’s paired t-test. Residents felt significantly more comfortable handling verbal de-escalation post training (score of 6 vs. 8, P&lt;0.0001) and more competent evaluating and managing agitated patients (6 vs. 8, p&lt;0.0001). They showed significant (p&lt;0.05) changes in attitudes around seclusion and restrains and causes of agitation on MAVAS. The most used de-escalation interventions were: Explaining the situation and process, Summarizing the content, and Identifying patient’s feelings, wants and needs. Triggering behaviors included interrupting/ talking over the patient, not prioritizing patient’s needs, insisting on using medications. Conclusion: This project showed simulation-based training successfully addressed an important practice and knowledge gap and lent structure to the tailored protocol-based approach for managing agitated patients, especially in busy ER settings. Residents appreciated the simulation-based training with real life scenarios – they found it useful and engaging and they welcomed the interaction with standardized patients (SPs) during the training.

Improving Medical Handover in the Tyrone and Fermanagh Psychiatric Inpatient Unit

AimsThis project was undertaken in the Tyrone and Fermanagh Hospital, an inpatient Psychiatric Unit in Omagh, Northern Ireland. It was recognised that the previous method of medical handover via anonymised WhatsApp messages had several issues including patient data on personal phones, over-reliance on phone apps which have the potential to crash and short messages with limited details were included. The aim of our project was to improve patient safety by improving communication between medical staff members.MethodsThe previous method of medical handover was via text message on messaging platform WhatsApp. A message was sent the morning of handover, to the WhatsApp group.We continued to use a digital platform, but used Microsoft word, and Western Trust email addresses to record and send the handover. At the start of this project, we allowed free space recording, resulting in variation in the handovers.We agreed a minimum number of details to be included to ensure quality of handover, and audited the word documents, to assess the adherence to this.This change, still does not require face to face handover. There have been pros and cons to the change, which will be discussed in this presentation.We reviewed four months’ worth of handovers. They were reviewed for specific elements of essential handover criteria. The areas included Patient Name, H&amp;C, detained or voluntary, admission or review, presenting complaint, patient's history, risks, physical issues, and handover to specific person.It should be noted that the doctors involved were aware of the changes made, and standards being introduced, and therefore were aware that they would be auditing their own handovers. This might have created bias in the subsequent handovers.We then analysed each month to see what percentage of handovers had been concordant with the standards. These data were then represented in graphs, as we will show.ResultsWe identified areas which were performed well when completing handover. The areas which were consistently 100% included the date of handover and patient name or initials. Outstanding jobs were performed in 97.5% of handovers.Areas for improvement identified when collecting results were the status of admission (i.e. voluntary or detained), the main patient risks and use of the document password.100% of the shifts used the new digitalised format for handover using Microsoft word and trust email system.ConclusionWe reviewed the results of the data, which highlighted areas for improvementWe hope to implement a standard performa for handovers, reducing the chance of key information being missed, thereby improving patient safety. We aim to collect data following this 2nd intervention in the next rotation and continue to examine handover processes using PDSA cycles.

Reduction of adverse events in a psychiatric inpatient eating disorder unit during the COVID-19 pandemic.

Globally, the COVID-19 pandemic had impacted the health care delivery including inpatient psychiatric facilities. Within psychiatric settings, life of inpatients was profoundly altered. This paper aimed to understand if pandemic-related changes within an inpatient Eating Disorder Unit in a specialized psychiatric hospital in Ontario, Canada impacted incidence of aggression and use of coercive methods among adolescents. An exploratory study design was used to examine incidence of aggression, self-harm, code whites, staff assist, restraints and seclusion, and nasogastric feeding (NGF) among adolescents with eating disorders before and after the modified service delivery within the inpatient unit. Descriptive analyses were conducted. Analyses revealed a complete reduction in episodes of self-harm, aggression, staff assists, use of restraint and seclusion as well as an 80.14% reduction on average use of NGF. Authors speculate that the change in environment and program delivery method, peer influence, and shift in power relations between patient and staff may have resulted in improved experiences. This report provides insights to adopt a recovery-oriented service delivery for adolescents with eating disorders in inpatient settings.

Retrospective cohort observation on psychotropic drug-drug interaction and identification utility from 3 databases: Drugs.com®, Lexicomp®, and Epocrates®.

Pharmacotherapy is necessary for many people with psychiatric disorders and polypharmacy is common. The psychotropic drug-drug interaction (DDI) should be concerned and efficiently monitored by a proper instrument. This study aimed to investigate the prevalence and associated factors of psychotropic DDI and to compare the identification utility from three databases: Drugs.com®, Lexicomp®, and Epocrates®. This was a retrospective cohort design. We collected demographic and clinical data of all patients hospitalised in the psychiatric inpatient unit in 2020. Psychotropic DDI profiles were examined through three databases. Descriptive statistics were used to report comprehensiveness of each database and prevalence of psychotropic DDI. The Fleiss' kappa index would be analysed to indicate agreement strength of DDI severity classification among three databases. From 149 total admissions, the psychotropic DDIs were found in 148 admissions (99.3%). Thorough the study, there were 182 of both psychotropic and other agents prescribed under 1,357 prescriptions. In total, 2,825 psychotropic DDIs were identified by using Drugs.com® 2,500 times, Epocrates® 2,269 times, and Lexicomp® 2,265 times. Interactions with clonazepam was the three most frequent agents when co-administrated with quetiapine (n = 56), risperidone (n = 36), and valproic acid and derivatives (n = 36). Serious DDIs were comparatively lower in incidence and there was no evidence of its association with reported clinical adverse consequences. The study revealed slight and fair agreement regarding severity classification among the three databases was found. DDI events detected by Drugs.com® were greatest in number, but Lexicomp® provided the broadest list of medications prescribed in our study. Among three databases, interactions detected by Drugs.com® were greatest in number, whereas Lexicomp® provided the broadest list of medications. Development of such databases, based on both theoretical and clinical conceptions, should be focused to balance safety of patients and weariness of healthcare providers.

Commentary on “Why am I still in hospital? Evaluation of delayed discharges from two learning disability assessment and treatment units in England”

PurposeThis commentary explores the challenges and themes enumerated by the associated article “Why am I still in hospital? Evaluation of delayed discharges from two learning disability assessment and treatment units in England”. This commentary broadens and outlines the research’s background, premise and potential impact. This paper aims to critically examine the evidence on this subject.Design/methodology/approachThis commentary considers the attitudes to inpatient care for people with learning disabilities in the past decade and outlines a possible compact for the future.FindingsContrary to popular and emotive beliefs that using specialist inpatient psychiatric settings for people with learning disabilities is universally a poor practice, there are defined occasions when such settings are needed and imperative in the clinical pathway. If people with learning disabilities can access inpatient settings at the right time for the right reason, psychiatric outcomes could be improved. Timely discharge is imperative and currently lacking due to a lack of suitable engagement mechanisms between inpatient settings and the community. Thus, evidence-based outcome tools are essential to facilitate appropriate discharge.Originality/valueThere is an ongoing debate on the value and utility of specialist inpatient psychiatric units for people with learning disabilities. This commentary provides a balanced, evidence-based insight into this discussion.

Mild Vitamin C Deficiency Is Common in the Inpatient Psychiatric Setting.

Objective: Mild vitamin C deficiency is a psychiatrically relevant nutritional state, with symptoms including apathy, fatigue, and low mood. Although complete vitamin C deficiency has largely been eradicated, mild deficiency remains common in certain populations. Here, we aimed to identify the prevalence of mild vitamin C deficiency in the inpatient psychiatric setting.Methods: We identified 221 patients with plasma vitamin C levels collected on an inpatient psychiatric unit serving a metropolitan area between January 1, 2015, and March 7, 2022. We identified demographic (age, sex, race, housing status, Area Deprivation Index [an index of neighborhood disadvantage]), substance use (tobacco use, alcohol use), diagnostic (depressive, bipolar, psychotic, anxiety, substance use, catatonia, neurocognitive, autism spectrum), and micronutrient (folate, vitamin B12, vitamin D) risk factors. DSM-5-TR was used as the diagnostic system. Bayesian log-normal regressions were constructed to predict vitamin C as a function of these risk factors. We used these same models to predict vitamin C as a function of significant risk factors.Results: We found that 64% (141 of 221; 95% confidence interval 57%-70%) of patients met criteria for mild vitamin C deficiency. While we did not identify robust demographic, substance use, or diagnostic-based risk factors, we found that folate and vitamin D strongly predicted vitamin C levels. To test the utility of these predictors, we simulated vitamin C as a function of folate and vitamin D and found that predicted deficiency remained high (∼ 50%-55%), even when folate/vitamin D were sufficiently replete.Conclusions: We find that vitamin C deficiency is highly prevalent in the inpatient psychiatric setting and remains high even when the relevant risk factor profile is favorable.

An analysis of Chinese nursing electronic medical records to predict violence in psychiatric inpatients using text mining and machine learning techniques.

The prevalence of violence in acute psychiatric wards is a critical concern. According to a meta-analysis investigating violence in psychiatric inpatient units, researchers estimated that approximately 17% of inpatients commit one or more acts of violence during their stay. Inpatient violence negatively affects health-care providers and patients and may contribute to high staff turnover. Therefore, predicting which psychiatric inpatients will commit violence is of considerable clinical significance. The present study aimed to estimate the violence rate for psychiatric inpatients and establish a predictive model for violence in psychiatric inpatients. We collected the structured and unstructured data from Chinese nursing electronic medical records (EMRs) for the violence prediction. The data was obtained from the psychiatry department of a regional hospital in southern Taiwan, covering the period between January 2008 and December 2018. Several text mining and machine learning techniques were employed to analyze the data. The results demonstrated that the rate of violence in psychiatric inpatients is 19.7%. The patients with violence in psychiatric wards were generally younger, had a more violent history, and were more likely to be unmarried. Furthermore, our study supported the feasibility of predicting aggressive incidents in psychiatric wards by using nursing EMRs and the proposed method can be incorporated into routine clinical practice to enable early prediction of inpatient violence. Our findings may provide clinicians with a new basis for judgment of the risk of violence in psychiatric wards.

Mpox exposure on a congregate inpatient psychiatry unit: Description of the investigation and outcomes—New York City, 2022

Background: In May 2022, New York City (NYC) experienced a large outbreak of human mpox (clade IIb). Data on mpox transmission following exposure in healthcare facilities in nonendemic settings are limited. Because mpox was previously not seen in NYC, our healthcare staff may not always recognize a suspected case and therefore may neglect to implement timely infection prevention and control measures, leading to infectious exposures. The risk of transmission from unrecognized mpox may be higher in inpatient psychiatric units where direct physical contact is more common in the setting of common spaces for patients. In July 2022, a patient was admitted to NYC Health + Hospitals–Bellevue (Bellevue) psychiatry with signs and symptoms of mpox that were not recognized for 4 days, at which point the patient was tested for mpox and was isolated. We describe the investigation of staff and patients exposed during the 4 days prior to diagnosis and isolation of the index patient, and we report on the outcome mpox infection among those exposed. Methods: This study was a retrospective chart review of adult patients admitted to and staff working on an inpatient psychiatric unit where the patient with mpox was admitted to Bellevue, the largest municipal hospital in NYC. Each individual was classified regarding degree of exposure, based on criteria from the CDC, and was offered postexposure mpox vaccination where indicated. We describe the nature of contact with the patient for those with high-risk exposures. The outcome of interest was development of mpox infection during 21 days after last exposure. Results: In total, 29 patients and 84 staff members were identified to have been on the psychiatric unit prior to isolation of the index case of mpox. All exposed individuals were monitored for signs and symptoms of mpox for 21 days after last exposure. The exposed and unexposed patients were kept apart in the psychiatric unit. All patients who had contact were classified as having a low-to-intermediate risk exposure. Among 23 staff members exposed, 8 had high-risk exposures, 4 had intermediate-risk exposures, and 11 had low-risk exposures. Those with high-risk exposures were offered Jynneos as postexposure vaccination, but they declined. None of the exposed staff or patients developed mpox during the follow-up period. Conclusions: Mpox transmission was not observed despite several exposures in a congregate psychiatry unit. Given limited data, further studies are needed to better understand transmission risk in congregate healthcare settings.Disclosures: None

Using the Theoretical Domain Framework to understand what helps and hinders the use of different sensory approaches in Australian psychiatric units: A survey of mental health clinicians.

Although sensory approaches are recommended to relieve distress and agitation and reduce the use of seclusion and restraint, many Australian psychiatric units have struggled to sustain their practice. The aim of this study was to investigate the barriers and enablers influencing the use of different sensory approaches across one health region in Australia and to obtain recommendations for strategies to improve their use. This cross-sectional survey was informed by the Theoretical Domain Framework. Likert scale questions considered barriers and enablers to the use of non-weighted sensory interventions, weighted modalities, sensory rooms, and sensory assessments/plans. Open-ended questions explored participant concerns and recommendations to improve the use of sensory approaches. Participants (n= 211) were from nursing, allied health, medical, and peer support staff across inpatient psychiatric units. Factors most frequently identified as enablers for using sensory approaches were beliefs of positive benefits to consumers (e.g. decreasing distress and agitation); belief it was within the staff's role; and knowledge of the approaches. Limited time was the most common identified barrier. Factors statistically associated with more frequent use were knowledge, skills, confidence, availability, and easy access to sensory tools/equipment. Only 30% of participants were concerned about potential risks of sensory approaches, with this risk mitigated through adequate supervision and thorough risk assessment. Recommendations to improve practice included improved access to, and maintenance of, equipment, more training, and increased staffing. This study revealed how barriers and enablers vary for different sensory approaches and how these factors impact their frequency of use in psychiatric units. It provides insights into staff recommendations to improve the use of sensory approaches in one health region in Australia. This knowledge will lead to the development of implementation strategies to address identified barriers and improve the use of sensory approaches in psychiatric units.

COVID-19 outbreak in an acute psychiatric unit—Unique challenges and creative solutions

Background: We describe the management of a major COVID-19 outbreak in January 2022 during the SARS-CoV-2 omicron-variant winter surge involving the only inpatient psychiatric facility of Santa Clara County, California, which serves a population of 1.9 million. Methods: On January 14, 2022, infection prevention staff were notified of a symptomatic COVID-19 case in our locked inpatient psychiatric unit who had been admitted since October 2021. The index patient had no visitors or transfers outside the unit. The patients in this unit were noncompliant with masking and mingled with each other during meals. Initial testing identified 23 positive cases among 47 patients and 12 staff cases. Mitigating actions included closing the unit to new admissions, creating alternate care areas in the emergency psychiatric unit, and separating patients into “exposed but negative” and “infected” cohorts and housing them in “red,” and “yellow” zones, respectively. A “green” zone was created by clearance of positive cases. For the cohort exposed to COVID-19, masking was enforced by supervision, dining was scheduled in batches, and daily symptom screening and antigen testing were performed in addition to standard postexposure RT-PCR testing on day 4 and day 7. Mandatory N95 respirators and eye protection were implemented for staff on unit entry. Exposed staff followed employee health protocols for postexposure testing. Enhanced environmental control measures included terminal cleaning and UV-C disinfection of common areas and patient rooms and a thorough investigation of airflow. Discharged patients were contacted if they were residing in congregate facilities. Results: Of 47 patients, 39 (83%) tested positive for COVID-19. However, 8 patients remained negative; all 8 had received at least their primary vaccine series (Table 1). In total, 16 HCWs were SARS-CoV-2 positive in this outbreak. The outbreak officially ended 25 days after the first case. All SARS-CoV-2–positive patients had mild illness, not requiring treatment or hospitalization. We identified vaccine immune escape, staff presenteeism, patient noncompliance with masking, and comingling as major causes of transmission. We determined through contact tracing and temporality that the outbreak likely started from a positive staff member or visitor because most patients had been long-term residents. Conclusions: This outbreak was challenging due to the specialized behavioral needs of the involved patients. It was imperative to reopen this unit quickly and safely to provide psychiatric care to our county’s most vulnerable patients. Ongoing PPE education, repeated reinforcement, engagement in staff wellness to combat pandemic fatigue, and aggressive vaccination are all crucial to minimizing the impact of future outbreaks.Disclosures: None

(286) Goldmember: A Novel Approach to Remove Entrapped Metal Rings Around a Penis

Abstract Introduction Penile strangulation with metal objects is a rare urologic emergency that can present considerable challenges. The treatment approach can vary depending on the type of constricting device, degree of injury, and available equipment. Prior medical reports document the use of various instruments such as bolt cutters, oscillating saws, and power drills. Our case demonstrates a safe and reproducible means to remove metal rings entrapped around a penis using the Midas Rex® drill. Objective To describe a novel treatment approach in penile strangulation with the use of the Midas Rex® drill. Methods A 70-year-old male with a history of paranoid schizophrenia presented to our institution’s emergency department with urinary retention and penile pain due to the placement of five rings onto the penis two weeks prior. On exam, he had swelling of the glans and skin necrosis underneath the rings (Figure 1). After initial bedside attempts to remove the rings proved unsuccessful, he was promptly taken to the operating room. Further attempts to remove the rings using orthopedic pin cutters were also unsuccessful. Next, the Midas Rex® drill (Figure 2a) was used to cut each ring into two segments. The penis was protected from traumatic and thermal injury with careful retraction and continuous irrigation (Figure 2b). All five rings were successfully removed without sustaining iatrogenic injuries (Figure 2c). The injuries were limited to pre-existing superficial wounds of the penile skin (Figure 3a). A cystoscopy was performed and did not reveal any evidence of urethral injury. A suprapubic catheter (SPC) was placed to allow for urethral rest with 1,200 ml of urine drained. Postoperatively, the patient was stable and was transferred to the inpatient psychiatric unit the next day. After adjustment of his psychiatric medications and six days of observation, he was discharged. At his two-week urology follow-up, he had near-complete healing of the penile skin (Figure 3b). His SPC was also removed with low post-void residual noted. Results We present a case where mechanical methods could not be used to remove entrapped metal rings around a penis. In cases requiring the use of electrical tools, it is of utmost importance to protect the penis from iatrogenic injuries. Although the use of non-medical devices such as electric saws have been described in penile strangulation, they can often be bulky. Also, in several reports these devices have caused thermal injuries, leading to urethral strictures and urethrocutaneous fistulae. We were able to use the Midas Rex® drill, an instrument typically used in neurosurgical and orthopedic procedures, with excellent results. By using the diamond-tipped metal cutter attachment and powering the drill with compressed nitrogen set at 120 psi, all five metal rings were safely removed in under 30 minutes. Conclusions Penile strangulation represents a rare urologic entity requiring prompt removal of constricting devices to avoid ischemic complications. From our experience, we demonstrated that the Midas Rex® drill can be safely and expeditiously used to remove metal rings entrapped around a penis with minimal risk of iatrogenic injury. Disclosure No

Longitudinal Relations Between Childhood Maltreatment, Emotion Regulation Difficulties, and Suicidal Ideation and Non-Suicidal Self-Injury: An 18-Month Investigation of Psychiatrically Hospitalized Adolescents.

Within the Dimensional Model of Adversity and Psychopathology, extant research shows that exposure to threat-including emotional, physical, and sexual abuse-is linked to psychopathology among adolescents; problems with emotion regulation may, at least in part, explain this association. Both theoretical and empirical work also suggests that emotion regulation difficulties-particularly access to emotion regulation strategies-may mediate the relation between threat and self-injurious thoughts and behavior, though no studies to date have explicitly tested this model. The current study tested relations between threat, limited access to emotion regulation strategies, and self-injurious thoughts and behaviors among high-risk youth across an 18-month follow-up. The sample consisted of 180 adolescents (Mage = 14.89; SD = 1.35; ages 12-17; 71.7% female; 78.9% White; 55.0% heterosexual) recruited from an inpatient psychiatric unit. Threat was assessed at baseline using the abuse subscales from Childhood Trauma Questionnaire. Access to emotion regulation strategies was assessed using the Difficulties in Emotion Regulation Scale at baseline, 6-, and 12-months. Presence (versus absence) of non-suicidal self-injury and suicidal ideation severity were assessed at baseline, 12-, and 18-months using the Self-Injurious Thoughts and Behaviors Interview and the Suicidal Ideation Questionnaire-JR, respectively. After accounting for baseline levels of the mediator, outcome, and depressive symptoms, structural equation models supported the role of 12-month access to emotion regulation strategies as a mediator between baseline threat and 18-month suicidal ideation and non-suicidal self-injury. Treatment aimed at bolstering access to emotion regulation strategies may help reduce suicide risk among youth who have experienced childhood abuse.

Should stressful life events be monitored after a first episode of psychosis?

In the 3 years following a first episode of psychosis, 50% of individuals will experience a relapse, which could be expressed as symptom exacerbation or readmission to a psychiatric inpatient unit. 1 Alvarez-Jimenez M Priede A Hetrick SE et al. Risk factors for relapse following treatment for first episode psychosis: a systematic review and meta-analysis of longitudinal studies. Schizophr Res. 2012; 139: 116-128 Crossref PubMed Scopus (312) Google Scholar Hence, finding the relevant risk factors for new episodes is an urgent matter in psychiatric research and clinical practice. Whereas risk factors such as substance misuse and non-adherence to medication are well understood and can be targeted by interventions, less is known about other factors that might also be important, such as sleep deprivation, depressive or manic symptoms, or stressful life events. 1 Alvarez-Jimenez M Priede A Hetrick SE et al. Risk factors for relapse following treatment for first episode psychosis: a systematic review and meta-analysis of longitudinal studies. Schizophr Res. 2012; 139: 116-128 Crossref PubMed Scopus (312) Google Scholar Among these factors, stressful life experiences are associated with an increased risk of developing psychosis in people who are already considered as having a high risk of psychosis. 2 Betz LT Penzel N Kambeitz-Ilankovic L et al. General psychopathology links burden of recent life events and psychotic symptoms in a network approach. NPJ Schizophr. 2020; 6: 40 Crossref PubMed Scopus (20) Google Scholar , 3 Mayo D Corey S Kelly LH et al. The role of trauma and stressful life events among individuals at clinical high risk for psychosis: a review. Front Psychiatry. 2017; 8: 55 Crossref PubMed Scopus (110) Google Scholar Therefore, it could be possible that stressful life experiences also affect the risk of relapses after the first episode of psychosis. Stressful life events and relapse of psychosis: analysis of causal association in a 2-year prospective observational cohort of individuals with first-episode psychosis in the UKThese results provide converging evidence of a causal effect of stressful life events on the risk of relapse in psychosis. They suggest that there is a need to develop interventions at the individual and health-service level that could mitigate the harmful effects of stressful life events. Full-Text PDF Open Access

Examining readmission factors in psychiatric emergency care for individuals with personality disorders: A 6-year retrospective study.

People with personality disorders (PDs) are often admitted to psychiatric emergency services due to the frequent repetition of acute crises. This study drew on the ICD diagnostic records of 2,634 individuals with PDs who were admitted to a specialized inpatient psychiatric crisis unit over a 6-year period. Multiple logistic regressions and survival regressions were performed to examine whether PD categories, gender, and other individual, interpersonal, and precipitating factors were associated with readmission and time-to-readmission. The results showed a 16.1% readmission rate. Of these, 99.5% of readmissions occurred within 4 years following the first admission. Gender was the main factor associated with both readmission and time-to-readmission: while men were readmitted faster, more women in total were readmitted for a second psychiatric emergency hospitalization. Findings also indicated that readmission rate and time-to-readmission differed following the category of PD: readmission rate in a ratio of 1-2 (from 8% to 10% for dissocial and paranoid PD up to 19%-21% for impulsive and borderline PD), and time-to-readmission in a ratio of 1-5 (from 1 month for anankastic and dependent, to 5 months for impulsive, histrionic and anxious-avoidant PD). Limitations of this naturalistic study include a lack of self-reported measures and generalizability to less specialized emergency settings. Future research should include a prospective longitudinal design using standardized scalable measurement tools to improve the completeness and accuracy of the data concerning the psychological processes involved in risk and time-to-readmission after brief hospitalizations in emergency psychiatry. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Group Cognitive Behavioral Therapy for Substance Use Disorders Among Psychiatric Inpatients in a Medically Underserved Area: An Intervention for Opioid Misuse.

Opioid misuse is a serious public health concern, yet few people seek treatment for this condition. Hospitals may be one opportunity to identify those with opioid misuse and to teach them skills to help manage their opioid misuse upon discharge. We tested the relationship between opioid misuse status and motivation to change substance use among patients admitted with substance misuse to an inpatient psychiatric unit in a medically underserved area in Baton Rouge, Louisiana, who attended at least 1 group session of motivation enhancement therapy combined with cognitive behavioral therapy (MET-CBT) from January 29, 2020, through March 10, 2022. Of the 419 patients in our sample, 86 (20.5%) appeared to misuse opioids (62.5% male; mean age, 35.0 y; 57.7% non-Hispanic/Latin White). At the beginning of each session, patients completed 2 measures of motivation-importance and confidence to change substance use-from 0 (not at all) to 10 (most). At the end of each session, patients rated perceived session helpfulness from 1 (extremely hindering) to 9 (extremely helpful). Opioid misuse was associated with greater importance (Cohen d = 0.12) and confidence (Cohen d = 0.13) to change substance use and with attending more MET-CBT sessions (Cohen d = 0.13). Patients with opioid misuse rated sessions as highly helpful (score of 8.3 of 9), and these ratings did not differ from patients who used other substances. Inpatient psychiatry hospitalizations may provide an opportunity to identify patients with opioid misuse and introduce these patients to MET-CBT to learn skills to manage opioid misuse upon discharge.