Open Ward Research Articles

Clozapine for schizophrenia: Clinical effect, financial considerations, and quality requirements

Twenty-six years ago at Sanderud Hospital we started treating schizophrenic patients with clozapine (Leponex®). This treatment has led to a better life for many schizophrenic patients and represents a breakthrough in regard to the quality of their remaining years. Between 1973 and 1995, 103 schizophrenic patients were given clozapine treatment on a trial basis. The patients had long medical histories. We observed considerable improvement after up to 3 years' treatment with regard to both clearly positive psychotic symptoms and negative symptoms such as social withdrawal and isolation. There were few and very short-lasting re-hospitalizations. After 3 years 64 patients were living at home. Those patients who are still in institutions are being treated in open wards, psychiatric care centres, or communal nursing homes. Drowsiness and ?too much saliva? were the commonest side effects. One patient developed agranulocytosis but survived. Two developed leucopenia. Abrupt self-termination of treatment quickly leads to relapse and may have severe consequences. None of our patients committed suicide. All the patients had extrapyramidal side effects before starting clozapine therapy. These side effects disappeared, and clozapine itself did not cause extrapyramidal side effects. Treatment with clozapine is clearly cost-effective. The study is a naturalistic one, registering the effect of treatment with clozapine, but changes in practice over the years since 1973 must be taken into consideration.

Sustained ventricular tachycardia in the emergency department

The aim of the study was to evaluate the demographics, haemodynamics, ECG characteristics, underlying disease, tachycardia termination and outcome of patients with sustained ventricular tachycardia (VT). We registered 75 patients presenting with VT (51 male, median age 63) from December 1993 to August 1998 in our emergency department (ED). Seventeen of these patients were haemodynamically unstable (23%), and 58 patients were stable (77%); there was no difference in the tachycardia cycle length (median 320 ms) and QRS width (median 140ms) between the two groups; however, five of the seven patients with polymorphic VT pattern were in the unstable group. Ischaemic heart disease was the underlying disorder in 57 patients (76%). Acute myocardial infarction (AMI) was present in 12 of the 58 stable (21%) compared to 11 of the 17 unstable (65%) patients. In three patients (4%) VT terminated spontaneously, in 34 patients (45%) VT was terminated by first-line intravenous drug therapy, and in 38 patients (51%) including all 17 unstable and 22 stable who failed to respond to the intravenous antiarrhythmic therapy challenge out of 55 patients, VT was terminated by electrical therapy. Within 2 days, 48 patients (64%) were transferred to an open ward, 13 (17%) still needed intensive care, nine (12%) were discharged to home and five (7%) died. Death occurred due to cardiac failure from AMI with extensive anterior wall infarction in three patients, and due to constrictive pericarditis and reocclusion of stented LAD each in one patient. At presentation in the emergency department, the majority of the patients with VT were haemodynamically stable, thus allowing first-line antiarrhythmic drug administration. However, in the course of the disease, half needed electrical therapy for definitive termination of the tachycardia. Therefore, direct current cardioversion must be available in the emergency department. Haemodynamic instability and death occurs significantly more often if VT occurs during the course of AMI.

Treatment of leg ulcers with split skin grafts: early and late results.

Sixty patients (mean age 73.5 years) with 88 leg ulcers that had not responded to conservative treatment had split skin grafts applied at the Department of Plastic Surgery, Linköping, Sweden. Of 51 venous leg ulcers 45 (88%) healed after a mean of 15 days (range 5-30); and 13 (62%) of the 21 arterial ulcers healed after a mean of 18 days (range 8-30). Additional skin grafting was done on nine of the venous and on three of the arterial ulcers. Twenty-two (49%) of the healed venous ulcers recurred after a mean of four months while only two (15%) of the healed arterial ulcers recurred after a mean of 10 months. At late follow up after a mean of four years 18 of the patients were dead and 10 had had the leg in question amputated. Of the 34 patients still alive who had not had amputations, 31 were investigated at open ward or interviewed by telephone and 23 patients were examined with colour duplex scan. Seven of these patients had open leg ulcers. At duplex scan six patients had no venous or arterial insufficiency that could cause a leg ulcer. Of 16 patients with venous insufficiency 10 patients had only an inadequate superficial system. The mean cost for treating one leg ulcer by skin grafting is estimated at SEK 89000 (US$11125). We conclude that leg ulcers often heal with skin grafting but that venous ulcers often recur. To reduce the recurrence rate we suggest a better preoperative aetiological evaluation and improved postoperative treatment with a compression bandage.

Public Attitude and Opinion Toward Mental Illness in Cheju, Korea

This study was attempted to describe the public attitude and opinion toward mental illness in Cheju, Korea. The subjects were 129 adults residing in Che judo. Structural interview was used to ask about attitudes, opinions toward mental illness or mentally ill persons.Opinions about the signs of mental illness were divided 6 categories : bizarre behavior (47.4%), aggressive behavior(16.4%), withrawal (17.7%), inadequate thought (8.6%), inadequate emotion(4.3%), others (5.6%).Opinions about the cause of mental illness were divided 3 categories : sociopsychological (59.9%), supernatural (18.8%), physical (16.9%).Opinions about the treatment of mental illness were divided 6 categories ; folk psychological (36.8%), supernatural(28%), modern psychiatric (26.1%), other folk(3.9%), primitive medicine (1.7%), others(3.4%).Prognostic outlooks of mental illness were generally pessimistic.Attitudes about mentally ill person were divided 6 categories : pity(43.6%), unwellness( 21%), fear (14.9%), fear and pity(10.2%), curosity(7.1%), indifference (3.1%).66.9% of the subjects would feel shameful, if one of their family members were mentally ill, and also 65.4% of the subjects would not frankly their friends know this fact. 62% of the subjects preferred home treatment to hospital treatment and 60.9% of the subjects regard psychiatric hospital to be the place in which mentally ill patients are confined and gen erally attitudes for the open ward policy of mental hospital was negative.Considering the results in view of cheju community mental health, positive and humanistic attitudes would have favorable aspects in spreading the movement of community mental health with acceptable atmosphere for the improved patients. On the contrary the prejudice toward mental illness, family member's shame, supernatural illness concept, and negative response to the therapeutic function of mental hospital would result in a difficult social atmosphere in detecting patients and pursuing adequate treatment.

The management of severe psychiatric disorder: A comparison of the use of neuroleptic medication in two intensive therapy units

Concern over the use of high dose neuroleptic medication has led to the introduction of guidelines for prescribing. This is of particular importance in the treatment of patients with severe psychiatric disorder. This study evaluates how physical security of the ward relates to prescribing in two close supervision units. A prospective analysis of 93 consecutive admissions to two wards, one locked and the other open, was undertaken. Data included patient characteristics, diagnosis and medication received. There was no difference in total neuroleptic dosage between the two wards, but mean daily dose (2,108 mg chlorpromazine equivalent) exceeded maxima specified in guidelines. In the early stages of admission, the open ward used higher regular doses, whereas the locked ward prescribed more on an as required basis. The high incidence of absconding from the open ward must be considered against the more custodial environment of the locked ward. The wider use of chlorpromazine equivalence calculations is recommended.

The nursing management of MRSA on a spinal injuries unit.

The aim of this article is to encourage nurses to question their actions when caring for patients with methicillin-resistant Staphylococcus aureus (MRSA). Some of the main effects of isolation are discussed with reference to specific problems encountered by spinal cord-injured patients in isolation. The advantages and potential problems of a policy for the management of MRSA in a spinal injuries unit are outlined. It concludes that it is not always necessary to isolate all patients who are colonized/Infected with MRSA; provided that basic Infection control measures are followed carefully, and staff, patients, and visitors are educated on the risks of MRSA, it is safe to nurse some of these patients on an open ward.

A survey of patient satisfaction as a means of evaluating quality of care in an open psychiatric ward

Patients' satisfaction with their stay in an open psychiatric ward was studied retrospectively by means of a standardized questionnaire. The questionnaire was mailed during the autumn of 1995 to all patients discharged from the ward in 1990 and 1994. Overall response rate was 66.5%. Patients discharged during 1994 were more satisfied with the hospitalization, but the differences between the two populations were small. A major proportion of patients, including compulsorily admitted subjects, were highly satisfied. Men were more satisfied than women. The only factor that related to symptom relief at the time of the study was the reported benefit from pharmacotherapy. The questionnaire may be used in further research towards a consensus on good quality of inpatient psychiatric care.

The post anesthesia care unit: Unique contribution, unique risk

The environment in the postanesthesia care unit (PACU) is unique in the modern hospital. It was born of necessity and continues of necessity. The modern PACU has evolved from a simple room designed to house a single patient and a nurse to a modern, bustling room of great proportions. Today's PACU is an open ward, probably the only one left in the modern hospital, and contains many immunocompromised patients, including pediatric patients; knowledge of the patient's medical history may be sketchy or brief. Patients undergo cough-inducing procedures and exhale waste anesthesia gases. The PACU has a high ratio of health care workers (HCWs) to patients. HCWs, often in their childbearing years, function in close proximity to the patient's face. These environmental conditions coupled with the epidemic proportions of tuberculosis in the United States, the increase in incidence of hepatitis C virus, the consequences of human immunodeficiency virus, and the possible adverse effects of waste anesthesia gases result in a milieu that is a risk to both patients and HCWs that cannot be managed with air exchange controls alone. This article reviews the historical contribution of the PACU and the factors in the PACU environment that increase the vulnerability of HCWs and patients to respiratory diseases, bloodborne pathogens, and adverse effects of waste anesthetic gases.

User adoption issues in renal telemedicine.

We carried out a longitudinal survey to evaluate the users' attitudes to the introduction of telemedicine into the dialysis units of a renal ward in South Australia. The first questionnaire was distributed to all members of staff involved with the introduction of the system. There were 44 responses (80%). Staff were fairly positive about the telemedicine system, and felt that it was easy to use and reliable. They also clearly felt that the confidentiality and privacy offered by the system in an open ward were unsatisfactory. A second questionnaire was distributed to all staff about six months later and there were 40 responses (66%). Of these, 22 could be matched with the responses from the first survey (a response rate of 50% from the first sample). There were no significant differences in the staff members' feelings between the two surveys, except in two cases: there were significant changes in staff opinion about the degree of confidentiality (P < 0.05) and privacy (P < 0.01) offered by the system, with attitudes becoming more positive in each case. The results indicate the need for dialogue with users, in order to address their concerns regarding the system and practical difficulties. This study highlights the importance of planning, effort, cooperation and an appropriate culture within a renal unit in order for telemedicine to be accepted.

Blanket use of intranasal mupirocin for outbreak control and long-term prophylaxis of endemic methicillin-resistant Staphylococcus aureus in an open ward

In December 1992, a thoracic ward in a Melbourne teaching hospital experienced an increase in patients infected with methicillin-resistant Staphylococcus aureus (MRSA). It was decided to attempt to control the outbreak by cohorting positive patients (infected and colonized), as well as nurse cohorting, emphasis on handwashing, and use of intranasal mupirocin initially three times a day for three days, then thrice weekly, for all patients in the ward (with or without MRSA). The campaign comprised four phases of 53, 45, 92 and 365 days, respectively. Patient and nurse cohorting stopped at the end of phase I. In phases I and II, surveillance nose swabs were taken on admission, then twice weekly; in phase III, on admission and weekly and in phase IV, on admission until the end of 1993. In phases I and II (98 days), only one patient acquired MRSA. When the frequency of mupirocin prophylaxis was decreased to once weekly (phase III), two patients acquired MRSA in 92 days (no significant difference): thrice weekly administration resumed (phase IV), during which there were three acquisitions in 365 days. The rates of nose colonization of admissions were 6·4%, 6·3%, 9·7% and 3·1% in phases I–IV, respectively. Only three patients were treated with vancomycin between July 1993 and June 1994 (significantly lower than historical rates, P = 0·0086). No mupirocin resistance was seen in MRSA isolates from this ward during phases I, II and III. In areas of low-level endemic MRSA, the blanket use of thrice-weekly intranasal mupirocin may be effective in decreasing serious infections with MRSA, and does not necessarily elicit mupirocin resistance.

Hospital at war: treatment changes in mental patients

The implications of the chemical war threat and the missile attacks during the Gulf War for a medium-sized psychiatric community are analyzed in terms of psychiatric care and management. Changes in medication, physical restraint, and ward transfer were observed for schizophrenic patients in active psychotic phase (n=50), in residual post-active phase (n = 37), and patients with long-term residual type (n = 167). The variables for the first week of the war (n = 250) were compared to those the same week 1 year before (n = 254). Patients in active phase and patients in residual phase received more supplementary treatment and radical changes in treatment; patients in active phase received more treatment reinforcement, as well as physical restraint, compared to patients in phase and residual type patients. Residual type patients remained unchanged on all variables. Residual type patients remained mostly indifferent, while many severely disturbed patients residing in open wards required only minor tranquilizers. Patients in active phase tended to behave very erratically while denying being affected by the war, and patients in residual phase overtly expressed their anxiety and remained in control.

A prospective three-year follow-up study of borderline personality disorder inpatients.

Prospective long-term follow-up studies on patients with borderline personality disorder (BPD) have been uncommon. Clinical data suggest that their treatment is highly demanding and that short-term results are sometimes limited. In this study, changes in symptoms and social management were monitored during a hospitalization period of 91 days (mean, range 21-296 days) and during a 3-year follow-up period in 62 patients admitted during 1989 to an open ward specializing in the psychotherapeutic treatment of BPD. The patients were thoroughly evaluated, using various rating scales, at the beginning and at the end of the index admission and after the follow-up period. Forty-two patients (70%) participated in the follow-up evaluation. Most patients suffered from overt anxiety and depressive symptoms at the beginning of hospitalization, and these declined significantly during hospital treatment. At the end of the follow-up period, depressive and anxiety symptoms were at the same level as on discharge, as assessed by the Beck Depression Inventory and Hamilton Depression Rating Scale. Although treatment response was otherwise maintained, the patients often showed suicidal behavior. During the follow-up period the sample clearly differentiated in two groups: those continually fit for work (33%) and those chronically incapable of working (46%).

The Risk for Transmission of Mycobacterium tuberculosis at the Bedside and during Autopsy

To emphasize the differing infectious potentials of a patient with tuberculosis. Hospital ward and autopsy room. An epidemiologic investigation of tuberculin skin test conversions in a clinical setting and during autopsy when results of tuberculin tests done before exposure were available for all participants. Tuberculin skin test results after the discovery of tuberculosis exposure from a patient with unsuspected tuberculosis for comparison with the test results before exposure; culture of sputum and autopsy material for Mycobacterium tuberculosis; and DNA fingerprinting of organisms. Preventive therapy for persons with skin test conversion. None of the 40 skin test-negative health care workers caring for the patient for 3 weeks on an open medical ward showed a skin test conversion, even though they had not used respiratory precautions. By contrast, among personnel present during the 3-hour autopsy, the test results of all five nonreactors converted from negative to positive (mean reaction, 24 mm). Two of these persons had a positive sputum culture 8 weeks later. The DNA fingerprints of all three isolates were identical. A patient who did not transmit tuberculosis before death released a prodigious number of tubercle bacilli during autopsy.

Marketing the mental health care hospital: identification of communication factors.

The current study provides guidance to hospital administrators in their effort to develop more effective marketing communication strategies. Two types of communication factors are revealed: primary and secondary. Marketers of psychiatric hospitals may use the primary factors as basic issues for their communication campaign, while secondary factors may be used for segmentation or positioning purposes. The primary factors are open wards, special treatment for adolescents, temporary absence, while patient, in-patient care, and visitation management. The secondary factors are temporary absence while a patient, voluntary consent to admit oneself, visitation management, health insurance, open staff, accreditation, physical plant, and credentials of psychiatrists.

Psychiatric services are dangerous, warn doctors

Potentially violent psychiatric patients in parts of London are waiting up to two months for beds in private medium secure units. Some patients are being placed as far away as Yorkshire. “We have a five bedded locked ward for patients who need intensive treatment, but this is for a population of nearly 200000—we used to have 15 beds five years ago,” said Dr Zerrin Atakan, a senior lecturer in psychiatry at South Western Hospital in West Lambeth. “The unit is at times completely blocked with forensic patients, and when we admit a new patient who is acutely disturbed we have to move someone from the unit on to an open ward because these patients are waiting to be placed in private secure units. We believe that some of these patients are a risk to themselves and to others. “I have not been able to …

Understanding who improves after psychiatric hospitalization.

This study attempts to identify variables associated with improved functioning after psychiatric hospitalization. The relationship between 25 clinical and demographic variables and improvements and functioning at discharge of 309 consecutive patients in an open ward over 2 years were studied using stepwise logistic regression. Measures of patients functioning at discharge were score above or below 50 on the (Global Assessment of Functioning scale) (GAF) and 3-point scale of functioning 1 week after discharge (needs constant supervision, functions independently at home, functions on the job). We created a logistic regression model of outcome based on the information available at admission and one based also on information at time of discharge (i.e., medication, therapy and length of stay etc.). Discharge models predicted 6-10% better than admission models. Discharge models correctly predicted whether GAF level was above 50 in 72% of the cases and return to preadmission functioning in 71% of the cases. We also created a model of functioning at discharge using a hierarchical logistic regression model. It correctly predicted 74% of the lowest level of functioning, 47% of the middle level and 68% of the highest level. The best predictors of improved functioning after discharge were preadmission levels of functioning, psychotherapy in hospital, absence of organic brain syndrome, attendance at occupational therapy and hospitalization less than 4 months. Diagnosis had almost no discernible effect on outcome of hospitalization.

Chemoprophylaxis of invasive pulmonary aspergillosis.

Invasive aspergillosis in now the second most common mycosis encountered in patients with cancer, particularly those with haematological malignancies. The present review discusses strategies for the chemoprophylaxis of invasive pulmonary aspergillosis. Recommendations for chemoprophylaxis are currently based on the particular fungal pathogens seen in individual centres and the resources available. In many units, only BMT recipients are nursed in protected environments and the majority of patients at risk of invasive mycosis, i.e. patients undergoing remission induction or consolidation therapy, are nursed on open wards. The studies so far reported have included relatively small numbers of patients and provide insufficient data for definitive recommendations. The measures used at present should be considered as ad hoc approaches for use in units in which spore-free air for profoundly neutropenic patients is lacking. Nebulized amphotericin B allows deposition of a chemical barrier throughout the airways. Intravenous low dose amphotericin B would be protective when invasion occurs and is clearly the chemoprophylaxis of choice in patients with an established diagnosis of previous invasive aspergillosis at any site. The role of surgery in removing a focus of infection before further chemotherapy, should not be overlooked. The potential role of cytokines in accelerating host defence recovery may in future also prove to be important in controlling invasive fungal infection.

Factors predicting outcome of psychiatric hospital treatment in patients with borderline personality organization

The aim of the present study was to identify factors predicting the outcome of psychiatric hospital treatment carried out on a ward specializing in psychotherapeutic treatment of borderline personality disorders. The sample included patients admitted during 1989 to an open psychiatric ward at the Department of Psychiatry of Kuopio University Hospital in Finland (n=66). The success of treatment was assessed by means of the Beck and Hamilton depression scales, on the basis of which the sample was divided into two groups: those who benefited from treatment and those who did not. Fifty independent variables reflecting the patients' background, previous treatment and expectations were evaluated. A statistically significant association was found between 14 variables and the outcome of the treatment. A good outcome was predicted by subjective symptoms such as tension and suicidal tendencies at the beginning of treatment and a poor outcome by fear of delusions. Active and positive expectations of symptom decline ...

Noise in the ICU.

The growing number of technical devices in ICUs makes noise exposure a major stressor. The purpose of this study was to assess noise levels during routine operation in our ICU. Our ICU is an open ward with four rooms, constructed in the 1960s. During the study period, 4 patients were in the controlled room and were treated by 4 nurses during the day and by 2 at night. A-weighted sound pressure levels (SPL) were measured continuously for 2 days and nights. Also measured were the alarms of various appliances. For gross overall evaluation it is customary to state the Leq, i.e. the energy-averaged level during measurement. The annoyance caused by noise depends more on rare events of high intensity. Therefore, the distribution of SPL values (Ln) over time was also analysed. SPL was roughly the same during the day and at night, with Leq between 60-65 dB(A) and peaks up to 96 dB(A). Most alarms reach an SPL of 60-70 dB(A), but some exceed 80 dB(A). During teaching rounds Leq exceeds 65 dB(A). During the day and at night SPL always surpasses the permissible noise exposure for 24 h of 45 db(A) recommended by the US Environmental Protection Agency. Alarms cause the most irritating noise. Hospital management should pay attention to internal noise, and SPL should be measured routinely.

Evaluation of music therapy and other treatment modalities by adult psychiatric inpatients.

The purpose of this study was to investigate adult psychiatric patients' evaluation of music therapy and other aspects of their overall treatment. Twenty-seven patients hospitalized on an open psychiatric ward of Tulane Medical Center in New Orleans served as subjects. They rated music therapy, art therapy, recreation therapy, traditional therapies, and general aspects of care provided during their hospitalization with a semantic differential consisting of four adjective pairs. Results from a one-way analysis of variance showed that music therapy was rated significantly higher than art and recreation therapy on the pleasurable/painful scale, but no significant differences were found among the activity therapies on the three remaining scales. Further one-way analyses of variance showed that the activity therapies taken as one aspect were rated significantly higher than several therapies on specific scales; also, they were not significantly less important or less successful than medication, which was rated highest on these two scales. The author suggests that an instrument with multiple evaluation scales may be specifically adapted to any program, and can provide information to guide music therapists in delivering valuable therapeutic services.