PRN Medication Research Articles

Approval Ratings of Inpatient Coercive Interventions in a National Sample of Mental Health Service Users and Staff in England

Approval Ratings of Inpatient Coercive Interventions in a National Sample of Mental Health Service Users and Staff in England

Approval Ratings of Inpatient Coercive Interventions in a National Sample of Mental Health Service Users and Staff in England

This study sought to ascertain the degree to which psychiatric inpatients and staff approved of various coercive measures commonly used in acute inpatient care. A cross-sectional design was adopted. The Attitudes to Containment Measures Questionnaire (ACMQ) was completed by 1,361 service users and 1,226 staff (68% nurses) in acute care mental health services from three regions of England. This provided evaluation of 11 coercive measures (for example, seclusion) on six dimensions of approval (for example, whether the coercive measure is seen as being acceptable or safe to use) in a large national sample. Comparisons between groups were tested with independent-samples t tests, chi square analysis, or Spearman correlations. Service users and staff strongly disapproved of net beds and mechanical restraint. The three methods that received the most approval by the service user group were intermittent observation, time out, and PRN (as needed) medication; for the staff group, the three methods that were most approved of were transfer to a psychiatric intensive care unit, PRN medication, and observation. Male staff, older service users, and staff who had been involved in implementing coercion expressed greater approval of coercive measures. There are clear gender differences in how coercive measures that are used in inpatient settings are viewed. Personal involvement in deploying coercive interventions was linked to greater acceptance, suggesting a link between experience and attitudinal changes.

An Innovative Program to Help Novice Nurses Select Appropriate PRN Medications for Their Hospitalized Palliative Care Patients with Nausea and Vomiting (756)

An Innovative Program to Help Novice Nurses Select Appropriate PRN Medications for Their Hospitalized Palliative Care Patients with Nausea and Vomiting (756)

Restraint, Seclusion and PRN Medication in English Services for People with Learning Disabilities Administered by the National Health Service: An Analysis of the 2007 National Audit Survey

Background There is much interest in the use and prevention of unnecessary restrictive behavioural procedures; however, accurate estimates of their use are lacking. The Healthcare Commission and Commission for Social Care Inspection (2007) recently reported such data from a large sample of units administered by the National Health Service (NHS).Materials This study analysed data from The Healthcare Commission on the use of personal and mechanical restraint, PRN (as needed) medication and other restrictive procedures were analysed from 509 service units and 3902 service users.Results Approximately 80% of service units reported using PRN medication and approximately half of service units used personal or mechanical restraints. A small number of services units used restrictive procedures much more than most service units. A small number of service users experience a very large number of applications of restrictive procedures.Conclusion Contemporary English services administered by the NHS and independent health care use restrictive behaviour management procedures commonly, including non‐evidence‐based practices, such as PRN medication. These services should focus resources on the small proportion of services units and service users and adopt evidence‐based practices to safely reduce these restrictive procedures, enhance service user quality of life and ensure value for money from commissioned services.

The use of prn medication in a child and adolescent mental health inpatient service in France

Objective. The aim of this study was to investigate the use of “as needed” (pro re nata or prn) psychotropic medication in a child and adolescent psychiatric inpatient population. The study was carried out on the psychiatry ward of a paediatric teaching hospital in Paris, France. Methods. A prospective analysis of prn psychotropic drug prescriptions and administrations was conducted for all patients hospitalised over a period of 4 months. The study group consisted of 187 patients. Results. In total, 93 prn prescriptions were written, for 27% of the patients (51) but only 14% (26) received a total of 76 administrations. Antipsychotic drugs accounted for 54% of the prescriptions, anxiolytics for 33%, antiepileptic drugs for 8%, antiparkinsonian drugs for 4% and hypnotic drugs for 1%. Anxiety was the reason given for 67% of the prn administrations, with hydroxyzine used in 69% of these cases. Disruptive behaviour accounted for 22% of prn administrations, with antipsychotic drugs accounting for 88% of these administrations. Insomnia accounted for 8% of prn administrations, and antipsychotic drug-induced dystonia accounted for 3% of such administrations. Conclusion. Controlled studies are required to assess the efficacy and safety of prn medication and the conditions in which its use is indicated.

The use of prn medication in a child and adolescent mental health inpatient service in France

The use of prn medication in a child and adolescent mental health inpatient service in France

Wards features associated with high rates of medication refusal by patients: a large multi-centred survey

Objective This article aimed to explore the relationship of medication-related conflict [refusal of regular medication, refusal of pro re nata (prn) medication, demanding prn medication] to other conflict behaviours, the use of containment methods, service environment, physical environment, patient routines, staff demographics and staff group variables. Method The Patient-staff Conflict Checklist (PCC-SR), an end-of-shift report completed by nurses on the frequency of conflict and containment events, was collected for a 6-month period on 136 acute mental health wards in 67 hospitals within 26 NHS Trusts in England, in 2004–2005. Multilevel modelling was used to assess associations with medication-related conflict rates. Results The mean daily rate (at ward level, standardised to 20 beds) of incidents of regular medication refusal was 0.89 (S.D. 0.52), prn medication refusal 0.30 (S.D. 0.19) and demanding prn medication 1.09 (S.D. 0.63). The frequency of these events was found to be associated with passive resistant patient behaviours, higher levels of containment (specifically locking the main ward door, the use of special observation, and time out) and unstable staffing profiles. Conclusion It may be possible to achieve greater medication concordance amongst patients in acute mental health wards through a more consensual approach to care. Paradoxically, fewer restrictions may promote better treatment acceptance and safer outcomes. Consistent nurse staffing and therefore better staff–patient relationships are also likely to improve cooperation and outcomes.

Comparison in attitudes between nursing and other students in relation to containment measures for disturbed psychiatric patients

The aim of this study was to compare university student attitudes to containment with that of psychiatric students. Nurses face the potential for aggression and violence in everyday psychiatric nursing practice and as such are by necessity required to employ measures that contain and control patients with difficult or destructive behaviours. The attitudes to containment methods questionnaire was employed to gather data from a sample of non-nursing students (n=117) and student psychiatric nurses (n=114) at a UK University between May and September 2002. Data were analysed in SPSS using multivariate analysis of variance. Significant differences on attitudes to containment measures for the non-nursing students were found for gender, age and if the respondent had known anyone who had been a patient on a psychiatric ward. There was greater approval of physical restraint, IM medication, mechanical restraint and net beds by male respondents who were also more likely to consider containment methods acceptable and dignified. The non-nursing sample approved significantly less of PRN medication and significantly more of mechanical restraint and net beds than the student nurses. The views of non-nursing students differed significantly, indicating the presence of stereotypical negative views about nurses' level of responsibility in providing medical care; a greater acceptance of containment methods considered abhorrent by nursing students; and in contradiction, a lesser approval of the more severe methods of containment that are in current use.

Behavior Management on an Acute Brain Injury Unit

To measure the effect of behavior management training on restraint use and prn medication delivery on an acute inpatient brain injury unit. Interdisciplinary staff and hospitalized brain injury patients on a 20-bed unit within a freestanding rehabilitation hospital. Staff participated in the Nonviolent Crisis Intervention (NCI) program from the Crisis Prevention Institute. Applied physical restraints and delivered prn medications. Despite comparable patient levels of agitation severity across the duration of the study, the use of physical restraints initially declined and then increased after training. Data collected on prn medication delivery also indicated a trend for an increase in the delivery of select medication categories across time. NCI training resulted in a temporary, short-lived reduction in physical restraint use, but had an inverse effect on prn medication delivery for select categories of medication. Medication delivery significantly increased over time and restraint use eventually exceeded baseline level. Ramifications of these results are discussed.

Smoking Bans on Psychiatric Units: Boundaries and Health Promotion

Back to table of contents Previous article Next article LetterFull AccessLetterVincenzo Villari M.D.Giulio Barzega M.D.Vincenzo Villari M.D.Search for more papers by this authorGiulio Barzega M.D.Search for more papers by this authorPublished Online:1 Sep 2008https://doi.org/10.1176/ps.2008.59.9.1063bAboutSectionsPDF/EPUB ToolsAdd to favoritesDownload CitationsTrack Citations ShareShare onFacebookTwitterLinked InEmail Smoking Bans on Psychiatric Units: Boundaries and Health PromotionTo the Editor: On January 10, 2005, the Italian government implemented a law that bans smoking in all enclosed places. An emerging body of evidence shows that it is possible to introduce smoking bans in psychiatric units ( 1 , 2 ). However, many psychiatric settings in Italy lack a clear smoking policy. In this letter we describe the impact on staff and patients of a complete smoking ban that was implemented in a 14-bed psychiatric emergency service that serves primarily an inner-city population in Turin, Italy. The service admits patients from the hospital's emergency department 24 hours per day. Six months before and six months after the ban was implemented, staff members completed a brief questionnaire about their attitudes toward the desirability of the smoking ban and its perceived impact on patients' mental status and the ward milieu. In addition, objective indicators of ward disruption were measured, including rates of aggression, use of PRN medications, need for restraint, elopement, and discharge against medical advice. Chi square tests were used to evaluate the impact of the ban on objective indices of ward functioning. Charts were reviewed for 248 patients discharged from the unit during the six months before the ban and 220 patients discharged during the six months after its implementation. No significant differences in demographic or clinical characteristics were found between the two groups. Our analyses found no significant differences in objective indicators of ward disruption before and after the ban. Most of the monitored parameters of disruptive behavior remained stable; for other parameters the changes did not reach statistical significance. No changes were noted between the two periods in staff turnover or in problems related to staff illnesses or casualties. Staff members' responses to the questionnaire indicated that they initially disagreed with the new smoking policy. Such early opposition has been found in other studies ( 3 , 4 ). Spontaneous comments were generally negative, reflecting staff members' belief that patients need to smoke in order to relieve the stress and discomfort of their illness and to counter the side effects of drugs. Almost all respondents feared that the smoking ban would increase verbal and physical assaults. Staff members reported that they often used cigarettes to offer support, to manage threatening violence, and to reward appropriate behavior in difficult situations. The prospect of removing this bargaining tool and reward raised concerns that use of restrictive approaches, such as restraint, would increase. Only one respondent offered a positive comment, remarking that the patients and staff who did not smoke would appreciate a smoke-free environment. Six months after the ban was implemented, questionnaire responses and spontaneous comments indicated that many staff members had changed their minds and appreciated the new policy. Many felt that the old approach was a typically paternalistic one in which cigarettes were used like tokens to keep patients quiet and that such an approach hindered staff from developing insights about patients and good relations with them. Staff reported that the new policy helped them find alternative ways of interacting with patients. Staff noted that when they used a cigarette as a reward, patients demonstrated the desired behavior just to obtain it. With the ban in place, staff found new ways to negotiate with and empower patients. Thus the new environment was not just physically healthier but also mentally healthier.Smoking bans in institutional settings provide an opportunity for staff to work with patients on boundaries and limits. Staff helped patients manage their smoking behavior when patients were faced with the limitation imposed on their behavior by the ban. The situation provided a basis for staff to work with patients to manage other behaviors and gain insight about other limitations. In addition, helping patients understand limits is a key factor in the deescalation approach to managing psychiatric emergencies. On the basis of our experience, we conclude that smoking bans in psychiatric settings can lead to better patient care, although such bans are often difficult to implement. Before the ban, it was clear that staff gave little thought to this problem. Some of them even believed that their smoking with patients had therapeutic value ( 3 , 5 ). However, after an initial phase of opposition, both patients and staff adapted to the new policy. Acknowledgments and disclosuresThe authors report no competing interests.The authors are affiliated with the psychiatric emergency service at Giovanni Battista Hospital in Turin, Italy.

Use of Pro Re Nata Medications in Acute Inpatient Care

Available evidence suggests that the use of 'as needed' (PRN; from the Latin pro re nata: for an occasion that has arisen) medications has remained a standard aspect of treatment in acute inpatient mental health units over a number of years despite lack of evidence from controlled clinical trials. The practice is one in which doctors and nurses are interdependent; that is, while doctors prescribe the medications, professional nurses are the ones who make the clinical decisions to administer them. The aim of the present study was to provide a detailed description of the circumstances surrounding the use of PRN medications across four inpatient units in Sydney. The medical records of all patients admitted for >24h during a 2 month period were retrospectively audited for details regarding prescriptions and administrations of PRN medications. A total of 420 records were reviewed, producing a total of 3868 PRN medication administrations. Ninety-seven per cent of all patients were prescribed PRN medications and 93.8% were prescribed regular medications. The most frequently prescribed medications were second-generation antipsychotics for regular use along with benzodiazepine for PRN use. Nearly 84% of patients received at least one PRN medication during their admission, while patients diagnosed with personality disorder received more PRNs per day. The most common reason for PRN administration was patient agitation. The results indicated poor documentation in the prescription and documentation of PRN administrations. Also, the findings show that a small subset of the patients (5%) received >30% of all PRN medications. PRN medication use has endured as standard practice and the results of the present study are consistent with the reported frequency of use increasing slightly over the years. The combination of second-generation antipsychotics as regular medications and benzodiazepines for PRN medication is consistent with recommended treatment guidelines. The small subset of patients who were overrepresented in the PRN administrations is noteworthy.

Pro Re Nata Medication for Psychiatric Inpatients: Time to Act

Pro re nata (PRN; 'as needed') medication is an archetypal mainstay for managing acute psychiatric inpatient symptoms and behaviours. Psychiatric and mental health nursing practices have circumnavigated the development of a uniform medical-ethical standard for the administration of PRN psychotropic medication. This paper examines the evidence for administration of PRN psychotropic medications and, in the context of evidence-based best practice, current mental health policy and professional ethics, proposes a standardized Australian PRN administration protocol. The procedures and circumstances leading to a nurse administering psychotropic PRN medication are divided into five simple steps, namely (i) medical prescription; (ii) nurse evaluation of patient indications for an intervention; (iii) nurse consideration of therapeutic options; (iv) obtaining patient informed consent; and (v) documentation of outcomes of PRN administration. The literature associated with each step is reviewed, along with national and international professional ethics, guidelines and patient rights documents pertaining to the care of mental health patients. Recommendations for best-practise care are discussed for each step. There is a lacuna of published evidence supporting the use of PRN medications in psychiatric inpatients. Yet there is published evidence that PRN medications are associated with increased risks of morbidity, inappropriate use, may result in above-recommended dosages or polypharmacy, and complicate the assessment of efficacy of regular scheduled medicines. Alternative non-pharmacological treatment options to PRN medication are effective and associated with fewer side-effects. There are no national explicit standards, operational criteria or quality assurance for the use of PRN medication in inpatient psychiatric units. Contemporary PRN practices are largely unregulated and driven by essentially anecdotal evidence, leaving the clinicians and the service open to claims of poor accountability and misuse (intentional and unintentional) of psychotropic medications. Development of best practice guidelines for the use of PRN administration is essential.

Best practice in use of PRN medication

Latest information from journals

A Study of Polypharmacy with Second Generation Antipsychotics in Patients with Severe and Persistent Mental Illness

There is a paucity of empirical support for polypharmacy with second generation (atypical) antipsychotics (SGAs), especially in understudied populations. To investigate the frequency, effectiveness, and safety of this practice in patients with severe and persistent mental illness who are chronically hospitalized. A chart review was conducted at a state psychiatric hospital in Syracuse, NY. The study subjects (N=26) were chronically hospitalized individuals with DSM-IV diagnoses of schizophrenia or schizoaffective disorder who were initially prescribed at least one SGA and then received at least one other SGA during the study period. Demographic and clinical data were collected. Baseline and 6-month assessments were compared for statistical significance (p<0.05). Of the 117 chronically hospitalized inpatients at the study center, 22.2% (N=26) received treatment regimens involving polypharmacy with SGAs. These patients as a group achieved statistically significant reductions on their scores on the Brief Psychiatric Rating Scale (34.2 +/- 11.0 compared with 25.3 +/- 11.8; p=0.016) and the Clinical Global Impressions-Improvement Scale (5.5 +/- 0.6 compared with. 5.0 +/- 0.8; p=0.016) at 6 months. There was a significant decrease in the use of prn medications (7.6 +/- 19.6 compared with 1.6 +/- 2.6; p<0.04). However, the number of patients receiving anticholinergic medications increased from 5 to 8 (p<0.04). Polypharmacy with SGAs is quite frequent among chronic inpatients with severe and persistent mental illness despite a limited empirical database supporting its use. The results of our pilot study do not demonstrate the effectiveness and safety of this practice. However, methodological shortcomings may have contributed to our failure to detect a true, positive effect. Controlled studies are needed to accurately determine the risks and benefits of SGA polypharmacy.

Assessing the functions of aggression in psychiatric inpatients.

Conflict is inevitable in psychiatric wards where patients are admitted and treated involuntarily. Moreover, in these wards aggression is common and most probably also inevitable. How staff understand the determinants of a patient's aggression impacts on their willingness to help the patient. Causal attributions also influence the nature of prevention, management and treatment strategies that are activated. Traditionally, the most common way of describing and classifying aggression has been according to the anger-mediated/ instrumental dichotomy. This is however, a flawed dichotomy that may limit options for prevention, management and treatment. This paper describes a behaviorally oriented classification and recording system that may be used to structure assessments of aggression in psychiatric wards. It also describes an aggressive behavior recording form that can be used by nursing staff to monitor and record the functions of aggression. The advantage of these two instruments is that they emphasize the adaptive value of aggression for the patient and encourage the identification of function, from which effective treatments may be derived. An indirect benefit associated with the focus on function is that the number of incidents classified as motiveless (having no obvious function) may be reduced. For ward staff, this may lessen fear and increase confidence in their management of aggressive patients. Future research needs and opportunities for clinical application are described. Keywords: Aggressive behavior, behavioural classification system, function of aggressive behavior, motivation ********** The aggressive behavior of psychiatric patients admitted for hospital treatment has a profound impact on patients, staff, and ward functioning. Research relating to aggression in psychiatric hospitals has primarily adopted a structural assessment framework. The focus of this work has been to describe the frequency and type of aggressive behavior in different settings. The delineation of individual patient characteristics, specifically the psychopathological features of aggressive patients, has also been a focus of attention (for review see Daffern & Howells, 2002). Recently, the interactional nature of aggression (Whittington & Richter, 2005) and situational variables influencing aggression (Gadon, Johnstone & Cooke, 2006), including the physical structure of the ward, the remit and regime of the ward, and the behavior of staff and other patients, has been the focus of empirical and scholarly inquiry. Published studies of inpatient aggression have rarely adopted the function analytic approach despite a long tradition of behavioral principles being used to understand, treat and manage aggression and other disruptive behavior within psychiatric hospitals (see for example Paul & Lentz, 1987). Consequently, few methods are available to support practitioners examine the determinants and functions of inpatient aggression. In the absence of systematic and structured methods for organising information and formulating hypotheses about the determinants and functions of aggression, the selection of management strategies commonly used to contain aggressive patients (e.g., seclusion, one to one supervision, and provision of prn medication) may be inconsistent, and biased by characteristics of the patient that are unrelated to those factors that activated or maintain the aggressive behavior. For example, numerous patient characteristics, including diagnosis (Ionno, 1983), age (Tardiff, 1983), ethnicity and victim status (Gudjonsson, Rabe Hesketh & Szmukler, 2004) have been shown to bias the type of management strategy selected. Furthermore, it is often argued that these interventions are aversive, that their use should reduce the incidence of aggression and contribute to more adaptive behavior (Goren, Singh & Best, 1993). There is however little evidence to support this proposition and some evidence that coercive staff behaviors may paradoxically maintain and exacerbate undesirable behavior in hospitalized patients (Garrison et al. …

Focus on inpatient units

Inpatient units, once the mainstay of mental health care and treatment, now tend to be viewed as a last resort, even as evidence of system failure. Irrespective of one’s views about the need for, or importance of, acute inpatient mental health services, it is evident that attitudes to this area of practice have changed. A hierarchy has emerged that places community care at the top and inpatient units towards the bottom of the pecking order. This presents an interesting divergence from the dynamics of the general health-care system, where Intensive Care, Critical Care and Coronary Care units are considered to represent the need for a higher level of nursing knowledge and skill. Why is this? In simple terms, these nurses provide care and treatment to people who are most ill and most in need. Is this not the same in acute inpatient units? Given the emphasis on the least restrictive environment and community care the answer is clearly yes. So why then do we place less value on the nursing work of inpatient units? I make this point not to suggest that inpatient nurses should be considered more skilled than their community colleagues, but rather to suggest that they should not be considered less skilled. Personally I oppose the notion of hierarchy within nursing practice. The value placed on nursing should reflect its contribution to positive outcomes for people who use the services, rather than less relevant factors such as the practice setting, nature of clientele or degree of autonomy. Suffice it to say that nursing in an inpatient unit requires skill, knowledge and expertise, which may be different to but is not lesser than the skills, knowledge and expertise required in other practice settings. We need to value and support our inpatient nurses for the important contribution they make within mental health services. With this in mind, I proudly introduce the December Edition of the International Journal of Mental Health Nursing with a focus on acute inpatient nursing. A guest editorial by Dr Margaret Grigg sets the scene for an exciting edition by calling for the elimination of restraint and seclusion, an issue that will hopefully be the springboard for passionate discussion and debate within the profession. The feature articles highlight the complexity inherent within the acute inpatient setting. We are alerted by Johansson and colleagues from Sweden to the environment of control that can so easily dominate nursing practice at the expense of therapeutic intervention. This issue of therapy versus control is further considered through the work of Whitehead and Mason who suggest that risk assessment and special observations may indeed lessen the need for more controlling interventions such as restraint and seclusion. Bowers and colleagues describe the negative impact of untoward events (such as suicide, homicide and assault) on both consumers and inpatient nurses and herald the need for an organizational response to limit the occurrence and minimize their impact. The work of Steinert and colleagues challenges the traditional medical model of leadership by describing a successful model of shared leadership between medicine and nursing in psychiatric hospitals in Germany. As mental health policy increasing acknowledges the importance of consumer participation in mental health services, McCann and colleagues explore the attitudes of nurses in inpatient settings to the role and functions of consumer consultants. Thomas and colleagues provide research evidence to support the value of nursing initiatives in reducing the use of PRN medication. For something completely different, but nevertheless important, Reilly and colleagues describe a quit smoking programme for inpatient staff. Given the disproportional number of people with mental illness who smoke, this initiative has significant implications for health promotion in mental health services. I hope you will agree that this Edition provides an important contribution to mental health nursing knowledge in relation to inpatient units. The articles provide interest, diversity and relevance for all nurses, regardless of practice setting. To the authors, reviewers and readers who again have contributed so much to the continued success of this journal, I sincerely thank you. I wish you all the best for Christmas and the New Year festivities and look forwards to working with you once again in 2007.

Letters

Back to table of contents Previous article Next article LettersFull AccessLettersKris A. McLoughlin D.N.P., A.P.R.N.Jeffrey L. Geller M.D., M.P.H.Kris A. McLoughlin D.N.P., A.P.R.N.Search for more papers by this authorJeffrey L. Geller M.D., M.P.H.Search for more papers by this authorPublished Online:1 Jul 2006https://doi.org/10.1176/ps.2006.57.7.1045AboutSectionsPDF/EPUB ToolsAdd to favoritesDownload CitationsTrack Citations ShareShare onFacebookTwitterLinked InEmail The Recovery Model and Seclusion and RestraintTo the Editor: We are writing in reply to Dr. Liberman's well-articulated letter to the editor ( 1 ) about seclusion and restraint in the April 2006 issue. We agree with Dr. Liberman's observation that the elimination of seclusion and restraint is "laudable in idealism but lacking in clinical reality." The aim should be reduction to minimal use, because elimination carries many unacceptable risks, including patient and staff injury; overuse of scheduled, PRN, and stat medication for sedation (in essence, chemical restraint); and premature discharge and blacklists to keep potential users of these "last-ditch-effort safety measures" from accruing inpatient days or ever being admitted. However, we take issue with Dr. Liberman's point that implementing psychosocial rehabilitation by using rationales of "recovery" and "empowerment" cannot contribute to a reduction in the use of seclusion and restraint. Dr. Liberman cites data from California and does so to the best of our knowledge accurately. But the outcome in California may not be a failure of the rehabilitation-recovery model. It may well be a failure in implementation of the model. In our experience, state hospitals have effectively adapted the principles of recovery and empowerment, especially through the use of "treatment malls." Outcomes have included fewer patient and staff injuries, fewer missed days of work from staff injuries, and less use of seclusion and restraint accompanied by less use of PRN and stat medication and lower rates of polypharmacy. One such state hospital earned a Significant Achievement Award in 2000 from the American Psychiatric Association for developing a centralized psychosocial rehabilitation program focused on recovery while decreasing staff injuries and the use of restraint and seclusion ( 2 ). Another state hospital received a Best Practice in the Treatment of Schizophrenia Award in 2002 from the American Psychiatric Nurses Association for developing a safety infrastructure to support off-ward recovery-focused rehabilitation programs ( 3 ). We are aware that more research is needed in this area, but let's not throw out a model because one state seems to be struggling with its implementation. Every opportunity is a rehabilitation opportunity.Dr. McLoughlin is a mental health clinical and systems consultant and federal court-appointed special monitor in Honolulu. Dr. Geller is professor of psychiatry and director of public-sector psychiatry, University of Massachusetts Medical School, Worcester.

Letters

Back to table of contents Previous article Next article LettersFull AccessLettersGregory M. Smith M.S.Aidan Altenor Ph.D.Robert H. Davis M.D.Gregory M. Smith M.S.Search for more papers by this authorAidan Altenor Ph.D.Search for more papers by this authorRobert H. Davis M.D.Search for more papers by this authorPublished Online:1 Apr 2006https://doi.org/10.1176/ps.2006.57.4.576aAboutSectionsPDF/EPUB ToolsAdd to favoritesDownload CitationsTrack Citations ShareShare onFacebookTwitterLinked InEmail In Reply: The Pennsylvania state hospital system has achieved a culture change that rejects the use of seclusion and restraint. We believe that these traumatizing procedures produce significant barriers to a recovery and have no clinical value. The total elimination of these interventions is a clinical reality for Pennsylvania state hospitals and for many psychiatric facilities worldwide. As of this date, six of our eight state hospitals have eliminated the use of seclusion and two hospitals have eliminated the use of mechanical restraint. Our reliance on these interventions continues to decrease. In January 2006, during which 67,000 days of care were rendered in the civil and forensic services, seclusion was used only two times for a total of 75 minutes, and mechanical restraint was used only seven times for a total of 7.83 hours. This decrease represents a 99.9 percent reduction from the 1996 rate. The transformation occurred without increases in hospital staffing. From 1996 to 2006 the patient-to-staff ratio has remained constant, with an on-unit ratio of one nursing worker for every five patients on the first and second shifts.The "enormous transinstitutionalization" referred to by Dr. Liberman has not been a significant issue for Pennsylvania, which, like other states, provides services to an increasing number of people who have had contact with the criminal justice system. Our approach to service is the same for this group. Indeed, use of seclusion and restraint in our hospitals' forensic centers has historically been much less than in the general (civil) psychiatric service units. In our article we did express concern about use of unscheduled (PRN) medications as a possible substitute for the hands-on use of restrictive procedures. After publication of findings by Thapa and colleagues ( 1 ) of exposure of patients to unnecessary psychotropic medications, our hospital system conducted a 15-month study of the psychiatric use of PRN medications in its nine civil hospitals and three forensic centers. The effort showed widespread differences within the hospitals and forensic centers in exposure rates. The findings led to a uniform policy change that discontinued the psychiatric use of PRN orders in the hospital system in March 2005. Since this change, we have seen marked improvements in our patient safety measures, including further decreases in the use of seclusion and restraint, incidents of aggression, and patient-to-patient assaults with injury ( 2 ). The work of the APA task force on seclusion and restraint cited by Dr. Liberman still represents a good start for any psychiatric facility or clinician wishing to engage in this change. We also recommend the work of the National Technical Assistance Center of the National Association of Mental Health Program Directors: (www.nasmhpd.org/ntac.cfm).Finally, we welcome this kind of exchange and scrutiny. Pennsylvania's state hospital system has been transparent in its efforts to share its experiences. Each month we distribute data to several states in the form of a summary report that details incident data. Interested readers who desire more information or data should contact the first author ([email protected]).

A Program Using Environmental Manipulation, Music Therapy Activities, and the Somatron(C) Vibroacoustic Chair To Reduce Agitation Behaviors of Nursing Home Residents with Psychiatric Disorders

ABSTRACT: Agitation is a behavior frequently associated with residents of nursing home facilities, especially persons with diagnoses of dementia or associated brain disorders. Agitated behaviors can affect the entire facility and have the potential to impact overall quality of life. Finding positive, non-pharmaceutical, interventions to control agitation is a challenge for health care professionals. This study describes a program using multiple interventions of environmental noise reduction, controlled background music, individualized receptive and active music therapy, and vibroacoustic sessions with the Somatron. The program was implemented for 6 months and included 2 interventions. The first intervention was to manipulate the facility environment. The second intervention was to identify residents not responding to the environmental manipulation and refer them to music therapy. Three residents were referred during the intervention period. An original assessment instrument Somatron Placement Matrix was developed to assign residents to individualized music therapy sessions, Somatron sessions, or a combination of the two. Results indicated a reduction of 82% in accidents/incidents, 91% reduction of PRN medication, 36% reduction in STAT orders by physicians, and a reduction of unplanned staff absences of 44% during the intervention period. Case study information (n = 1) of individualized music therapy sessions resulted in a 100% decrease of 2 identified agitation behaviors, 71% decrease in one identified behavior, and 11% decrease in one behavior. Case study information of the Somatron sessions (n = 2) resulted in none of the baseline agitation behaviors being present and an increase in positive behaviors of closing eyes during sessions, coherent verbalizations during sessions, and an increase in positive verbalizations. Introduction Agitation behaviors are easily observed when entering a nursing home, especially a facility in which residents have psychiatric disorders. Behaviors associated with agitation may include muscle tension, irritability, aggression, repetitive body movements, restlessness, and inappropriate verbalizations (Cohen-Mansfield, Marx, & Rosenthal, 1989). Identifying precipitators of agitation and finding positive, non-pharmaceutical, interventions to reduce agitation will benefit individual residents and can create a calm, relaxing milieu that enhances quality of life. Causes for agitation stem from a variety of factors and usually have multiple influences. The individual's personality before hospitalization, level of cognitive functioning, medication, and degree of disorientation and confusion may all play a role in exhibiting behaviors (Giacino, 2003). The nursing home setting consists of heterogeneous placements, large numbers of persons residing in close proximity, and regimens that are necessary for medical treatment. These factors can produce a stressful environment. Agitation may be related to this potentially stressful environment and even is a means for patients to communicate displeasure at their surroundings (Ragneskog, Kihigren, Gerdner, & Josefsson, 1998). Environmental noise levels have also been frequently cited as a contributing factor in agitation behaviors. McClaugherty, Valibhai, Womack, and Desai (2003) evaluated the effects of noise on patients and staff in 13 nursing homes. Typical noises were intercom systems, telephones, cleaning equipment, and televisions. Behaviors reported by staff in response to high noise levels were irritability, anxiety, difficulty concentrating, and increases in errors. It is a rational assumption that patients will have similar responses to the same stimuli. Patients, however, may not have the communication or coping skills necessary to tolerate the noise. Even more importantly, patients have limited control over the situation and cannot remove themselves from the stimuli. Using background music to mask environmental noises in conjunction with lowering the actual noise levels has been shown to reduce episodes of agitation among patients. …

Impact of a clinical-administrative review procedure on reducing reliance on psychotropic PRN medication.

The author reviews and evaluates the impact of a clinical/administrative review procedure, previously demonstrated as useful for reducing seclusion/restraint reliance, on psychotropic PRN reliance within a public psychiatric hospital (average census=310; 215 with a stay of greater than 30 days). After 20 weeks of baseline, the impact of the review procedure on PRN reliance was evaluated over an additional 52 weeks. This review procedure reduced the number of individuals who exceeded a review threshold from 20.8 per week prior to initiation to 12.4 per week after initiation, a reduction of 40%. The results underscore the importance of clinical/administrative behavior for encouraging alternatives to psychotropic PRN reliance in behavior management.