Psychiatric Hospital In Ontario Research Articles

Psychiatric inpatient services in Ontario, 2019-2021: a cross-sectional comparison of admissions, diagnoses and acuity during the COVID-19 prerestriction, restriction and postrestriction periods.

The COVID-19 pandemic was associated with increased mental health problems in the general population, yet psychiatric hospital admissions decreased. Early evidence suggested that psychiatric admissions normalized within weeks; we sought to examine the longer-lasting impacts on the psychiatric inpatient population beyond this initial period. We compared Ontario Mental Health Reporting System admission data for patients admitted to 8 psychiatric hospitals in Ontario, Canada, between 3 time periods - before restrictions were imposed (June 22, 2019, to Mar. 16, 2020), during restrictions (Mar. 17 to June 21, 2020) and after restrictions were lifted (June 22, 2020, to Mar. 16, 2021) for changes in involuntary status, diagnoses and clinical presentation using descriptive analysis. For clinical presentation, we extracted scores on 4 Resident Assessment Instrument-Mental Health symptom scales (Depressive Severity Index, Cognitive Performance Scale, Positive Symptoms Scale-Long Version and Social Withdrawal Scale), and 2 behaviour scales (Aggressive Behavior Scale and Violence Sum). A cross-sectional sample of 9848 patients was included in the analysis. The mean number of daily admissions decreased 19% from 16.4 (standard deviation [SD] 8.0) before the restriction period to 13.3 (SD 6.1) during the restriction period, and was still 6% below prerestriction levels after restrictions were lifted 15.4 (SD 6.8), with standard error difference of 1.03 (95% confidence interval -0.22 to 2.29). From the pre- to the postrestriction periods, the proportion of involuntary patients increased by 6 percentage points, and the proportions of patients diagnosed with a psychotic disorder or personality disorder increased by 4 percentage points and 1 percentage point, respectively. Psychiatric admissions did not fully return to prerestriction levels in absolute rates and patient acuity after COVID-19 restrictions were lifted. Psychiatric services must prepare to appraise and respond to any increased acuity through interventions for patients, workforce planning and mental health support for staff.

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.

Privacy and safety: Issues of dual compliance in high-secure and other forensic psychiatric hospitals

Health care organizations are obligated to provide safe and effective treatment to their patients and also protect the safety of their workers. This paper analyzes the tensions arising from legislative regimes that, respectively, protect privacy and workplace safety, using a large, tertiary high-secure forensic psychiatric hospital in Ontario, Canada, as an example. In Ontario, the Personal Health Information Protection Act (PHIPA) prohibits personal health information (PHI) from being disclosed to individuals who fall outside the “circle of care,” including nonclinical employees who have direct involvement with patients and may be at risk of violence. PHIPA permits the disclosure of information where there is a risk of violence, but the statute's scheme for privacy protection was not designed to address, and may not be compatible with, the operations and requirements of high-secure forensic and other psychiatric hospitals. At the same time, the Occupational Health and Safety Act (OHSA) creates a regulatory framework that sets health and safety standards, including an employer's duty to disclose the risk of violence. OHSA prosecutions and proceedings demonstrate how these duties have been enforced against psychiatric hospitals. We examine this regulatory backdrop, explaining that PHIPA provides little guidance to psychiatric hospitals, where the risk of violence is elevated. We also discuss issues of dual compliance that arise from a hospital's legal obligations under PHIPA and OHSA. Finally, we turn to the ongoing clinical and operational challenges, suggesting strategies for increasing staff safety. These include strengthening the therapeutic alliance and providing patients with the option of consenting to disclosure of PHI to those outside the circle of care.

Validating the SAPROF with Forensic Mental Health Patients

ABSTRACT Assessing and managing level of violence risk among forensic mental health patients is a primary role of clinical staff. Forensic risk assessments are typically focused on risk factors and deficits, whereas patient protective factors are either partially included or excluded by clinicians. The Structured Assessment of Protective Factors for Violence Risk (SAPROF) is a recently developed measure of protective factors designed to augment the conventional use of risk assessment tools with a correctional/forensic population. In the current study, the psychometric properties of the SAPROF were examined in a sample of 50 forensic inpatients and outpatients found Not Criminally Responsible (NCR) at a psychiatric hospital in Ontario, Canada. The SAPROF was found to have adequate internal, intrarater, and interrater reliability. Using a subsample of inpatients only, incremental predictive validity was demonstrated for institutional misconducts at six-month follow-up over the HCR-20 V3. Taken together, the results suggest that the SAPROF may be a useful addition to clinical practice and inform review board decisions about risk prediction, risk management, and treatment planning.

Who’s going to leave? An examination of absconding events by forensic inpatients in a psychiatric hospital

ABSTRACTAbsconding is a potentially risky event that has wide reaching consequences both for the institution and greater community; however, few studies have examined the characteristics of clients who abscond, their motivations, and details about their absconding event, especially within a forensic context. The purpose of this research was to determine if risk factors could be identified that might predict absconding behavior. A retrospective chart review was conducted of all reported absconding events between 1 January 2012 and 31 August 2015 by clients on forensic units in a public psychiatric hospital in Ontario, Canada. In addition, these clients were matched with a comparison group. Categories of motivations for absconding including goal-directed, frustration/boredom, symptomatic/disorganized, and impulsive/opportunistic were identified. The best indicator of a client’s risk for absconding was having experienced a stressful, significant event in the two weeks prior to the absconding event. Additionally, total scores on the HCR-20 and the presence of a co-occurring substance use disorder differentiated the absconders from the comparison group. This research contributes to our knowledge base regarding absconding events by forensic psychiatric patients and highlights specific targets for clinical staff in assessing risk for absconding and managing privileges leading to more effective care planning.

Re-examination of classic risk factors for suicidal behavior in the psychiatric population.

. Background: For decades we have understood the risk factors for suicide in the general population but have fallen short in understanding what distinguishes the risk for suicide among patients with serious psychiatric conditions. Aims: This prompted us to investigate risk factors for suicidal behavior among psychiatric inpatients. Method: We reviewed all psychiatric hospital admissions (2008–2011) to a centralized psychiatric hospital in Ontario, Canada. Using multivariable logistic regression we evaluated the association between potential risk factors and lifetime history of suicidal behavior, and constructed a model and clinical risk score to predict a history of this behavior. Results: The final risk prediction model for suicidal behavior among psychiatric patients (n = 2,597) included age (in three categories: 60–69 [OR = 0.74, 95% CI = 0.73–0.76], 70–79 [OR = 0.45, 95% CI = 0.44–0.46], 80+ [OR = 0.31, 95% CI = 0.30–.31]), substance use disorder (OR = 1.30, 95% CI = 1.27–1.32), mood disorder (OR = 1.49, 95% CI = 1.47–1.52), personality disorder (OR = 2.30, 95% CI = 2.25–2.36), psychiatric disorders due to general medical condition (OR = 0.52, 95% CI = 0.50–0.55), and schizophrenia (OR = 0.42, 95% CI = 0.41–0.43). The risk score constructed from the risk prediction model ranges from −9 (lowest risk, 0% predicted probability of suicidal behavior) to +5 (highest risk, 97% predicted probability). Conclusion: Risk estimation may help guide intensive screening and treatment efforts of psychiatric patients with high risk of suicidal behavior.

Exploring the impact of common assessment instrumentation on communication and collaboration in inpatient and community-based mental health settings: a focus group study.

BackgroundRecognition that integrated services can lead to more efficient and effective care has made the principle of integration a priority for health systems worldwide for the last decade. However, actually bringing fully integrated services to life has eluded most health care organizations. Mental health has followed the rule, rather than the exception, when it comes integrating services. The lack of effective mechanisms to evaluate the needs of persons across mental health care services has been an important barrier to communication between professionals involved in care. This study sought to understand communication among inpatient and community-based mental health staff during transfers of care, before and after implementation of compatible assessment instrumentation.MethodsTwo focus groups were held with staff from inpatient (n = 10) and community (n = 10) settings in an urban, specialized psychiatric hospital in Ontario (Canada) – prior to and one year after implementation of compatible instrumentation in the community program. Transcripts were coded and aggregated into themes.ResultsVery different views of current communication patterns during transfers of care emerged. Inpatient mental health staff described a predictable, well-known process, whereas community-based staff emphasized unpredictability. Staff also discussed issues related to trust and the circle of care. All agreed that compatible assessments in inpatient and community mental health settings would facilitate communication through use of a common assessment language. However, no change in communication patterns was reported one year post implementation of compatible instrumentation.ConclusionsThough all participants agreed on the potential for compatible instrumentation to improve communication during transfers of care, this cannot happen overnight. A number of issues related to trust, evidence-based practice, and organizational factors act as barriers to communication. In particular, staff noted the need for the results of comprehensive mental health assessments to be transformed into meaningful, user-friendly clinical summaries to facilitate uptake of assessment information, and consequently use of a common assessment language across mental health settings.

Real-World Evaluation of the Resident Assessment Instrument-Mental Health Assessment System

We evaluated the Resident Assessment Instrument-Mental Health (RAI-MH) assessment platform at a large psychiatric hospital in Ontario during the 3 years following its provincially mandated implementation in 2005. Our objectives were to document and consider changes over time in front-line coding practices and in indicators of data quality. Structured interviews with program staff were used for preliminary information-gathering on front-line coding practices. A retrospective data review of assessments conducted from 2005 to 2007 examined 5 quantitative indicators of data quality. There is evidence of improved data quality over time; however, low scores on the outcome scales highlight potential shortcomings in the assessment system's ability to support outcome monitoring. There was variability in implementation and performance across clinical programs. This evaluation suggests that the RAI-MH-based assessment platform may be better suited to longer-term services for severely impaired clients than to short-term, highly specialized services. In particular, the suitability of the RAI-MH for hospital-based addictions care should be re-examined. Issues of staff compliance and motivation and problems with assessment system performance would be highly entwined, making it inappropriate to attempt to allocate responsibility for areas of less than optimal performance to one or the other. The ability of the RAI-MH to perform well on clinical front lines is, in any case, essential for it to meet its objectives. Continued evaluation of this assessment platform should be a priority for future research.

Adults with Autism Spectrum Disorders using psychiatric hospitals in Ontario: Clinical profile and service needs

Background Adults with Autism Spectrum Disorders (ASD) represent a small, but challenging sub-group of patients within Ontario's mental health care system. However, few studies have documented the clinical characteristics of this population and examined how such individuals differ from other psychiatric patients, with or without intellectual disabilities (ID). Method A secondary analysis of data from the 2003 Comprehensive Assessment Projects from three psychiatric hospitals in Ontario was conducted to describe patients with ASD and ID and to determine how their profile compared to other hospital users. Results Twenty-three patients with ASD and ID were matched on gender and patient status (inpatient/outpatient) to individuals with and without ID. Individuals with ASD and ID were similar in terms of demographics to patients with and without ID. However, individuals with ASD and ID were younger, spent more days in hospital and were less likely to have a psychotic disorder diagnosis than both patients with and without ID. Inpatients with ASD and ID were recommended for a higher level of care than hospital service users without ID. Conclusions Clearly, this small sub-group of individuals within the hospital population has high clinical needs that are not always well met.

Treatment delays for involuntary psychiatric patients associated with reviews of treatment capacity.

To determine the duration of delays in treatment initiation when involuntary patients apply for a review of a finding of treatment incapacity and to estimate the cost of keeping patients hospitalized without treatment in these circumstances. Using a computerized database and written records, we identified all patients at 2 psychiatric hospitals in Ontario who applied for a review of a finding of treatment incapacity during a 10-year period. We recorded clinical and demographic variables, dates of stopping and starting medication, and dates of review board hearings and outcomes. We also noted all cases in which a patient appealed a decision from the review board to the court. Two hundred and thirty-seven patients made 334 applications to the review board. The board overturned the physician's finding of incapacity in only 5 (1.5%) applications; 15 appealed the review board's finding to the courts. None of these appeals were successful. In the absence of an appeal to the courts, the average delay in initiating treatment was 25 days. For patients appealing to the court, the average delay was 253 days. The cost of hospitalizing untreated patients while their capacity was under legal review was estimated at $3,867,000, of which $1,333,000 could have been saved if treatment had started immediately after the review board confirmed incapacity. We have identified extensive delays in initiating psychiatric treatment for a number of patients. These delays are associated with legal review of treatment capacity. There are serious clinical risks and substantial costs associated with delay in treating patients with acute psychiatric illness. Where jurisdictions review treatment capacity, we recommend that treatment not be impeded once a review board has confirmed a clinical finding of incapacity.

Why are patients discharged by review boards?

To identify why Review Boards revoked certificates for involuntary hospitalization. The outcome of all applications for a Review Board hearing at 2 psychiatric hospitals in Ontario were recorded from the beginning of 1987 to the end of 1996. All cases where a certificate of involuntary hospitalization was revoked were identified. For each of these cases, the clinical record, including the Review Board's written reasons for its decision, was reviewed. During the study period, 2644 patients applied for a review of their involuntary hospitalization. Only 42% of applications reached a hearing. Of these, 9% were revoked. Several recurring reasons for overturning certificates were identified. These included the physician relying too much on hearsay evidence, relatives supporting discharge at the hearings, and the patient clearly having recovered by the time the hearing took place. Relatives or staff who observe dangerous behaviour should be encouraged to give evidence at hearings. The treatment team should take careful note of the views of patients' families and friends and review the patients' progress before hearings.

Assessment of the sexuality needs of individuals with psychiatric disability.

Individuals with psychiatric disorders are at risk of experiencing a variety of difficulties related to their sexuality. The objective of the study described here was examination of nursing staff attitudes, assessment of issues related to the sexuality of clients, and assessment of clients' perceptions of their own sexuality needs. The descriptive design included staff survey, client interviews and chart (in-patient record) audits. The setting was a tertiary care provincial psychiatric hospital in Ontario, Canada. One hundred in-patient records were randomly selected for a concurrent chart audit, followed by client interviews. Staff surveys included 68 nurses. Clients were found to be at increased risk for sexual aggression and sexually transmitted diseases. Clients identified learning needs regarding contraception and safe sexual practices. The nurses who completed the staff survey reported high levels of comfort related to clients' sexuality, yet infrequent teaching related to safe sexual practices. Individuals with psychiatric disorders are at increased risk for a number of problems related to sexuality and identify several learning needs. There is also a risk that these needs go unrecognized by nursing staff.

Occupational therapy in long term psychiatry: what's new?

This paper summarizes the results of a survey of the role of occupational therapy in provincial psychiatric hospitals in Ontario. Occupational therapy was found to provide major programming in three areas: 1) functional skills assessment and training, 2) life skills assessment and training and, 3) self awareness and personal growth. Subjects used a variety of frames of reference, but models based upon Glasser's Reality Therapy predominated. A complementary relationship was found between occupational therapy and vocational and recreational services, with occupational therapy playing a clinical or therapeutic role, while vocational and recreational services provided normalizing experiences. A comparison of occupational therapy programming in the institutions surveyed, with programming reported in the recent occupational therapy literature indicated that techniques and media utilized paralleled those used in acute and community psychiatric programs.

Sensory Integration and Chronic Schizophrenia: Past, Present and Future

This paper briefly outlines the therapy of sensory integration as developed by Dr. A. Jean Ayres, including a breakdown of the most prevalent types of dysfunction. In an extensive literature review which includes writings from 1811 through to the present day, the symptoms of schizophrenia which may be related to sensory integrative deficit are then examined. Finally, current research and treatment programs which utilize sensory integrative treatment with schizophrenics are reviewed, with emphasis on a program review conducted at Whitby Psychiatric Hospital in Ontario, 1981. Implications for future treatment and research are explored.

An aftercare program for problem patients.

The high readmission rates of discharged psychiatric patients have forced mental health professionals to play closer attention to aftercare planning. A program was developed at a psychiatric hospital in Ontario in 1977 to deal with "problem patients"--those who were deemed difficult to place in the community by the referral person or department. The program was characterized by shared institutional-community staffing, systematic aftercare assessment and planning, a crisis intervention approach to discharge, the use of a transitional staff member with patients, and the development of close relationships with community agencies. Study data show that the program was effective in limiting the number of readmissions during its first two years to 20 per cent.