Inpatient Psychiatric Facility Research Articles

Strange Behavior in a Transgender Teenager.

1. Salvador R. Maffei, MD* 2. Andrea Dean, MD* 1. *Baylor College of Medicine, Texas Children’s Hospital, Houston, TX A 12-year-old transmale ( transgender male or transmale is the term used for a person who is assigned female at birth [and is, usually, XX genotype] but who identifies as male) presents to the emergency department (ED) from an inpatient psychiatric facility for evaluation of new gait abnormalities and decreased oral intake. He initially presented to the ED 2 weeks earlier with acute onset of confusion, agitation, and suicidal ideation in the setting of a recent disclosure of his gender identity to family and classmates without their acceptance. After medical evaluation for toxic ingestion and intracranial abnormality, he was referred for inpatient psychiatric evaluation and was admitted for 2 weeks. While hospitalized he was started on chlorpromazine, haloperidol, risperidone, and escitalopram. Over the next 2 weeks he developed slowing and stiffening of movements, with progressively impaired motor function and cognitive abilities. For the past 3 days he has demonstrated mutism, minimal oral intake, tongue thrusting, and refusal to walk. At times he would hit himself in the forehead repeatedly. Symptoms did not improve with benztropine, amantadine, and lorazepam use, so he was transferred back to the ED for further evaluation. On presentation he is alert but nonverbal and does not follow commands. He is afebrile, his heart rate is 129 beats/min, and his blood pressure is 136/83 mm Hg. He has dry mucous membranes. There is an ecchymosis on his forehead, consistent with described self-injurious behavior. Cranial nerves, strength, and coordination cannot be assessed, but global hypertonia and lower extremity clonus are elicited. Laboratory evaluation demonstrates a serum sodium level of 151 mEq/L (151 mmol/L) (reference range, 135–145 mEq/L [135–145 mmol/L]) …

Managing COVID + ve patients on inpatient adolescent psychiatry unit- A unique challenge

The Corona virus disease 2019 (COVID-19) has had a profound impact on the physical as well as mental well-being of people around the globe. The response to and resulting consequences of the COVID-19 pandemic poses significant challenges for patients suffering from mental health disorders as demonstrated by a recent study by Xie et al. examining adult COVID-19 patients admitted for inpatient psychiatric treatment for first-episode mental health issues [1]. Children, too, have the potential to experience adverse mental health outcomes due to distress resulting from the pandemic: a study by Jolly et al. examined recently surfacing reports on varied presentations of pediatric patients undergoing hospitalization in psychiatry hospitals in context of COVID-19. One major source of stress is the institution of widespread social distancing practices as schools have transitioned to partial or full-time virtual learning [2]. In addition, extracurricular activities have undergone restrictions or been canceled entirely and in-person contact with peers and other important social supports has been limited. These changes place strain on children which can lead to distress and worsening mental health outcomes [2]. The pandemic has also caused significant economic stress for many families. Increased unemployment, forced changes in interpersonal interactions, the wide-ranging effects caused by the safety measures being taken in response to COVID-19, and even concern over COVID-19-related illness or death itself may directly impact the mental health of children as well as indirectly impacting their mental health due to increased stress experienced by parents and the family as a whole [2]. Moreover, children who become COVID-positive and are subject to specific safety protocols in their care are under additional pressure that can further exacerbate mental health problems related and unrelated to the COVID-19 pandemic. There have been limited studies evaluating the treatment of COVID-19 pediatric patients admitted for the treatment of mental health disorders [3,4]. Here we present two cases of COVID-positive pediatric patients in an inpatient psychiatric facility and how the milieu was changed around them.

COVID-19 Transmission in a Psychiatric Long-Term Care Rehabilitation Facility: An Observational Study.

To report the clinical characteristics and transmission rate of coronavirus disease 2019 (COVID-19) in a community inpatient long-term care psychiatric rehabilitation facility designed for persons with serious mental illness to provide insight into transmission and symptom patterns and emerging testing protocols, as well as medical complications and prognosis. This study examined a cohort of 54 residents of a long-term care psychiatric rehabilitation program from March to April 2020. Baseline demographics, clinical diagnoses, and vital signs were examined to look for statistical differences between positive versus negative severe acute respiratory syndrome coronavirus 2 (SARS-COV-2) groups. During the early phase of the pandemic, the facility closely followed the local shelter-in-place order (starting March 19, 2020) and symptom-based testing. Of the residents, the primary psychiatric diagnoses were schizoaffective disorder: 28 (51.9%), schizophrenia: 21 (38.9%), bipolar I disorder: 3 (5.5%), and unspecified psychotic disorder: 2 (3.7%). Forty (74%) of 54 residents tested positive for SARS-COV-2, with a doubling time of 3.9 days. There were no statistical differences between the positive SARS-COV-2 versus negative groups for age or race/ethnicity. Psychiatric and medical conditions were not significantly associated with contracting SARS-COV-2, with the exception of obesity (n = 17 [43%] positive vs n = 12 [86%] negative, P = .01). Medical monitoring of vital signs and symptoms did not lead to earlier detection. All of the residents completely recovered, with the last resident no longer showing any symptoms 24 days from the index case. Research is needed to determine optimal strategies for long-term care mental health settings that incorporate frequent testing and personal protective equipment use to prevent rapid transmission of SARS-COV-2.

Single-Session Dance/Movement Therapy for Thought and Behavioral Dysfunction Associated With Schizophrenia: A Mixed Methods Feasibility Study.

This purposes of this mixed methods feasibility study were to determine whether people with schizophrenia in an inpatient psychiatric facility were able to complete the research protocol, and to obtain preliminary treatment effects of a single-session dance/movement therapy (DMT) intervention versus verbal treatment as usual (TAU). Thirty-two participants were randomized to a 45-minute DMT or verbal TAU session. Data were collected quantitatively using the Brief Psychiatric Rating Scale (BPRS) and qualitatively through open-ended interviews. Results indicated that participants in the DMT group had statistically significant symptom reduction compared with those in the TAU group in overall BPRS scores (effect size [ES] = 0.67), psychological discomfort (ES = 0.64), negative symptoms (ES = 0.67), and positive symptoms (ES = 0.55). No statistical significance was shown for resistance. Qualitative findings substantiate the quantitative findings, however, show divergence regarding resistance. Participants in the DMT group expressed feeling in control, less angry, and motivated for treatment.

Factors explaining variation in recommended care pathways following hospital-presenting self-harm: a multilevel national registry study

People who present to hospital following self-harm are at high risk of suicide. Despite this, there are considerable variations in the management of this group across hospitals and the factors influencing such variations are not well understood. The aim of this study was to identify the specific hospital and individual factors associated with care pathways following hospital-presenting self-harm. Data on presentations to hospitals by those aged 18 years and over were obtained from the National Self-Harm Registry Ireland for 2017 and 2018. Factors associated with four common outcomes following self-harm (self-discharge, medical and psychiatric admission and psychosocial assessment before discharge) were examined using multilevel Poisson regression models. Care pathways following self-harm varied across hospitals and were influenced by both hospital and individual factors. Individual factors were primarily associated with self-discharge (including male gender, younger age and alcohol involvement), medical admission (older age, drug overdose as a sole method and ambulance presentations) and psychiatric admission (male gender, methods associated with greater lethality and older age). The hospital admission rate for self-harm was the only factor associated with all outcomes examined. The availability of psychiatric in-patient facilities and specialist mental health staff contributed to variation in psychiatric admissions and psychosocial assessments prior to discharge. Hospital factors explained the majority of observed variation in the provision of psychosocial assessments. Characteristics of the presenting hospital and hospital admission rates influence the recommended care pathways following self-harm. Provision of onsite mental health facilities and specialist mental health staff has a strong impact on psychiatric care of these patients.

The incidence and economic impact of aggression in closed long-stay psychiatric wards

Objective Aggressive behaviour is highly prevalent in long-term psychiatric inpatient care. We aimed to estimate the overall incidence of aggression, the time staff took to handle aggression incidents, and the weighted average financial costs thereof. Methods A random sampling procedure was conducted at long-term psychiatric inpatient care facilities. Nurses were asked to recall all incidents (i.e., verbal, physical towards objects, self, or others) of their shift. For the time spent on each type of incident, staff were monitored in real-time. Estimated costs were calculated by the time spent multiplied by hourly wages in addition to material-related costs. Results Incidence rates were 90 incidents per patient year. The average time spent per incident was 125 min but differed for each type of incident. Almost 80% of this time was consumed by nursing staff. The average cost per aggression incident was €78; extrapolated per patient year, the total costs were approximately €7000. Conclusions The current study found a high rate of aggression incidents in closed long-stay psychiatric wards. Reports of aggression on these types of wards are scarce. Nevertheless, aggression seems to have a severe impact on invested time and related costs, which suggests a need for aggression-prevention and de-escalating programs. Key points Aggression incidents are highly prevalent and are accompanied by high costs. The effect of aggression incidents on the workload for staff members is high, especially for nursing staff. Studies across countries on the incidence and the costs of aggression among psychiatric inpatients are needed to help model the effects of (new) strategies for aggression reduction.

The Effect of Centers for Medicare and Medicaid's Inpatient Psychiatric Facility Quality Reporting Program on the Use of Restraint and Seclusion.

Patients in inpatient psychiatry settings are uniquely vulnerable to harm. As sources of harm, research and policy efforts have specifically focused on minimizing and eliminating restraint and seclusion. The Centers for Medicare and Medicaid's Inpatient Psychiatric Facility Quality Reporting (IPFQR) program attempts to systematically measure and reduce restraint and seclusion. We evaluated facilities' response to the IPFQR program and differences by ownership, hypothesizing that facilities reporting these measures for the first time will show a greater reduction and that ownership will moderate this effect. Using a difference-in-differences design and exploiting variation among facilities that previously reported on these measures to The Joint Commission, we examined the effect of the IPFQR public reporting program on the use and duration of restraint and seclusion from the end of 2012 through 2017. There were a total of 9705 observations of facilities among 1841 unique facilities. Results suggest the IPFQR program reduced duration of restraint by 48.96% [95% confidence interval (95% CI), 16.69%-68.73%] and seclusion by 53.54% (95% CI, 19.71%-73.12%). There was no change in odds of zero restraint and, among for-profits only, a decrease of 36.89% (95% CI, 9.32%-56.07%) in the odds of zero seclusion. This is the first examination of the effect of the IPFQR program on restraint and seclusion, suggesting the program was successful in reducing their use. We did not find support for ownership moderating this effect. Additional research is needed to understand mechanisms of response and the impact of the program on nontargeted aspects of quality.

Measures of Care Coordination at Inpatient Psychiatric Facilities and the Medicare 30-Day All-Cause Readmission Rate.

Since late 2012, the Medicare Inpatient Psychiatric Facility Quality Reporting (IPFQR) program of the Centers for Medicare and Medicaid Services (CMS) has required inpatient psychiatric facilities to collect and publicly report a suite of quality measures. This study explored the association between facility-level 30-day risk-adjusted all-cause readmission (medical or psychiatric) after psychiatric hospitalization (READM-30-IPF) and care coordination process measures in the IPFQR program. The study used publicly reported IPFQR facility-level performance data of the Hospital Compare Web site for 1,343 inpatient psychiatric facilities, reflecting performance from July 2015 to June 2017. The authors used a cross-sectional design and linear regression models controlling for hospital and community characteristics and using state as fixed effect. The mean±SD facility-level READM-30-IPF was 20%±3%, with substantial variation by facility type, ownership status, rurality, and percentage of racial-ethnic minority residents in the county. Regression results showed that facilities with performance in the top tercile on the measure of 7-day mental health follow-up after discharge had readmission rates significantly lower than facilities in the bottom tercile (coefficient=-0.58, p<0.01), although the magnitude of this difference was small. READM-30-IPF, however, did not vary by facilities' performance on measures of discharge plan creation and transmission. Results suggest that facilities have substantial opportunities to reduce readmissions after psychiatric hospitalization. The association between hospital performance on care coordination process measures and the all-cause readmission measure currently included in the IPFQR program was minimal. The CMS should evaluate whether the IPFQR measures adequately capture compliance with evidence-based processes and desired outcomes.

Older adults on involuntary hold status in the emergency department.

As the United States' population ages, the health care system will experience overall change. This study aims to identify factors in the older adult that may contribute to involuntary hold status in the ED. This study is a retrospective review conducted at a suburban acute-care hospital ED of adult patients evaluated while on involuntary hold from January 1, 2014, through November 30, 2015. Older adults (patients born on or before 06/31/1964) were compared to younger adults (born on or after 07/01/1964) according to demographic and clinical variables including medical comorbidity, ED length of stay, reason for involuntary hold, psychiatric disorder, suicide attempt, substance use disorder, serum alcohol level, urine drug testing, medical comorbidity, violence in the ED, 30-day ED readmission, and 30-day mortality. Of 251 patients, 90 (35.9%) were older adults. The most common reason for involuntary hold in both cohorts was suicidal ideation. Medical comorbidities were more prevalent in older adults [60 (66.7%) vs. 64 (39.8%), P≤.0001]. Older adults were less likely to report current drug abuse [31 (34.4%) vs. 77 (47.8%), P=.04]. The most commonly misused substance in both groups was alcohol; however, despite similar rates, blood alcohol levels (BAC) and urine drug screen (UDS) were performed less often in older adults. Cohorts were not significantly different with respect to sex, race, violence in the ED, psychiatric diagnosis, and ED LOS. Involuntary older adult patients present with medical comorbidities that impact mental health. In the ED, they are less likely report substance use, and drug screening may be underutilized. Medical needs make their care unique and may present challenges in transfer of care to inpatient psychiatric facilities.

The Effect of CMS’ Inpatient Psychiatric Facility Quality Reporting Program on Nontargeted Indicators of Safety in Massachusetts

Research ObjectiveIn 2012, CMS implemented the Inpatient Psychiatric Facility Quality Reporting Program (IPFQR), which publicly reports facilities’ performance on a suite of measures, including targeted measures of restraint and seclusion (R/S). To perform, facilities could respond with approaches that are harder (eg, improving staff‐patient relationships) or easier (eg, increasing sedatives). If a facility responds meaningfully, this could have positive spillover on other aspects of quality outside R/S use. If a facility does not respond meaningfully or at all, the IPFQR program could negatively impact quality given the resources needed to comply with the reporting program (ie, burden on frontline staff). Given lack of choice and weak incentives to perform, economic theories suggest for‐profits would be more likely to exhibit a negative spillover. This study aims to evaluate the differential spillover effect of the IPFQR program on non‐targeted (but proximal) indicators of safety (ie, complaints) between for‐profit and nonprofit inpatient psychiatric facilities in Massachusetts.Study DesignEpisodes of R/S (targeted), complaints (nontargeted), and discharges (used to create rates) were obtained for 2008‐2017 through a series of public record requests made to the Massachusetts Department of Mental Health. Five summary scores were created using the complaint data: 1) overall complaints; 2) substantiated complaints; 3) safety‐related; 4) abuse‐related (verbal, sexual, physical); and 5) R/S‐related. Univariate and bivariate analyses were conducted using nonparametric methods given skewedness. A difference‐in‐differences estimator was employed using a Poisson distribution, with discharges as the exposure. A fixed effect for the facility was included to control for time‐invariant differences between facilities and errors were clustered on the facility. Coefficients are reported as incident rate ratios (IRRs).Population StudiedFor‐profit and nonprofit psychiatric facilities in Massachusetts who participated in the IPFQR program (N = 50 unique facilities, 490 observations for 2008‐2017).Principal FindingsResults from the regression models demonstrate that for‐profits had a greater increase in overall complaints (IRR = 1.47, P = .002), safety‐related complaints (IRR=1.51, P = .005), abuse‐related complaints (IRR = 1.59, P = .026), and, most strongly, R/S‐related complaints (IRR = 3.34, P = .002). There was no statistically significant relative increase in substantiated complaints or episodes of R/S use. A visual inspection of complaints across years suggests clear parallel trends in the preperiod and clear divergence in 2013. Segmented regressions with placebo intervention dates support these findings.ConclusionsThere was a greater increase in complaints, especially those related to the target of R/S, among for‐profits relative to nonprofits, but no change in the targeted construct of R/S use. This could be due to the burden of complying with the IPFQR program on frontline staff and resource constraints. Ad hoc analyses of death data suggest this is a true change in quality rather than an increase in reporting. There are several limitations, including lack of information related to each complaint and lack of patient‐level data.Implications for Policy or PracticeThis is the first study to examine the effect of a national public reporting program on non‐targeted quality among inpatient psychiatric facilities, as well as variation across ownership. The findings point to the need to improve our data infrastructure to support tracking of intended and unintended consequences of policy interventions on quality of inpatient psychiatry.Primary Funding SourceNational Institutes of Health.

Can Paramedics Safely Screen Patients for Transport to a Mental Health Crisis Center? Evidence from California

Research ObjectiveHistorically, ambulances have only transported patients to emergency departments (EDs). By 2017, at least 64 ambulance providers across the United States were transporting patients to facilities other than EDs, including outpatient mental health crisis centers, urgent care centers, and physician offices. In 2020, Medicare’s new Emergency Triage, Treat, and Transport Model will reimburse ambulance providers for transporting patients to alternative destinations. This study analyzed data from four ambulance providers in California to assess whether paramedics can accurately identify patients who can be treated safely in a mental health crisis center without first being transported to an ED for medical clearance.Study DesignData regarding transports to mental health crisis centers in the four communities were collected as part of an evaluation of 20 pilot projects in California that are testing multiple concepts for utilizing paramedics outside their traditional roles. All four projects have trained paramedics to implement a screening protocol to determine whether patients with mental health needs could be treated safely in a crisis center. Patients whose vital signs are within the parameters of the protocol and do not have symptoms of injury or physical illness are offered transport to a crisis center instead of an ED.Pilot projects used a standardized data collection tool to report data regarding the numbers of patients enrolled, the numbers transported to an ED within six hours of admission to a crisis center, reasons for ED transports, and the disposition of patients transported to an ED. Descriptive statistics were tabulated.Population Studied911 calls involving people with suspected mental illness.Principal FindingsThe four projects transported 3,087 patients to a mental health crisis center between September 2015 and September 2019. In all four communities, the majority of patients were uninsured or enrolled in Medicaid. Crisis centers accepted almost all patients transported to them, with rare exceptions related to resources (eg, not able to dispense methadone) and patient insurance type. Across all four projects, 65 patients (2%) were transported to an ED within six hours of admission to a crisis center. Patients were transported to an ED for a range of reasons including elevated vital signs, pain, seizure, urinary incontinence, and alcohol withdrawal. Among the 65 patients transported to an ED, 38 were treated in an ED and released, 21 were treated and transferred back to the crisis center or to an inpatient psychiatric facility, and 6 (0.2% of all patients) were admitted to a hospital for inpatient medical care.ConclusionsThe experience of California’s four pilot projects suggests that paramedics can apply a protocol to identify patients with suspected mental illness who can be treated safely in a mental health crisis center instead of an ED. Patients were rarely transported to an ED, and ED visits rarely resulted in an inpatient admission.Implications for Policy or PracticeTransporting patients experiencing a mental health crisis directly to a crisis center enables them to obtain mental health services more quickly and in a calmer, less costly environment than an ED and can help reduce ED overcrowding. States should consider requiring payers to reimburse ambulance providers for these transports.Primary Funding SourceCalifornia Health Care Foundation.

APA’s Ethics Committee Responds to Question Related to COVID-19

Back to table of contents Previous article Next article ProfessionalFull AccessAPA’s Ethics Committee Responds to Question Related to COVID-19, Search for more papers by this author, Search for more papers by this authorPublished Online:14 Jul 2020https://doi.org/10.1176/appi.pn.2020.7b17AbstractiStock/Maksim TkachenkoAPA’s Ethics Committee has received a number of questions related to ethical practice during the COVID-19 pandemic. Below is one of them, along with the committee’s response.Q. I would appreciate your consideration of these questions, which have arisen at our public sector inpatient psychiatric facility: It was recently decided to have all admissions given nasopharyngeal swab screening for COVID-19. For patients who were admitted voluntarily prior to this decision, is it ethical to compel them to submit to testing as a condition for continued hospitalization, even if asymptomatic? For patients seeking voluntary admission and meeting medical necessity criteria for admission (that is, expressing suicidal ideation, homicidal ideation, or appearing unable to care for themselves), is it ethical to deny voluntary admission based on their refusal to voluntarily submit to testing? For example, would a psychiatrist be ethically justified to admit an otherwise voluntary patient involuntarily so as to force testing and continue with inpatient treatment thereafter?A. While it is not recommended to force an individual patient, competent or not, to undergo nasopharyngeal swab for COVID-19 testing, clinical administrators of the unit do have an obligation to keep the other patients safe. They can meet this responsibility by maintaining the refusing patient in quarantine for 14 days, the time it would take for any individual exposed to a suspected or confirmed COVID-19-positive person to develop and exhibit symptoms of the infection, if the resources to do so are available. After 14 days without symptoms, the refusing patient would be deemed COVID-19 negative.It may be unethical to deny admission to patients meeting medical necessity for psychiatric admission (voluntary or involuntary) based on their refusal to submit to testing for COVID-19, although in the setting of contagion and a global pandemic, institutions have broad latitude to protect the public health, and physicians have responsibilities to both individual patients and to the greater public good that must be balanced.If there are other interventions available to clinicians to protect other patients on the unit from the newly admitted patient with unclear COVID-19 status and to protect the patient from him/herself, accommodations may be made. It is important to note that testing for COVID-19 is a medical and not a psychiatric intervention, and it is not based on the legal status of a patient’s admission, voluntary or involuntary. Competent patients have a right to refuse treatment or testing of any kind in ordinary circumstances, even if they were admitted to the hospital involuntarily.For patients without the capacity for informed consent, their representative may have the authority to request testing against the patients’ wishes. It would be best, however, to work hard to avoid this situation as much as possible, for example, by quarantining patients, forming an alliance with them, and trying to obtain the testing through gaining their trust. If that proves not possible, the patient’s quarantine could be continued for 14 days.Finally, isolating patients is not without risk to staff and without cost. For example, the added use of personal protective equipment at a time of shortage and the need for extra personnel may not be reasonable or responsible. Ultimately, the final consideration is a balancing between the individual patient and risk to other patients in the facility and the greater public health situation given the current global pandemic. It is important to be aware that every new admission is a risk to older, confined patients with comorbid conditions; under some circumstances, there could be an argument for limiting or pausing admission to a particular hospital and/or ethical imperative for at least a strong effort to persuade or induce unwilling patients to be tested in high-risk settings. Hospitals have the prerogative to set their admission standards and requirements for both voluntary and involuntary admission but not to violate the law in setting them. Infection control and management during the pandemic is a legitimate and paramount consideration for any facility, public or private.Psychiatrists may wish to examine the laws in their jurisdictions regarding quarantine and other public health measures in an epidemic or pandemic regarding who, if anyone, may have the authority to mandate testing or isolation. As a public health issue, the commissioner for public health, rather than mental health, may be the legal authority regarding testing and other contagion-related guidance or regulations. ■APA members with questions about ethics issues related to the COVID-19 pandemic may send them to the Ethics Committee at [email protected]. The committee will respond directly to those who submit questions. More opinions are posted here. ISSUES NewArchived

Rhabdomyolysis, Methamphetamine, Amphetamine and MDMA Use: Associated Factors and Risks

Objective Rhabdomyolysis is associated with methamphetamine, amphetamine, and methylenedioxymethamphetamine (MA) use. The aim of this study was to determine the frequency, severity, and risk factors of rhabdomyolysis associated with MA use. Methods: We reviewed patients with an MA-positive toxicology screen with and without diagnosed rhabdomyolysis based on initial creatine kinase (CK) concentration over a period of 6 years. Demographics, vital signs, disposition, diagnoses, and laboratory results were recorded. Results: There were 7,319 patients with an MA-positive toxicology screen, of whom 957 (13%) were screened for rhabdomyolysis and included in the study. The majority were male, White, and middle-aged and smoked tobacco. Psychiatric (34%), neurological (15%), and trauma (13%) were the most common discharge diagnostic groups. The majority (55%) were admitted, and 8% were discharged to an inpatient psychiatric facility. Concomitant substance use included ethanol (10%) and cocaine (8%), and 190 (20%) had rhabdomyolysis with median (interquartile range) CK of 2,610 (1,530–6,212) U/L and range 1,020 to 98,172 U/L. There was significant difference in renal function between the rhabdomyolysis and non-rhabdomyolysis patients. Other differences included gender and troponin I concentration. A higher proportion of patients screening positive for both MA and cocaine use experienced rhabdomyolysis. Multiple logistic regression analysis revealed elevated troponin I, blood urea nitrogen, and/or creatinine concentration and male gender to be significant factors associated with rhabdomyolysis. Conclusions: The frequency of rhabdomyolysis in patients screening positive for MA was 20%. Factors associated with rhabdomyolysis in MA-positive patients included elevated troponin, blood urea nitrogen, creatinine concentration, and male gender. Clinicians caring for patients who screen positive for MA should also consider concomitant rhabdomyolysis, especially if renal/cardiac laboratory tests are abnormal and even if there is no history of injury, agitation, or physical restraint.

Screening for SARS-CoV-2 Infection Within a Psychiatric Hospital and Considerations for Limiting Transmission Within Residential Psychiatric Facilities - Wyoming, 2020.

In the United States, approximately 180,000 patients receive mental health services each day at approximately 4,000 inpatient and residential psychiatric facilities (1). SARS-CoV-2, the virus that causes coronavirus disease 2019 (COVID-19), can spread rapidly within congregate residential settings (2-4), including psychiatric facilities. On April 13, 2020, two patients were transferred to Wyoming's state psychiatric hospital from a private psychiatric hospital that had confirmed COVID-19 cases among its residents and staff members (5). Although both patients were asymptomatic at the time of transfer and one had a negative test result for SARS-CoV-2 at the originating facility, they were both isolated and received testing upon arrival at the state facility. On April 16, 2020, the test results indicated that both patients had SARS-CoV-2 infection. In response, the state hospital implemented expanded COVID-19 infection prevention and control (IPC) procedures (e.g., enhanced screening, testing, and management of new patient admissions) and adapted some standard IPC measures to facilitate implementation within the psychiatric patient population (e.g., use of modified face coverings). To assess the likely effectiveness of these procedures and determine SARS-CoV-2 infection prevalence among patients and health care personnel (HCP) (6) at the state hospital, a point prevalence survey was conducted. On May 1, 2020, 18 days after the patients' arrival, 46 (61%) of 76 patients and 171 (61%) of 282 HCP had nasopharyngeal swabs collected and tested for SARS-CoV-2 RNA by reverse transcription-polymerase chain reaction. All patients and HCP who received testing had negative test results, suggesting that the hospital's expanded IPC strategies might have been effective in preventing the introduction and spread of SARS-CoV-2 infection within the facility. In congregate residential settings, prompt identification of COVID-19 cases and application of strong IPC procedures are critical to ensuring the protection of other patients and staff members. Although standard guidance exists for other congregate facilities (7) and for HCP in general (8), modifications and nonstandard solutions might be needed to account for the specific needs of psychiatric facilities, their patients, and staff members.

Pediatric Intentional Self-poisoning Evaluated in the Emergency Department: An International Study.

Suicide is a growing public health problem during late childhood and adolescence. The leading method of suicide attempts in this age group is intentional self-poisoning. A first self-poisoning episode is a strong predictor of subsequent suicide and premature death. The objective of this study was to analyze the presentation and management of children younger than 18 years with intentional self-poisonings admitted to an emergency department (ED) in a global research network of pediatric EDs. We performed a secondary analysis of a large, international, multicenter, cross-sectional prospective registry of childhood poisoning presentations to 105 EDs in the Pediatric Emergency Research Networks (PERN) network. Data collection started at each ED between January and September 2013 and continued for 1 year. During the study period, we included 1688 poisoning exposures. Of these, 233 (13.8%) were intentional self-poisonings, with significant variation between regions. Female/male ratio was 4.7/1 and most occurred at home. The most common toxicants were therapeutic drugs, mainly psychotropics and analgesics. Ninety patients (38.6%) gave a history of a previous episode of intentional self-poisoning. Sixty-three children (27.0%) were not assessed by a psychiatric service nor transferred to a psychiatric inpatient facility. No patient died. There was significant variation in the involved toxicants and interventions among EDs in different global regions. Most intentional self-poisoning presentations to pediatric EDs globally are related to intentional ingestions of therapeutic drugs at home by females. Best practices have to be translated into care to guarantee the best outcomes of these patients.

Methamphetamine, Amphetamine, and MDMA Use and Emergency Department Recidivism.

Emergency department (ED) recidivism and the use of amphetamine and associated derivatives such as methamphetamine and MDMA (MAE), are intersecting public health concerns. This study aims to determine the frequency of ED recidivism of patients who use MAE and associated factors. The study was a retrospective 6-year electronic medical record review of patients with MAE-positive toxicology screens and single and multiple ED visits in the span of 12months. There were 7844 ED visits by 5568 MAE-positive patients. Average age was 42±13years. The majority were male (65%), white (46%), tobacco smokers (55%), and in the psychiatric discharge diagnostic-related group (41%), followed by blunt trauma (20%). Admission rate was 35%, with another 17% transferred to inpatient psychiatric treatment facilities. Occasional (2-5 visits/year), heavy (6-11 visits/year), and super users (≥12 visits/year) altogether accounted for 20% of patients and 43% of visits. Heavy and super users combined represented 2% of patients and 10% of visits, with significant differences for race/ethnicity, health insurance, tobacco smoking, and psychiatric/cardiovascular/trauma discharge diagnostic-related groups. Heavy and super users were less likely to be admitted and more likely to be discharged to an inpatient psychiatric treatment facility. Regression analysis revealed racial/ethnic differences, female gender, and tobacco smoking to be associated with super and heavy use. Heavy users were more likely to have cardiovascular-related discharge diagnoses. The prevalence of ED recidivism in patients who use MAE is similar to published ranges for general ED users. Significant differences in demographics, discharge diagnoses, insurance, smoking, and disposition exist between nonfrequent and frequent ED users.

Evaluating the Effectiveness of an Educational Intervention for Care of Anemic Patients in a Long-Term Care Geropsychiatric Unit: A Pilot Study.

Anemia is one of the most common age-related health conditions. When concurrently present with psychiatric conditions, the problem is confounded. The primary objective of the current research was to evaluate the effectiveness of an educational intervention for geropsychiatric nurses about nutritional deficiency anemia, anemia of chronic disease, and unexplained anemia in older adults. Fifty nurses employed by an inpatient psychiatric facility participated in the pilot study. A 10-item knowledge evaluation questionnaire was administered prior to and following a 45-minute educational intervention. Analysis of a paired samples t test indicated a significant difference between pretest scores (mean = 36.8, SD = 16.3) and posttest scores (mean = 90.8, SD = 10.66) (p < 0.001). Despite initial knowledge gaps, significant improvement in nursing knowledge was noted following the intervention. As a result of improved knowledge, RNs may be better able to recognize and respond to signs and symptoms that commonly go unnoticed in geropsychiatric patients with anemia. [Journal of Gerontological Nursing, 46(8), 12-16.].

EQ-5D-Y-5L as a patient-reported outcome measure in psychiatric inpatient care for children and adolescents \u2013 a cross-sectional study

BackgroundPsychiatric disorders have a major individual and societal impact. Until now, the association between health-related quality of life and physical disorders has been far more investigated than the association with psychiatric disorders. Patient-reported outcome measures makes it possible to capture the patient perspective to improve treatments and evaluate treatment outcomes. The aim of this study is to measure health-related quality of life with the EQ-5D-Y-5L among patients in child and adolescent psychiatric inpatient care and to test the instrument’s psychometric properties in terms of feasibility and construct validity.MethodsData were collected at the child and adolescent psychiatric inpatient facility in Region Stockholm. A questionnaire including the EQ-5D-Y-5L instrument, the Strengths and Difficulties Questionnaire with an impact supplement and a self-rated health question, was administered for self-completion using paper and pencil, with an interviewer present. The Chi-square test was used to investigate differences in proportion of reported problems in the EQ-5D-Y-5L dimensions and the Mann-Whitney U test was used for differences in mean EQ VAS scores. Feasibility was assessed by investigating proportion of missing and ambiguous answers and Spearman’s and Pearson’s correlation were used to examine construct validity.ResultsIn total 52 adolescents participated in the study and the majority were girls. The most common diagnosis at admission was depressive episode/recurrent depressive disorder. All participants reported problems on at least one dimension. Most problems were reported in the dimension ‘feeling worried, sad or unhappy’, where 64% reported severe or extreme problems. Mean EQ VAS score was 29.2. Feasibility was supported and construct validity indicated as some of the hypothesised correlations between the EQ-5D-Y-5 L and the Strengths and Difficulties Questionnaire were found, however, for ‘doing usual activities’ and ‘having pain or discomfort’ the correlations were weaker than hypothesised.ConclusionsThis is the first study where the newly developed EQ-5D-Y-5L instrument has been used in psychiatric inpatient care for youth. Participants reported problems in all severity levels in most of the EQ-5D-Y-5L dimensions; mean EQ VAS score was considerably low. Feasibility of the EQ-5D-Y-5L was supported, however other psychometric properties need to be further tested in a larger sample.

Electronic Health Information Exchange At Discharge From Inpatient Psychiatric Care In Acute Care Hospitals.

To address the complex health care needs of patients with mental illness-who commonly have co-occurring medical conditions and substance use disorders-it is critically important for providers to use electronic health records (EHRs) for health information exchange (HIE) when patients are transferred from inpatient psychiatric units in acute care hospitals. Efficient and timely HIE is necessary to ensure that patients receive adequate and informed follow-up care. This study examined the percentage of inpatient psychiatric units that reported using EHRs for HIE at transfers of care and hospital characteristics associated with that use. We linked national data from the Inpatient Psychiatric Facility Quality Reporting Program of the Centers for Medicare and Medicaid Services, the American Hospital Association Annual Survey, and state mental health privacy laws. In 2016 the use of electronic HIE upon transfer from psychiatric units lagged behind the corresponding overall use rates from acute care hospitals (56.3 percent versus 88 percent), with wide variation across states. Hospital size and accountable care organization participation were associated with electronic HIE, but a state's having mental health privacy laws more stringent than the Health Insurance Portability and Accountability Act did not. Given these results, policy efforts to incentivize the use of electronic HIE in psychiatric settings should be strengthened.

Psychiatry in the Middle East: the rebirth of lunatic asylums?

This article briefly assesses the historical trajectory of psychiatric institutions in the Middle East. It underlines a key observation: the persistence and expansion of psychiatric institutionalisation, specifically in the Arab world. In contrast to the deinstitutionalisation that eventually closed large psychiatric hospitals in the 1960s and 1970s, notably in Europe and North America, psychiatric hospitals have continued to grow in size in the Arab world. This absence of deinstitutionalisation marks a major departure from how psychiatry developed in the West, which is worth reflecting on if we are to understand the current crumbling infrastructure of in-patient psychiatric facilities in the Arab region.