Economic grand rounds: Variation in staffing and activities in psychiatric inpatient units

In 1999 the Balanced Budget Refinement Act mandated the development of a per diem prospective payment for all psychiatric inpatients. To assist Medicare in developing a per diem patient-based payment system, this study surveyed a representative sample of psychiatric inpatient units in 40 facilities for one week in 2001 through 2003 to determine how units are staffed and how staff members spend their time caring for patients. On general adult units, psychiatric staff averaged ten hours per patient per 24-hour day, roughly 55 percent of staff time was involved in psychiatric care, medical-related nursing and personal care accounted for 10 percent of staff time, and milieu time took up 34 percent of staff time. Small general adult and geriatric units required 50 percent more staff time per patient than large units. More research is needed to determine how recent changes in the method of payment affect these facilities.     

Identifying risk factors and key strategies in linkage to outpatient psychiatric care

OBJECTIVE: The substantial failure of psychiatric patients to engage in outpatient specialty mental health care after an acute hospitalization at a time when managed care companies and others increasingly hold hospitals accountable for outcomes underscores the importance of identifying patients at high risk for not completing referrals. This study explored patient risk factors for not completing referrals and examined the success of several interventions targeted to achieving linkage with outpatient care. METHOD: A clinically detailed, structured form was used in abstracting information from the medical records of 229 inpatients with a primary psychiatric diagnosis. Clinicians and staff at outpatient programs were contacted to determine whether patients completed their referrals. RESULTS: Approximately two-thirds (65%) of the patients failed to attend scheduled or rescheduled initial outpatient mental health appointments after a hospital discharge. At high risk for unsuccessful linkage to outpatient care were patients with a persistent mental illness and those who had no prior public psychiatric hospitalization, were admitted involuntarily, and had longer lengths of stay. Controlling for risk factors, three clinical interventions used during the hospital stay more than tripled the odds of successful linkage to outpatient care: communication about patients' discharge plans between inpatient staff and outpatient clinicians, patients' starting outpatient programs before discharge, and family involvement during the hospital stay. CONCLUSIONS: Effective clinical bridging strategies can be used to avoid unnecessary gaps in the delivery of psychiatric services. Incorporating these strategies into routine care would enhance continuity of care, especially for some high-risk patients.     

Improving the validity of measures of patient satisfaction with psychiatric care and treatment

Surveys of consumer satisfaction with psychiatric services are frequently included in program evaluations, ostensibly providing the patient's perspective. However, the consistently high levels of satisfaction reported, despite a wide variety of measures, suggest that these surveys may be of questionable validity. Recognizing that most surveys ask patients to rate aspects of care that professionals feel are important, the authors used a focus-group method to generate attributes of ideal care from the patient's viewpoint. A pool of 50 patient-generated items were rated for importance by a second group of inpatients on locked units of a provincial psychiatric hospital. A factor analysis and mean importance ratings identified interpersonal relations with staff as a key factor of patient satisfaction. The authors designed a seven-item measure of satisfaction based on this key factor.     

A retrospective study of alcohol use by VA psychiatric inpatients

Psychiatric inpatients are prone to the use of alcohol, often in attempts to self-medicate. A retrospective review of patient records in a Veterans Administration neuropsychiatric facility identified 28 patients for whom use of alcohol was documented while they were in the hospital; the number of episodes totaled 47. The patients tended to be young and unmarried and to have a diagnosis of schizophrenia. The study found a trend toward underreporting of alcohol use by hospitalized patients because staff believe it to be an accepted part of adult life in American society. Possibly because staff do not identify alcohol use as a serious problem for psychiatric inpatients, it is not considered in treatment planning. The authors conclude with recommendations for management of inpatients who use alcohol.     

Quality of life for patients with schizophrenia in a Japanese psychiatric hospital

Providing a good quality of life (QOL) has recently been recognized as a central purpose of health care in psychiatry. In this study, we performed a detailed evaluation of the subjective QOL of schizophrenic inpatients and examined the relationship of QOL to various patient characteristics. This study was conducted on schizophrenic inpatients and nursing staff members in a Japanese private psychiatric hospital. As a result, only depression showed a weak, but significant, relationship with subjective QOL. Other characteristics showed no meaningful correlation to subjective QOL. Comparison between the schizophrenic group and the nursing staff group revealed that schizophrenic inpatients showed a lower QOL in the domains of physical health and social relationships. Schizophrenia itself and/or accompanying disabilities might induce lower subjective QOL. It is difficult to determine what the important factors are, except for depression, for subjective QOL of schizophrenic inpatients. However, depression should receive more attention for the QOL in the physical health and psychological health domains.     

Patterns of staff perception of difficult patients in a long-term psychiatric hospital

In a study to determine which psychiatric patients are perceived by staff as most difficult to treat, clinical staff from several disciplines rated problem behaviors of 127 long-term inpatients in a private psychiatric hospital; staff also rated overall treatment difficulty, progress, and prognosis. No single patient characteristic determined staff's perception of patients as difficult to treat. Instead, four clusters of patient characteristics contributed to this perception; in decreasing order of influence, they are withdrawn psychoticism, severe character pathology, suicidal-depressed behavior, and violence-agitation. The study also showed that the patients who are considered particularly difficult are perceived as improving less and as having a poor prognosis.     

Schizophrenia and Parkinson's disease lead to equal motor-related changes in cortical and subcortical brain activation: an fMRI fingertapping study

The aim of the present study was to examine the relationships between behavioral disturbances and patient characteristics of inpatients with dementia nationwide. The five patient characteristics used were age, gender, years of education, cognitive status, and walking ability. The subjects consisted of 730 inpatients selected by systematic sampling from 180 units that have specialized psychiatric beds for acute/long-term care of dementia. Clinical staff members assessed the 730 patients with the Mini-Mental State Examination (MMSE), and filled out a questionnaire for long-term care insurance, including 19 items relating to behavioral disturbances and walking scale. Five meaningful factors were identified out of the 19 behavioral disturbances by factor analysis. Linear regression analysis revealed that the factor 'psychotic/neurotic' was not related to any patient characteristics; 'aggression/negativistic' was related to male gender and a lower MMSE score; and 'dirty/destructive' and 'disorientation/fire management' were related to a lower MMSE score and higher walking score. The factor 'sexual behavior' included only one behavior at a very low frequency. These findings suggest that different behavioral disturbance factors have different correlations with patient characteristics, while cognitive dysfunction has a relatively important role in behavioral disturbances of inpatients with dementia.     

Downsizing psychiatric hospitals: needs for care and services of current and discharged long-stay inpatients.

BACKGROUND: With the psychiatric deinstitutionalization movement in its fourth decade, questions are being raised concerning its relevance for long-stay inpatients with severe disabilities and the risk that those discharged into the community may be abandoned. METHODS: A random sample taken in 1989 of long-stay inpatients at Louis-H Lafontaine Hospital made it possible to examine 96 pairs of patients. Each pair included 1 patient discharged between 1989 and 1998 and 1 patient hospitalized. Pairs were matched for sex, age, length of stay, and level of psychiatric care in 1989. Patients and staff were interviewed using standardized questionnaires, and case notes were reviewed to assess symptoms, daily living skills, residential status, quality of residential setting, and clinical and social problems and needs. RESULTS: The investigation revealed that discharged patients moved to highly supervised settings, which included professionally supervised group homes, supervised hostels, and foster families. About 20% went to nursing homes owing to loss of autonomy from physical disorders. Only 4 discharged patients were lost to follow-up, of whom 2 were probable vagrants. Both those discharged and those remaining as inpatients presented with major clinical problems and daily living skill deficits. The care needs of discharged patients were generally met, and placement in the community was considered appropriate. Of those who had remained hospitalized, over one-half could be moved to supervised settings immediately, or after 1 to 2 years' preparation in a discharge unit, while 13% could be moved to nursing homes. Over 25% required intensive, individualized rehabilitation treatment targeting engagement, psychotic symptoms, withdrawal, and dangerous and socially embarrassing behaviours. CONCLUSION: Deinstitutionalization in the largest Canadian psychiatric hospital did not lead to patient abandonment in the community.     

Risk factors for aggressive behavior among psychiatric inpatients

The evaluation of a patient's potential for aggressive behavior is an important component of care on psychiatric units. In this study, the aggressive behavior of 111 new psychiatric inpatients in Taiwan was recorded by nursing staff using the Overt Aggression Scale (OAS) during the patients' hospitalization. Psychiatrists made diagnoses in accordance with DSM-IV criteria and collected information about psychosocial risk factors for aggression. On average, aggressive patients were hospitalized longer than nonaggressive patients. After duration of hospitalization was controlled for, it was found that patients with an earlier onset of illness were more likely to be aggressive than other patients.     

Adopting new models for continuity of care: the ward as mini-mental-health-center.

Several years ago the staff of a traditional psychiatric ward in a Veterans Administration hospital began trying to provide continual care for their former inpatients after they left the hospital. Nursing assistants conducted basic-skills groups and other groups in board-and-care homes; staff members made themselves available to former inpatients and theri families, roommates, or board-and-care sponsors through a 24-hour telephone service and home visits; and a day-care program and follow-up groups for the ward's outpatients were set up. Later the staff establiched additional day-care and follow-up programs in a downtown satellite unit. In a recent three month period, patients made a total of 4488 visits to the satellite and hospital programs. The preceding paper discusses some of the theoretical considerations on which this program and other alternatives to traditional care are based.     

Self-harm as a risk factor for inpatient aggression among women admitted to forensic psychiatric care

Background: Inpatient aggression among female forensic psychiatric patients has been shown to be associated with self-harm, that is considered to be a historical risk factor for violence. Research on associations between previous or current self-harm and different types of inpatient aggression is missing.

Aim: The aim of this register study was to investigate the prevalence of self-harm and the type of inpatient aggression among female forensic psychiatric inpatients, and to study whether the patients’ self-harm before and/or during forensic psychiatric care is a risk factor for inpatient aggression.

Methods: Female forensic psychiatric patients (n?=?130) from a high security hospital were included.

Results: The results showed that 88% of the female patients had self-harmed at least once during their life and 57% had been physically and/or verbally aggressive towards staff or other patients while in care at the hospital. Self-harm before admission to the current forensic psychiatric care or repeated self-harm were not significantly associated with inpatient aggression, whereas self-harm during care was significantly associated with physical and verbal aggression directed at staff.

Conclusions: These results pointed towards self-harm being a dynamic risk factor rather than a historical risk factor for inpatient aggression among female forensic psychiatric patients. Whether self-harm is an individual risk factor or a part of the clinical risk factor ‘Symptom of major mental illness’ within the HCR-20V3 must be further explored among women. Thus, addressing self-harm committed by female patients during forensic psychiatric care seems to be important in risk assessments and the management of violence, especially in reducing violence against staff in high-security forensic psychiatric services.     

Psychosocial risk factors associated with suicide attempts and violence among psychiatric inpatients

OBJECTIVES: To better understand the relationship between suicidal behavior and violence directed toward others among patients with major psychiatric disorders, this study examined how suicide attempts and violent behaviors were associated with various psychosocial problems. METHODS: Participants were inpatients in two psychiatric state hospitals. They included 216 inpatients who had physically assaulted another patient or a staff member and a comparison group of 81 inpatients who had not assaulted anyone. History of suicide attempts and historical information about various risk factors for violence and suicide were obtained through chart review and patient interviews. RESULTS: Patients in the violent group did not differ from those in the nonviolent group in whether they had attempted suicide. Suicide attempts and violence were associated with different historical variables. Suicide attempts were associated with a history of head trauma, harsh parental discipline, and parental psychopathology. Violence against others was associated with having a history of school truancy and foster home placement. CONCLUSIONS: Among inpatients with major psychiatric disorders, violence and suicide attempts were not related to each other and were associated with dissimilar psychosocial risk factors.     

Relationship between behavioral disturbances and characteristics of patients in special units for dementia

Abstract The aim of the present study was to examine the relationships between behavioral disturbances and patient characteristics of inpatients with dementia nationwide. The five patient characteristics used were age, gender, years of education, cognitive status, and walking ability. The subjects consisted of 730 inpatients selected by systematic sampling from 180 units that have specialized psychiatric beds for acute/long‐term care of dementia. Clinical staff members assessed the 730 patients with the Mini‐Mental State Examination (MMSE), and filled out a questionnaire for long‐term care insurance, including 19 items relating to behavioral disturbances and walking scale. Five meaningful factors were identified out of the 19 behavioral disturbances by factor analysis. Linear regression analysis revealed that the factor ‘psychotic/neurotic’ was not related to any patient characteristics; ‘aggression/negativistic’ was related to male gender and a lower MMSE score; and ‘dirty/destructive’ and ‘disorientation/fire management’ were related to a lower MMSE score and higher walking score. The factor ‘sexual behavior’ included only one behavior at a very low frequency. These findings suggest that different behavioral disturbance factors have different correlations with patient characteristics, while cognitive dysfunction has a relatively important role in behavioral disturbances of inpatients with dementia.     

Managing sexual behavior on adult acute care inpatient psychiatric units

OBJECTIVE: Protecting and safeguarding persons with impaired decisional capacity are among the critical functions of a psychiatric hospital. The objective of this study was to investigate the elements of these functions as they relate to sexual behavior on an adult acute care inpatient psychiatric unit and to develop a policy to prevent or at least manage such behavior. METHODS: The authors undertook an extensive literature review of articles and legal cases. The review was presented at numerous meetings of staff and interdisciplinary teams on the adult teaching unit at Bellevue Hospital in New York City. The findings from the review and the results of staff discussions were used in creating the policy. RESULTS AND CONCLUSIONS: In the acute care setting, it may be both reasonable and prudent to prevent all sexual interactions between patients, especially given the potential risks of such behavior. Concerns include the transmission of sexually transmitted disease, reproductive issues, and the legal implications of nonconsensual activity. Despite these concerns, adult psychiatric inpatients should be granted as many rights as are possible without having an adverse effect on their treatment or recovery. There is currently no standard for a sexual behavior policy for psychiatric inpatients. Thus ward staff are left with minimal guidance and potential confusion in the event that sexual incidents do occur, and there is a greater likelihood of arbitrary responses. The policy developed through this study is an example of how individual institutions can enforce a structured protocol when dealing with an ambiguous and difficult issue.     

Continuity of care: A patient-centered model

A patient-centered model for the delivery of mental health services to acute psychiatric patients is described. This model may also be applicable to more comprehensive delivery systems. Mental health systems usually are centered around separate staff and physical locations of various units. The psychiatric patient's sensitivity to disruptions of the environment may respond favorably to a system of patient-staff continuity, which avoids fragmentation of care.The patient-centered care model allows the treatment staff to follow patients throughout the entire course of their treatment program. Impressions are that this model results in a marked decrease in acting out, suicide gestures, and other regressive manifestations at the time of transfer from one phase of the program to another. Specific issues of patient care account-ability, patient follow-through, and compliance with treatment recomendations, and cost-effectiveness are also discussed. In addition, staff satisfaction and professional growth are enhanced by the ability to follow patients and families through all phases of their treatment. Decreased staff turnover and increased interdisciplinary communication can enhance staff growth as well as patient care.     

An acute psychiatric rating scale for the clinical assessment of functionally disturbed inpatients

A 28-item behavioral rating scale, the Acute Psychiatric Rating Scale (APRS), was developed using factor-analytic methods for the assessment of functionally disturbed psychiatric inpatients. Fifty-eight staff rated 74 patients on the scale. Seven factorial dimensions were extracted comprising neuroticism, aggression, emotional withdrawal, cognitive impairment, schizophrenia, hypomania and self-injuriousness. The scale was evaluated in 4 different psychiatric inpatient units: two acute admission wards, an intensive care unit and a regional secure unit. Behavioral ratings on the scale were related to several patient demographic and treatment variables, including age, sex, marital status, legal status, length of admission and electroconvulsive therapy. The scale was found to possess a clear factorial structure, good interrater reliability and promising clinical validity for further research use in psychiatric inpatient settings.     

Conflict in treatment goals between patients and staff

Summary This paper studies treatment goals of inpatients on psychiatric units. A wide gap is demonstrated between the goal ideology of patients and staff. Staff favor a goal of insight; whereas patients consistently rank insight as their last choice. This goal discordance persists over a one year period of study and is not associated with increased patient dissatisfaction.     

Characteristics of Patient and Staff Victims of Assaults in Community Residences by Previously Nonviolent Psychiatric Inpatients

There currently exists a large body of empirical research examining patient assaults in inpatient psychiatric facilities. These studies have focused primarily on staff and have found younger, male mental health workers with lower levels of formal education and experience as well as nurses involved in restraint procedures to be most at risk. However, despite the increased utilization of community-based services, little attention has been directed toward patient assaults on patients and staff in community settings, particularly residential services. This study began to respond to this need by examining patient assaults toward other patients and staff in community residences during the first twelve months post-discharge for a group of newly discharged patients who were not violent as inpatients. This study found female patients and staff to be at greater risk for assault than male patients. Lack of experience by staff was also a risk factor. The clinical, administrative, and research implications of these findings are discussed.     

THERAPEUTIC ABORTION: The PSYCHIATRIC NURSE As Therapist, Liaison, And Consultant

It is noted that as abortion becomes an accepted medical practice, more nurses will be involved in the treatment and counseling of the therapeutic abortion patient. The authors, psychiatric nurses in a Colorado comprehensive urban mental health center, became involved in the treatment of the therapeutic abortion patient with the passing of the State's liberalized 1967 abortion law. As they became involved with all aspects of therapeutic abortion patients' care, they identified 3 specific roles for the psychiatric nurse: 1) providing direct They treatment, 2) providing liaison service and promoting continuity of care for the patient, and 3) providing consultation service to the staff involved with the patient. As the psychiatric nurses shared their own mixed feelings about abortion with the obstetrical staff, the staff began to feel less guilty and less alone with their feelings. The became more involved with the patients and benefited them more.     

Psychiatric inpatient care and the availability of hospital beds: A comparison of three catchment areas

Tysk L, Wessén B. Psychiatric inpatient care and the availability of hospital beds: A comparison of three catchment areas.

The psychiatric care in Gävleborg county was formerly centralized to a mental hospital and a small psychiatric department at a general hospital. It was then decided that the care system should be reorganized. The county was divided into three catchment areas. Each of these will have a comprehensive psychiatric care with both in- and out-patient facilities, but the intramural care will be reduced considerably. During the reorganization phase an almost experimental situation existed, as accessibility and availability of hospital beds differed among the three sectors. The inpatients for each sector were counted, and some patient characteristics were compared. Except for a considerable difference in the use of hospital beds small differences were otherwise noted. The sector with the smallest number of inpatients had relatively more schizophrenic patients. The accessibility and availability of hospital beds seemed to decide the number of inpatients even when deinstitutionalization was an accepted common goal. Local habits and traditions may also be important.