Consistency of Violence: Implications for Effective Inpatient Psychiatric Care

Abstract

Instances of violence and aggression in acute psychiatric settings are common and highly distressing for service users and staff. They also incur financial costs. This study aimed to identify the proportion of service users at risk of consistent violence/aggression enactment. It also aimed to analyse associated service use to explore the potential need for specialised, targeted approaches. Five years’ worth of data were extracted from 2016 to 2020 on inpatient stays across South London and Maudsley NHS Foundation Trust (SLaM) acute adult wards and Psychiatric Intensive Care Units (PICUs). Service users were divided into cohorts based on relative number of violent/agressive incidents enacted. Differences in frequency of acute service use during the period 1st January-31st December 2020 were analysed. In total, 2524 service users had at least one inpatient stay during 2020. 679 were recorded as having enacted at least one incident of violence or aggression. Just 4% of all service users accounted for 50% of all violence/aggression enactment. Results further showed strong evidence of group differences between violence cohorts in the following domains: internal transfers, occupied bed days, admissions and Place of Safety (PoS) referrals. There was weaker evidence for group differences in referrals to Home Treatment teams (HTTs) and Psychiatric Liaison Teams. A small proportion of service users disproportionately account for the majority of violent and aggressive incidents and higher levels of violence and aggression are associated with more acute service use. The provision of targeted, personalised interventions for this cohort may reduce the enactment of violence and aggression, leading to improved quality life and a reduction in financial expenditure.

Reducing violence and aggression: a quality improvement project for safety on an acute mental health ward

“… 6 38 39 A variable strongly correlated with V&A is history of aggression 40 41 and a recent study found 4% of service users accounted for 50% of V&A. 19 Epidemiological studies of violence and serious mental illness have shown low risk for violence associated with serious mental illness unless there is a comorbidity with illicit substance misuse. 10 11 For Manchester hospital admissions where drug-related mental and behavioural disorders were a factor, the rate is almost double the national average at 183%.…”

“…17 There are also financial costs associated with assaults, verbal abuse and damage to property with an estimated annual cost of £20.5 million per year in psychiatric wards in England, 18 this can result in more acute service use including internal transfers and increased occupied bed days. 19 There are a range of methods or techniques used to manage V&A on psychiatric wards, including talking to the patient, increasing observation levels, oral PRN (when required) medication, rapid tranquilisation (RT) medication given intramuscularly, physical restraint and seclusion (where patients are secluded in a locked room for containment of severe behavioural disturbance likely to cause harm to others, MHA code 2015). On occasion restrictive practices (defined here as RT medication, physical restraint and seclusion) are necessary for safety of both staff and patients.…”

“…17 There are also financial costs associated with assaults, verbal abuse and damage to property with an estimated annual cost of £20.5 million per year in psychiatric wards in England, 18 this can result in more acute service use including internal transfers and increased occupied bed days. 19 …”