Factors associated with use of psychiatric intensive care and seclusion in adult inpatient mental health services

Abstract

Aims. Within acute psychiatric inpatient services, patients exhibiting severely disturbed behaviour can be transferred to a psychiatric intensive care unit (PICU) and/or secluded in order to manage the risks posed to the patient and others. However, whether specific patient groups are more likely to be subjected to these coercive measures is unclear. Using robust methodological and statistical techniques, we aimed to determine the demographic, clinical and behavioural predictors of both PICU and seclusion.Methods. Data were extracted from an anonymised database comprising the electronic medical records of patients within a large South London mental health trust. Two cohorts were derived, (1) a PICU cohort comprising all patients transferred from general adult acute wards to a non-forensic PICU ward between April 2008 and April 2013 (N = 986) and a randomly selected group of patients admitted to general adult wards within this period who were not transferred to PICU (N = 994), and (2) a seclusion cohort comprising all seclusion episodes occurring in non-forensic PICU wards within the study period (N = 990) and a randomly selected group of patients treated in these wards who were not secluded (N = 1032). Demographic and clinical factors (age, sex, ethnicity, diagnosis, admission status and time since admission) and behavioural precursors (potentially relevant behaviours occurring in the 3 days preceding PICU transfer/seclusion or random sample date) were extracted from electronic medical records. Mixed effects, multivariable logistic regression analyses were performed with all variables included as predictors.Results. PICU cases were significantly more likely to be younger in age, have a diagnosis of bipolar disorder and to be held on a formal section compared with patients who were not transferred to PICU; female sex and longer time since admission were associated with lower odds of transfer. With regard to behavioural precursors, the strongest predictors of PICU transfer were incidents of physical aggression towards others or objects and absconding or attempts to abscond. Secluded patients were also more likely to be younger and legally detained relative to non-secluded patients; however, female sex increased the odds of seclusion. Likelihood of seclusion also decreased with time since admission. Seclusion was significantly associated with a range of behavioural precursors with the strongest associations observed for incidents involving restraint or shouting.Conclusions. Whilst recent behaviour is an important determinant, patient age, sex, admission status and time since admission also contribute to risk of PICU transfer and seclusion. Alternative, less coercive strategies must meet the needs of patients with these characteristics.

Modern forensic psychiatric hospital design: clinical, legal and structural aspects

“…National mental health laws in most countries stipulate that psychiatric patients who exhibit dangerous and difficult-to-treat behaviors can be subjected to coercive measures, such as seclusion [ 67 , 68 ], if specific criteria are met. However, being subjected to coercive measures can cause significant displeasure [ 61 ]—even when considered necessary by patients themselves [ 69 ]—and might be experienced as traumatic and unjust [ 70 ].…”

Seclusion and Psychiatric Intensive Care Evaluation Study (SPICES): combined qualitative and quantitative approaches to the uses and outcomes of coercive practices in mental health services

“…This method removes the influence of pathway length that complicates other types of analysis. Two levels of analysis were conducted, one at the level of the whole interview for interventions used when the Show of force 4 (27) Transfer to a PICU 3 (20) Call the police 2 (13) Discuss medication 2 (13) Talk to others 1 (7) Move other patients 1 (7) LSE, low-stimulus environment. Total number of nurses interviewed was 15.…”

Machine Learning: An Approach in Identifying Risk Factors for Coercion Compared to Binary Logistic Regression

“…During the last years specialized psychiatric intensive care units (PICU) had been the center of extensive research and it could be shown that some patient characteristics are associated with the transfer from a general psychiatric unit to a PICU and with the usage of coercion on these specialized wards ( 15 ). Furthermore psychotic disorders were shown to be frequently associated with coercion ( 16 – 24 ).…”