Background: Acute inpatient care has come under sustained criticism. Services suffer from high occupancy, increased acuity, and patient dissatisfaction with care. The number of beds has been reduced ...in favour of alternative services.
Aim: To articulate clearly the role of acute inpatient care.
Method: Drawing on research evidence and the experiences of inpatient and community staff, we present a model to describe the function and tasks of inpatient care.
Results: An admission is the result of severity of acute mental disorder, coupled with an acute admission problem. The decision to admit is processed through a filter composed of bed availability, social supports and other services available to the prospective patient. That combined reason provides the primary task of the admission. However patients also bring with them other life and health problems. While not a cause of admission, these problems have to be managed by inpatient staff. Where they can be resolved, they represent an "admission bonus". Finally, acute care functions because of the legitimate authority of staff, their 24-hour availability for support and supervision, and the provision of treatment and containment.
Conclusion: This model explicates many aspects of acute inpatient care that otherwise create confusion.
Celotno besedilo
Dostopno za:
BFBNIB, DOBA, IZUM, KILJ, NUK, OILJ, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK, VSZLJ
Although individual conflict and containment events among acute psychiatric inpatients have been studied in some detail, the relationship of these events to each other has not. In particular, little ...is known about the temporal order of events for individual patients. This study aimed to identify the most common pathways from event to event. A sample of 522 patients was recruited from 84 acute psychiatric wards in 31 hospital locations in London and the surrounding areas during 2009-2010. Data on the order of conflict and containment events were collected for the first two weeks of admission from patients' case notes. Event-to-event transitions were tabulated and depicted diagrammatically. Event types were tested for their most common temporal placing in sequences of events. Most conflict and containment occurs within and between events of the minimal triangle (verbal aggression, de-escalation, and PRN medication), and the majority of these event sequences conclude in no further events; a minority transition to other, more severe, events. Verbal abuse and medication refusal were more likely to start sequences of disturbed behaviour. Training in the prevention and management of violence needs to acknowledge that a gradual escalation of patient behaviour does not always occur. Verbal aggression is a critical initiator of conflict events, and requires more detailed and sustained research on optimal management and prevention strategies. Similar research is required into medication refusal by inpatients.
Previous research shows that too often acute psychiatric inpatient care is neither safe nor therapeutic for patients. Earlier studies focused on promoting safety through good ward design, staff being ...able to anticipate and prevent violence, and use of medication. The current evidence base overwhelmingly reflects a staff perspective on risk management, and there is little evidence on how service users cope in this environment or about the strategies they employ to manage the risks they face or pose to others. This paper presents findings on this from two studies: (a) ethnographic research on three UK acute psychiatric wards, undertaken between 2000 and 2002, and (b) a content analysis of qualitative data from a 1999/2000 survey of psychiatric wards in England.
Findings show that while some users perceive their ward to be comparatively safe—given the crisis they were in before being admitted—it is nonetheless a volatile environment in which risks are concentrated. Many risks, such as physical assault, are attributable to other patients. However, they are better understood as an outcome of the interplay between a range of interactional and contextual factors: for example, low staffing levels/minimal or poor surveillance may increase the risk of assault. Users were found to employ 10 strategies to manage risk on the ward, including actively avoiding risky situations/individuals, seeking staff protection, and getting discharged. Integral to these strategies are the risk assessments that patients make of one another.
These findings shed light on how people cope while living in one of the most anxiety-inducing institutions of a ‘risk management society’. Service users routinely take an active role in making a safe environment for themselves, in part because they cannot rely on staff to do this for them. Future clinical practice guidelines should consider how to harness what users are already doing to manage risk.
Somatoform disorders have rarely been addressed in epidemiological and health care services studies of the elderly. The few existing studies vary considerably in their methodologies limiting ...comparability of findings. Data come from the MentDis_ICF65+ study, in which a total of 3142 community‐dwelling respondents aged 65–84 years from six different countries were assessed by the Composite International Diagnostic Interview adapted to the needs of the elderly (CIDI65+). The 12‐month prevalence rate for any somatoform disorders was found to be 3.8, whereby the prevalence for somatization disorder according to DSM‐IV was 0%, the prevalence for abridged somatization was 1.7% and the rate for 12‐months somatoform pain disorder was 2.6%. We found a significant variation by study centre (p < 0.005). There was a significant gender difference for pain disorder, but not for abridged somatization. Significant age‐related effects revealed for both disorder groups. Somatoform disorders were found to be associated with other mental disorders odds ratio (OR) anxiety =4.8, OR affective disorders 3.6, as well as with several impairments and disabilities. Somatoform disorders are prevalent, highly impairing conditions in older adults, which are often associated with other mental disorders and should receive more research and clinical attention.
Low secure services provide care for psychiatric patients whose risk cannot be safely managed in other settings. The physical environment in these units plays an important role in supporting recovery ...and risk management. We developed the Quality of Environment in Low secure Services (QELS) checklist to assess the quality of the physical environment of these services. Using recommendations from previously published standards we piloted a draft checklist with a weighted scoring system reflecting the views of patients and providers. The checklist showed good criterion validity and inter-rater reliability. Data collected from 33 low secure services showed considerable variation in the quality of the physical environment. The QELS checklist provides an accessible and reliable means for managers and clinicians to assess whether the quality of the physical environment of low secure units meets recommended standards and can be used to support efforts to improve the quality of care delivered by these services.
Celotno besedilo
Dostopno za:
BFBNIB, DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, UILJ, UKNU, UL, UM, UPUK
Background
Concerns have repeatedly been expressed about the quality of inpatient care that people with dementia receive. Policies and practices have been introduced that aim to improve this, but ...their impact is unclear.
Aims
To identify which aspects of the organisation and delivery of acute inpatient services for people with dementia are associated with higher-quality care and shorter length of stay.
Design
Mixed-methods study combining a secondary analysis of data from the third National Audit of Dementia (2016/17) and a nested qualitative exploration of the context, mechanism and outcomes of acute care for people with dementia.
Setting
Quantitative data from 200 general hospitals in England and Wales and qualitative data from six general hospitals in England that were purposively selected based on their performance in the audit.
Participants
Quantitative data from clinical records of 10,106 people with dementia who had an admission to hospital lasting ≥ 72 hours and 4688 carers who took part in a cross-sectional survey of carer experience. Qualitative data from interviews with 56 hospital staff and seven carers of people with dementia.
Main outcome measures
Length of stay, quality of assessment and carer-rated experience.
Results
People with dementia spent less time in hospital when discharge planning was initiated within 24 hours of admission. This is a challenging task when patients have complex needs, and requires named staff to take responsibility for co-ordinating the discharge and effective systems for escalating concerns when obstacles arise. When trust boards review delayed discharges, they can identify recurring problems and work with local stakeholders to try to resolve them. Carers of people with dementia play an important role in helping to ensure that hospital staff are aware of patient needs. When carers are present on the ward, they can reassure patients and help make sure that they eat and drink well, and adhere to treatment and care plans. Clear communication between staff and family carers can help ensure that they have realistic expectations about what the hospital staff can and cannot provide. Dementia-specific training can promote the delivery of person-centred care when it is made available to a wide range of staff and accompanied by ‘hands-on’ support from senior staff.
Limitations
The quantitative component of this research relied on audit data of variable quality. We relied on carers of people with dementia to explore aspects of service quality, rather than directly interviewing people with dementia.
Conclusions
If effective support is provided by senior managers, appropriately trained staff can work with carers of people with dementia to help ensure that patients receive timely and person-centred treatment, and that the amount of time they spend in hospital is minimised.
Future work
Future research could examine new ways to work with carers to co-produce aspects of inpatient care, and to explore the relationship between ethnicity and quality of care in patients with dementia.
Funding
This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full in
Health Services and Delivery Research
; Vol. 8, No. 22. See the NIHR Journals Library website for further project information.
Aims and methodWe conducted a secondary analysis of data from the National Audit of Psychosis to identify factors associated with use of community treatment orders (CTOs) and assess the quality of ...care that people on CTOs receive. RESULTS: Between 1.1 and 20.2% of patients in each trust were being treated on a CTO. Male gender, younger age, greater use of in-patient services, coexisting substance misuse and problems with cognition predicted use of CTOs. Patients on CTOs were more likely to be screened for physical health, have a current care plan, be given contact details for crisis support, and be offered cognitive-behavioural therapy.Clinical implicationsCTOs appear to be used as a framework for delivering higher-quality care to people with more complex needs. High levels of variation in the use of CTOs indicate a need for better evidence about the effects of this approach to patient care.Declaration of interestNone.
Research on “risk behaviour” in the time of AIDS has emphasised how social relationships influence individuals' responses to risk. Yet the social relationship remains an under-utilised unit of ...analysis in risk behaviour research. Drawing on qualitative research with illicit drug users in London, this paper illustrates how drug users' sexual relationships act as key sites of risk management in individuals' drug use and everyday lifestyles. First, while recent research has almost exclusively focused on the dangers of disease transmission, our findings show that drug users perceived their sexual relationships as influencing a variety of risks associated with heroin and other opioid drugs. Here, two types of relationships—“gear” and “straight” relationships—were perceived to be particularly important. Second, while research has tended to focus on drug and health risks as an outcome of relationships, drug users' accounts emphasise that managing risks to their relationships is an important facet of everyday risk management made complicated by drug use. It is argued that risk is a product of social interactions, and that the sexual relationship is an important site of risk management in this process. Future interventions should target drug users' sexual relationships as agents of risk management and behaviour change.
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