Christopher Pelic

Systematic Investigation of Initiatives to Reduce Seclusion and Restraint in a State Psychiatric Hospital

OBJECTIVES This study used an experimental design to examine the effect of systematic implementation of behavioral interventions on the rate of seclusion and restraint in an inpatient psychiatric hospital. METHODS With a variant of the multiple-baseline design, a model designed to reduce seclusion and restraint was implemented at a large state-funded hospital in the southeastern United States. The implementation schedule was established such that each of five inpatient units was randomly assigned to implement the intervention components in a different order, and each unit served as its own control. Participants were patients and staff, for a total of 89,783 patient-days over a 3.5-year period from January 2005 through June 2008. The components included trauma-informed care training, changes to unit rules and language, changes to the physical characteristics of the therapeutic environment, and involvement of patients in treatment planning. The rate of inpatient psychiatric seclusion and restraint (per patient day) was tracked continuously during the 3.5-year period. RESULTS A significant reduction of 82.3% (p=.008) in the rate of seclusion and restraint was observed between the baseline phase (January 2005 through February 2006) and the follow-up, postintervention phase (April 2008 through June 2008). After control for illness severity and nonspecific effects associated with an observation-only phase, changes to the physical environment were uniquely associated with a significant reduction in rate of seclusion and restraint during the intervention rollout period. CONCLUSIONS These data suggest that substantial reductions in use of seclusion and restraint are possible in inpatient psychiatric settings and that changes to the physical characteristics of the therapeutic environment may have a significant effect on use of seclusion and restraint.

Enhancing patient safety in psychiatric settings.

Objective. There is growing national consensus that use of institutional measures of control, such as seclusion, restraint, enforced medications, and hand-cuffed transport, within psychiatric hospitals is all too common and is potentially counter-therapeutic. Unfortunately, little is known about how to reduce such measures of last resort. This article reviews the available literature and describes a proposed research agenda involving a behavioral effort, the Engagement Model, for reducing seclusion and restraint procedures and enhancing patient safety in psychiatric settings. Methods. Using Medline and PsychInfo, we reviewed studies that specifically evaluated efforts to reduce seclusion and restraint on psychiatric units. Key search terms included seclusion, restraint, reduc*, psychiatric patient safety, psychiatric safety, psychiatric sanctuary, and quality of care psychiatry. Results. Only very limited data are available on reducing measures of last resort and improving the safety of psychiatric settings, and virtually no controlled data are available concerning the effectiveness of specific behavioral efforts on subsequent reduction of seclusion and restraint events. In light of the paucity of data, we describe efforts to incorporate and evaluate such a model in a large academic psychiatric hospital using a multiple baseline times-series design and review principles for and obstacles to implementing this model. Conclusions. It is hoped this discussion will stimulate research on this understudied topic and provide a framework for improving patient safety in psychiatric settings.

Evaluating Initiatives to Reduce Seclusion and Restraint

&NA; The use of institutional measures of control such as seclusion and restraint within psychiatric hospitals is common and arguably countertherapeutic; however, little is known about how best to reduce the use of these measures. The development and implementation of new institutional strategies to reduce the use of seclusion and restraint are important. Although traditional performance improvement (PI) project methodology might seem well‐suited to helping managers and administrators identify effective hospital‐wide interventions to decrease seclusion and restraint rates, the logic of the standard PI model precludes managers from making valid inferences about which interventions actually cause change. This article presents a model (derivative of the multiple baseline time‐series design with randomization) for testing individual elements of a large‐scale PI project to reduce the use of seclusion and restraint in a behavioral healthcare organization. The proposed model is flexible, accommodates overlapping organizational initiatives, and simultaneously allows for meaningful inferences to be made about the active components of the interventions. The ability to make meaningful inferences is important because, if the initiatives to reduce seclusion and restraint rates work, other healthcare organizations would benefit from knowing which specific interventions actually lead to change and which interventions have little impact on seclusion and restraint rates. Early experiences with this model from a hospital managers perspective are discussed, along with the costs and benefits of using it.

An autocorrelation-corrected nonparametric control chart technique for health care quality applications.

Recently, Alemi proposed a nonparametric control chart technique (Tukeys control chart) for quality management applications when few data points are available and when data do not conform to the assumptions of traditional control chart techniques. Borckardt et al then published an empirical evaluation of the technique and concluded that the presence of autocorrelation in control-chart data negatively impacted the techniques ability to help managers make accurate decisions about the presence of special-cause variation in their data. Thus, there is still a need for control chart techniques that appropriately handle short data streams that do not necessarily conform to the assumptions of traditional control chart techniques but are not negatively impacted by autocorrelation in the data. In this article, the authors empirically evaluate a modified version of the technique presented by Alemi that is designed to account for autocorrelation. Empirical analyses indicate that the modified technique demonstrates superior false-positive performance with very little degradation of power compared with the original technique proposed by Alemi.

Psychiatry Clerkship Students’ Preparation, Reflection, and Results on the NBME Psychiatry Subject Exam

ObjectivePsychiatry clerkship training involves many learning components, one of which is acquisition of scholarly knowledge. The authors investigate the reading materials and learning methods used by clinical clerks in their preparation for the National Board of Medical Examiners (NBME) Psychiatry Subject Exam (PSE).MethodsClerkship students from six U.S. medical schools who had recently completed their psychiatry clerkship and PSE were surveyed regarding reading material use, teaching methods encountered, and other relevant resources which may have influenced their PSE scores.ResultsThe most frequently used PSE preparation material was a “step-or-prep” book, followed by practice questions, handouts and assigned texts. No single preparation material type or combination proved significantly different in influencing PSE scores. The didactic methods used in clerkships did differ significantly in their influence on PSE scores. Students in the top quartile used slightly more books and different combinations of books than students in the bottom quartile.ConclusionStudents exhibited several trends in their preparation for the PSE. The most striking findings were the heavy student reliance on step-or-prep books over other learning resources and that step-or-prep books did not demonstrate significance as a superior preparation resource for the PSE. These trends in third-year psychiatric rotations have important implications for medical student education.

How Unusual Are the “Unusual Events” Detected by Control Chart Techniques in Healthcare Settings?

&NA; Statistical process control (SPC) charts have become widely implemented tools for quality monitoring and assurance in healthcare settings across the United States. SPC methods have been successfully used in industrial settings to track the quality of products manufactured by machines and to detect deviations from acceptable levels of product quality. However, problems may arise when SPC methods are used to evaluate human behavior. Specifically, when human behavior is tracked over time, the data stream generated usually exhibits periodicity and gradualism with respect to behavioral changes over time. These tendencies can be quantified and are recognized in the statistical field as autocorrelation. When autocorrelation is present, conventional SPC methods too often identify events as “unusual” when they really should be understood as products of random fluctuation. This article discusses the concept of autocorrelation and demonstrates the negative impact of autocorrelation on traditional SPC methods, with a specific focus on the use of SPC charts to detect unusual events.

The Role of Amantadine Withdrawal in 3 Cases of Treatment-refractory Altered Mental Status

Amantadine, which was originally developed as an antiviral medication, functions as a dopamine agonist in the central nervous system and consequently is utilized in the treatment of Parkinson disease, drug-induced extrapyramidal reactions, and neuroleptic malignant syndrome. For reasons that are not entirely understood, abrupt changes in amantadine dosage can produce a severe withdrawal syndrome. Existing medical literature describes case reports of amantadine withdrawal leading to delirium, which at times has progressed to neuroleptic malignant syndrome. Amantadine withdrawal may be under-recognized by mental health clinicians, which has the potential to lead to protracted hospital courses and suboptimal outcomes. The goal of this case series is to highlight the role of amantadine withdrawal in the cases of 3 medically complex patients with altered mental status. In the first case, the cognitive side effects of electroconvulsive therapy masked acute amantadine withdrawal in a 64-year-old man with Parkinson disease. In the second case, a 75-year-old depressed patient developed a catatonic delirium when amantadine was discontinued. Finally, a refractory case of neuroleptic malignant syndrome in a 57-year-old patient with schizoaffective disorder rapidly resolved with the reintroduction of outpatient amantadine. These cases highlight several learning objectives regarding amantadine withdrawal syndrome: First, it may be concealed by co-occurring causes of delirium in medically complex patients. Second, its symptoms are likely to be related to a cortical and limbic dopamine shortage, which may be reversed with electroconvulsive therapy or reintroduction of amantadine. Third, its clinical presentation may occur on a spectrum and may include features suggestive of delirium, catatonia, or neuroleptic malignant syndrome.

Cultural Change: Implementation of a Recovery Program in a Veterans Health Administration Medical Center Inpatient Unit:

INTRODUCTION:The Freedom Commission’s recommendations, Substance Abuse and Mental Health Services Administration’s framework, and policy directives on recovery-oriented services have fueled the recovery transformation. Mental health recovery services have been implemented in a broad range of outpatient settings. However, psychiatric inpatient units remained embedded in the traditional model of care. AIMS: The purpose of this article is to describe an ongoing quality improvement implementation of recovery services in a Veterans Health Administration acute psychiatric inpatient unit. METHOD: An interprofessional Partnership for Wellness delivered 4 to 6 hours per day of evidence-based recovery and holistic population-specific health programs. Veteran, system, and program indicators were measured. RESULTS: Preliminary indicators over a 2-year period suggest that Veterans rated group content and relevance high, pre–post psychiatric rehospitalization rates decreased by 46%, and fidelity to recommended strategies was high. CONCLUSIONS: The project success reflects strong leadership, a partnership of committed staff, effective training, and an organizational culture exemplifying excellence in Veteran services and innovation.