Community Treatment Orders and Other Forms of Mandatory Outpatient Treatment.

This position paper has been substantially revised by the Canadian Psychiatric Association's Professional Standards and Practice Committee and approved for republication by the CPA's Board of Directors on July 26, 2018. The original position paper1 was first approved by the Board of Directors on January 25, 2003. It was subsequently reviewed and approved for republication with minor revisions on June 2, 2009.

Should influenza vaccination be mandatory for healthcare workers?

Each year, many healthcare organizations deal with low influenza immunization rates among staff. Mandatory influenza vaccination programs may be considered in order to address this issue. These types of programs have caused controversy in the past, as staff has argued that they infringe upon their liberties and right to autonomy. However, if viewed from a public health perspective, mandatory vaccination programs are beneficial for both employees and patients and can be justified. When individuals make the decision to work in the medical field, it is assumed that their values align with those of the organization for which they work. This overrides their right to autonomy, since they are expected to put the safety of their patients ahead of their own personal interests. Although some may argue that receiving a flu shot is unsafe, evidence has demonstrated the opposite, and the minimal discomfort that may result from a vaccine is not enough to negate the responsibilities that healthcare workers have toward the patients they serve.

What does being on a community treatment orders entail? A 3-year follow-up of the OCTET CTO cohort.

PURPOSE: Community Treatment Orders lack evidence of effectiveness. Very little is known about how they are used in practice and over time in terms of what it obliges patients to do and the judicial threshold for remaining on an order. AIMS: To investigate CTO implementation in England in terms of the use of specified conditions, and judicial hearings; whether these change over time, and; the level of continued coercion. METHOD: 36-month observational prospective study of patients on CTO in the OCTET follow-up study. RESULTS: The number of CTO conditions remained stable over time but consolidated around medication adherence and remaining in contact with services. Ten percent of Mental Health Tribunal Hearings and only 1 percent of Hospital Managers Hearings resulted in discharge. Twenty-seven percent of patients experienced more than one CTO episode and eighteen percent remained under compulsion until the end of follow-up. CONCLUSIONS: CTOs seem to be used primarily to oblige patients to take medication and stay in contact with services. There is agreement between clinical and legal judgements about their appropriateness and threshold for use. A pattern of continuous coercion for a significant group of patients raises concerns. If CTOs are to be continued to be imposed, their use should be carefully monitored with further cohort studies with long-term follow-up.

Newborn screening of inherited metabolic disorders: the Italian situation.

Starting from an international overview of the current status of screening programs, the present paper focuses on the legal situation in Italy and the great differences among Italian regions. Since the introduction of tandem mass spectrometry (MS/MS) in the ‘90s the paradigm “one spot-one disease” changed. Only recently, some regions issued legislative acts to promote expanded newborn screening with MS/MS. This approach raises medico-legal and ethical issues because a fast neonatal diagnosis of an inborn error of metabolism (IEM) could increase chances of an early treatment and reduce disabilities, therefore citizens ought to have the same access to care countrywide. Enacting a mandatory standard for a disease screening panel using MS/MS and a few centers specialized in diagnosis, treatment and follow-up of patients affected by IEM (inborn errors of metabolism) can reduce legal and ethical issues.

A hybrid health service accreditation program model incorporating mandated standards and continuous improvement: interview study of multiple stakeholders in Australian health care.

The study aim was to investigate the understandings and concerns of stakeholders regarding the evolution of health service accreditation programs in Australia. Stakeholder representatives from programs in the primary, acute and aged care sectors participated in semi-structured interviews. Across 2011-12 there were 47 group and individual interviews involving 258 participants. Interviews lasted, on average, 1 h, and were digitally recorded and transcribed. Transcriptions were analysed using textual referencing software. Four significant issues were considered to have directed the evolution of accreditation programs: altering underlying program philosophies; shifting of program content focus and details; different surveying expectations and experiences and the influence of external contextual factors upon accreditation programs. Three accreditation program models were noted by participants: regulatory compliance; continuous quality improvement and a hybrid model, incorporating elements of these two. Respondents noted the compatibility or incommensurability of the first two models. Participation in a program was reportedly experienced as ranging on a survey continuum from "malicious compliance" to "performance audits" to "quality improvement journeys". Wider contextual factors, in particular, political and community expectations, and associated media reporting, were considered significant influences on the operation and evolution of programs. A hybrid accreditation model was noted to have evolved. The hybrid model promotes minimum standards and continuous quality improvement, through examining the structure and processes of organisations and the outcomes of care. The hybrid model appears to be directing organisational and professional attention to enhance their safety cultures. Copyright © 2015 John Wiley & Sons, Ltd.

The impact of legislative standards on batterer intervention program practices and characteristics.

Changes in social policy are often pursued with the goal of reducing a social problem by improving prevention efforts, intervention program practices, or participant outcomes. State legislative standards for intimate partner violence intervention programs have been adopted nearly universally across the US, however, we do not know whether such standards actually achieve the intended goal of affecting programs' policies and practices. To assess the effect that batterer intervention program (BIP) standards have on policies and practices of programs, this study used longitudinal surveys collected as part of an ongoing evaluation conducted from 2001 to the present to compare intervention program (N = 74) characteristics and practices at three time points before and after the adoption of standards in Oregon. Analyses were conducted to examine all BIPs in Oregon at each time point, as well as change among a subset of programs in existence at all survey assessments. Results indicate that across all programs, the use of mixed gender group co-facilitation increased by 14% between 2004 and 2008, while program length increased by approximately 12 weeks. However, other practices such as programs' coordination with community partners were unchanged. Analyses of within-program change revealed fewer differences, with only program length increasing significantly over the three assessments. These and other findings indicate that while standards affected program length as intended, other practices commonly addressed by legislative standards remained unchanged. The findings provide needed information regarding programs' compliance with components of the standards, the potential need for compliance monitoring, and the potential impact of state standards on program effectiveness and on the prevalence of intimate partner violence.

Mandatory pain scoring at triage reduces time to analgesia.

STUDY OBJECTIVE: We study whether mandatory triage pain scoring and an educational program reduces the time to initial analgesic treatment. METHODS: We performed a prospective interventional study in the emergency department (ED) of an adult tertiary referral hospital and major trauma center. After an observational assessment of baseline time to analgesic administration, we mandated the recording of triage pain scores through our computerized information system. In a second separate phase, we administered a staff educational package on the importance of timely analgesia. We measured time to initial analgesia after each phase and at 12-month follow-up. RESULTS: We studied 35,628 patients (8,743 baseline, 8,462 after mandating pain scoring, 9,043 after the educational program, and 9,380 at follow-up), with 12,925 patients (36.3%) overall receiving analgesics. At baseline, the median time to analgesia was 123 minutes (interquartile range [IQR] 58 to 231 minutes), which reduced with pain scoring (95 minutes; IQR 45 to 194 minutes) but no further with the educational package (98 minutes; IQR 45 to 191 minutes). At 12-month follow-up, the median time to analgesia was 78 minutes (IQR 45 to 143 minutes), 45 minutes (36.4%) faster than at baseline. CONCLUSION: The simple act of altering our ED computerized information system to require pain scoring at triage led to substantially faster provision of initial analgesia, with the effect sustained at 12 months.

Compulsory treatment and patient responsibility.

OBJECTIVE: Current legislative provisions for compulsory treatment of people with mental illness allow decisions to treat people under compulsion to be made on the basis of presence of a mental illness or mental disorder without consideration of whether the patient has the capacity to make decisions that are in his/her best interest. Issues of autonomy, equity, justice and beneficence in relation to treatment of people with mental illness are explored to determine decision-making rules that should be applied for compulsory mental health treatment. CONCLUSIONS: It is proposed that assessment of the capacity of the individual to make decisions in his/her best interest, rather than presence of diagnosable mental illness, should be the key consideration for compulsory mental health treatment.

Human papillomavirus vaccination rates and state mandates for tetanus-containing vaccines.

OBJECTIVE: We sought to examine nationally the association between school mandates for adolescent tetanus-containing vaccines (Td and/or Tdap) and adolescent female human papillomavirus (HPV) vaccination. METHODS: Each state was categorized by whether a school mandate for adolescent Td and/or Tdap vaccines was enacted. Mean HPV vaccine series initiation levels among adolescent females were compared between each mandate category. RESULTS: Mean HPV vaccine series initiation levels were significantly lower in states without Td/Tdap vaccine mandates than in those with mandates (42.9% vs. 47.3%; p=0.004). CONCLUSIONS: School mandates for adolescent Td/Tdap vaccination may have a carry-over effect on HPV vaccination.

Considerations for fair prioritization of COVID-19 vaccine and its mandate among healthcare personnel.

With current COVID-19 vaccine demand outweighing supply and the emergency authorization/rollout of three novel vaccines in the United States, discussions continue regarding fair prioritization among various groups for this scarce resource. The US federal government's recommended vaccination schedule, meant to assist states with vaccine allocation, demonstrates fair ethical considerations; however, difficulties remain comparing various groups to determine fair vaccine access and distribution. Although strides have been taken to analyze risks versus benefits of early vaccination across certain high-risk populations, prioritizing vulnerable populations versus essential workers remains challenging for multiple reasons. Similarly, as COVID-19 vaccine allocation and distribution continues in the US and in other countries, topics that require continued consideration include sub-prioritization among currently prioritized groups, prioritization among vulnerable groups disproportionately affected by the COVID-19 pandemic, like ethnic minorities, and holistic comparisons between groups who might receive various and disparate benefits from vaccination. Although all current COVID-19 vaccines are emergency authorization use only and a vaccine mandate would be considered only once these vaccines are licensed by the US Food and Drug Administration, future vaccination policies require time and deliberation. Similarly, given current vaccine hesitancy, mandatory vaccination of certain groups, like healthcare personnel, may need to be considered when these vaccines are licensed, especially if voluntary vaccination proves insufficient. Continued discussions regarding risks versus benefits of mandatory COVID-19 vaccination and the unique role of healthcare personnel in providing a safe healthcare environment could lead to better deliberation regarding potential policies. This commentary aims to address both questions of fair prioritization and sub-prioritization of various groups, as well as ethical considerations for mandatory COVID-19 vaccination among healthcare personnel.

Responses of Massachusetts hospitals to a state mandate to collect race, ethnicity and language data from patients: a qualitative study.

BACKGROUND: A Massachusetts regulation implemented in 2007 has required all acute care hospitals to report patients' race, ethnicity and preferred language using standardized methodology based on self-reported information from patients. This study assessed implementation of the regulation and its impact on the use of race and ethnicity data in performance monitoring and quality improvement within hospitals. METHODS: Thematic analysis of semi-structured interviews with executives from a representative sample of 28 Massachusetts hospitals in 2009. RESULTS: The number of hospitals using race, ethnicity and language data internally beyond refining interpreter services increased substantially from 11 to 21 after the regulation. Thirteen of these hospitals were utilizing patient race and ethnicity data to identify disparities in quality performance measures for a variety of clinical processes and outcomes, while 16 had developed patient services and community outreach programs based on findings from these data. Commonly reported barriers to data utilization include small numbers within categories, insufficient resources, information system requirements, and lack of direction from the state. CONCLUSIONS: The responses of Massachusetts hospitals to this new state regulation indicate that requiring the collection of race, ethnicity and language data can be an effective method to promote performance monitoring and quality improvement, thereby setting the stage for federal standards and incentive programs to eliminate racial and ethnic disparities in the quality of health care.

Should plant-based hospital meals be the law? An American experience.

Hospitalization is an unparalleled opportunity for physicians to educate patients about the interconnection between poor dietary choices and the occurrence of many chronic diseases. For those patients who are ready to embrace nutrition as an essential part of the healing process, however, it is oftentimes difficult to find healthy menus at hospitals. Meat-based entrées, sugar-sweetened beverages and candy appear to be omnipresent in cafeterias and restaurants at U.S. hospitals. On the other hand, healthy plant-based menus are still the exception rather than the rule. Some states undertook considerable efforts to change this and made plant-based meals the law. Upon request by a patient, hospitals in New York are now required by law to provide plant-based options at every meal. This recent development triggered a controversial discussion within the medical community whether other states should follow this example and make plant-based hospital menus the law as well. This editorial illuminates why mandatory plant-based hospital menus could be a win-win situation for many involved stakeholders, including patients, hospitals and food services. This step is not a loss-marking venture for hospitals but rather a chance to save money and to improve corporate brand marketing at the same time. The introduction of mandatory plant-based menus in hospitals at a large scale represents a unique opportunity at the nexus of health, innovative corporate strategies and economics. Adequate framework conditions are necessary to ensure that all individuals can make healthy and affordable dietary choices while being hospitalized.

Falling short: When testing is mandated and follow-up is not.

In 1999, the Texas Legislature mandated acanthosis nigricans (AN) screening in primary schools in designated regions of the state through the passage of House Bill 1860 to identify children at risk for diabetes by identifying the skin condition AN. AN is related to insulin resistance, and, thus, is associated with type 2 diabetes (diabetes mellitus type 2 [DMT2]), a growing concern among school-aged children. Since 1999, millions of children have been screened and hundreds of thousands have been screened positive. No data are available about the effectiveness of the program in identifying DMT2 among the school-aged population because no follow-up is mandated. The current practice is to send a letter to the parents of the child who screens positive, advising the parents to take the child to a health care provider for further assessment. Hence, children within the state may have diabetes or are developing diabetes but have yet to be diagnosed. In light of the presence of a law mandating AN screening, mandating a follow-up to identify those who have diabetes or are developing the condition of diabetes can provide early intervention and decrease costs of care. It is not known why the follow-up of those who screen positive was not included in the initial legislation. It may have been due to the cost of the necessary blood tests that are used to assess an individual for diabetes. Related to this is the reality that blood tests are invasive procedures, whereas screening for a skin disorder is not, thereby possibly explaining the omission of mandated follow-up from the legislation .

Child care as an untapped setting for obesity prevention: state child care licensing regulations related to nutrition, physical activity, and media use for preschool-aged children in the United States.

INTRODUCTION: Child care is a potential setting for obesity prevention; 8.6 million preschool-aged children participated in child care in 2001. Each US state creates and enforces its own child care licensing regulations. We analyzed obesity-related child care licensing regulations of US states. METHODS: We downloaded state licensing regulations for children in child care centers (CCCs), small family child care homes (SFHs), and large family or group child care homes (LFGHs) in each state and the District of Columbia (collectively referred to as "states") in 2006 from national and state Web sites. We conducted a quantitative content analysis to identify 13 coding dimensions related to nutrition, physical activity, and media use. RESULTS: We found variability among and within states. CCCs were the most heavily regulated and had the most specific regulations, followed by LFGHs. SFHs had the fewest and most general regulations. Just 2 states, Michigan and West Virginia, specified that CCC menus should be consistent with the Dietary Guidelines for Americans. Only 12 states had regulations that limited foods of low nutritional value in CCCs. Thirty-six states required that children have daily outdoor activity time in CCCs; only 9 states set specific minimum lengths of time that children should be outdoors each day. Eight states set quantified time limits on screen time per day or per week in SFHs. CONCLUSION: Opportunities exist for strengthening state licensing regulations to prevent childhood obesity. The increasing prevalence of childhood obesity underscores the urgency for state policy efforts to create child care environments that foster healthful eating and participation in physical activity.

Obesity prevention in child care: a review of U.S. state regulations.

OBJECTIVE: To describe and contrast individual state nutrition and physical activity regulations related to childhood obesity for child care centers and family child care homes in the United States. METHODS: We conducted a review of regulations for child care facilities for all 50 states and the District of Columbia. We examined state regulations and recorded key nutrition and physical activity items that may contribute to childhood obesity. Items included in this review were: 1) Water is freely available; 2) Sugar-sweetened beverages are limited; 3) Foods of low nutritional value are limited; 4) Children are not forced to eat; 5) Food is not used as a reward; 6) Support is provided for breastfeeding and provision of breast milk; 7) Screen time is limited; and 8) Physical activity is required daily. RESULTS: Considerable variation exists among state nutrition and physical activity regulations related to obesity. Tennessee had six of the eight regulations for child care centers, and Delaware, Georgia, Indiana, and Nevada had five of the eight regulations. Conversely, the District of Columbia, Idaho, Nebraska and Washington had none of the eight regulations. For family child care homes, Georgia and Nevada had five of the eight regulations; Arizona, Mississippi, North Carolina, Oregon, Tennessee, Texas, Vermont, and West Virginia had four of the eight regulations. California, the District of Columbia, Idaho, Iowa, Kansas, and Nebraska did not have any of the regulations related to obesity for family child care homes. CONCLUSION: Many states lack specific nutrition and physical activity regulations related to childhood obesity for child care facilities. If widely implemented, enhancing state regulations could help address the obesity epidemic in young children in the United States.