RETRACTED: Reduced self-harm on acute mental health wards following the implementation of a vision-based patient monitoring system: Evidence from five NHS trusts.

WHAT IS KNOWN ON THE SUBJECT?: Inpatient mental health settings pose unique challenges for patient safety, in part because psychiatric disorders are well-known risk factors for self-harm and suicide. Ward staff follow protocols to try and keep patients safe including carrying out in-person safety checks, usually every 15 min, but patients unfortunately still find opportunities to harm themselves. A vision-based patient monitoring system (VBPMS) is a contact-free technology that can help mental health nurses to monitor patients in hospital more effectively. For example, the tool alerts staff to situations where a patient might need assistance, like when they spend a long period of time in their ensuite bathroom. Research has shown that the VBPMS can support staff to prevent safety incidents from occurring and a recent study found a decrease in self-harm after the tool was implemented at one NHS mental health trust. WHAT DOES THE PAPER ADD TO EXISTING KNOWLEDGE?: This paper presents data from five NHS mental health trusts and suggests that the VBPMS can consistently help staff to prevent self-harm on acute mental health wards. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: Managing self-harm behaviours is a challenge for mental health nursing staff. Standard safety protocols are not effective enough - staff need new ways to monitor patients. In general hospitals, technology is used every day to support care. This research shows that the VBPMS can be used to improve patient safety in mental health hospitals. ABSTRACT: Introduction Self-harm is sadly relatively common in mental health inpatient settings, and the effectiveness and appropriateness of strategies used to prevent it have long been disputed. The use of vision-based patient monitoring systems (VBPMS) has been shown to improve various safety outcomes. Their potential to support staff in preventing inpatient self-harm warrants further exploration. Aim This research investigated whether implementing a VBPMS-as an adjunct to existing clinical practice-within acute inpatient services at five NHS England mental health trusts led to reductions in self-harm. Method Five quasi-experimental studies assessed the number of bedroom self-harm incidents, across 12 adult wards, before and 5-12 months after a VBPMS was deployed. Percentage changes were calculated. Four studies used control groups and were included in a fixed-effect meta-analysis. Results In the meta-analysis, a significant inverse-weighted average relative risk percentage change of -38.9% was recorded. For the study with no control groups, reductions in self-harm were seen across all wards (range: -9.1% to -29.8%). Discussion This research demonstrates that VBPMS can support clinicians to create safer ward environments by preventing incidents of self-harm from occurring. Implications for Practice The results provide preliminary support for wider rollout of the technology on acute mental health wards.

Experiences of Black Adults Evaluated in a Locked Psychiatric Emergency Unit: A Qualitative Study.

OBJECTIVE: Evidence shows that Black individuals have higher rates of coercive emergency psychiatric interventions than other racialized groups, yet no studies have elevated the voices of Black patients undergoing emergency psychiatric evaluation. This qualitative study sought to explore the experiences of Black individuals who had been evaluated in a locked psychiatric emergency unit (PEU). METHODS: Electronic health records were used to identify and recruit adult patients (ages ≥18 years) who self-identified as Black and who had undergone evaluation in a locked PEU at a large academic medical center. In total, 11 semistructured, one-on-one interviews were conducted by telephone, exploring experiences during psychiatric evaluation. Transcripts were analyzed with thematic analysis. RESULTS: Participants shared experiences of criminalization, stigma, and vulnerability before and during their evaluation. Although participants described insight into their desire and need for treatment and identified helpful aspects of the care they received, they noted a mismatch between their expectations of treatment and the treatment received. CONCLUSIONS: This study reveals six major patient-identified themes that supplement a growing body of quantitative evidence demonstrating that racialized minority groups endure disproportionate rates of coercive interventions during emergency psychiatric evaluation. Interdisciplinary systemic changes are urgently needed to address structural barriers to equitable psychiatric care.

Virtual Acute Psychiatric Ward: Evaluation of Outcomes and Cost Savings.

OBJECTIVE: The COVID-19 pandemic motivated rapid expansion of virtual care. In Winnipeg, Canada, the authors launched a virtual psychiatric acute care ward (vWARD) to divert patients from hospitalization through daily remote treatment by a psychiatry team using telephone or videoconferencing. This study examined vWARD patient characteristics, predictors of transfer to a hospital, use of acute care postdischarge, and costs of the vWARD compared with in-person hospitalization. METHODS: Data for all vWARD admissions from March 23, 2020, to April 30, 2021, were retrieved from program documents and electronic records. Emergency department visits and hospitalizations in the 6 months before admission and the 30 days after discharge were documented. Logistic regression identified factors associated with transfer to a hospital. Thirty-day acute care use after discharge was modeled with Kaplan-Meier curves. A break-even cost analysis was generated with data for usual hospital-based care. RESULTS: The 132 vWARD admissions represented a diverse demographic and clinical population. Overall, 57% involved suicidal behavior, and 29% involved psychosis or mania. Seventeen admissions (13%) were transferred to a hospital. Only presence of psychosis or mania significantly predicted transfer (OR=34.2, 95% CI=3.3-354.6). Eight individuals were hospitalized in the 30 days postdischarge (cumulative survival=0.93). vWARD costs were lower than usual care across several scenarios. CONCLUSIONS: A virtual ward is a feasible, effective, and potentially cost-saving intervention to manage acute psychiatric crises in the community and avoid hospitalization. It has benefits for both the health system and the individual who prefers to receive care at home.

Monitoring Mental Health: Legal and Ethical Considerations of Using Artificial Intelligence in Psychiatric Wards.

Artificial intelligence (AI) is being tested and deployed in major hospitals to monitor patients, leading to improved health outcomes, lower costs, and time savings. This uptake is in its infancy, with new applications being considered. In this Article, the challenges of deploying AI in mental health wards are examined by reference to AI surveillance systems, suicide prediction and hospital administration. The examination highlights risks surrounding patient privacy, informed consent, and data considerations. Overall, these risks indicate that AI should only be used in a psychiatric ward after careful deliberation, caution, and ongoing reappraisal.

Impact of COVID-19 Mitigation Efforts on Adults With Serious Mental Illness: A Patient-Centered Perspective.

ABSTRACT: In response to COVID-19 mitigation policies, mental health and social service agencies have had to rapidly change their operations, creating challenges for patients with serious mental illness (SMI). This study aimed to explore the experiences of adults with SMI navigating these altered systems during the pandemic. In-depth interviews were conducted with 20 hospitalized adults with SMI in the fall of 2020; they were coded using thematic analysis. Most participants found the new systems effective at meeting their essential needs. However, several reported significant unmet needs, including inability to access mental health care and public benefits. These participants lacked identification documents, housing, and/or a personal device. Although none of the participants used telemedicine before COVID-19, most reported no or minimal problems with telemental health. Those reporting difficulties did not have personal devices, were receiving audio-only services, or viewed telemedicine as less personal or too distracting.

Social inclusion and violence prevention in psychiatric inpatient care. A qualitative interview study with service users, staff members and ward managers.

BACKGROUND: Many psychiatric services include social inclusion as a policy with the aim to offer users the opportunity to participate in care and to form reciprocal relationships. The aim of this study was to explore opportunities and problems with regard to participation, reciprocity and social justice that different stakeholders experience when it comes to social inclusion for service users and minimizing violence in psychiatric inpatient care. METHODS: Qualitative interviews were performed with 12 service users, 15 staff members, and six ward managers in three different kinds of psychiatric wards in Sweden. The data were analyzed using the framework method and qualitative content analysis, which was based on the three following social inclusion values: participation, reciprocity, and social justice. RESULTS: Themes and subthemes were inductively constructed within the three social inclusion values. For participation, staff and ward managers reported difficulties in involving service users in their care, while service users did not feel that they participated and worried about what would happen after discharge. Staff gave more positive descriptions of their relationships with service users and the possibility for reciprocity. Service users described a lack of social justice, such as disruptive care, a lack of support from services, not having access to care, or negative experiences of coercive measures. Despite this, service users often saw the ward as being safer than outside the hospital. Staff and managers reported worries about staffing, staff competence, minimizing coercion and violence, and a lack of support from the management. CONCLUSIONS: By applying the tentative model on empirical data we identified factors that can support or disrupt the process to create a safe ward where service users can feel socially included. Our results indicate that that staff and service users may have different views on the reciprocity of their relationships, and that users may experience a lack of social justice. The users may, due to harsh living conditions, be more concerned about the risk of violence in the community than as inpatients. Staff and ward managers need support from the management to foster a sense of community in the ward and to implement evidence-based prevention programs.

Impact of closure of the in-house psychiatric care unit on prehospital and emergency ward length of stay and disposition locations in patients who attempted suicide: A retrospective before-and-after cohort study at a community hospital in Japan.

ABSTRACT: Suicide is an increasingly serious public health care concern worldwide. The impact of decreased in-house psychiatric resources on emergency care for suicidal patients has not been thoroughly examined. We evaluated the effects of closing an in-hospital psychiatric ward on the prehospital and emergency ward length of stay (LOS) and disposition location in patients who attempted suicide.This was a retrospective before-and-after study at a community emergency department (ED) in Japan. On March 31, 2014, the hospital closed its 50 psychiatric ward beds and outpatient consultation days were decreased from 5 to 2 days per week. Electronic health record data of suicidal patients who were brought to the ED were collected for 5 years before the decrease in in-hospital psychiatric services (April 1, 2009-March 31, 2014) and 5 years after the decrease (April 1, 2014-March 31, 2019). One-to-one propensity score matching was performed to compare prehospital and emergency ward LOS, and discharge location between the 2 groups.Of the 1083 eligible patients, 449 (41.5%) were brought to the ED after the closure of the psychiatric ward. Patients with older age, burns, and higher comorbidity index values, and those requiring endotracheal intubation, surgery, and emergency ward admission, were more likely to receive ED care after the psychiatric ward closure. In the propensity matched analysis with 418 pairs, the after-closure group showed a significant increase in median prehospital LOS (44.0 minutes vs 51.0 minutes, P < .001) and emergency ward LOS (3.0 days vs 4.0 days, P = .014) compared with the before-closure group. The rate of direct home return was significantly lower in the after-closure group compared with the before-closure group (87.1% vs 81.6%, odds ratio: 0.66; 95% confidence interval: 0.45-0.96).The prehospital and emergency ward LOS for patients who attempted suicide in the study site increased significantly after a decrease in hospital-based mental health services. Conversely, there was significant reduction in direct home discharge after the decrease in in-house psychiatric care. These results have important implications for future policy to address the increasing care needs of patients who attempt suicide.

A Critique on Psychiatric Inpatient Admissions for Suicidality in Youth.

ABSTRACT: For the last few decades, psychiatric inpatient admissions for the treatment of suicidality in US youth have been increasing. Nonetheless, since 2007, the national rate of completed suicides by youth has steadily and sizably increased. Therefore, a literature review was performed to evaluate the usefulness of the psychiatric inpatient admission of suicidal youths. The analysis concluded that suicidality is surprisingly common in youth, completed suicide is very uncommon in early adolescence, suicidal ideation is a major reason in early adolescence for inpatient admission, girls are admitted to psychiatric inpatient units three times more than boys even though boys complete suicide four times more than girls, inpatient stays average 6 days and are quite expensive, and repeat attempts after inpatient treatment are common. Thus, filling more beds for youth with suicidality lacks evidence of a public health, long-term benefit. Expanding the focus in psychiatry to population efforts including means reductions is recommended.

COVID-19 pandemic inpatient bed allocation planning - A Canada-wide approach.

OBJECTIVE: A Canada-wide survey was disseminated to collect information regarding changes in processes related to providing care to patients on inpatient psychiatry units in response to the COVID-19 pandemic. Our aim was to share this information with those who have an interest in problem-solving these significant and unique challenges. METHOD: The survey was distributed through the Association of Chairs of Psychiatry of Canada to Department Heads of Psychiatry at all sixteen medical schools. Information was collected via SurveyMonkey April 26-May 9, 2020. Eleven psychiatrists representing 11 different Canadian city/centre/zone(s) completed the survey. RESULTS: Information was collected about process changes: physical separation on the wards, symptom and vital signs screening, testing, isolation, rationales for number of beds allocated for COVID-positive, -suspect and -negative patients and for selecting a particular hospital to provide care to these different groupings of patients. One subsection of the information is presented in this letter. Further information is available upon request. CONCLUSION: Similarities and differences existed between city/centre/zone(s) regarding approaches to providing care to patients on inpatient psychiatry wards. Significant preparation and consideration was put into determining necessary changes in response to this pandemic, and this is reflected in the information provided from each city/centre/zone.

The incidence and economic impact of aggression in closed long-stay psychiatric wards.

OBJECTIVE: Aggressive behaviour is highly prevalent in long-term psychiatric inpatient care. We aimed to estimate the overall incidence of aggression, the time staff took to handle aggression incidents, and the weighted average financial costs thereof. METHODS: A random sampling procedure was conducted at long-term psychiatric inpatient care facilities. Nurses were asked to recall all incidents (i.e., verbal, physical towards objects, self, or others) of their shift. For the time spent on each type of incident, staff were monitored in real-time. Estimated costs were calculated by the time spent multiplied by hourly wages in addition to material-related costs. RESULTS: Incidence rates were 90 incidents per patient year. The average time spent per incident was 125 min but differed for each type of incident. Almost 80% of this time was consumed by nursing staff. The average cost per aggression incident was €78; extrapolated per patient year, the total costs were approximately €7000. CONCLUSIONS: The current study found a high rate of aggression incidents in closed long-stay psychiatric wards. Reports of aggression on these types of wards are scarce. Nevertheless, aggression seems to have a severe impact on invested time and related costs, which suggests a need for aggression-prevention and de-escalating programs.Key pointsAggression incidents are highly prevalent and are accompanied by high costs.The effect of aggression incidents on the workload for staff members is high, especially for nursing staff.Studies across countries on the incidence and the costs of aggression among psychiatric inpatients are needed to help model the effects of (new) strategies for aggression reduction.

An evaluation of the implementation of Safewards on an assessment and treatment unit for people with an intellectual disability.

This study evaluates the implementation of Safewards on an assessment and treatment unit (ATU) for people with an intellectual disability. There are no previous studies evaluating this model in this context and previous research has focused largely on acute mental health services. The 'Patient-Staff Conflict Shift Report' was used at baseline for 1 month and 1 year later, after all the interventions had been implemented, to evaluate the impact of Safewards. Significant reductions were found in conflict and containment measures used within the service after the implementation of Safewards. Staff who led on the interventions were also asked to give feedback on their experiences, the challenges they faced and how they would like to move forward. Safewards was generally seen as a positive approach by the team. Limitations of this study are highlighted and suggestions for future research are made.

Monitoring risk assessment on an acute psychiatric ward: Effects on aggression, seclusion and nurse behaviour.

Evidence of risk assessment procedures is scarce and inconclusive. The aim of this study is to evaluate the effects of risk assessment on aggression and the use of coercive interventions in an acute psychiatric admission setting. In addition, we evaluated nurse behaviour before and after the use of risk assessment. To take the fluctuations with regard to aggression and coercive interventions into account, we allowed 26 weeks for baseline measurements, followed by a 26 weeks steady-state period after the implementation of the risk assessment instrument. Contrary to expectations, no positive effects of risk assessment were found on aggression or on coercive interventions. Time spent in seclusion increased significantly with more than 10 hours on average after implementation. Furthermore, there were only negative effects on nurse behaviour and experiences. Among other things, they felt more stressed, spent more time on administration tasks and spent less time with patients after the implementation. In conclusion, there is insufficient evidence to use structured short-term risk assessment to reduce aggression or coercive interventions.

Prevalence, management, and outcomes of SARS-CoV-2 infections in older people and those with dementia in mental health wards in London, UK: a retrospective observational study.

BACKGROUND: People living in group situations or with dementia are more vulnerable to infection with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Older people and those with multimorbidity have higher mortality if they become infected than the general population. However, no systematic study exists of COVID-19-related outcomes in older inpatients in psychiatric units, who comprise people from these high-risk groups. We aimed to describe the period prevalence, demographics, symptoms (and asymptomatic cases), management, and survival outcomes of COVID-19 in the older inpatient psychiatric population and people with young-onset dementia in five National Health Service Trusts in London, UK, from March 1 to April 30, 2020. METHODS: In this retrospective observational study, we collected demographic data, mental health diagnoses, clinical diagnosis of COVID-19, symptoms, management, and COVID-19-related outcome data of inpatients aged 65 years or older or with dementia who were already inpatients or admitted as inpatients to five London mental health Trusts between March 1 and April 30, 2020, and information about available COVID-19-related resources (ie, testing and personal protective equipment). Patients were determined to have COVID-19 if they had a positive SARS-CoV-2 PCR test, or had relevant symptoms indicative of COVID-19, as determined by their treating physician. We calculated period prevalence of COVID-19 and analysed patients' characteristics, treatments, and outcomes. FINDINGS: Of 344 inpatients, 131 (38%) were diagnosed with COVID-19 during the study period (period prevalence 38% [95% CI 33-43]). The mean age of patients who had COVID-19 was 75·3 years (SD 8·2); 68 (52%) were women and 47 (36%) from ethnic minority groups. 16 (12%) of 131 patients were asymptomatic and 121 (92%) had one or more disease-related comorbidity. 108 (82%) patients were compulsorily detained. 74 (56%) patients had dementia, of whom 13 (18%) had young-onset dementia. On average, sites received COVID-19 testing kits 4·5 days after the first clinical COVID-19 presentation. 19 (15%) patients diagnosed with COVID-19 died during the study period, and their deaths were determined to be COVID-19 related. INTERPRETATION: Patients in psychiatric inpatient settings who were admitted without known SARS-CoV-2 infection had a high risk of infection with SARS-CoV-2 compared with those in the community and had a higher proportion of deaths from COVID-19 than in the community. Implementation of the long-standing policy of parity of esteem for mental health and planning for future COVID-19 waves in psychiatric hospitals is urgent. FUNDING: None.

[Health care delivery and psychiatric hospitalizations in the prisons of the North of France: An observational study]. / Offre de soins et recours aux hospitalisations psychiatriques en milieu pénitentiaire : une étude observationnelle dans le Nord de la France.

BACKGROUND: In French prisons, psychiatric care for inmates is organized into three levels: ambulatory care within each jail in "unités sanitaires en milieu pénitentiaire" (USMP: sanitary units in correctional settings), day hospitalizations in the 28  services médico-psychologiques régionaux (SMPR, "regional medical-psychological services") and full-time hospitalizations in one of the nine "unités d'hospitalisation spécialement aménagées" (UHSA: specially equipped hospital units). Despite high prevalence of mental disorders among French prisoners, the efficiency of these specialized psychiatric care units has been insufficiently studied. The main goal of this study is to describe full-time psychiatric hospitalizations for inmates in the twenty prisons located in the North of France. METHODS: We conducted a descriptive study based on medical and administrative data and survey results. The following data were collected for each prison regarding 2016: 1) number and occupancy rates for mental health professionals and 2) psychiatric hospitalization rates (in the UHSA of Lille-Seclin and the general psychiatric hospitals). RESULTS: Provision of care is incomplete: the vacancy rate in the health units studied reaches 40 %. Moreover, access to UHSA is unequal: it varies pronouncedly according to the location of the prison; only inmates in prisons close to the UHSA benefit from satisfactory access. CONCLUSION: Access to psychiatric care for inmates remains problematic in France, particularly due to a lack of mental health professionals in USMPs, the overload of patients in UHSAs and the distance of theses facilities from certain prisons and jails.

Medical comorbid diagnoses among adult psychiatric inpatients.

OBJECTIVE: Shortened life expectancy of people with mental disorders has been attributed to medical comorbidities, yet these conditions remain under-recognized and under-treated. This study characterizes the medical demands placed on inpatient psychiatric units to help guide medical assessment and management practices in these settings. METHODS: Medicaid claims records and clinician data were linked with hospital and regional data for individuals with a principal diagnosis of any mental disorder admitted to psychiatric inpatient units in New York State from 2012 to 2013. A modified Elixhauser Comorbidity Index (ECI) score was calculated for each unique individual (n = 14,458). Adjusted odds ratios (AORs) of having a medical comorbidity were calculated using logistic regression analyses. RESULTS: 74.9% of psychiatric inpatients had at least one medical comorbidity, including 57.5% of people ages 18-24. Higher rates of medical comorbidity were associated with older age, female gender, non-schizophrenia diagnoses, and engagement in care prior to hospitalization. Patients with medical comorbidities had lower odds (AOR 0.54; 99% CI 0.35-0.83) of being treated in hospitals with 100 or more total beds compared to smaller hospitals. CONCLUSIONS: A high prevalence of common medical diagnoses among psychiatric inpatients underscores the importance of adequate detection and medical treatment of medical comorbidities in psychiatric inpatient settings.

Optimization strategies for the organization of mental healthcare.

AIM: The aim of this paper is to analyse the main issues and obstacles to optimizing the organization of mental healthcare and the strategies that should be applied by presenting the examples from practice. RESULTS: Outcomes of mental healthcare are in relation with 'improved legislation' and the introduction of up-to-date management and economic concepts including continuous treatment model, in addition to the advantages and disadvantages in the provision of mental healthcare within primary and secondary inpatient and outpatient healthcare. Some of these lessons are learned from reforms implemented in Serbia.

[Mental health care in French correctional facilities during the Covid-19 pandemic]. / Prisons confinées : quelles conséquences pour les soins psychiatriques et la santé mentale des personnes détenues en France ?

OBJECTIVE: The impact of the Covid-19 pandemic on the 11 million people currently incarcerated worldwide is the subject of many concerns. Prisons and jails are filled with people suffering from many preexisting medical conditions increasing the risk of complications. Detainees' access to medical services is already limited and overcrowding poses a threat of massive contagion. Beyond the health impact of the crisis, the tightening of prison conditions worries. On March 16, 2020, in France, the lockdown measures have been accompanied by specific provisions for prisons: all facilities have suspended visitations, group activities and external interventions. Over 10,000 prisoners have been released to reduce the prison population and the risk of virus propagation. These adjustments had major consequences on the healthcare system in French prisons. The objectives of this article are to describe the reorganization of the three levels of psychiatric care for inmates in France in the context of Covid-19 pandemic and to have a look at the impact of lockdown measures and early releases on mental health of prisoners. METHODS: This work is based on a survey conducted in April 2020 in France among psychiatric healthcare providers working in 42 ambulatory units for inmates and in the 9 full-time inpatient psychiatric wards exclusively for inmates called "UHSAs" (which stands for "unités hospitalières spécialement aménagées", and can be translated as "specially equipped hospital units"). A review of the international literature on mental healthcare system for inmates during the Covid-19 epidemic has also been performed. RESULTS: The Covid-19 epidemic has been rather contained during the period of confinement in French prisons but the impact of confinement measures on the prison population is significant. The three levels of psychiatric care for inmates have implemented specific measures to ensure continuity of care, to support detainees during Coronavirus lockdown and to prevent an infection's spread. Among the most important are: limitation of medical consultations to serious and urgent cases, creation of "Covid units", cancellation of voluntary psychiatric hospitalizations, reinforcement of preventive hygiene measures and reshuffling of medical staff. Prolonged confinement has consequences on mental health of detainees. Currently, mental health workers are facing multiple clinical situations such as forced drug and substance withdrawal (linked to difficulties in supplying psychoactive substances), symptoms of anxiety (due to concerns for their own and their relatives' well-being) and decompensation among patients with severe psychiatric conditions. Early releases from prison may also raise some issues. People recently released from prison are identified as at high risk of death by suicide and drug overdose. The lack of time to provide the necessary link between health services within prisons and health structures outside could have serious consequences, emphasizing the well-known "revolving prison doors" effect. DISCUSSION: The current lockdown measures applied in French jails and prisons point out the disparities between psychiatric care for inmates and psychiatric care for general population. Giving the high vulnerability of prison population, public health authorities should pay more attention to health care in prisons.