Association between Oropharyngeal Dysphagia and Malnutrition in Dutch Nursing Home Residents: Results of the National Prevalence Measurement of Quality of Care.

OBJECTIVES: Nursing home residents often suffer from multi-morbidities and geriatric syndromes leading to lower quality of life or mortality. Oropharyngeal dysphagia (OD) and malnutrition are profound conditions in this complex profile of multi-morbidities and are associated with deprived mental -and physical health status, e.g. aspiration pneumonia or dehydration. This study aimed to assess the association between OD and malnutrition in Dutch nursing home residents. DESIGN: Data for this cross-sectional study were obtained from the annual National Prevalence Measurement of Quality of Care (LPZ). SETTING: The National Prevalence Measurement of Quality of Care was conducted in Nursing Homes in The Netherlands. PARTICIPANTS: Participants were nursing home residents age 65 or older and admitted to psychogeriatric- or somatic wards. MEASUREMENTS: The measurements were taken by trained nurses from the participating nursing homes. Anthropometric measurements and unintended weight loss (%) were assessed to determine nutritional status (malnutrition). OD was assessed by means of a standardized questionnaire assessing clinically relevant symptoms of OD such as swallowing problems or sneezing/coughing while swallowing. Cox regression was applied to assess the association between malnutrition and clinically relevant symptoms of OD in older Dutch nursing home residents. RESULTS: Approximately 12% of the residents suffered from swallowing problems and 7% sneezed/coughed while swallowing liquids or solid foods. Approximately 10% of the residents was malnourished. Residents with OD symptoms were more often malnourished compared to residents without OD symptoms. Approximately 17% of the problematic swallowers were concurrently malnourished. Increased risk for malnutrition was found in residents suffering from swallowing problems (PR 1.5, 95%CI 1.2-1.9), as well as in residents that sneezed/coughed while swallowing (PR 1.3, 95%CI 1.0-1.7). Stratification based on wards revealed that problematic swallowers from somatic wards were at a high risk of malnutrition (PR 1.9, 95%CI 1.3-2.8). CONCLUSION: Clinically relevant symptoms of oropharyngeal dysphagia, such as swallowing problems and sneezing/coughing while swallowing are associated with increased risk of malnutrition in psychogeriatric and somatic Dutch nursing home residents.

Muscle, Health and Costs: A Glance at their Relationship.

OBJECTIVE: To assess the association between muscle parameters (mass, strength, physical performance) and activities of daily living (ADL), quality of life (QoL), and health care costs. DESIGN: Cross-sectional Maastricht Sarcopenia Study (MaSS). SETTING: Community-dwelling, assisted-living, residential living facility. PARTICIPANTS: 227 adults aged 65 and older. MEASUREMENTS: Muscle mass, hand grip strength and physical performance were assessed by bio-electrical impedance, JAMAR dynamometer and the Short Physical Performance Battery, respectively. Health outcomes were measured by the Groningen Activity Restriction Scale (disability in ADL) and the EQ-5D-5L (QoL). Health care costs were calculated based on health care use in the past three months. RESULTS: Muscle strength and physical performance showed a strong correlation with ADL, QoL, and health care costs (P<.01); for muscle mass no significant correlations were observed. Regression analyses showed that higher gait speed (OR 0.06, 95%CI 0.01-0.55) was associated with a lower probability of ADL disability. Furthermore, slower chair stand (OR 1.23, 95%CI 1.08-1.42), and more comorbidities (OR 1.58, 95%CI 1.23-2.02) were explanatory factors for higher ADL disability. Explanatory factors for QoL and costs were: more disability in ADL (OR 1.26, 95%CI 1.12-1.41 for QoL; B = 0.09, P<.01 for costs) and more comorbidities (OR 1.44, 95%CI 1.14-1.82 for QoL; B = 0.35, P<.01 for costs). CONCLUSION: Lower gait speed and chair stand were potential drivers of disability in ADL. Disability in ADL and comorbidities were associated with QoL and health care costs in community-dwelling older adults. Improving physical performance may be a valuable target for future intervention and research to impact health burden and costs.

Dysphagia in Hospitalized Older Patients: Associated Factors and Nutritional Interventions.

OBJECTIVES: To (1) assess the association between dysphagia and malnutrition as well as other related factors and (2) investigate the nutritional interventions that are initiated in dysphagic older patients. DESIGN: Cross-sectional, multi-center point prevalence measurement. SETTING: 53 Austrian hospitals. PARTICIPANTS: 3174 hospitalized patients, 65 years or older. MEASUREMENTS: A standardized and tested questionnaire was used for the data collection, which was based on both inspections of the patients and information documented in the patient chart. Medical diagnoses were assessed by referring to the International Classification of Diseases. Dysphagia was measured by asking the patient a dichotomous question. Several other data points were collected including: gender, age, number of diseases, malnutrition, care dependency scale (CDS) score and dependency during activities of daily living (ADL). To investigate the associations between dysphagia and malnutrition and other associated factors, cross tabulation, chi-squared test, t-test and Mann-Whitney U test were used. RESULTS: The prevalence of dysphagia among these patients was 7.6%. Dysphagia and malnutrition were significantly associated (< 0.001). Patients with dysphagia had statistically significant lower BMI values (p = 0.01), more medical diagnoses (p = 0.003) and were more care dependent (p < 0.001) than patients who did not suffer from dysphagia. The frequency of underlying respiratory diseases, dementia, nervous system disorders and cerebrovascular accidents also differed significantly between dysphagic and non-dysphagic patients. The following nutritional interventions were most frequently initiated in patients with dysphagia: provision of texture-modified food/fluid (32.2%), referral to a dietitian (31.4%), provision of an energy- and/or protein-enriched diet (27.3%), monitoring of nutritional intake (21.5%), enteral nutrition (19.4%) and provision of energy-enriched snacks (15.7%). 24% of patients received no nutritional interventions. CONCLUSION: This study demonstrates that a very strong association exists between dysphagia and malnutrition as well as high levels of care dependency and dependency in activities of daily living. Nearly one-quarter of the patients did not receive any nutritional intervention. Therefore, a potential for the improvement of nutritional therapy in older dysphagic hospitalized patients still exists.

Cost analysis of one of the first outpatient wound clinics in the Netherlands.

OBJECTIVE: To perform, from an insurance perspective, a cost analysis of one of the outpatient community wound care clinics in the Netherlands, the Knowledge Centre in Wound Care (KCWC) at Venray. METHOD: This study involved a cost analysis based on an observational cohort study with a one-year pre-admission and a one-year post-admission comparison of costs. Patients were included when they first consulted the outpatient wound care clinic. Participants were all insured by the same health insurance company, Coöperatie Volksgezondheidszorg (VGZ). A standard six-step procedure for performing cost studies was used to calculate the costs. Given the skewed cost data, non-parametric bootstrapping was used to test for statistical differences. RESULTS: There were 172 patients included in this study. The difference in costs related to wound care between the year before and the year after initial admission to the wound clinic amounted to an average reduction of €2621 (£1873) per patient in the base case analysis. The categories 'general practitioner', 'hospital care', 'mental health care' and 'transport' scored lower, indicating lower costs, in the year after admission to the wound clinic. CONCLUSION: In this study, only the reimbursement data of patients of one health insurance company, and specifically only those made under the 2006 Dutch Health Insurance Act, were available. Because of the observational design, definitive conclusions cannot be made regarding a demonstrated reduction of costs in the year post admission. Nevertheless, this study is a first attempt of a cost analysis of an equipped outpatient wound clinic as an innovative way of responding to the increasing number of chronic wounds in the Netherlands. The calculations show that savings in wound care are possible. DECLARATION OF INTEREST: A possible conflict of interest should be mentioned. First author AALM Rondas, PhD student at Maastricht University, is working at the KCWC wound clinic at Venray in the Netherlands as a physician. However, the research data were provided externally by Coöperatie Volksgezondheidszorg (VGZ) and checked by the academic co-authors, none of whom have a conflict of interest. The authors have no financial or commercial interest to declare.

Knowledge and Attitudes of Nursing Staff Towards Malnutrition Care in Nursing Homes: A Multicentre Cross-Sectional Study.

BACKGROUND: The international literature shows that there are considerable deficits in nutritional care provision in nursing homes. Limited knowledge and negative attitudes can contribute to these deficits but international studies on knowledge and attitudes among nursing staff are rare. OBJECTIVE: The study aimed to assess the knowledge and attitudes of registered nurses and nurse aides towards malnutrition care in nursing homes. DESIGN: This study followed a multicentre, cross sectional design. SETTING AND PARTICIPANTS: The study was performed in 66 Austrian nursing homes with 1152 participants. MEASUREMENTS: The validated Knowledge of Malnutrition-Geriatric (KoM-G) questionnaire and the Staff Attitudes to Nutritional Nursing Care Geriatric (SANN-G) scale were used for data collection. RESULTS: On average, 60.6% of the respondents answered the questions correctly, whereas registered nurses knew significantly more (65.6%) than nurse aides (57.3%). The question that was answered correctly by most dealt with the factors that positively affect oral nutritional intake (87.2%) while the question which was incorrectly answered by most was on the professions involved in malnutrition treatment (26.1%). 39.2% of respondents had positive attitudes towards nutritional care. Registered nurses displayed more positive attitudes (48.1%) than nurse aides (33.6%). The most positive attitudes were shown in the 'Intervention' subscale while the least positive attitudes were indicated in the 'Norms' subscale. A medium positive correlation between knowledge and attitudes was found (r=.423, p<0.000). CONCLUSION: This study identified specific knowledge deficits and areas of negative attitudes in registered nurses and nurse aides, which will enable tailored training programmes to be developed.

The effect of aggression management training programmes for nursing staff and students working in an acute hospital setting. A narrative review of current literature.

BACKGROUND: Patient aggression is a longstanding problem in general hospital nursing. Staff training is recommended to tackle workplace aggression originating from patients or visitors, yet evidence on training effects is scarce. AIMS: To review and collate current research evidence on the effect of aggression management training for nurses and nursing students working in general hospitals, and to derive recommendations for further research. DESIGN: Systematic, narrative review. DATA SOURCES: Embase, MEDLINE, the Cochrane library, CINAHL, PsycINFO, pubmed, psycArticles, Psychology and Behavioural Sciences Collection were searched for articles evaluating training programs for staff and students in acute hospital adult nursing in a 'before/after' design. Studies published between January 2000 and September 2011 in English, French or German were eligible of inclusion. REVIEW METHODS: The methodological quality of included studies was assessed with the 'Quality Assessment Tool for Quantitative Studies'. Main outcomes i.e. attitudes, confidence, skills and knowledge were collated. RESULTS: Nine studies were included. Two had a weak, six a moderate, and one a strong study design. All studies reported increased confidence, improved attitude, skills, and knowledge about risk factors post training. There was no significant change in incidence of patient aggression. CONCLUSION: Our findings corroborate findings of reviews on training in mental health care, which point to a lack of high quality research. Training does not reduce the incidence of aggressive acts. Aggression needs to be tackled at an organizational level.

Malnutrition in care home residents with dementia.

OBJECTIVES: To investigate the malnutrition prevalence in Dutch care home residents with dementia over the years. Secondly, to examine the relationship of malnutrition and dementia and the role of care dependency and co-morbidity within this relationship. DESIGN: This study is a secondary analysis of data of the annual independent Dutch National Prevalence Measurement of Care Problems of Maastricht University. The design involves a cross-sectional, multicenter point prevalence measurement. SETTING: Care homes. PARTICIPANTS: 75399 residents older than 65 years (4523 resident with dementia) participated over 5 years (2006-2010). Sixty organizations measured 4 times, 31 organizations 3 times, 68 organizations 2 times, 511 organizations 1 time. MEASUREMENTS: A standardized questionnaire was used to register amongst others data of weight, height, nutritional intake, undesired weight loss, comorbidity, dementia, and care dependency. RESULTS: The study was able to show that there is a significant decline in malnutrition prevalence in the group of non-demented residents over the years (Non-demented group p <0.001). The prevalence of malnutrition in the demented group showed no significant reduction over the years. GEE analysis showed that malnutrition and dementia are related and that care dependency and age are important influencing factors in this relation. CONCLUSION: The results show that compared to the non-demented residents, the prevalence of malnutrition does not decline in demented care home residents over the years. Moreover, the findings of this study stress that malnutrition and dementia are related, while care dependency and age are confounding factors in this relationship.

What patient characteristics guide nurses' clinical judgement on pressure ulcer risk? A mixed methods study.

BACKGROUND: Nurses' clinical judgement plays a vital role in pressure ulcer risk assessment, but evidence is lacking which patient characteristics are important for nurses' perception of patients' risk exposure. OBJECTIVES: To explore which patient characteristics nurses employ when assessing pressure ulcer risk without use of a risk assessment scale. DESIGN: Mixed methods design triangulating observational data from the control group of a quasi-experimental trial and data from semi-structured interviews with nurses. SETTING: Two traumatological wards at a university hospital. PARTICIPANTS: Quantitative data: A consecutive sample of 106 patients matching the eligibility criteria (age ≥ 18 years, no pressure ulcers category ≥ 2 at admission and ≥ 5 days expected length of stay). Qualitative data: A purposive sample of 16 nurses. METHODS: Quantitative data: Predictor variables for pressure ulcer risk were measured by study assistants at the bedside each second day. Concurrently, nurses documented their clinical judgement on patients' pressure ulcer risk by means of a 4-step global judgement scale. Bivariate correlations between predictor variables and nurses' risk estimates were established. Qualitative data: In interviews, nurses were asked to assess fictitious patients' pressure ulcer risk and to justify their risk estimates. Patient characteristics perceived as relevant for nurses' judements were thematically clustered. Triangulation: Firstly, predictors of nurses' risk estimates identified in bivariate analysis were cross-mapped with interview findings. Secondly, three models to predict nurses' risk estimates underwent multiple linear regression analysis. RESULTS: Nurses consider multiple patient characteristics for pressure ulcer risk assessment, but regard some conditions more important than others. Triangulation showed that these are measures reflecting patients' exposure to pressure or overall care dependency. Qualitative data furthermore indicate that nurses are likely to trade off risk-enhancing conditions against conditions perceived to be protective. Here, patients' mental capabilities like willingness to engage in one owns care seem to be particularly important. Due to missing information on these variables in the quantitative data, they could not be incorporated into triangulation. CONCLUSIONS: Nurses' clinical judgement draws on well-known aetiological factors, and tends to expand conditions covered by risk assessment scales. Patients' care dependency and self-care abilities seem to be core concepts for nurses' risk assessment.

Impact of Different Diagnostic Criteria on the Prevalence of Sarcopenia in an Acute Care Geriatric Ward.

BACKGROUND: Sarcopenia is probably an important causal factor for functional decline in acutely ill hospitalized geriatric patients. Low skeletal muscle mass, low gait speed and low grip strength are hallmarks of diagnosing sarcopenia. However there are many different diagnostic criteria to assess sarcopenia. OBJECTIVES: In this study the influence of different criteria for sarcopenia was studied on sarcopenia prevalence in geriatric patients admitted to an acute care hospital. DESIGN: Cross sectional study design. SETTING: A geriatric ward of a large Dutch hospital. PARTICIPANTS: Geriatric patients. MEASUREMENTS: Skeletal muscle mass measured using bio impedance analysis (BIA), gait speed using the 4 meter walking test and grip strength. The sarcopenia prevalence was investigated according to criteria of: muscle mass, grip strength, the European Working Group on Sarcopenia in Elderly People, the International Working Group on Sarcopenia and the Special Interest Group of Society of Sarcopenia, Cachexia and Wasting Disorders. RESULTS: 85 geriatric patients were included (61 women). Applying the 17 different criteria, the sarcopenia prevalence varied from 26-75% for women and from 42-100% for men. Comparing the Janssen calculation with the Maltron calculation sarcopenia prevalence ranged from respectively 26-67% and 67-70% for women and from 42-71% and 75-100% for men. Almost all patients (96%) had a low gait speed. CONCLUSIONS: Sarcopenia is highly prevalent in an acute hospitalized geriatric population, although the prevalence varies widely depending on the diagnostic criteria applied. A prospective study is needed to discover which criteria of sarcopenia can predict best adverse outcomes.

[Basic care in nursing homes: longitudinal presentation of care problems measured with the National Prevalence Measurement of Care Problems (LPZ)]. / Basiszorg in het verpleeghuis: longitudinale weergave van zorgproblemen gemeten door de Landelijke Prevalentiemeting Zorgproblemen.

Since 1998, the National Prevalence Measurement of Care Problems (LPZ) has annually measured the prevalence, prevention and treatment of a number of care problems in many health care organisations. These problems include pressure ulcers, incontinence, intertrigo, malnutrition, falls and the use of restraints. This article describes trends in the prevalence of these problems during the past few years and the preventive and treatment measures taken for clients residing in psychogeriatric and/or somatic wards of nursing homes. The results show that the prevalence of these care problems has declined in general. Nevertheless, the individual interventions (preventive measures and treatment) have not really changed in recent years. It is concluded that the extra attention paid to these care problems might already have had a positive effect on their prevalence. This must be further investigated. In any case, extra follow-up steps need to be taken to bring about a further decline. The article describes which steps the project group has already taken in this respect.

Back to basics: an introduction to statistics.

In the second in the series, Professor Ruud Halfens and Dr Judith Meijers give an overview of statistics, both descriptive and inferential. They describe the first principles of statistics, including some relevant inferential tests.

Pressure ulcer prevalence and quality of care in stroke patients in an Indonesian hospital.

OBJECTIVE: To explore the quality of pressure ulcer (PU) care in stroke patients in an Indonesian stroke-specialised hospital. The prevalence, prevention, wound treatment and hospital facilities related to PU structural quality indicators at the ward and institutional levels were assessed. METHOD: A multi-level cross-sectional survey was performed over three days in an Indonesian stroke-specialised hospital. All stroke patients present on the day of the measurement were included. The European Pressure Ulcer Prevalence Study Minimum Data Set and the Dutch National Prevalence Measurement of Care Problems (Landelijke Prevalentiemeting Zorgproblemen, LPZ) questionnaire were used. RESULTS: The prevalence rates of PUs, including and excluding Category I were high in this hospital (28% and 17%, respectively). More than half of the patients/families (56%) received education about PU prevention and 74% of the patients were repositioned, although irregularly, by nurses or families. No treatment was applied to Category I PUs. Category II PUs were treated by using NaCl 0.9% solution to cleanse the wound without dressings. Category III PUs were mainly treated by using anti-microbial gauze dressing. No patient suffered a Category IV PU. Only a few structural quality indicators of PU care at ward and hospital level were met. CONCLUSION: PUs were quite prevalent in these stroke patients. The quality of PU care in this hospital could be improved, especially in the areas of prevention, treatment and structural quality indicators.

The relationship between malnutrition parameters and pressure ulcers in hospitals and nursing homes.

OBJECTIVES: Pressure ulcers (PU) remain a major health care problem throughout the world. Although malnutrition is considered to be one of the intrinsic risk factors for PU, more evidence is needed to identify the exact relation between PU and malnutrition. This study aims to identify whether there exists a relationship between PU and malnutrition in hospitals and nursing homes. METHODS: A cross-sectional study was performed in April 2007 in hospitals and nursing homes in Germany. PU were assessed using the Braden scale. Malnutrition was assessed by low body mass index (BMI), undesired weight loss, and insufficient nutritional intake. RESULTS: Two thousand three hundred ninety-three patients from 29 nursing homes and 4067 patients from 22 hospitals participated in the study. PU in both hospital and nursing home patients were significantly (P < 0.01) related to undesired weight loss (5%-10%). Moreover low nutritional intake and low BMI (<18.5) were also significantly related to PU in hospitals and nursing homes. CONCLUSION: There is a significant relationship between malnutrition parameters like undesired weight loss, BMI < 18.5, and low nutritional intake and PU.

Prevalence of urinary incontinence among community-dwelling adults receiving home care.

We conducted a cross-sectional survey in 2005 to determine the prevalence of and factors associated with urinary incontinence (UI) in adults receiving home care. Of the 2,866 patients surveyed, 46% suffered from UI; 6.5% had stress, 16.6% had urge, 9% had mixed, and 17.6% had functional incontinence. No diagnosis regarding type of UI had been established in 50.2%. Factors associated with UI were advanced age, higher body mass index, and impaired mobility. UI is prevalent in older persons receiving home care, but the lack of diagnosis of type of UI in half of the participants surveyed impedes management of UI.

Evaluation of the dissemination and implementation of a nutritional guideline for pressure ulcer care.

OBJECTIVE: In 2004 the European Pressure Ulcer Advisory Panel nutritional working group developed a nutritional guideline for pressure ulcer prevention and treatment. This study investigated the degree to which the guideline was disseminated and implemented in clinical practice. METHOD: A cross-sectional study was undertaken in health-care organisations in The Netherlands, Germany and the UK. A printed, standardised questionnaire which followed Rogers' model of the innovation-decision process was developed, translated and distributed to 1087 health-care organisations. RESULTS: The response rate was 33% (n = 363). Sixty-one per cent of respondents knew of the guideline. Twenty-five per cent had applied it to their clinical practice and used it for nutritional screening. The main barrier to the provision of nutritional support appeared to be lack of knowledge and skills. CONCLUSION: One year after its dissemination, more than half of respondents knew of the guideline, with one in four applying it to their practice. The guideline was better disseminated and implemented in The Netherlands and UK than in Germany, where only 4% of participants had used it.

The effect of a training course on mental health nurses' attitudes on the reasons of patient aggression and its management.

Aggression in healthcare systems poses a major problem for nurses because they are the most susceptible to suffer violence. Studies demonstrate that attitudes of nurses influence their behaviour regarding aggression and violence. Training programmes can positively change nurses' attitudes. This quasi-experimental study aimed to examine the effects of a systematic training course in aggression management on mental health nurses' attitudes about the reasons for patients' aggression and on its management. Sixty-three nurses (29 in the intervention and 34 in the control group) participated in this quasi-experimental pre-test and post-test study. The attitude of the participants of a training course was recorded by the German version of the Management of Aggression and Violence Attitude Scale (MAVAS). No significant attitude changes occurred in the intervention group at post-test. It is concluded that trainings intending to influence attitudes regarding the reason for patient aggression should consider the impact of the pedagogical quality of the training course, organizational support, and the user's perception. Moreover, it remains questionable to what extent a single instrument of measurement can record attitude changes.

Pressure ulcer risk factors in cardiac surgery: a review of the research literature.

BACKGROUND: Pressure ulcer incidence in patients undergoing cardiac surgery is reported to be up to 29.5%. Common known risk factors for pressure ulcer development include compressive and shearing forces. However, knowledge about the specific risk factors in a defined population is helpful in the development of an effective prevention management. This literature review is part of a quality improvement project to reduce pressure ulcer incidence in the cardiac surgery population. OBJECTIVES: The objective is to determine "which specific risk factors for pressure ulcer development in the cardiac surgery population are identified in the literature." RESULTS: The results of this literature review indicate a high-risk potential in the tissue tolerance for oxygen as temperature manipulation, vasoactive drugs, hypotensive periods, and reduced hemoglobin and hematocrit levels. Time on the operating room table, frequency of repositioning, immobility time, older age, low albumin level, and corticosteroid are also found as significant risk factors in this population. CONCLUSION: Diseases that influence oxygen supply in older patients in combination with the special demands of temperature and circulation regulation during the cardiac surgical procedure place the patient at risk for pressure ulcer development. Prevention measures should be aimed at supporting tissue tolerance for pressure and tissue tolerance for oxygen. These measures should be additional to pressure-relieving devices on the operating room table and, postoperatively in bed, a defined minimum frequency of postoperative turning and early mobilization after the surgical procedure should be considered.

The effect of a training course in aggression management on mental health nurses' perceptions of aggression: a cluster randomised controlled trial.

Nurses' attitudes towards patient aggression may influence their behaviour towards patients. Thus, their enhanced capacity to cope with aggressive patients may nurture more positive attitudes and alleviate adverse feelings emanating from patient aggression. This cluster randomised controlled trial conducted on six psychiatric wards tested the hypotheses that a 5 day training course in aggression management would positively influence the following outcome measures: Nurses' perception and tolerance towards patient aggression and resultant adverse feelings. A repeated measures design was employed to monitor change. No effect was found. The short time frame between the training course and the follow up measurement or non-responsiveness of the measurement instruments may explain this finding.

The effectiveness of two interventions in the management of patient violence in acute mental inpatient settings: report on a pilot study.

Systematic risk assessment and training courses have been suggested as interventions to deal with patient violence in psychiatric institutions. A dual centre prospective feasibility study was conducted on two Swiss psychiatric admission wards to test the hypothesis that such interventions will reduce the frequency and severity of violent events and coercion. A systematic aggression risk assessment, in combination with a standardized training course in aggression management was administered and the frequency and severity of aggressive incidents and the frequency of coercive measures were registered. The incidence rates of aggressive incidents and attacks showed no significant reduction from the baseline through risk prediction and staff training, but the drop in coercive measures was highly significant. A 'ward effect' was detected with one ward showing a decline in attacks with unchanged incidence rates of coercion and the other ward showing the opposite. The severity of the incidents remained unchanged whilst the subjective severity declined after the training course. We conclude that a systematic risk assessment and a training course may assist in reducing the incidence rate of coercive measures on psychiatric acute admission wards. Further testing of the interventions is necessary to measure the effect of the training alone and to counteract 'ward effects'.