Transcript CONSEQ summary of findings

Understanding the
sequence
of conflict & containment
events: CONSEQ
Figure 2: Containment methods
Figure 1: Common conflict behaviours
PRN medication
Verbal aggression
Refused regular medication
Refusing to eat
Aggression against objects
Refusing to see workers
Physical violence
Refused PRN medication
Refusing to attend to hygiene
Attempting to abscond
Absconding
Self-harm
Demanding PRN medication
Refusing to go to bed
De-escalation
Intermittent observation
Time out
Restrained
Constant observation
Coerced IM medication
Show of force
Sent to intensive care
Seclusion
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Frequency
Background
Acute psychiatric inpatient wards
experience high levels of conflict
behaviour (e.g. violence,
absconding, self-harm) which are
managed by containment methods
(e.g. restraint, seclusion, time out,
sedation). Most previous studies
have only examined one or two
conflict and containment events,
therefore little is known about their
sequence, and what the common
pathways of events are for patients.
Aims
To identify conflict behaviours
exhibited by patients, containment
methods used by staff, the order of
these events and the characteristics
of patients involved in them.
Method
We collected information about the
first two weeks of admission from
the case notes of 522 patients (with
their consent). Patients were
recruited from 84 wards in 31
psychiatric hospitals across
Southern England. A range of
background information was also
collected on each patient. Mental
Health Research Network Clinical
Studies Officers assisted with data
collection.
Results
The most common conflict
behaviour was verbal aggression
which was displayed by half of
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1000 1200 1400 1600 1800 2000
Frequency
see workers, aggression against
objects
and physical violence were each
displayed at least 200 times during
the two week period (see Figure 1).
The least common behaviours were
refusing to drink, suicide attempts
and substance misuse (all less than
10% of patients).
The most common containment
measure used by staff was PRN (or
‘as required’) medication which was
used for two thirds of patients
(Figure 2). De-escalation techniques
(verbally calming a patient) and
intermittent observation (regular,
timed checks on a patient) were also
frequently used (over half the
sample received these interventions
at least once). The least frequently
used method of containment was
placing a patient in seclusion
(isolating a patient in locked room).
Emerging findings include:
Coerced IM medication
Received by one in ten patients,
usually in response to aggression
and medication refusal. Manual
restraint was used on half of
occasions. Coerced IM medication
brought most crises to an end.
Self-harm
Incidents tended to occur early in
admission. Absconding, medication
refusal and non-compliance were
frequent precursors. Incidents were
Seclusion & time out
There was significant variation in
rates of seclusion between
hospitals. Seclusion and time out
were used with similar patients & in
similar circumstances. Outcomes
for the management of physical
violence were also comparable.
Constant special observation
Used on admission in half of cases,
but typically preceded by
absconding, violence or self-harm.
Other containment, especially
intermittent special observation,
was often tried first. Most
episodes involved other
interventions, such as deescalation and extra medication.
Authors
Len Bowers
[email protected]
Duncan Stewart
[email protected]
Acknowledgement
This report presents independent
research commissioned by the
National Institute for Health
Research (NIHR) under its
Programme Grants for Applied
Research scheme (RP-PG-070710081) and supported by the NIHR
Mental Health Research Network.
The views expressed are those of
the authors and not necessarily
those of the NHS, the NIHR or the
Department of Health.