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Unlocking an acute psychiatric ward: The impact on unauthorised absences, assaults and seclusions

  • Ben Beaglehole (a1), John Beveridge (a2), Warren Campbell-Trotter (a2) and Chris Frampton (a1)
Abstract
Aims and method

The acute psychiatric inpatient service in Christchurch, New Zealand, recently changed from two locked and two unlocked wards to four open wards. This provided the opportunity to evaluate whether shifting to an unlocked environment was associated with higher rates of adverse events, including unauthorised absences, violent incidents and seclusion. We compared long-term adverse event data before and after ward configuration change.

Results

Rates of unauthorised absences increased by 58% after the change in ward configuration (P = 0.005), but seclusion hours dropped by 53% (P = 0.001). A small increase in violent incidents was recorded but this was not statistically significant.

Clinical implications

Although unauthorised absences increased, the absence of statistically significant changes for violent incidents and a reduction in seclusion hours suggest that the change to a less restrictive environment may have some positive effects.

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Copyright
This is an open-access article published by the Royal College of Psychiatrists and distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Corresponding author
Correspondence to Ben Beaglehole (ben.beaglehole@otago.ac.nz)
Footnotes
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Declaration of interest

None.

Footnotes
References
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1 Lang, UE, Hartmann, S, Schulz-Hartmann, S, Gudlowski, Y, Ricken, R, Munk, I, et al. Do locked doors in psychiatric hospitals prevent patients from absconding? Eur J Psychiat 2010; 24: 199204.
2 van der Merwe, M, Bowers, L, Jones, J, Simpson, A, Haglund, K. Locked doors in acute inpatient psychiatry: a literature review. J Psychiatr Ment Health Nurs 2009; 16: 293–9.
3 Rubin, B, Goldberg, A. An investigation of openness in the psychiatric hospital. Arch Gen Psychiatry 1963; 8: 269–76.
4 Molnar, G, Keitner, L, Swindall, L. Medicolegal problems of elopement from psychiatric units. J Forensic Sci 1985; 30: 44–9.
5 Department of Health. Code of Practice: Mental Health Act 1983. Department of Health, 2015.
6 O'Hagan, M, Divis, M, Long, J. Best Practice in the Reduction and Elimination of Seclusion and Restraint. Seclusion: Time for Change.Te Pou Te Whakaaro Nui: the National Centre of Mental Health Research, Information and Workforce Development, 2008.
7 Bowers, L, Jarrett, M, Clark, N. Absconding: a literature review. J Psychiatr Ment Health Nurs 1998; 5: 343–53.
8 Donat, DC. An analysis of successful efforts to reduce the use of seclusion and restraint at a public psychiatric hospital. Psychiatr Serv 2003; 54: 1119–23.
9 Bowers, L, Simpson, A, Alexander, J. Real world application of an intervention to reduce absconding. J Psychiatr Ment Health Nurs 2005; 12: 598602.
10 Bowers, L, Alexander, J, Gaskell, C. A trial of an anti-absconding intervention in acute psychiatric wards. J Psychiatr Ment Health Nurs 2003; 10: 410–6.
11 Nijman, HL, Merckelbach, HL, Allertz, WF, a Campo, JM. Prevention of aggressive incidents on a closed psychiatric ward. Psychiatr Serv 1997; 48: 694–8.
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BJPsych Bulletin
  • ISSN: 2056-4694
  • EISSN: 2056-4708
  • URL: /core/journals/bjpsych-bulletin
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Unlocking an acute psychiatric ward: The impact on unauthorised absences, assaults and seclusions

  • Ben Beaglehole (a1), John Beveridge (a2), Warren Campbell-Trotter (a2) and Chris Frampton (a1)
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eLetters

Unlocking an Acute Psychiatric Ward: Open doors, Absent Patients?

Damian Smith, Senior Registrar in General Adult Psychiatry and Clinical Tutor, Louth Meath Mental Health Services and Royal College of Surgeons Ireland
MacDara McCauley, Consultant Psychiatrist and Clinical Lecturer, Louth Meath Mental Health Services and Royal College of Surgeons Ireland
24 March 2018

In their recent paper, Beaglehole and colleagues1 reported on the impact of unlocking an acute psychiatric ward. Despite a 58% increase in unauthorised absences and an 8% increase in violent incidents, they concluded that a less restrictive environment had some positive effects, most notably a reduction in the total hours of seclusion per month.

Our service has recently undertaken a similar transition from a locked acute ward opened (and locked) in the 1930s, to an unlocked newly built unit opened in 2016.

When comparing the 6 months before and after this transition, we too found that the rate of unauthorised absences increased by 100% from a mean of 4 to 8 per month.

Unlike Beaglehole however, we observed a decrease in rates of violent incidents by 27.4% (mean of 31.7 to 23 per month), and an increase in the total hours of seclusion per month by 213.4% (mean of 28.21 to 88.42 hours per month). Of note, admission rates increased from a mean of 20 to 23 per month during the same time period.

Although a reduction in the rate of violent incidents, and in the case of Beaglehole reduced levels of seclusion, strengthen the case for provision of care in unlocked settings; should we be concerned about the increased rate of unauthorised absences found in both studies?

The largest available study on this topic2 would suggest not. In their 15 year observational study involving 145,738 German inpatients, Huber et al concluded that locked doors do not prevent suicide, or indeed unauthorised absences.

Although a rare event, suicide is undoubtedly one the most feared outcomes when any service user absconds. Preventing harm to self or others is often the main rationale for inpatient admission. It is also a ubiquitous criterion for involuntary admission. Consequently, preventing harm is one of the main motives for locking psychiatric units.

In our study 86% of unauthorised absences over the one year study period were by involuntarily admitted service users. In opening our doors are we doing these individuals a disservice by giving them the opportunity to leave hospital at a time when they are most unwell?

Previous studies have reported on the negative consequences of absconding for service users (interrupted treatment, suicide), staff (anxiety), family members (loss of trust in the service), and emergency services (expended resources)3.

It could be argued that a reduction in the number of violent incidents (and in Beaglehole’s case, seclusion), are worth the risk of these adverse outcomes. In our view however, a modern purpose built environment coupled with increased staffing levels, better explain these findings. Increased numbers of nursing staff result in improved relational security; an important element of therapeutic security provided by higher staff to patient ratios4.

Our study and that of Beaglehole and colleagues, indicate that unlocking acute psychiatric wards lead to an upsurge in unauthorised absences. The majority of service users who absconded were admitted involuntarily. We suggest that acute mental health services give careful consideration to all the risks associated with unauthorised absences before opening their doors. This is of particular relevance given that rates of involuntary admission are on the rise5.

1 Beaglehole B, Beveridge J, Campbell-Trotter W, Frampton C. Unlocking an acute psychiatric ward: the impact on unauthorised absences, assaults and seclusions. BJPsych Bulletin 2017; 41: 92–6.

2 Huber CG, Schneeberger AR, Kowalinski E, Fröhlich D, Felten von S, Walter M, et al. Suicide risk and absconding in psychiatric hospitals with and without open door policies: a 15 year, observational study. The Lancet Psychiatry 2016; 3: 842–9.

3 Bailey J, Page B, Ndimande N, Connell J, Vincent C. Absconding: reducing failure to return in adult mental health wards. BMJ Qual Improv Rep 2016; 5: u209837.w5117.

4 Kennedy HG. Therapeutic uses of security: mapping forensic mental health services by stratifying risk. Advances in Psychiatric Treatment 2002; 8: 433–43.

5 Gilhooley J, Kelly BD. Return of the asylum. Br J Psychiatry 2018; 212: 69–70.

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Conflict of interest: None declared

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