Managing risk and conflict behaviours in acute psychiatry: the dual role of constant special observation.
OBJECTIVE
This is a report of a study of events before and after the use of constant special observation on acute psychiatric wards, and the characteristics of patients who received it.


BACKGROUND
Constant special observation is a method of preventing acutely disturbed inpatients from harming themselves or others. It has been characterized as impersonal, intrusive and non-therapeutic. The circumstances of its use and place in broader intervention strategies are not well understood.


METHODS
A sample of 522 patients were recruited from 84 acute psychiatric wards in 31 hospital locations in London and surrounding areas during 2009-2010. Data were collected for the first 2 weeks of admission from patients' case notes.


RESULTS
Sixteen per cent of patients received constant special observation during the first 2 weeks in hospital (7% at the point of admission and 11% after admission), but with variation between hospitals. Absconding, violence and self-harm were the most common events to precede constant special observation during a shift. Other methods of containment, especially intermittent special observation, were frequently tried first. Episodes of constant special observation often involved de-escalation and extra medication. Aggression was more prominent during than before constant special observation. Attempted suicides were limited to postadmission episodes.


CONCLUSIONS
Constant special observation is usually used in combination with other forms of containment, irrespective of when it is initiated. Placing patients considered at risk of suicide under constant special observation on admission may have a protective effect.
Health Service and Population Research, Institute of Psychiatry, Kings College London, London, UK. duncan.stewart@kcl.ac.uk
Duncan
D
Stewart
Len
L
Bowers
Jamie
J
Ross
D000208:Acute Disease; D000293:Adolescent; D000328:Adult; D000368:Aged; D003430:Cross-Sectional Studies; D005260:Female; D006778:Hospitals, Psychiatric / Q000458:organization & administration*; D006801:Humans; D007297:Inpatients / Q000523:psychology; D016015:Logistic Models; D008131:London; D008297:Male; D001523:Mental Disorders / Q000188:drug therapy / Q000451:nursing* / Q000523:psychology; D008875:Middle Aged; D009723:Nurse-Patient Relations; D015279:Organizational Culture; D011568:Psychiatric Nursing / Q000379:methods; D011570:Psychiatry / Q000379:methods*; D012189:Retrospective Studies; D017751:Safety Management / Q000379:methods*; D016728:Self-Injurious Behavior / Q000517:prevention & control*; D014754:Violence / Q000517:prevention & control; D055815:Young Adult; D000092864:Suicide Prevention