title: Factors associated with use of psychiatric intensive care and seclusion in adult inpatient mental health services.
abstract: Within acute psychiatric inpatient services, patients exhibiting severely disturbed behaviour can be transferred to a psychiatric intensive care unit (PICU) and/or secluded in order to manage the risks posed to the patient and others. However, whether specific patient groups are more likely to be subjected to these coercive measures is unclear. Using robust methodological and statistical techniques, we aimed to determine the demographic, clinical and behavioural predictors of both PICU and seclusion.
  
  
  
  Data were extracted from an anonymised database comprising the electronic medical records of patients within a large South London mental health trust. Two cohorts were derived, (1) a PICU cohort comprising all patients transferred from general adult acute wards to a non-forensic PICU ward between April 2008 and April 2013 (N = 986) and a randomly selected group of patients admitted to general adult wards within this period who were not transferred to PICU (N = 994), and (2) a seclusion cohort comprising all seclusion episodes occurring in non-forensic PICU wards within the study period (N = 990) and a randomly selected group of patients treated in these wards who were not secluded (N = 1032). Demographic and clinical factors (age, sex, ethnicity, diagnosis, admission status and time since admission) and behavioural precursors (potentially relevant behaviours occurring in the 3 days preceding PICU transfer/seclusion or random sample date) were extracted from electronic medical records. Mixed effects, multivariable logistic regression analyses were performed with all variables included as predictors.
  
  
  
  PICU cases were significantly more likely to be younger in age, have a diagnosis of bipolar disorder and to be held on a formal section compared with patients who were not transferred to PICU; female sex and longer time since admission were associated with lower odds of transfer. With regard to behavioural precursors, the strongest predictors of PICU transfer were incidents of physical aggression towards others or objects and absconding or attempts to abscond. Secluded patients were also more likely to be younger and legally detained relative to non-secluded patients; however, female sex increased the odds of seclusion. Likelihood of seclusion also decreased with time since admission. Seclusion was significantly associated with a range of behavioural precursors with the strongest associations observed for incidents involving restraint or shouting.
  
  
  
  Whilst recent behaviour is an important determinant, patient age, sex, admission status and time since admission also contribute to risk of PICU transfer and seclusion. Alternative, less coercive strategies must meet the needs of patients with these characteristics.
authors.affiliation: Health Service & Population Research Department,Institute of Psychiatry, Psychology & Neuroscience, King's College London,UK.
authors.forename: A E
authors.identifier: 0000-0002-3178-3920
authors.initials: AE
authors.lastname: Cullen
authors.affiliation: Health Service & Population Research Department,Institute of Psychiatry, Psychology & Neuroscience, King's College London,UK.
authors.forename: L
authors.initials: L
authors.lastname: Bowers
authors.affiliation: Department of Applied Health Research,University College London,UK.
authors.forename: M
authors.initials: M
authors.lastname: Khondoker
authors.affiliation: Health Service & Population Research Department,Institute of Psychiatry, Psychology & Neuroscience, King's College London,UK.
authors.forename: S
authors.initials: S
authors.lastname: Pettit
authors.affiliation: Health Service & Population Research Department,Institute of Psychiatry, Psychology & Neuroscience, King's College London,UK.
authors.forename: E
authors.initials: E
authors.lastname: Achilla
authors.affiliation: Health Service & Population Research Department,Institute of Psychiatry, Psychology & Neuroscience, King's College London,UK.
authors.forename: L
authors.initials: L
authors.lastname: Koeser
authors.affiliation: Molloy College, Rockville Centre,New York,USA.
authors.forename: L
authors.initials: L
authors.lastname: Moylan
authors.affiliation: School of Healthcare, University of Leeds,UK.
authors.forename: J
authors.initials: J
authors.lastname: Baker
authors.affiliation: College Centre for Quality Improvement, Royal College of Psychiatrists,UK.
authors.forename: A
authors.initials: A
authors.lastname: Quirk
authors.affiliation: South London and Maudsley NHS Foundation Trust,UK.
authors.forename: F
authors.initials: F
authors.lastname: Sethi
authors.affiliation: Department of Health Sciences,University of York,UK.
authors.forename: D
authors.initials: D
authors.lastname: Stewart
authors.affiliation: Health Service & Population Research Department,Institute of Psychiatry, Psychology & Neuroscience, King's College London,UK.
authors.forename: P
authors.initials: P
authors.lastname: McCrone
authors.affiliation: Health Service & Population Research Department,Institute of Psychiatry, Psychology & Neuroscience, King's College London,UK.
authors.forename: A D
authors.identifier: 0000-0002-4657-6238
authors.initials: AD
authors.lastname: Tulloch
mesh_terms: D000328:Adult; D000367:Age Factors; D016022:Case-Control Studies; D004637:Emergency Services, Psychiatric; D005260:Female; D006302:Health Services Research; D006801:Humans; D007297:Inpatients; D007362:Intensive Care Units; D008297:Male; D001523:Mental Disorders / Q000523:psychology* / Q000628:therapy; D008605:Mental Health Services; D008875:Middle Aged; D010356:Patient Isolation / Q000523:psychology*; D012737:Sex Factors; D013997:Time Factors; D055815:Young Adult
keywords: Health service research; inpatient psychiatry; risk factors; treatment allocation; violence/aggression