[A clinical trial for developing PICU management scale, a tool reviewing the frequency and use of seclusion and restraint in psychiatric acute care]

Abstract

Objective and methods: Medical management in psychiatric acute care involving seclusion and restraint is an intervention of which reasonable use is often required. Regarding such measures, guidelines for seclusion and restraint are important, and also, psychiatric treatment facilities should engage in a continuous quality improvement process that seeks to minimize the use of seclusion and restraint. To review and monitor the existing use of seclusion and restraint, the authors developed a tool, the "PICU management scale", and investigated its usefulness in two functionally different psychiatric wards, a psychiatric emergency care unit (emergency ward) and a psychiatric acute care unit (acute ward) in the Japanese payment system. The PICU management scale is a tool which classifies the status of psychiatric intensive care into six categories by four factors; "S: seclusion", "R: restraint", "N: forced nutrition" and "Ph: physical care", and we evaluated its usefulness by occurrence of variance. In terms of minimizing or optimizing the use of seclusion and restraint, we also analyzed characteristics and risk factors of 1) recurrent application of seclusion and restraint, 2) high PICU management ranking, and 3) prolongation.

Results: During the five months of investigation, medical management involving seclusion and restraint was applied in 98 cases at the emergency ward and 50 at the acute ward. The total number of management days was 894 and 950, respectively. The mean management duration per case was 9.1 and 19.0 days, respectively. The variance was 2.5 % and 4.5 %, respectively, and our tool covered most of the statuses and conditions observed in psychiatric emergency and acute care. Analysis of the variance suggested the existence of a trend which is considered to be typical of the status of medical management. Most cases that required recurrent application of seclusion and restraint were diagnosed as F0 or F2 in ICD -10, and hebephrenic cases with a high grade of disability, refractory-paranoid schizophrenic, or drug-resistant cases in F2 were remarkable in this category. In the high PICU management ranking, most cases were related to consciousness disturbance, and the mean duration of intervention was short. Reversal of the therapeutic stage was considered to be a risk factor of prolongation.

Conclusion: The "PICU management scale" is considered to be a useful tool for minimizing the use of seclusion and restraint, in addition to the guidelines for the use of seclusion and restraint. Contributions to team strategy and consensus by the addition of objectivity or symbolizing are also expected. To verify these findings and make further progress, more clinical trials using this tool in various institutions are required.