Audit of Documentation of Forensic History on Admission Form in a Psychiatric Intensive Care Unit

By Usama Bin Zubair, Roy Brown

Affiliations

1. Department of Psychiatric Intensive Care Unit, Phoenix Care Centre, (HSE), Dublin-7, Ireland

doi: 10.29271/jcpsp.2021.06.707

ABSTRACT
Objective: To study the documentation of relevant components of forensic history on admission form for male patients admitted in psychiatric intensive care unit (PICU)/OAK ward of Phoenix Care Center.
Study Design: Clinical audit.
Place and Duration of Study: Psychiatric intensive care unit/OAK ward of Phoenix Care Center, from August 2019 to July 2020.
Methodology: Charts of all patients admitted in PICU from August 2019 to July 2020 were analysed, and admission forms were reviewed for documentation of relevant parameters of forensic history. A structured tool was made after literature search, which included drug and alcohol history, history of assaults, protection/barring orders, number of previous PICU admissions, previous charges, pending charges, use of depot medications and previous encounters with police without pending charges.
Results: A total of 50 patients were admitted during the given time period. Drug and alcohol history was documented in 98% of the cases, previous charges were documented in 88% of the cases, protection/baring order was documented in 62% of the cases, while previous encounter with the police without being charged was documented in only 32% of the cases.
Conclusion: Drugs and alcohol and previous charges were documented in most of the cases, but documentation of protection/baring order and encounter with the police without being charged was a neglected area, which should be worked upon in future.

Key Words: Admission form, Forensic history, Medical audit.

INTRODUCTION

Risk towards self or others has been the main factor which differentiates psychiatry from other fields of medicine. Relationship of risky behaviours with various mental health disorders has been discussed for ages and various management options have been tried before the availability of current formal psychiatric treatments to reduce the risk-related to these disorders.¹

Prediction and assessment of relevant risks is a key factor in management of these risks, especially in non-forensic and general adult settings. Psychiatric intensive care units may be regarded as step-up units from general adult wards in terms of risk management of mentally disordered patients.² Though they are not forensic settings, still sometimes their roles become more pronounced as they deal with such patients on regular basis without formal involvement of forensic teams.³

Various studies have highlighted the importance of forensic assessments in general adult and psychiatric ICU settings. Walker et al. concluded that 37 violent incidents took place in PICU in six months, and most of these incidents involved same patients. Therefore, adequate assessment at time of admission may help the team to identify high risk cases and manage them accordingly.⁴ Another study showed that nurses of PICU were at high risk for violence; and illicit drug use in patients was a significant risk factor, which predicted violence.⁵ Chadda et al. emphasised that young psychiatrist may have fear and anxiety in assessing the relevant forensic components in routine psychiatric evaluations. They also emphasised regarding the relevant areas, which need to be explored in routine non-forensic settings.⁶

Phoenix Care Center has both male and female intensive care units with Oak ward, dealing with male patients. It is a 12-bed facility with high patient turnover. It has been documented previously that assault has been the commonest reason for referral to this unit, which highlights the risk involved with the patients managed here.⁷ Keeping this in mind, accurate risk assessment at time of admission becomes one of the key components of overall psychiatric assessment. We, therefore, planned this clinical audit with the rationale to study the documentation of relevant components of forensic history on admission form for male patients admitted in psychiatric intensive care unit/OAK ward of Phoenix Care Center.

METHODOLOGY

This clinical audit was conducted at male psychiatric intensive care unit in Phoenix Care Center. Charts of patients admitted between August 2019 to July 2020 in Oak ward were reviewed and admission forms were analysed for documentation of relevant components of forensic history. The researchers made a structured tool including all the relevant components of forensic history for patients at PICU. Detailed literature search was done, especially studies of Bjo¨rkdahl et al. and Brown et al. were used to formulate the audit tool for this audit.^8,9 Components in the audit tool included drug and alcohol history, history of assaults, protection/barring orders, number of previous PICU admissions, previous charges, pending charges, use of depot medications and previous encounters with police without pending charges. Admission forms were screened with this audit tool for all the male patients admitted in PICU during the given period. Data was entered in SPSS version 24.0, and frequency and percentages were calculated for all the components included in the audit tool.

RESULTS

A total of 50 patients were admitted during the given time period. Drug and alcohol history was documented in 98% of the cases, previous charges were documented in 88% of the cases, previous physical assaults were documented in 80% of cases, number of previous admissions to PICU were documented in 66% of the cases, pending charges were documented in 82% of the cases, use of depot medications was documented in 86% of the cases, protection/baring order was documented in 62% of the cases, while previous encounter with the police without being charged was documented in only 32% of the cases (Table I).

Table I: Documentation of relevant components of forensic history on admission form in a psychiatric intensive care unit.

Component	Yes	No
Drug and alcohol history (n=50)	49 (98%)	1 (2%)
Previous physical assaults (n=50)	40 (80%)	10 (20%)
Protection/barring order  (n=50)	31 (62%)	19 (38%)
No. of previous admissions to PICU (n=50)	33 (66%)	17 (34%)
Previous charges (n=50)	44 (88%)	06 (12%)
Pending charges (n=50)	41 (82%	09 (18%)
Use of depot medications (n=50)	43 (86%)	07 (14%)
Previous encounters with police without charges (n=50)	16 (32%)	34 (68%)

DISCUSSION

Use of drugs and alcohol has always been linked with violence and aggression among patients with or without mental health problems. Recent meta-analysis by Dellazizo et al., published in American Journal of Psychiatry, highlighted the same findings.¹⁰ This fact has been well understood by the mental health professionals, and all of the cases had well documented drug and alcohol history. Precious physical assaults, especially in past few weeks, emerged as strong predictor of future violence and violence during PICU admission as well in studies done in the past.^7,9 Around 80% of admission forms in this audit had this information, while 20% lacked this vital information. More emphasis shall be laid on documentation of previous, especially recent assaults.

Spencer et al. in 2019 published a meta-analysis highlighting that psychiatric patients may be involved in domestic violence more as compared to people without any mental health disorder.¹¹ Therefore, importance of documenting any protection/barring orders taken against patients cannot be denied in terms of predicting future risks. From the charts, it is evaluated, that 38% did not show documentation of history of protection and barring order on admission forms, which was quite alarming. Violent behaviour remained main indication for PICU admission, and around 20% patients had re-admission in six months.^4,7 Around 66% admission forms had documented previous admission of patients to PICU, while 34% forms did not have this information documented.

History of pending and previous charges was recorded in 82% and 88% admission form, respectively. Previous researches have documented that these areas are really important in predicting the future risk, therefore, should not be missed in routine psychiatric assessment.^12,13

A recent study concluded that depot medication was effective in reducing violence as well as improving personality pathology across all dimensions among patients with mental health disorders.¹⁴ Infromation regarding use of depot medication was documented in 86% of admission forms in this clinical audit. There may be number of minor or even major aggressive or violent acts for which patients may have been picked up by police but not charged due to any reason.^12,15 This component of forensic history was most neglected, as only 32% of the admission forms had documented previous encounters with police without charges. As past, risky behaviors have been regarded as major predictors of future behaviours, therefore, they must be documented.  Re-auditing these parameters in our own setting and other intensive care or general adult setting can throw more light on this phenomenon that relevant forensic history components get documented upon admission or not. Documentation in hurry or taking for granted that these parameters may have been mentioned in other sections may be probable reasons for non- or under-documentation of these parameters.

Small sample size and auditing the charts of just one setting are limitations of this audit which may be addressed in future endeavours.

CONCLUSION

Drugs and alcohol and previous charges were documented in most of the cases but documentation of protection/baring order and encounter with the police without being charged was a neglected area, which should be worked upon in future.

CONFLICT OF INTEREST:
The authors declared no conflict of interest.

AUTHORS^’ CONTRIBUTION:
UBZ, RB: Designed audit tool.
UBZ: Authored the manuscript, did the audit under supervision of RB.
RB: Proofread the manuscript.

REFERENCES

1. Zubair UB. Differentiating between mad and bad: forensic psychiatry services may be the need of the hour. Pak Armed Forces Med J 2020; 70(4):878-79.
2. Bowers L, Jeffery D, Bilgin H, Jarrett M, Simpson A, Jones J. Psychiatric intensive care units: A literature review. Int J Soc Psychiatry 2007; 54(1):56-68.  doi: 10.1177/0020 764007082482.
3. Musisi SM, Wasylenki DA, Rapp MS. A psychiatric intensive care unit in a psychiatric hospital. Can J Psychiatry 1989; 34(3):200-4. doi:10.1177/070674378903400308.
4. Walker Z, Seifert R. Violent incidents in a psychiatric intensive care unit. Br J Psychiatry 1994; 164(6):826-828. doi: 10.1192/bjp.164.6.826.
5. Loubser I, Chaplin R, Quirk A. Violence, alcohol and drugs: The views of nurses and patients on psychiatric intensive care units, acute adult wards and forensic wards. J Psychiatr Intensive Care 2009; 5(1):33-9. doi:10.1017/ S1742646408001386.
6. Chadda RK. Forensic evaluations in psychiatry. Indian J Psychiatry 2013; 55(4):393-9. doi:10.4103/0019-5545. 120558.
7. Raaj S, Browne R, Bawagan A, Browne R, Pauline T, Firdouas M, et al. Referral patterns to psychiatry intensive care unit: Phoenix care centre. Int J of Integr Care 2017; 17(5):600. doi.org/10.5334/ijic.3920.
8. Bjo¨rkdahl A, Olsson D, Palmstierna T. Nurses short-term prediction of violence in acute psychiatric intensive care. Acta Psychiatr Scand 2006; 113(3):224-9. doi: 10.1111/ j.1600-0447.2005.00679.x.
9. Brown S, Langrish M. Evaluation of a risk assessment tool to predict violent behaviour by patients detained in a psychiatric intensive care unit. J Psychiatr Intensive Care 2012; 8(1):35-41. DOI: 10.1017/S1742646411000264.
10. Dellazizzo L, Potvin S, Dou BY, Beaudoin M, Luigi M, Giguère CÉ, et al. Association between the use of cannabis and physical violence in youths: A meta-analytical investigation. Am J Psychiatry 2020; 177(17):619-26. doi: 10.1176/appi.ajp.2020.19101008.
11. Spencer C, Mallory AB, Cafferky BM, Kimmes JG, Beck AR, Stith SM. Mental health factors and intimate partner violence perpetration and victimisation: A meta-analysis. Psychology Violence 2019; 9(1):1-17. doi: 10.1037/ vio0000156.
12. Ghiasi N, Azhar Y, Singh J. Psychiatric Illness and Criminality. [Updated 2020 Jun 23]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2020 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/ NBK537064/.
13. Morris NP. Taking legal histories in psychiatric assessments. Psychiatric Services 2018; 69(7):748-50. doi: 10.1176/appi.ps.201800183.
14. Mortlock AM, Larkin F, Ross CC, Gupta N, Sengupta S, Das M. Effectiveness of paliperidone depot injection in seriously violent men with comorbid schizophrenia and dissocial personality disorder in a UK high-security hospital. Ther Adv Psychopharmacol 2017; 7(5):169-79. doi:10.1177/ 2045125317693513.
15. Peterson J, Heinz K.  Understanding offenders with serious mental illness in the criminal justice system. Mitchell Hamline Law Review 2016; 42(2).