OBJECTIVE To determine the rate, indications and process for using seclusion for patients undergoing treatment at an older adolescent inpatient unit. METHOD Data were gathered prospectively and retrospectively as part of a quality assurance initiative at the Christchurch Youth Inpatient Unit (YIU); paper, electronic and legal documentation were examined. RESULTS During the time period of the investigation, approximately 13% of individuals admitted to the unit were secluded. Psychosis, involuntary admission and Maori ethnicity were significantly associated with the use of seclusion with aggression being the most documented indication. The vast majority of seclusions occurred within the first seven days of admission and over half utilized pro re nata medication prior to seclusion. CONCLUSIONS Opportunities exist for intensifying and focusing efforts to minimize the use of seclusion and restraint, particularly during the first week of hospitalization.

OBJECTIVE To evaluate a clinical guideline and an automated computer protocol for detection and respiratory isolation of tuberculosis (TB) patients. DESIGN An automated computer protocol was tested on a retrospective cohort of adult culture-positive TB patients admitted from 1992 to 1993 to Columbia-Presbyterian Medical Center and evaluated prospectively from July 1995 until July 1996. SETTING A large teaching hospital in New York City. PATIENTS 171 adult patients admitted from 1992 to 1993 and 43 patients admitted between July 1995 and July 1996. INTERVENTIONS The 1990 Centers for Disease Control and Prevention guidelines for preventing transmission of TB were adapted to formulate clinical guidelines to ensure early isolation of TB patients at Columbia-Presbyterian Medical Center. RESULTS Implementation of a clinical respiratory isolation protocol resulted in a significant improvement in TB patient isolation rates, from 45 (51%) of 88 in 1992 to 62 (75%) of 83 in 1993 (P<.001). In testing automated protocols, the theoretical improvement would have identified an additional 27 patients not isolated by clinicians, making the overall isolation rate 134 (78%) of 171. For the prospective evaluation, 30 (70%) of 43 TB patients were isolated by clinicians adhering to the clinical protocol. Four additional patients were identified by the automated TB protocol, making the combined isolation rate 34 (79%) of 43. CONCLUSIONS A clinical policy to isolate TB patients and suspected human immunodeficiency virus-infected patients with cough, fever, or radiographic abnormalities improved isolation of culture-documented TB patients from 1992 to 1993. Automated computer protocols were successful in identifying additional potentially infectious patients that clinicians failed to place on respiratory isolation. Clinical and automated protocols combined resulted in better isolation rates than a clinical protocol alone.

Acute infectious disease presentations among many at-risk patient groups (eg, uninsured, homeless, and recent immigrants) are frequently seen in emergency departments. Therefore EDs may be useful sentinel sites for infectious disease surveillance. This article describes the background, development, and implementation of EMERGE ncy ID NET, an interdisciplinary, multicenter, ED-based network for research of emerging infectious diseases. EMERGE ncy ID NET was established in cooperation with the National Center for Infectious Diseases, Centers for Disease Control and Prevention (CDC) as part of the CDC's strategy to expand and complement existing disease detection and control activities. The network is based at 11 university-affiliated, urban hospital EDs with a combined annual patient visit census of more than 900,000. Data are collected during ED evaluation of patients with specific clinical syndromes, and are electronically stored, transferred, and analyzed at a central receiving site. Current projects include investigation of bloody diarrhea and the prevalence of Shiga toxin-producing Escherichia coli, animal exposures and rabies postexposure prophylaxis practices, seizures and prevalence of neurocysticercosis, nosocomial ED Mycobacterium tuberculosis transmission, and hospital isolation bed use for adults admitted for pneumonia or suspected tuberculosis. EMERGE ncy ID NET also was developed to be a mechanism for rapidly responding to new diseases or epidemics. Future plans include study of antimicrobial use, meningitis, and encephalitis, and consideration of other public health concerns such as injury and national and international network expansion.

OBJECTIVE To investigate compliance with isolation precautions. DESIGN A prospective observational study carried out during ten weeks of 1989. Participants were unaware of the study. SETTING The isolation bay of a 24-bed surgical intensive care unit in a 900-bed university tertiary care facility. PARTICIPANTS Study participants included any healthcare worker or visitor entering the patient room during designated 15-minute intervals. RESULTS We observed 467 subjects entering patient rooms. Compliance with strict isolation (65%) was better than with wound/skin (40%) or excretion/secretion (36%) isolation (p less than .01). Visitors were more compliant than healthcare workers (88% versus 41%; p less than .01). Spending more time in the room was associated with improved compliance (p less than .01). Compliance was higher for subjects entering with a group compared with those entering alone (51% versus 41%; p less than .05). The compliance rate for nurses improved as the nurse/patient ratio improved (p =.14). Compliance was independent of severity of illness. Multivariate analysis revealed that the amount of time spent in the room, being a visitor, and use of strict isolation were independent predictors of compliance. CONCLUSIONS Noncompliance was widespread. When increased demands are placed on the time of physicians and nurses in the name of cost containment, unperceived consequences, such as those resulting from decreased compliance, must be considered.

This study assessed the effect of an intervention designed to reduce the use of seclusion and restraint on reported episodes of patient-related violence on an acute inpatient psychiatric service. Results showed a significant decrease in the total number of episodes of seclusion and restraint between the 12 months before and after the intervention. However, the number of episodes of assault on patients and staff increased significantly. Efforts to decrease seclusion and restraint may be accompanied by an increased risk of harm to psychiatric patients and staff, and intensive safety monitoring and staff training should accompany all such efforts.

This article reports on a literature review of the practice of seclusion in psychiatric inpatient facilities. Attention is paid to the moral debate on seclusion. Most publications consider seclusion as a necessary intervention to manage problem behavior. The first part of the article deals with definitional aspects leading toward concept clarification. The review shows differences in definitional aspects, motives for seclusion, hospital characteristics, and patient characteristics. Data on frequency, incidence, and duration appear to be widely divergent. The experiences of patients who have been secluded are mostly negative, but positive reactions are also reported. In the publications of the last decade, there is emphasis on the contribution of hospital characteristics to trends in use of seclusion. Finally, it is concluded that seclusion is an effective way to manage (potentially) dangerous behavior and that seclusion is an intervention that may create therapeutic possibilities for care.

OBJECTIVE: The authors examined rates of use restraint and seclusion during September 1992 in 125 psychiatric settings in New York State. METHODS: Psychiatric centers and general hospitals with psychiatric services were surveyed by mail about use of restraint and seclusion during a one-month period and about facility characteristics. Four measures of use of restraint and seclusion were calculated: percentage of patients restrained, percentage of patients secluded, rate of seclusion orders, and rate of restraint orders. RESULTS: Use of restraint and seclusion varied dramatically among the psychiatric settings studied. Use of restraint was not related to use of seclusion. Of the 112 tested relationships between facility and patient characteristics and variations in the restraint and seclusion measures, only 12 proved to be significant. None of the variables correlated significantly with variations in more than two of the four measures of restraint or seclusion, and only three correlated with at least two of the four measures. CONCLUSIONS: Variations in use of restraint and seclusion in psychiatric settings in New York State are dramatic and difficult to correlate with differences in the patient populations. The authors suggest that such variations prevail because of the disparate clinical perspectives on the advisability of restraint and seclusion and the limited comparative monitoring of restraint and seclusion practices in psychiatric settings.

We studied the seclusion records of an adolescent unit for a six-year period. Problems in the analysis of typical seclusion data are examined and statistical methods that overcame them are explained. Only a few relationships were found between the seclusion regime and available measures of patient and ward characteristics, though there was great variability in the frequency with which individuals were secluded and the duration of various episodes of seclusion. The average duration of seclusion (31 minutes) was much less than had been reported by other investigators. Furthermore, the durations became shorter over the period of study. The implications of these findings for further research and practice are discussed.

OBJECTIVES: State psychiatric hospitals across the U.S. were surveyed to develop national normative data on the incidence of seclusion and restrain and of injuries to patients and staff resulting from aggression by patients. METHODS: A survey instrument was sent to 225 state hospitals requesting information for a one-year period on the number of patients placed in seclusion or restraint, the number of discrete incidents of seclusion and restraint, the number of hours patients spent in seclusion or restraint, and the number of injuries to patients and staff attributable to aggression by patients. Rates of seclusion, restraint, and injuries were calculated to control for variation in hospital censuses. Percentile ranks for the various rates were calculated to allow hospitals to compare their rates. RESULTS AND CONCLUSIONS: A total of 101 state hospitals in 44 states and the District of Columbia returned the survey. In general, smaller hospitals had higher rates of seclusion and restraint. However, large standard deviations in the mean rates suggested considerable variability between hospitals in the sample. Small positive correlations between rates of seclusion and rates of restraint suggested that the hospitals did not use of the two interventions exclusively.

This descriptive study used two attributional frameworks to examine the causes psychiatric inpatients and nurses gave for the seclusion and restraint of patients. Patients were interviewed in restraints. The reasons patients and nurses gave for the patients restraint were recorded verbatim. A nominal system using the recorded responses was developed by two attribution researchers and were also coded along the dimensions of locus, controllability, and stability. The findings supported attribution theory and research in that most patients and nurses gave causes for the patients' restraint. However, the data suggest more research is needed in this area.

BACKGROUND The main objective of this study is to apply autoregressive integrated moving average (ARIMA) models to make real-time predictions on the number of beds occupied in Tan Tock Seng Hospital, during the recent SARS outbreak. METHODS This is a retrospective study design. Hospital admission and occupancy data for isolation beds was collected from Tan Tock Seng hospital for the period 14th March 2003 to 31st May 2003. The main outcome measure was daily number of isolation beds occupied by SARS patients. Among the covariates considered were daily number of people screened, daily number of people admitted (including observation, suspect and probable cases) and days from the most recent significant event discovery. We utilized the following strategy for the analysis. Firstly, we split the outbreak data into two. Data from 14th March to 21st April 2003 was used for model development. We used structural ARIMA models in an attempt to model the number of beds occupied. Estimation is via the maximum likelihood method using the Kalman filter. For the ARIMA model parameters, we considered the simplest parsimonious lowest order model. RESULTS We found that the ARIMA (1,0,3) model was able to describe and predict the number of beds occupied during the SARS outbreak well. The mean absolute percentage error (MAPE) for the training set and validation set were 5.7% and 8.6% respectively, which we found was reasonable for use in the hospital setting. Furthermore, the model also provided three-day forecasts of the number of beds required. Total number of admissions and probable cases admitted on the previous day were also found to be independent prognostic factors of bed occupancy. CONCLUSION ARIMA models provide useful tools for administrators and clinicians in planning for real-time bed capacity during an outbreak of an infectious disease such as SARS. The model could well be used in planning for bed-capacity during outbreaks of other infectious diseases as well.