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Mark Pitts Assessment Discharge Nurse M.I.E.T.S.

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Mark Pitts Assessment Discharge Nurse M.I.E.T.S.

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    1. Mark Pitts Assessment & Discharge Nurse M.I.E.T.S.

    2. People with learning disabilities in a low secure unit Comparison of offenders and non-offenders

    3. Background Adults with learning disability (LD): Annual cost to NHS & social services = 3 billion (DOH 2003) 16.7% have challenging behaviour (CB) Annual cost of those with CB = 50-140 million (Netten et al 2001)

    4. Background A significant proportion are: Excluded from ordinary services (Vaughan et al 2000) Treated out of area (Vaughan 1999; Kearns 2001) Face delayed discharge (Watts et al 2000) Worse for those with forensic history: Enter statutory care earlier (Alborz 2003) Exceptionally long admissions (Holland et al 2002)

    5. Background Services who are reluctant to accommodate LD offenders are: Contravening human rights Contravening government policy Increasing the burden on the NHS (Home Office 1990, 1995; DoH & Home Office 1992; DoH 1993, 2001)

    6. Questions Why worse for LD offenders? Are LD offenders different from people with LD & CB who do not offend?

    7. Research aim To test between group differences in aggression and treatment outcome in people with learning disability and challenging behaviour, with and without a forensic history

    8. Sampling frame All MIETS admissions prior to 31.01.01 N = 121 Exclusion criteria: Admissions < 8 weeks Current admissions

    9. Sample 86 former MIETS inpatients Legal status on admission: Informal, Section 2Section 3Section 35Section 37Section 37/41Section 38Probation OrderLegal status on admission: Informal, Section 2Section 3Section 35Section 37Section 37/41Section 38Probation Order

    10. Research design Retrospective survey of: Patient characteristics Admission & discharge data Clinical data Outcome measures: Frequency of CB Severity of CB Placement outcome

    11. Patient characteristics In the LDO group aggressive behaviours were indicated in the majority of index offences (physical assault in 36% of cases and criminal damage in 20%), and the remaining offences were arson (27%), sexual offences (16%), and theft (13%); custodial sentences had been served by 16%, and 27% had previously been admitted to Special Hospital no significant differences between the LDCB and LDO group in age, sex, ethnicity, IQ, length of admission,In the LDO group aggressive behaviours were indicated in the majority of index offences (physical assault in 36% of cases and criminal damage in 20%), and the remaining offences were arson (27%), sexual offences (16%), and theft (13%); custodial sentences had been served by 16%, and 27% had previously been admitted to Special Hospital no significant differences between the LDCB and LDO group in age, sex, ethnicity, IQ, length of admission,

    12. Patient characteristics or type of co-morbid psychiatric disorder - except in presence of pervasive developmental disorder (Table 1). Autistic disorder was diagnosed significantly more frequently in the LDCB group (X2 (1, n=63)=4.16, p=0.04). In contrast the LDO group was more frequently diagnosed with personality disorder but the difference did not reach statistical significance (X2 (1, n=63)=3.21, p=0.07). or type of co-morbid psychiatric disorder - except in presence of pervasive developmental disorder (Table 1). Autistic disorder was diagnosed significantly more frequently in the LDCB group (X2 (1, n=63)=4.16, p=0.04). In contrast the LDO group was more frequently diagnosed with personality disorder but the difference did not reach statistical significance (X2 (1, n=63)=3.21, p=0.07).

    13. no significant between-group differences in the inpatient rates of total incidents of challenging behaviour, violence towards property, sexual assault, and fire setting. However the LDCB group was significantly more assaultive to staff (p<0.01) and to other patients (p=0.01); and used weapons significantly more frequently (p<0.01). In contrast the LDO group had a significantly higher rate of self-injurious behaviour (p=0.02). Analysis of between group differences in treatment effect on frequency of challenging behaviour revealed a baseline to end-of stay decrease from 0.79 to 0.36 incidents per person per week in the LDO group compared to 0.23 to 0.11 incidents per person per week in the LDCB group. Thus there was a trend (p=0.08, 95%CI=0.16-1.10) for reduction in CB to be greater in the LDO group than in LDCB group but the difference was not statistically significant.no significant between-group differences in the inpatient rates of total incidents of challenging behaviour, violence towards property, sexual assault, and fire setting. However the LDCB group was significantly more assaultive to staff (p<0.01) and to other patients (p=0.01); and used weapons significantly more frequently (p<0.01). In contrast the LDO group had a significantly higher rate of self-injurious behaviour (p=0.02). Analysis of between group differences in treatment effect on frequency of challenging behaviour revealed a baseline to end-of stay decrease from 0.79 to 0.36 incidents per person per week in the LDO group compared to 0.23 to 0.11 incidents per person per week in the LDCB group. Thus there was a trend (p=0.08, 95%CI=0.16-1.10) for reduction in CB to be greater in the LDO group than in LDCB group but the difference was not statistically significant.

    14. Severity of CB The LDCB group required restraint and relocation significantly more frequently than the LDO group (Table 3). This finding also remained significant after removal of potential outliers. There were no significant between group differences in rate of seclusion or change in rate of seclusion during admission.The LDCB group required restraint and relocation significantly more frequently than the LDO group (Table 3). This finding also remained significant after removal of potential outliers. There were no significant between group differences in rate of seclusion or change in rate of seclusion during admission.

    15. Placement outcome There was an expected difference in place of origin with a greater frequency of people in the LDO group admitted from non-community settings (e.g. hospital, special hospital, prison) and people with LDCB admitted from community settings (X2 (1, n=86)=8.88, p<0.01). Data on discharge placement was available for 78 (91%) people (Table 4). As expected there was a significant association between forensic status and discharge setting, with a greater proportion of the LDO group being discharged to non-community settings (X2 (1, n=78)=5.00, p=0.03). When place of discharge was compared to place of origin the LDO group tended towards a better outcome with 71% achieving discharge to a placement less restrictive than that admitted from, compared to 59% of the LDCB group. However the difference was not statistically significant.There was an expected difference in place of origin with a greater frequency of people in the LDO group admitted from non-community settings (e.g. hospital, special hospital, prison) and people with LDCB admitted from community settings (X2 (1, n=86)=8.88, p<0.01). Data on discharge placement was available for 78 (91%) people (Table 4). As expected there was a significant association between forensic status and discharge setting, with a greater proportion of the LDO group being discharged to non-community settings (X2 (1, n=78)=5.00, p=0.03). When place of discharge was compared to place of origin the LDO group tended towards a better outcome with 71% achieving discharge to a placement less restrictive than that admitted from, compared to 59% of the LDCB group. However the difference was not statistically significant.

    16. Placement outcome

    17. Findings Clinical and behavioural differences: Smaller proportion of LD offenders were autistic Compared to relatively high prevalence of people with Autistic Spectrum Disorder in prison (DOH 1992) Greater prevalence of personality disorder in the offenders group. Compares with previous findings (Linaker, 1994; Vaughan et al, 2000) We compared clinical and behavioural factors recorded in the case notes of people admitted to a low secure unit and found differences between learning disability offenders and those with learning disability and challenging behaviour not categorised as offenders. The LDCB non-offenders were significantly more likely to; have a diagnosis of pervasive developmental disorder; assault others; require restraint and relocation; and use weapons during admission. In contrast the offender group was significantly more likely to harm themselves, and to have a diagnosis of personality disorder; and tended to have a more favourable treatment outcome as measured by reduction in CB A smaller proportion of people in the offender group was diagnosed with pervasive developmental disorder (Autistic Spectrum Disorder (ASD)). This is surprising since the triad of impairments associated with ASD might be expected to generate more socially unacceptable behaviours and hence offence statistics. Also, others have reported a relatively high prevalence of people with ASD in prison (DOH 1992). The trend for a greater prevalence of PD in the offender group is consistent with epidemiological surveys of people with LD that have reported an association between PD and aggressive or offending behaviours (Linaker, 1994; Vaughan et al, 2000). a high prevalence of self-injury has previously been noted in people with LD, people with PD, and in forensic populations (Winchel & Stanley, 1991; Hillbrand et al, 1996; Haw et al, 2001). Hence a combination of these individual factors may be having a cumulative effect on risk of self-injury in LDO's. Alternatively, as the majority of the LDO's were admitted from institutional care settings it may be that their prior environment has exacerbated SIB; or that those already made subject to forensic proceedings have more motivation to avoid further trouble and are therefore directing aggression towards themselves rather than towards others. We compared clinical and behavioural factors recorded in the case notes of people admitted to a low secure unit and found differences between learning disability offenders and those with learning disability and challenging behaviour not categorised as offenders. The LDCB non-offenders were significantly more likely to; have a diagnosis of pervasive developmental disorder; assault others; require restraint and relocation; and use weapons during admission. In contrast the offender group was significantly more likely to harm themselves, and to have a diagnosis of personality disorder; and tended to have a more favourable treatment outcome as measured by reduction in CB A smaller proportion of people in the offender group was diagnosed with pervasive developmental disorder (Autistic Spectrum Disorder (ASD)). This is surprising since the triad of impairments associated with ASD might be expected to generate more socially unacceptable behaviours and hence offence statistics. Also, others have reported a relatively high prevalence of people with ASD in prison (DOH 1992). The trend for a greater prevalence of PD in the offender group is consistent with epidemiological surveys of people with LD that have reported an association between PD and aggressive or offending behaviours (Linaker, 1994; Vaughan et al, 2000). a high prevalence of self-injury has previously been noted in people with LD, people with PD, and in forensic populations (Winchel & Stanley, 1991; Hillbrand et al, 1996; Haw et al, 2001). Hence a combination of these individual factors may be having a cumulative effect on risk of self-injury in LDO's. Alternatively, as the majority of the LDO's were admitted from institutional care settings it may be that their prior environment has exacerbated SIB; or that those already made subject to forensic proceedings have more motivation to avoid further trouble and are therefore directing aggression towards themselves rather than towards others.

    18. Findings Where LD & forensic order for treatment co-exist increased risk of SIB Previous research supports this (Winchel & Stanley, 1991; Hillbrand et al, 1996; Haw et al, 2001) Higher frequency of assault on others & use of weapons in non-offenders group. Less use of relocation and restraint in the offenders group.

    19. Findings Treatment outcome: No association between forensic status and length of stay Higher proportion of offenders discharged to non-community settings Trend for greater reduction in CB in offender group of particular concern in the LD population for whom community living has long been hindered by segregated care systems and institutionalisation. Our study does not support the theory that forensic status is associated with protracted admission or that LDO's are less likely to move on. Despite having lower levels of aggression to others than the LDCB group, a significantly greater proportion of the LDO group were discharged to non-community settings. Nevertheless our findings demonstrate positive treatment outcomes in a LDO group and a trend for greater reduction in CB compared to their non-offender counterparts. Although the latter does not reach statistical significance it confirms that LD offenders and non-offenders may benefit equally in this service option. of particular concern in the LD population for whom community living has long been hindered by segregated care systems and institutionalisation. Our study does not support the theory that forensic status is associated with protracted admission or that LDO's are less likely to move on. Despite having lower levels of aggression to others than the LDCB group, a significantly greater proportion of the LDO group were discharged to non-community settings. Nevertheless our findings demonstrate positive treatment outcomes in a LDO group and a trend for greater reduction in CB compared to their non-offender counterparts. Although the latter does not reach statistical significance it confirms that LD offenders and non-offenders may benefit equally in this service option.

    20. Study limitations Tolerance of offences in LD settings (Lyall et al 1995; Hakeem & Fitzgerald, 2002) and subsequent use of Mental Health Act poses difficulties in use as measure of offending Retrospective gathering of data Investigation limited to inpatient service and cannot be generalised to other settings The use of staff intervention to measure severity Long term success of community placement after discharge was not studied

    21. Clinical implications People with LD who are detained in hospital on forensic grounds present less risk to others but are more likely to harm themselves than LD non-offenders People with LD who offend can reduce the frequency of CB and achieve community resettlement There is no room for therapeutic nihilism in the treatment of this group of people.

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