TRIAGE AND PATHWAYS IN MEDIUM SECURE CARE Harry Kennedy Executive - - PowerPoint PPT Presentation

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TRIAGE AND PATHWAYS IN MEDIUM SECURE CARE Harry Kennedy Executive - - PowerPoint PPT Presentation

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TRIAGE AND PATHWAYS IN MEDIUM SECURE CARE Harry Kennedy Executive Clinical Director National Forensic Mental Health Service Central Mental Hospital Dundrum, Dublin and Clinical Professor of Forensic Psychiatry Trinity College Dublin

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TRIAGE AND PATHWAYS IN MEDIUM SECURE CARE Harry Kennedy

Executive Clinical Director National Forensic Mental Health Service Central Mental Hospital Dundrum, Dublin and Clinical Professor of Forensic Psychiatry Trinity College Dublin

Forensic Conference 1-3 February 2012

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Co-researchers

  • Conor O’Neill
  • Grainne Flynn
  • Clare McInerney
  • Mary Davoren
  • Zareena Abidin
  • Damian Mohan
  • Pauline Gill
  • David Timmons
  • Leena Naughten
  • Olivia Gibbons
  • Ronan Mullaney
  • Stephen Monks
  • Kim McDonnell
  • Paul Braham
  • Darran Flynn
  • Damian Smith
  • Andrea Nulty
  • Norah Byrne
  • Sally Linehan
  • Brenda Wright
  • Helen O’Neill
  • Charles Smith

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Forensic Conference 1-3 February 2012

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Why study triage at all?

  • 1. Triage – who should we admit to

high secure, medium secure, low secure or open / community services, and why?

  • 2. Urgency - on a waiting list of

people qualified for admission, who should be given priority?

  • 3. When is a patient ready to move to

a less secure place, or to the community? –

  • 3. How do we know that a

patient has successfully completed relevant treatments to address the reason they were admitted to a given level of therapeutic security? –

  • 4. What does ‘recovery’ mean

in a forensic context e.g. ‘conditional discharge’ or CTO? 3

Forensic Conference 1-3 February 2012

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Drivers

  • Policy and rights – least restrictive option
  • Transparency – MHTs, Habeas Corpus, ECHR.
  • Commissioning – quality: consistency, reliability, criterion

setting.

  • Validity – what do we teach, what do we do.

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Forensic Conference 1-3 February 2012

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What do consultant forensic psychiatrists do?

  • Admission assessments /

decisions,

  • movement along the recovery

path

  • Discharge recommendations /

decisions

  • What do we teach SpRs?
  • Have we any evidence for any of

what we do?

  • How do we study what we do?
  • RCTs, ethics committees, AUCs,

linear regression……

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Forensic Conference 1-3 February 2012

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Admission triage

  • Who should be admitted, what level of therapeutic security does the patient

need?

  • Several existing structured professional judgement instruments, ACSeSS

(1998), Coid & Khatan (2000), STD (2001), OPRISK (2002), HONOS-S (2004), SNAP (2005).

  • Risk not considered
  • Two elements – security need and urgency.
  • Decisions are made in the context of a system and a pathway

– prison screening systems, – court liaison/diversion, – pre-admission assessment and – admissions panels

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DUNDRUM-1 triage security

  • Seriousness of violence
  • Seriousness of self-harm
  • Immediacy of risk of violence
  • Immediacy of risk of suicide/ self

harm

  • Specialist forensic need
  • Absconding / eloping
  • Preventing access
  • Victim sensitivity/public confidence

issues

  • Complex Risk of Violence
  • Institutional behaviour
  • Legal process

7

α = 0.949 K > 0.85

Forensic Conference 1-3 February 2012

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DUNDRUM-1 triage security

SCORE DUNDRUM-1:TRIAGE SECURITY ITEMS

1 2 3 4

S1 Seriousness of violence S2 Seriousness of self-harm S3 Immediacy of risk of violence S4 Immediacy of risk of suicide/ self harm S5 Specialist forensic need S6 Absconding / eloping S7 Preventing access S8 Victim sensitivity/public confidence issues S9 Complex Risk of Violence S1 Institutional behaviour S1 1 Legal process

1 2 3 4 high medium PICU Open wards Independent / community

Forensic Conference 1-3 February 2012

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Three months Jan 2008 to Dec 2009

246 assessed after screening 30 admitted hospitals / CMHTs

159 GP follow up 57 psych follow up in prison 9

921 screened on committal – Birmingham & Grubin Prison-based court diversion – Ensures full screening of at risk population

Forensic Conference 1-3 February 2012

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DUNDRUM-1 Prison triage

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ANOVA F=360.1/2/0.001

Forensic Conference 1-3 February 2012

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DUNDRUM-1 Triage Security score

April to June 2009, those not transferred from prison to hospital (n=216) v transferred from prison to any hospital (n=30) Area Under the Curve =0.984 (95% confidence interval 0.971 to 0.997) At threshold score 6, sensitivity =0.95, sensitivity=0.92

Forensic Conference 1-3 February 2012

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Two years Jan 2008 to Dec 2009

1454 assessed after screening 47 admitted to MSU / HSU

GP follow up psych follow up in prison 27 divert to hospital / CMHT 26 divert to PICU 12

7454 screened on committal – Birmingham & Grubin Prison based court diversion – Screens full population at risk

Forensic Conference 1-3 February 2012

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DUNDRUM-1 Prison triage

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ANOVA F=75.2/2/0.001

Forensic Conference 1-3 February 2012

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DUNDRUM-1 Triage Security score

Two year period 2008 to 2009, those transferred to open wards (n=27) compared to those transferred to psychiatric intensive care units (n=26) Area Under the Curve =0.805 (95% confidence interval 0.680 to 0.930) At threshold score 13, sensitivity 0.78, specificity 0.71.

Forensic Conference 1-3 February 2012

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Figure 4 - DUNDRUM-1 Triage Security score

Two year period 2008 to 2009, those transferred to psychiatric intensive care units (n=26) compared to those transferred to forensic medium and high security at Central Mental Hospital (n=47) Area Under the Curve =0.866 (95% confidence interval 0.784 to 0.949) At threshold score 20, sensitivity=0.73, specificity=0.83

Forensic Conference 1-3 February 2012

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D-1 triage security: item to outcome

nil v

  • pen v

PICU v any adm PICU MSU AUC AUC AUC 1.Seriousness of violence 0.915 0.722 0.644

  • 2. Seriousness of self-harm

0.515ns 0.568ns 0.601ns

  • 3. Immediacy of risk of violence

0.961 0.693 0.644

  • 4. Immediacy of risk of suicide/ self harm

0.546ns 0.573ns 0.609ns

  • 5. Specialist forensic need

0.973 0.786 0.695

  • 6. Absconding / eloping

0.930 0.860 0.726

  • 7. Preventing access

0.905 0.825 0.670

  • 8. Victim sensitivity/public confidence

0.806 0.775 0.690

  • 9. Complex risk of violence

0.767 0.762 0.596

  • 10. Institutional behaviour

0.907 0.698 0.599

  • 11. Legal process

0.945 0.927 0.969 16

Forensic Conference 1-3 February 2012

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17

Observed proportion in Agreement (n=316)a 95% CI of

  • bserved

proportion in agreement Spearman rank correlation coefficientb TS1: serious violence 0.75 0.70 – 0.80 0.803 TS2: serious self harm 0.61 0.56 – 0.67 0.259 TS3: immediacy of violence risk 0.75 0.70 – 0.80 0.879 TS4: immediacy of self harm risk 0.67 0.62 – 0.73 0.236 TS5: specialist forensic need 0.78 0.74 – 0.83 0.908 TS6: absconding risk 0.80 0.76 – 0.85 0.879 TS7: preventing access 0.78 0.74 – 0.83 0.831 TS8: victim sensitivities 0.80 0.76 – 0.85 0.806 TS9: complex risks 0.72 0.67 – 0.77 0.828 TS10: institutional behaviour 0.71 0.66 – 0.76 0.758 TS11: legal procedure 0.92 0.90 – 0.95 0.921

EXACT AGREEMENT BETWEEN ITEMS AND DISPOSALS

Forensic Conference 1-3 February 2012

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Male admission 2:1 Medium 1.4:1 Medium 1.1:1 Rehab 0.7:1 Pre- discharge 0.4:1 SABU 3:1 High support Community residence

PRISON AND COURT DIVERSION R&R TEAM Acute Cluster/High Secure Medium Cluster/Medium Secure

Slow stream Rehab 0.7:1

How do we decide to move patients from high to medium, medium to low secure and to the community?

Forensic Conference 1-3 February 2012

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Dynamic risk

ITEM ITEM DESCRIPTION Scoring C1 Lack of insight C2 Negative attitudes C3 Active symptoms of major mental illness C4 Impulsivity C5 Unresponsiveness to treatment ITEM ITEM DESCRIPTION Scoring ‘IN’ ‘OUT’ R1 Plans lack feasibility R2 Exposure to destabilisers R3 Lack of personal support R4 Non-compliance with remediation attempts R5 Stress

Mueller-Isberner, Webster, Gretenkord 2007 Dolan & Blattner 2010

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Treatment Programmes

Physical Health

Healthy Eating Physical Activity National Screening Programmes Primary Health GP Optician

Mental Health

Information wellness Wrap MCT Grow

Drugs and Alcohol Harmful Behaviours Psychosocial functioning

Pillars of Care

Needs strengths and risks Information treatment and self -management Individual Care Plan Achievable Goals

Psycho- Education Abstinence Social & Coping Skills Self Managemen t

AA

Offence related Therapy Victim Empathy Social Role Modelling Self Risk Management Vocational & Occupational Social & Recreational Family Therapy

TREATMENT PROGRAMMES: FIVE PILLARS

Forensic Conference 1-3 February 2012

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DUNDRUM-3 programme completion

  • Physical health
  • Mental health
  • Drugs and Alcohol
  • Problem behaviours
  • Self-care and activities of

daily living

  • Education, Occupation and

Creativity

  • Family and Social Networks

O: ready for independence 3: ready for a move 4: not ready to move down a level of security

Not ready for a move down

4 3 2 1

ready for a move e.g. from high to medium security ready for a move e.g. from medium to low security ready for a move to supported community living ready for independence

Forensic Conference 1-3 February 2012

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DUNDRUM-4 recovery

  • Stability
  • Insight
  • Rapport and Working

Alliance

  • Leave
  • HCR-20 Dynamic Items
  • Victim Sensitivity Issues

O: ready for independence 3: ready for a move 4: not ready to move down a level of security

Not ready for a move down

4 3 2 1

ready for a move e.g. from high to medium security ready for a move e.g. from medium to low security ready for a move to supported community living ready for independence

Forensic Conference 1-3 February 2012

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, stability Maintenance, supported Action / decisional balance Contemplation & preparation, ambivalence Pre-contemplation Taking personal responsibility Positive engagement Active engagement Passive engagement Reluctance / resistance Growth Rebuilding Preparation Awareness Moratorium Physiological needs Safety and basics of life Friendship and family relationships Self-esteem, confidence, social standing Self- actualisation

Maslow Recovery Engagement Cycle of change

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Forensic Conference 1-3 February 2012

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Positive moves

  • Twelve month prospective observational study
  • 86 in-patients at varying levels of therapeutic security.
  • HCR-20 and S-RAMM
  • PANSS & GAF
  • DUNDRUM-1 triage security, DUNDRUM-3 programme completion,

DUNDRUM-4 recovery.

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10 20 30 40 50 60 DUNDRUM-1 DUNDRUM-3 DUNDRUM-4 GAF PANSS pos PANSS neg HCR-H HCR-dyn CANFOR No Move n=75 Positive move n=11 10 20 30 40 50 60 70 DUNDRUM-1 DUNDRUM-3 DUNDRUM-4 GAF PANSS pos PANSS neg HCR-H HCR-dyn CANFOR No Move n=75 Positive move n=11 *

RAW DATA MARGINAL MEANS ADJUSTED FOR LOCATION

* * * * * * * * * *

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Positive moves

10 20 30 40 50 60 No Move n=75 Positive move n=11

Marginal means adjusted for location And HCR-dyn

When adjusted for HCR-20 dynamic scores only the DUNDRUM-1 triage security score remains significant p<0.001 *

Forensic Conference 1-3 February 2012

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Negative moves

  • Twelve month prospective observational study
  • 86 in-patients at varying levels of therapeutic security.
  • HCR-20
  • PANSS & GAF
  • DUNDRUM-1 triage security, DUNDRUM-3 programme completion,

DUNDRUM-4 recovery.

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Forensic Conference 1-3 February 2012

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10 20 30 40 50 60 DUNDRUM-1 DUNDRUM-3 DUNDRUM-4 GAF PANSS pos PANSS neg HCR-H HCR-dyn CANFOR No Move n=77 Negative move n=9 10 20 30 40 50 60 DUNDRUM-1 DUNDRUM-3 DUNDRUM-4 GAF PANSS pos PANSS neg HCR-H HCR-dyn CANFOR No Move n=77 Negative move n=9 *

RAW DATA MARGINAL MEANS ADJUSTED FOR LOCATION

* * * * * * * *

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Forensic Conference 1-3 February 2012

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Negative moves

10 20 30 40 50 60 No Move n=77 Positive move n=9

Marginal means adjusted for location And HCR-dyn

When adjusted for the HCR-20 dynamic score, Only the DUNDRUM-1 triage security, DUNDRUM-4 recovery and PANSS neg remain significant p<0.001 * * *

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Forensic Conference 1-3 February 2012

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Prospective Discharges

  • 96 in-patients assessed February-March

2011(78 reviewed by MHRB) .

  • Eleven month follow-up following the

introduction of conditional discharge

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96 CL(I)A 78 MHA 18 prisoner N=22 UTP N=7 NGRI N=49 14 released N=14 discharged N=7 total 96 total 96 total 96 MHA N=18 MHA N=18 S15 prisoner N=8 UTP N=7 NGRI N=42 total 96

Forensic Conference 1-3 February 2012

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Conditional discharge

» AUC

  • D-3 programme completion

0.921, p<0.001

  • D-4 recovery

0.935, p<0.001

  • GAF

0.911, p<0.001

  • START-V

0.882, p<0.001

  • START-S

0.870, p=0.001

  • PANSS gen

0.823, p=0.005

  • PANSS neg

0.803, p=0.009

  • SAPROF

0.798, p=0.010

  • HCR-dynamic

0.787, p=0.013

  • HCR-total

0.779, p=0.016

  • PANSS pos

0.752, p=0.029

  • D-1 triage security

0.635, NS 32

N=78, MHRB

Forensic Conference 1-3 February 2012

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DUNDRUM-3 programme completion and conditional discharge

AUC 95% CI

  • Physical health

0.834 0.715-0.952

  • Mental health

0.882 0.771-0.992

  • Drugs and Alcohol

0.798 0.679-0.917

  • Problem behaviours

0.904 0.786-1.000

  • Self-care and activities of daily living

0.902 0.813-0.991

  • Education, Occupation and Creativity

0.894 0.795-0.993

  • Family and Social Networks

0.817 0.590-1.000

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Forensic Conference 1-3 February 2012

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DUNDRUM-4 recovery

AUC 95%CI

  • Stability

0.929 0.842-1.00

  • Insight

0.915 0.837-0.994

  • Rapport and Working Alliance

0.781 0.540-1.000

  • Leave

0.813 0.681-0.945

  • HCR-20 Dynamic Items

0.892 0.799-0.985

  • Victim Sensitivity Issues

0.936 0.879-0.993

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Forensic Conference 1-3 February 2012

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HCR-20 ‘clinical’ & ‘risk’

AUC 95%CI

  • Lack of insight

0.742 0.530-0.954

  • Negative attitudes

0.615 0.425-0.805

  • Active symptoms

0.735 0.592-0.877

  • Impulsivity

0.563 0.359-0.768

  • Unresponsive to treatment

0.765 0.557-0.974

  • Plans lack feasibility

0.709 0.550-0.868

  • Exposure to destabilisers

0.562 0.356-0.768

  • Lack of personal support

0.697 0.530-0.864

  • Non-compliance with rem

0.477 0.257-0.696

  • Stress

0.563 0.332-0.794

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Forensic Conference 1-3 February 2012

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SAPROF and conditional discharge

AUC

  • Intelligence

0.730 0.476-0.983

  • Secure attachment in childhood

0.593 0.401-0.785

  • Empathy

0.644 0.421-0.867

  • Coping

0.783 0.620-0.945

  • Self-control

0.720 0.552-0.889

  • Work

0.688 0.494-0.881

  • Leisure activities

0.614 0.404-0.824

  • Financial management

0.757 0.627-0.887

  • Motivation for treatment

0.677 0.469-0.884

  • Attitudes towards authority

0.626 0.407-0.844

  • Life goals

0.786 0.650-0.922

  • Medication

0.564 0.319-0.810

  • Social network

0.764 0.637-0.892

  • Intimate relationship

0.552 0.311-0.793

  • Professional care

0.429 0.184-0.674

  • Living circumstances

0.429 0.184-0.674

  • External control

0.429 0.184-0.674

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Forensic Conference 1-3 February 2012

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START-V START-S

AUC 95% CI AUC 95% CI

  • Social skills

0.681 0.501-0.856 0.657 0.477-0.837

  • Relationships

0.703 0.607-0.878 0.794 0.652-0.936

  • Occupational

0.743 0.607-0.878 0.715 0.563-0.867

  • Recreational

0.705 0.548-0.862 0.684 0.521-0.847

  • Self-care

0.657 0.489-0.825 0.664 0.499-0.830

  • Mental state

0.750 0.617-0.883 0.772 0.626-0.919

  • Emotional state

0.692 0.518-0.866 0.682 0.510-0.854

  • Substance use

0.707 0.558-0.856 0.707 0.558-0.854

  • Impulse control

0.609 0.419-0.800 0.624 0.413-0.836

  • External triggers

0.787 0.652-0.921 0.779 0.413-0.836

  • Social support

0.750 0.617-0.883 0.764 0.637-0.892

  • Material resources

0.693 0.538-0.847 0.736 0.597-0.874

  • Attitudes

0.615 0.399-0.831 0.674 0.464-0.885

  • Medication adherence

0.579 0.382-0.776 0.686 0.529-0.843

  • Rule adherence

0.540 0.327-0.752 0.533 0.318-0.747

  • Conduct

0.600 0.411-0.789 0.632 0.448-0.816

  • Insight

0.759 0.607-0.911 0.801 0.660-0.942

  • Plans

0.814 0.707-0.922 0.800 0.687-0.913

  • Coping

0.836 0.737-0.935 0.814 0.707-0.922

  • Treatability

0.748 0.601-0.895 0.694 0.484-0.903 37

Forensic Conference 1-3 February 2012

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Male admission 2:1 Medium 1.4:1 Medium 1.1:1 Rehab 0.7:1 Pre- discharge 0.4:1 SABU 3:1 High support Community residence

PRISON AND COURT DIVERSION R&R TEAM Acute Cluster/High Secure Medium Cluster/Medium Secure

Slow stream Rehab 0.7:1

How do we decide to move patients from high to medium, medium to low secure and to the community?

Forensic Conference 1-3 February 2012

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Conclusions: triage and pathways in MSU care

  • Decisions to admit, and to what level of therapeutic security, are made on the basis of

a needs assessment that is different from risk assessment.

  • Decisions to move from high to medium to low security are made on the basis of

dynamic risk (HCR-20 ‘C’ and ‘R’ items) and the static assessment of need for therapeutic security (DUNDRUM-1) along with recovery (DUNDRUM-4). Assessments of treatment completion (DUNDRUM-3) are as good however.

  • Conditional discharge is decided on the basis of treatment completion and recovery

(DUNDRUM-3 and DUNDRUM-4). Only some risk items are relevant. This is not the same as predicting reoffending or recall.

  • Items defined in structured professional judgement instruments are more important

than scales – ‘apps’ rather than ‘programmes’.

  • Open source publishing may progress to research ‘Wikis’ for developing these SPJ

definitions.

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references

  • Grainne Flynn, Conor O'Neill, Harry G Kennedy. DUNDRUM-2: Prospective validation of a

structured professional judgment instrument assessing priority for admission from the waiting list for a Forensic Mental Health Hospital. BMC Research Notes 2011,4:230. doi:4:23010.1186/1756- 0500-4-23021722397

  • S O'Dwyer, M Davoren, Z Abidin, E Doyle, K McDonnell, HG Kennedy. The DUNDRUM Quartet:

validation of structured professional judgement instruments DUNDRUM-3 assessment of programme completion and DUNDRUM-4 assessment of recovery in forensic mental health

  • services. BMC Research Notes 2011, 4:229 doi:10.1186/1756-0500-4-22921722396
  • Grainne Flynn, Conor O'Neill, Clare McInerney, Harry G Kennedy. The DUNDRUM-1 structured

professional judgment for triage to appropriate levels of therapeutic security: retrospective-cohort validation study. BMC Psychiatry 2011, 11:43 doi:10.1186/1471-244X-11-43

  • Kennedy HG, O’Neill C, Flynn G, Gill P, The Dundrum Toolkit. Dangerousness,

Understanding, Recovery and Urgency Manual (The Dundrum Quartet) V1.0.22 (18/03/10). Four Structured Professional Judgment Instruments for Admission Triage, Urgency, Treatment Completion and Recovery Assessments, Dublin, Ireland, Trinity College Dublin, April, 2010. http://hdl.handle.net/2262/39131 40

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D-2 urgency: item to outcome

AUC TU1 - Current Location 0.924 TU2 - Mental Health 0.792 TU3 - Suicide Prevention 0.644 TU4 – Humanitarian 0.788 TU5 – Systemic 0.808 TU6 - Legal Urgency 0.593 all p<0.001 except TU6 NS

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