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Contact isolation of infected or colonised hospitalised patients is instrumental to interrupting multidrug-resistant organism (MDRO) cross-transmission. Many studies suggest an increased rate of adverse events associated with isolation. We aimed to compare isolated to non-isolated patients in intensive care units (ICUs) for the occurrence of adverse events and medical errors. Methods We used the large database of the Iatroref III study that included consecutive patients from three ICUs to compare the occurrence of pre-defined medical errors and adverse events among isolated vs. non-isolated patients. A subdistribution hazard regression model with careful adjustment on confounding factors was used to assess the effect of patient isolation on the occurrence of medical errors and adverse events. Results Two centres of the Iatroref III study were eligible, an 18-bed and a 10-bed ICU (nurse-to-bed ratio 2.8 and 2.5, respectively), with a total of 1,221 patients. After exclusion of the neutropenic and graft transplant patients, a total of 170 isolated patients were compared to 980 non-isolated patients. Errors in insulin administration and anticoagulant prescription were more frequent in isolated patients. Adverse events such as hypo- or hyperglycaemia, thromboembolic events, haemorrhage, and MDRO ventilator-associated pneumonia (VAP) were also more frequent with isolation. After careful adjustment of confounders, errors in anticoagulant prescription [subdistribution hazard ratio (sHR) = 1.7, p  = 0.04], hypoglycaemia (sHR = 1.5, p  = 0.01), hyperglycaemia (sHR = 1.5, p  = 0.004), and MDRO VAP (sHR = 2.1, p  = 0.001) remain more frequent in isolated patients. Conclusion Contact isolation of ICU patients is associated with an increased rate of some medical errors and adverse events, including non-infectious ones.

Healthcare staff use coercive measures to manage patients at acute risk of harm to self or others, but their effect on patients' mental health is underexplored. This nationwide Swiss study emulated a trial to investigate the effects of coercive measures on the mental health of psychiatric inpatients at discharge. We analysed retrospective longitudinal data from all Swiss adult psychiatric hospitals that provided acute care (2019-2021). The primary exposure was any coercive measure during hospitalization; secondary exposures were seclusion, restraint and forced medication. Our primary outcome was Health of the Nations Outcome Scale (HoNOS) score at discharge. We used inverse probability of treatment weighting to emulate random assignment to the exposure. Of 178,369 hospitalizations, 9.2% (  = 18,800) included at least one coercive measure. In patients exposed to coercive measures, mental health worsened a small but statistically significant amount more than in non-exposed patients. Those who experienced at least one coercive measure during hospitalization had a significantly higher HoNOS score (1.91-point,  < .001, 95% confidence interval [CI]: 1.73; 2.09) than those who did not experience any coercive measure. Results were similar for seclusion (1.60-point higher score,  < .001, 95% CI: 1.40; 1.79) and forced medication (1.97-point higher score,  < .001, 95% CI: 1.65; 2.30). Restraint had the strongest effect (2.83-point higher score,  < .001, 95% CI: 2.38; 3.28). Our study presents robust empirical evidence highlighting the detrimental impact of coercive measures on the mental health of psychiatric inpatients. It underscores the importance of avoiding these measures in psychiatric hospitals and emphasized the urgent need for implementing alternatives in clinical practice.

Background People admitted to psychiatric hospitals with a diagnosis of schizophrenia may display behavioural problems. These may require management approaches such as use of coercive practices, which impact the well-being of staff members, visiting families and friends, peers, as well as patients themselves. Studies have proposed that not only patients’ conditions, but also treatment environment and ward culture may affect patients’ behaviour. Seclusion and restraint could possibly be prevented with staff education about user-centred, more humane approaches. Staff education could also increase collaboration between patients, family members and staff, which may further positively affect treatment culture and lower the need for using coercive treatment methods. Methods This is a single-blind, two-arm cluster randomised controlled trial involving 28 psychiatric hospital wards across Finland. Units will be randomised to receive either a staff educational programme delivered by the team of researchers, or standard care. The primary outcome is the incidence of use of patient seclusion rooms, assessed from the local/national health registers. Secondary outcomes include use of other coercive methods (limb restraint, forced injection, and physical restraint), service use, treatment satisfaction, general functioning among patients, and team climate and employee turn-over (nursing staff). Discussion The study, designed in close collaboration with staff members, patients and their relatives, will provide evidence for a co-operative and user-centred educational intervention aiming to decrease the prevalence of coercive methods and service use in the units, increase the functional status of patients and improve team climate in the units. We have identified no similar trials. Trial registration ClinicalTrials.gov NCT02724748 . Registered on 25 th of April 2016.

Impact of COVID‐19 pandemic: isolation, impairment of well‐being, and insecurity With the current COVID‐19 pandemic, unprecedented restrictions have been decided by governmental authorities on social freedoms in order to allow strict social distancing to reduce transmission of SARS‐CoV‐2 and risk of COVID‐19 spread. 1 These measures aim to drastically reduce social interactions (school shutdown and home working), prohibiting visits from relatives and minimizing the use of public transports, and were gradually adopted worldwide. A greater duration of confinement, inadequate supplies, limited access to medical care and medications, and financial losses are aggravating factors. 2 Fear, uncertainty on the future, unclear or even contradictory messages from the authorities, and continuous and alarming media reports (daily number of deaths and insecurity) may play an additional impact on the emergence of emotional stress. 3 Takotsubo physiopathology and role of stressful event The pathophysiology of takotsubo syndrome (TTS) is complex and still not fully understood, but the role of stress and its interaction with the autonomic nervous system seems predominant. An increase in circulating and intracardiac catecholamines has been frequently described, as well as a modification of the activity of G proteins coupled to B2 receptors. 4 Animal TTS models (immobilization stress) have demonstrated a protective effect of beta‐blockers and alpha‐blockers, 5 which is also suspected in humans at the acute stage of TTS but does not persist in the long term. 6 Chronic stress (dependent, cancer and depression) seems to facilitate TTS occurrence. 7 An acute emotional or physical trigger is found in almost 50% of TTS cases. 8 Impact of COVID‐19 pandemic on TTS occurrence In this context of pandemic and containment, one could expect a rise in the rate of TTS episodes by an increase of triggering mechanisms such as stress and anxiety, but this remains to be proven.

By April 2, 2020, >1 million persons worldwide were infected with severe acute respiratory syndrome coronavirus 2. We used a mathematical model to investigate the effectiveness of social distancing interventions in a mid-sized city. Interventions reduced contacts of adults >60 years of age, adults 20-59 years of age, and children <19 years of age for 6 weeks. Our results suggest interventions started earlier in the epidemic delay the epidemic curve and interventions started later flatten the epidemic curve. We noted that, while social distancing interventions were in place, most new cases, hospitalizations, and deaths were averted, even with modest reductions in contact among adults. However, when interventions ended, the epidemic rebounded. Our models suggest that social distancing can provide crucial time to increase healthcare capacity but must occur in conjunction with testing and contact tracing of all suspected cases to mitigate virus transmission.

The use of coercive measures such as seclusion and restraint in forensic mental healthcare settings is widespread but controversial. Efforts to reduce these measures require knowledge of patient-related risk factors. The present study aimed to identify and confirm factors related to seclusion and restraint that can be assessed upon admission among men and women admitted to forensic hospitals in Ontario, Canada. We included cross-sectional Ontario Mental Health Reporting System admission data for adult patients admitted to 10 forensic psychiatric hospitals between April 1, 2013, and March 31, 2023. We determined patient demographic, administrative, and clinical characteristics associated with seclusion and physical and manual restraint episodes during the first three days of admission. We conducted logistic Generalized Linear mixed Models (GLMM) to examine the association between the independent variables and restraint and seclusion while accounting for variability across facilities. Of 7635 patients, 30.2% (n = 2302) were secluded, and 3.7% (n = 286) were restrained within their first three days of admission. Secluded patients were more likely to be young adults, male, and scored higher on violence and aggression measures. Being admitted due to fitness-related reasons, lack of insight, medication non-adherence, higher scores on the mania scale and cognitive impairment further contributed to the higher odds of being secluded, whereas neurocognitive disorder diagnosis and elopement behavior were protective factors. Restrained patients were also more likely to be young adults, have a diagnosis of mood or anxiety, neurodevelopmental or personality disorder, and scored higher on violence and aggression measures. Fitness-related status, medication non-adherence, and cognitive impairment further contributed to this model of restraint. Indigenous self-identification and immigration status were not significant contributors to either model. Clinicians can assess indicators associated with seclusion and restraint when forensic patients are admitted to forensic hospitals or during the first three days of their stay, enabling effective targeting of those needs to reduce the use of coercive measures.

BackgroundIsolation precautions have negative effects on patient safety, psychological well-being, and healthcare worker contact. However, it is not known whether isolation precautions affect certain hospital-related outcomes.ObjectiveTo examine the effect of isolation precautions on hospital-related outcomes and cost of care.DesignRetrospective, propensity-score matched cohort study of inpatients admitted to general internal medicine (GIM) services at three academic hospitals in Toronto, Ontario, Canada between January 2010 and December 2012.ParticipantsAdult (≥18 years of age) patients on isolation precautions for respiratory illnesses and methicillin-resistant Staphylococcus aureus (MRSA) were matched to controls based on propensity scores derived from nine covariates: age, sex, Resource Intensity Weight, number of hospital readmissions within 90 days, total length of stay for hospital admissions within 90 days, site of admission, month of isolation, year of isolation, and Case Mix Group.Main MeasuresThirty-day readmission rates and emergency department visits, hospital length of stay, expected length of stay, adverse events, in-hospital mortality, patient complaints, and cost of care in Canadian doll ars (CAD).Key ResultsA total of 17,649 non-isolated patients were admitted to the participating hospitals during the study period. We identified 1506 patients isolated for respiratory illnesses and 745 patients isolated for MRSA. Compared to non-isolated individuals, those on isolation precautions for respiratory illnesses stayed 17 % longer (95 % CI: 9 %, 25 %), stayed 9 % longer than expected (95 % CI: 3 %, 15 %), and had 23 % higher cost of care (95 % CI: 14 %, 32 %). Patients isolated for MRSA had similar outcomes, but they also had a 4.4 % higher (95 % CI: 1.4 %, 7.3 %) rate of readmission to hospital within 30 days.ConclusionsIsolation precautions are associated with adverse effects which may result in poorer hospital outcomes. Balancing the benefits for the many with the harms to the few will be a future challenge.

Background Whether admission to a single-bed intensive care unit (ICU) isolation room is associated with subsequent psychiatric morbidity remains uncertain. We investigated the association between ICU isolation and new-onset psychiatric disorders after discharge. Methods Using South Korea’s National Health Insurance Service database, we conducted a nationwide retrospective cohort study including adults admitted to any ICU between Jan 1 2020 and Dec 31 2022. We excluded patients < 18 years, those who died within 1 year, and those with psychiatric diagnoses in the preceding 12 months. Outcomes were new diagnoses of depression, anxiety disorder, or post-traumatic stress disorder (PTSD) within 1 year after ICU admission. Exposure was any stay in a single-bed ICU isolation room; isolation duration (days) was also analyzed. Results Among 517 917 ICU survivors, 136 172 (26.3%) developed a psychiatric disorder within 1 year (depression 15.6%, anxiety 16.8%, PTSD 0.1%). Admission to an ICU isolation room was modestly associated with any psychiatric disorder (odds ratio [OR], 1.03; 95% confidence interval [CI], 1.01–1.06; P  = 0.034). This association was primarily driven by depression (OR, 1.06; 95% CI, 1.03–1.10; P  < 0.001). There were no significant associations with anxiety disorder ( P  = 0.64) or PTSD ( P  = 0.307). When treating the duration of ICU isolation as a continuous variable, each additional day of isolation showed a small incremental association with psychiatric disorder (OR per day, 1.01; 95% CI, 1.01–1.01; P  < 0.001) and depression (OR, 1.01; 95% CI, 1.01–1.02; P  < 0.001). Conclusions ICU admission to a single-bed isolation room showed a small yet consistent association with post-ICU psychiatric morbidity, mainly depression. Given the minimal absolute difference and observational design, causality cannot be inferred. Nevertheless, isolation represents a potentially modifiable environmental exposure that warrants further confirmatory and mechanistic research, as well as pragmatic evaluation of mitigation strategies such as improved communication, family engagement, and circadian cueing. Key points Question: Is admission to a single-bed ICU isolation room associated with new-onset psychiatric disorders among ICU survivors? Findings: In a nationwide cohort of 517,917 survivors, 26.3% developed a psychiatric disorder within 1 year. Isolation-room admission was modestly associated with higher odds of any psychiatric disorder (OR 1.03, 95% CI 1.01–1.06), driven by depression (OR 1.06, 95% CI 1.03–1.10); anxiety and PTSD were not significant. Each additional isolation day showed a small incremental association (OR/day 1.01). Meaning: ICU environmental isolation appears to be a minor but consistent associative factor for post-ICU depression. Although causal inference is not possible, these findings highlight the need for further studies and feasible mitigation strategies such as enhanced communication and circadian support.

Background The reduction of coercion is a central challenge of inpatient mental health services. Little is known about the use of seclusion and restraint in open-door settings. This work aims to analyse the prevalence and risk factors of coercive measures in open inpatient wards of a Swiss university psychiatric hospital. Methods The use of seclusion and restraint was retrospectively analysed between 2017 and 2019. Incidence rate ratios using multivariable Poisson regressions were calculated to determine patient- and hospital stay-related risk factors for coercion. Results Of 1764 patients, 293 (16.6%) underwent at least one coercive measure (mostly seclusion) during their stay. The experience of coercive measures was associated with the following factors: male gender (IRR 1.34 [1.26, 1.38], p  < 0.001), younger age (IRR 0.97 [0.97, 0.97], p  < 0.001), being single or divorced (IRR 1.49 [1.43, 1.60], p  < 0.001), diagnoses of organic (IRR 13.43 [13.38, 13.48], p  < 0.001), psychotic (IRR 1.79 [1.79, 1.79], p  < 0.001), or bipolar (IRR 2.17 [2.16, 2.17], p  < 0.001) disorders, receiving disability benefits (IRR 1.92 [1.90, 2.07], p  < 0.001), higher number of previous psychiatric hospitalizations (IRR 1.03 [1.03, 1.03], p  < 0.001), and higher Health of the Nation Outcome Scales (HoNOS) item 1-scores (overactive, aggressive, or agitated behaviour) at admission 1.27 [1.27, 1.27], p  < 0.001). Referrals from the emergency department (ED) (IRR 0.78 [0.77, 0.86], p  < 0.001) were associated with a lower risk of coercion. Conclusions Young age, being single or divorced, male gender, diagnoses of organic, bipolar, or psychotic disorders, being on disability benefits, and previous psychiatric hospitalizations were identified as risk factors of coercion. The incidence of coercion was lower in ED referrals. Item 1 HoNOS scores at admission might be sufficient for a meaningful assessment of coercion risk. Our results suggest a strong link between aggressive behaviour and the use of coercive measures. Identification of patients at risk should be integrated to coercion reduction programs. The role of institutional and cultural factors influencing the use of coercion should be further investigated.