Overcrowding appears to contribute to adverse events in Israeli inpatient psychiatric wards

Overcrowding is a common problem in Israeli inpatient psychiatric wards, and appears to contribute to higher rates of problem incidents--including falls and aggressive behavior, reports a study in the March issue of Medical Care. The journal is published by Wolters Kluwer.

"Our study confirms previous studies that overcrowding in psychiatric wards can be dangerous and can lead to an increased number of adverse events, such as violence and falls," according to the new research, led by Dr. Anat Tsur of Clalit Health Services and Dr. Alexander Teitelbaum of Kfar Shaul Psychiatric Hospital, Jerusalem. The results show evidence of a "dose-response" effect: as overcrowding increases, so does the risk of incidents.

Call for 'Emergency Measures' to Address Overcrowding on Psychiatric Wards

The researchers analyzed the relationship between bed occupancy rates and adverse events at four closed wards in an Israeli state psychiatric hospital during 2011-12. Closed wards, where patients' movements are restricted, were studied on the assumption that they might be more likely to show the effects of overcrowding.

The study focused on two types of incidents: aggressive behavior and falls. Of approximately 700 adverse events, about 400 were incidents of aggressive behavior, including nearly 300 episodes of physical violence between patients. Overall, at least one incident occurred on 24 percent of days.

The average net occupancy rate, reflecting all patients actually present, was about 96 percent; while the gross occupancy rate, including patients temporarily off the ward, was 106 percent. "These figures stress the fact that overcrowding is a serious problem in this psychiatric hospital," Dr. Teitelbaum comments. The researchers note that the rates far exceeded the maximal 85 percent occupancy rate recommended for optimal patient and staff safety and outcomes.

Incidents were more likely on days when the wards were more crowded. Net occupancy averaged 98.6 percent on days when aggressive behavior or falls occurred versus 95.7 percent on days without incidents. There was a similar difference for gross occupancy: 107.7 versus 105.5 percent.

The risk of adverse events increased from 18.6 percent when on days with net occupancy of 85 percent or less to 26.7 percent on days when net occupancy rose to 106 percent or higher. "This trend suggests a causal link between overcrowding and increasing risk of adverse incidents," Dr. Tsur and colleagues add.

At the same rates, the probability of aggressive behavior increased from 8.3 to 14.1 percent. Overcrowding was associated with violent incidents for all wards overall and for three out of the four wards individually.

The researchers believe the situation at their hospital reflects recent dramatic declines in psychiatric inpatient beds in Israel. They note that shortages of psychiatric inpatient beds are even more pronounced in some other countries, including the United States and Canada.

At least in Israel, mental health care reforms are underway, with the goal of strengthening psychiatric community services and reducing hospitalization rates. In the meantime, Dr. Tsur comments, "We hope this study will convince healthcare providers and policymakers of the necessity to take efficient measures aimed at reducing overcrowding in psychiatric hospitals and making inpatient facilities safer for patients and staff."