Markers of inappropriate placement in acute psychiatric inpatient care: a five hospital study

Background: Previous researchers in the UK have measured the prevalence of the 'inappropriateness' of acute adult psychiatric inpatient placements by eliciting the judgements of health professionals. We extended the methodolo gy by identifying inpatient sub-groups with stable characteristics that wer e associated with elevated risk of inappropriate placement, and by calculat ing the level of that risk. Methods: A 1-day census was taken in five hospi tals. Using a structured instrument, consultant psychiatrists recorded judg ements on current placements, recommended alternative placements and stated why alternatives had not been used. Judgements were obtained for 100% of t he 261 inpatients. Risk ratios and adjusted odds ratios were calculated to identify sub-groups that were at high risk. Results: Eighty-eight inpatient s were inappropriately placed, a point prevalence of 34% (95% CI 28-40%). C onsultants recorded that services outside hospital, if available, could hav e supported most of these inpatients as an alternative to at least part of their hospital stay. Diagnostic rather than socio-demographic or administra tive characteristics, in particular primary diagnoses of substance-related disorder, personality disorder, anxiety/stress, and schizophrenia with co-m orbid substance misuse, were the strongest markers of elevated risk. Conclu sions: The point prevalence of inappropriate placement within the British m ental health-care system is considerable. Diagnostic categories are reasona ble pragmatic markers. Further research should aim to identify a strong mar ker of risk within the numerically large sub-group of schizophrenia without substance misuse.