Évaluation de l’implantation d’un nouveau protocole de garde en établissement : profil de la clientèle, audit de dossiers et recommandations Evaluating the implementation of involuntary hospitalisation procedures: a profile of people, audits and recommendations

Résumé

Les difficultés d’application des réformes législatives visant à réduire l’hospitalisation involontaire des personnes qui présentent un danger pour elles-mêmes ou pour autrui ont été soulevées dans de nombreux rapports, tant au Québec qu’ailleurs. Pour aplanir ces difficultés, un nouveau protocole de garde en établissement a été élaboré et implanté dans la région de l’Outaouais. La présente étude a pour but d’évaluer son implantation et ce faisant, établir le profil des personnes mises sous garde en établissement. Les résultats indiquent que la majorité de ces personnes sont aux prises avec des troubles mentaux graves et que les professionnels perçoivent positivement le nouveau protocole, sans toutefois faire le nécessaire pour consigner de façon rigoureuse les données dans les formulaires requis. Il est recommandé de non seulement informer les professionnels sur la procédure légale, mais aussi s’assurer que la structure organisationnelle est propice à son implantation.

Mots-clés :

• garde en établissement,
• loi P-38.001,
• évaluation de l’implantation,
• audit de dossiers,
• troubles mentaux graves

Abstract

Since the 1990s, legislative reforms have been undertaken in many Western countries to reduce involuntary hospitalization. Studies examining fluctuation rates before and after the legislative reform show a general trend toward an increase rather than a decrease in involuntary hospitalization rates (de Stefano & Ducci, 2008). In Quebec, many reports have shown that consent for psychiatric evaluation and hospitalisation for people who present an imminent danger to themselves or to others is difficult to obtain due to clinical, legal, and ethical considerations. To facilitate this process, a new protocol was developed and implemented following the training of 335 health workers and 85 medical doctors in 6 hospitals. Our study evaluated this protocol and established a profile of people who had been hospitalized against their will. Using a retrospective analysis, we examined the files of 179 patients who underwent a psychiatric evaluation process during an involuntary hospitalization. This file analysis allowed us to develop a better profile of these people and determine whether the required forms were present and how adequately they were filled out by the professionals. We also conducted a study with the professionals responsible for applying the new protocol to get a better idea of its characteristics (relative advantage, compatibility, simplicity, reversibility and observability) as well as the principles of consent and the obstacles to its implementation.

Our study showed that that half of the patients were diagnosed with schizophrenia or another psychosis. Fifty-four point two percent (54.2%) of the patients were males, 79% were single or separated and only 18,4% were working. At the time of their crisis situation, 30,7% were brought to the hospital by police officers and 19% were already hospitalized. The remaining patients were brought in by ambulance, family members or they came in by themselves. Professional opinion of the new protocol was positive however they did not rigorously enter the data required in the new forms. The new form was present in only 51% of files and when consent was given, it was only documented in 27% of the cases.

These results highlight the need to improve the documentation process given in the protocol. It would be very useful to establish strategies to obtain this consent in light of the specific characteristics that make up this subgroup of people who have been hospitalized against their will. Legislation alone is not enough to invoke a change in the involuntary hospitalisation rate. The clinical and organisational context must also be actively prepared to receive this new practice. In order to do this, evaluative research could contribute to improving the level of implementation and be of benefit to people in crisis and those with mental disorders.

Keywords:

• Institutional care,
• law P38.001,
• implementation evaluation,
• file analysis,
• serious mental problems