Dangerosité des patients : nouveau rapport des inspections générales

Prise en charge des patients susceptibles d’être dangereux : un rapport supplémentaire

Le rapport de l’Inspection Générale de l’Administration (IGA), de l’Inspection Générale de l’Action Sociale (IGAS) et de l’Inspection Générale des Services Judiciaires (IGSJ) de février 2006 relatif à « La prise en charge des patients susceptibles d’être dangereux », concluant à la nécessité de clarifier l’organisation des soins en psychiatrie dans le but de mieux prévenir et gérer leur éventuelle dangerosité, recommande une nouvelle loi sur la prise en charge des patients présentant des troubles mentaux permettant de réformer certaines pratiques mais aussi la diffusion de circulaires, l’élaboration de protocoles et le lancement de recherches. Il s’agit du quatrième rapport sur le sujet rendu en deux ans et demi, après le rapport IGA-IGPN-IGN sur les problèmes de sécurité liés aux régimes d’hospitalisation sans consentement (mai 2004), le rapport IGAS-IGSJ sur la réforme de la loi du 27 juin 1990 (mai 2005) et le rapport de la commission Burgelin santé-justice « santé, justice et dangerosité, pour une meilleure prévention de la récidive » (juillet 2005).

Le rapport confirme aussi certaines recommandations des précédents rapports et recommande notamment des changements législatifs qui ont été intégrés dans le projet de loi sur la prévention de la délinquance, notamment réserver l’indication de troubles à l’ordre public pour les hospitalisations d’office (HO) et une meilleure information de la justice sur le devenir des personnes déclarées irresponsables pénalement pour des actes délictueux ou criminels et hospitalisées en psychiatrie. Dans la partie « état des lieux » du rapport, les inspecteurs dressent un constat alarmant pour le système de soins : hôpitaux en « surchauffe », conduisant à des sorties d’hospitalisation « prématurées » ; ratio personnel/malade en diminution ; professionnels en situation de « fragilité », avec une moindre cohésion des équipes, une mise en cause de la formation des infirmiers diplômés d’Etat en psychiatrie ; cadre d’exercice des soignants « instable » à cause d’une « incertitude sur l’avenir du secteur psychiatrique » et d’un « flottement sur le plan de la théorie et des pratiques ».

Le même constat de surchauffe est établi pour les prisons, ce qui rend difficile le repérage et surtout la prise en charge adaptée des détenus dangereux ou susceptibles de l’être.

Pour mieux organiser les soins, le rapport recommande de redéfinir, par voie législative, la sectorisation psychiatrique, c’est-à-dire ses fonctions et les modalités de mise en oeuvre.

Pour clarifier les pratiques, le rapport préconise d’organiser des conférences de consensus sur la prise en charge des états d’agitation et sur l’intervention en urgence des équipes psychiatriques au domicile d’un patient. Il demande aussi de développer des recherches sur les tests biologiques permettant d’assurer le dépistage d’un usage de toxiques, sur les nouvelles molécules à effet sédatif, sur les principes d’emploi des associations médicamenteuses, sur « le mélange de pathologies dans les unités de soins » et sur les courtes hospitalisations répétées. L’Agence nationale de la recherche (ANR), le Programme hospitalier de recherche clinique (PHRC) et les laboratoires pharmaceutiques doivent être sollicités sur ces sujets. Pour établir « des perspectives de gestion claire », les inspections estiment qu’il faut moduler l’arrêt de la fermeture des lits en psychiatrie en fonction des besoins, concevoir un financement des établissements assurant une « juste rémunération » des activités de psychiatrie et adopter une stratégie face à l’évolution démographique à la baisse des psychiatres. Sur ce dernier point, il suggère notamment d’engager une réflexion sur les transferts de compétence vers les psychologues. Le rapport insiste aussi sur la conception architecturale des bâtiments de psychiatrie en suggérant un appel d’offres du ministère de la santé auprès des architectes pour des unités types et un audit conduit par les ARH sur les solutions les plus efficaces d’évolution des centres hospitaliers spécialisés et sur la mise en elle-même d’un accueil adapté aux urgences générales.

Constatant que la dangerosité est une notion floue, le rapport estime d’abord qu’il faut mieux l’évaluer, en développant les observatoires de la violence dans les établissements et en étudiant les outils d’évaluation de la dangerosité qui existent mais qui ont des limites. Il préconise aussi de mieux encadrer l’usage de la contention et de la mise en chambre d’isolement, en recourant à des protocoles -à élaborer par la Haute autorité de santé-, pour le recours aux sédatifs, le recours aux liens physiques et le recours à la chambre d’isolement. Il insiste sur les conditions de sécurité à respecter ainsi que le respect de la dignité humaine dans ces pratiques. Le rapport estime qu’il ne faut pas encourager la spécialisation de structures ou d’équipes dans la prise en charge de la violence, car cela risquerait de laisser désarmés les soignants dans les autres services.

Il se prononce aussi pour le respect de la liberté d’aller et venir des patients en HL, ce qui nécessitera parfois de créer des espaces spécifiques pour les patients en hospitalisation sous contrainte. La création d’une obligation de soins en ambulatoire, décidée par le préfet ou sur demande d’un tiers, déjà préconisée dans les rapports précédant, est jugée urgente. Pour améliorer l’expertise judiciaire, le rapport propose notamment une conférence de consensus sur le sujet, la création d’un repérage des troubles mentaux (pour éviter un recours systématique à l’expertise psychiatrique par les magistrats), la mise en place d’équipes pluridisciplinaires au niveau régional et un relèvement de la rémunération des experts. L’évaluation et l’orientation des détenus doivent être revues pour être « plus performantes », sur le modèle de ce qui est fait au Centre national d’observation (CNO) de Fresnes mais en le renforçant. Le rapport préconise également de renforcer les coopérations entre les institutions (psychiatrie, police, justice) pour clarifier les obligations déontologiques et les devoirs de coopération de chacun, en prenant appui sur des principes qui seraient établis au niveau national et interministériel sur les cas d’intervention au domicile d’un patient, de transport, de rupture d’une obligation de soins ambulatoire, de fugues d’un patient hospitalisé sous contrainte et d’intervention des forces de l’ordre en milieu hospitalier.

Ces travaux pourraient aboutir à la rédaction d’un schéma départemental des coopérations entre les collectivités locales, la santé, la police nationale, la gendarmerie nationale, les sapeurs-pompiers, les services de probation et d’insertion professionnelle des établissements pénitentiaires en relation avec la justice.

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