Psychiatric Intensive Care Unit Research Articles

Dr Dominic Beer DM, FRCPsych

![Figure][1] Dominic Beer was one of the pioneers in the reform of psychiatric intensive care units. In the mid-1990s he and his colleagues Carol Paton and myself realised that the quality of care in the locked wards that remained after the opening up of the mental hospitals in the 1950s was

“It Br o ke O u r H ea rts”: Understanding Parents’ Lived Experiences of Their Child’s Admission to an Acute Mental Health Care Facility

This article reports the evaluative findings of an Early Psychosis Education Program (EPEP) designed to support parents caring for their child who was recently admitted to the psychiatric intensive care unit of an inpatient mental health care facility in Australia. The EPEP offered education on mental illness, treatment options, and medication, as well as information on the recovery model of care. The EPEP was facilitated by two RNs and was evaluated for educational effectiveness using a simple pre- and postevaluation questionnaire. The evaluation revealed two themes expressed by parents: "We didn't see it coming," and "Hopelessness and helplessness." The themes highlighted the parents' lack of mental health care knowledge prior to the EPEP, which had a significant impact on the parents' experiences and well-being. The evaluative findings highlighted a need for a nurse-led EPEP within the community. A community EPEP has the potential to strengthen the partnership between parents, families, and mental health service providers and to help with the provision of a recovery framework of care.

Predicting risk of seclusion and restraint in a Psychiatric Intensive Care (PIC) unit

Journal of Psychiatric and Mental Health NursingVolume 21, Issue 5 p. 466-470 RESEARCH IN BRIEF Predicting risk of seclusion and restraint in a Psychiatric Intensive Care (PIC) unit S. Roles RN MScN, S. Roles RN MScN Clinical Nurse Specialist orcid.org/0000-0001-5797-5536 Health Sciences North, Sudbury, ON, CanadaSearch for more papers by this authorA. Gouge PhD C Psych, A. Gouge PhD C Psych Clinical Specialist Health Sciences North, Sudbury, ON, CanadaSearch for more papers by this authorH. Smith RN BScN, H. Smith RN BScN Registered Nurse Health Sciences North, Sudbury, ON, CanadaSearch for more papers by this author S. Roles RN MScN, S. Roles RN MScN Clinical Nurse Specialist orcid.org/0000-0001-5797-5536 Health Sciences North, Sudbury, ON, CanadaSearch for more papers by this authorA. Gouge PhD C Psych, A. Gouge PhD C Psych Clinical Specialist Health Sciences North, Sudbury, ON, CanadaSearch for more papers by this authorH. Smith RN BScN, H. Smith RN BScN Registered Nurse Health Sciences North, Sudbury, ON, CanadaSearch for more papers by this author First published: 27 March 2014 https://doi.org/10.1111/jpm.12152Citations: 4Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Citing Literature Volume21, Issue5June 2014Pages 466-470 RelatedInformation

The administration of psychotropic PRN medication in Scottish psychiatric intensive care units

Information concerning the administration of psychotropic PRN medication in Scottish PICUs is scarce. The medical notes and prescription charts of all patients (n = 75) admitted during the study period were consulted to determine the frequency and nature of PRN practice. 65% of patients (n = 49) were administered up to 11 drugs comprising of antipsychotics (n = 8), benzodiazepines (n = 2) and zopiclone. The most frequently administered PRN medicines were lorazepam, haloperidol and zuclopenthixol. The mean dose administered for oral and intramuscular (IM) forms of both lorazepam and haloperidol were very similar. The mean number of PRN administrations per patient per day was 0.4. 40% of psychotropic PRN administrations were initiated by the nurse with the majority of doses administered at bedtime. Ten patients received an IM injection. Four patients were restrained during these administrations. Documentation pertaining to the rationale for IM administrations and of pre and post rapid tranquillisation physical health monitoring was lacking. This study highlights variation in practice between units, inadequate monitoring and documentation, a possible lack of understanding by prescribers of the differences in bioavailability between oral and injectable forms of medication and relatively limited use of newer drugs.

EPA-1279 - Pharmacological management of aggression and violent behaviour : audit of rapid tranquilisation of acutely disturbed service-users in the psychiatric intensive care unit

Prevalence of violent behaviour within acute psychiatric services is about 10%. To assess compliance of management of acutely disturbed patients with the National Institute for Health and Clinical Excellence (NICE) guidance for use of Rapid Tranquilisation (RT). A sample of 24 patients admitted to local Psychiatric Intensive Care Unit (PICU) receiving RT during 2011 was assessed using retrospective analysis of records. 100% compliance was achieved in many of the criteria assessed, including recording the risk assessment and management plan appropriately. None of the patients had up-to-date advance directive detailing their preferred strategies in case of violent incidents. 50% of patients had their baseline blood pressure, pulse, temperature and respiratory rate recorded and 33% at regular intervals. 25% were debriefed and none offered an opportunity to write their account of RT. 38% had their medication reviewed following RT. 46% were suffering from psychotic disorders; manic episode accounted for 25% of all patients. 54% of all (65% of men) received Zuclopenthixol acetate for RT and 46% the combination of Haloperidol plus Lorazepam; however, the combination of Haloperidol plus Lorazepam was used in 71.4% of women and 35% of men. 12.5% required a short period of seclusion. All patients were detained under the Mental Health Act. Training of the PICU staff in the NICE Guidance: The short-term management of disturbed/violent behaviour in psychiatric inpatient settings and emergency departments.

Accreditation Models of Mental Health Care: A Systematic Review

Purpose: To identify accreditation models in mental health and their effects on performance of health plans and health facilities. Methods: We conducted a free search in Databases of PubMed , Scopus , EMBASE , PsycINFO and Google Scholar up to March 2014 ,searching for “mental health” and “accreditation” in keywords, titles , abstracts and all indexed fields . Inclusion criteria were English or Persian language of of the articles, and Presentig accreditation models in mental health (processes or effects). Exclusion criteria were manuals of accreditation ,guidelines of accreditation,revisions of standards and Interview with pioneers. Results: Seven models of accreditation in mental health were determined. They were Peer or professional accreditation, The Memory Services National Accreditation Programme (MSNAP), Accreditation of acute in-patient mental health services (AIMS), Psychiatric Liaison Accreditation Network (PLAN), Electroconvulsive Therapy accreditation Service (ECTAS), psychiatric intensive care unit (AIMS-PICU), JCAHO Mental Health Care Network .All models used self-review and external peer review in collection of related data. Five accreditation models clearly focused on Continous Quality Improvement projects. Conclusion: Upon results of this systematic review, it is concluded that there are various accreditation models in mental health care . there arent enough researches about accreditation impacts on community mental health . It is recommended that a study be conducted about accreditation effect on efficiency and effectiveness of health programs and mental health care.

Care zoning in a psychiatric intensive care unit: strengthening ongoing clinical risk assessment

To implement and evaluate the care zoning model in an eight-bed psychiatric intensive care unit and, specifically, to examine the model's ability to improve the documentation and communication of clinical risk assessment and management. Care zoning guides nurses in assessing clinical risk and planning care within a mental health context. Concerns about the varying quality of clinical risk assessment prompted a trial of the care zoning model in a psychiatric intensive care unit within a regional mental health facility. The care zoning model assigns patients to one of 3 'zones' according to their clinical risk, encouraging nurses to document and implement targeted interventions required to manage those risks. An implementation trial framework was used for this research to refine, implement and evaluate the impact of the model on nurses' clinical practice within the psychiatric intensive care unit, predominantly as a quality improvement initiative. The model was trialled for three months using a pre- and postimplementation staff survey, a pretrial file audit and a weekly file audit. Informal staff feedback was also sought via surveys and regular staff meetings. This trial demonstrated improvement in the quality of mental state documentation, and clinical risk information was identified more accurately. There was limited improvement in the quality of care planning and the documentation of clinical interventions. Nurses' initial concerns over the introduction of the model shifted into overall acceptance and recognition of the benefits. The results of this trial demonstrate that the care zoning model was able to improve the consistency and quality of risk assessment information documented. Care planning and evaluation of associated outcomes showed less improvement. Care zoning remains a highly applicable model for the psychiatric intensive care unit environment and is a useful tool in guiding nurses to carry out routine patient risk assessments.

Use of a Sensory Room on an Intensive Care Unit

This study explores the use of a sensory room on a psychiatric intensive care unit (PICU), with a particular focus on the effect on seclusion rates and staff and patients' experiences of using the sensory room. A mixed method research design was used, with the collection of seclusion data before and after a sensory room was introduced followed by qualitative interviews with staff and patients. No significant reduction in seclusion rates was noted with the introduction of the seclusion room. However, the interviews revealed a perception among staff that there had been a reduction in seclusion rates. Other findings from the interviews were that staff and patients viewed the sensory room as a positive therapeutic intervention, and use of the sensory room had improved staff-patient communication and patients' overall experience of the PICU. The use of a sensory room should be an intervention considered by other PICUs and inpatient psychiatric settings.

Non-forensic secure services for adolescents: what are we talking about?

There is considerable variability in the ethos of the various adolescent in-patient units in Britain. Currently, there are few services within NHS settings able to manage acute behavioural disturbance in adolescents despite the prevalence of psychiatric disorder in this population group. Due to this variation, individual units around the country have developed their own bespoke services for managing disturbance. These services are given different names although may be operating with similar models. However, there is little consensus on these definitions, resulting in services with similar titles providing differing levels of service and varying capacity to manage violence or aggression. We attempt to define patient populations in need of such services and suggest a nomenclature for defining such services that could be universally adopted. We also describe the five-year review of admissions of one adolescent psychiatric intensive care unit and suggest how well its name fits with our proposed model.

P.I.C.U., H.D.U., A.O.A. What treatment do we provide? Current descriptions of the function of intensive care for inpatient psychiatric health care

Purpose – This paper adds to growing research of psychiatric intensive care units (PICU) by recounting descriptions of psychiatric intensive care settings and discusses the perceptions held by nurses of the organisational interfaces, arrangements and provisions of care in these settings. Design/methodology/approach – Data gathered from focus groups held with nurses from two PICUs was used to establish terminology, defining attributes, related concepts, antecedents, values, processes and concepts related to current practices. A literature search was conducted to permit a review of the conceptual arrangements and contemporary understanding of intensive care for people experiencing acute psychiatric illness based on the perspectives held by the nurses from the focus groups. Findings – Dissonance between service needs and the needs and management of individual patients overshadow strategies to implement comprehensive recovery-oriented approaches. Three factors are reported in this paper that influence standards and procedural practice in PICU; organisational structures; physical structures; and subtype nomenclature. Practical implications – Acute inpatient care is an important part of a comprehensive approach to mental health services. Commonly intensive acute care is delivered in specialised wards or units co-located with acute mental health inpatient units mostly known as PICU. Evidence of the most effective treatment and approaches in intensive care settings that support comprehensive recovery for improved outcomes is nascent. Originality/value – Current descriptions from nurses substantiate wide variations in the provisions, design and classifications of psychiatric intensive care. Idiosyncratic and localised conceptions of psychiatric intensive care are not adequately entailing effective treatment and methods in support of recovery principles for improved and comprehensive outcomes. The authors suggest that more concrete descriptions, guidelines, training and policies for provision of intensive psychiatric health care encompassing the perspective of nursing professionals, would reinforce conceptual construction and thus optimum treatments within a comprehensive, recovery-oriented approach to mental health services.

Profiles of Patients Admitted to a Psychiatric Intensive Care Unit: Secluded with or without Restraint

To identify and describe the profiles of patients admitted to a psychiatric intensive care unit (PICU) as they relate to seclusion and restraint. Multiple correspondence analysis (MCA) and cluster analysis were performed with data for 114 patients admitted to a PICU from June 8, 2010, to June 7, 2011. The MCA revealed that the presence or absence of seclusion and restraint was the main factor explaining the variance. Admitted patients fall into 5 profiles, 2 of which are significantly associated with seclusion and restraint: young psychotic men and women with bipolar disorder. The differentiation of patient profiles as they relate to seclusion and restraint should lead to the development of profile-specific interventions before, during, and after seclusion and restraint.

Student nurses' attitudes towards professional containment methods used in psychiatric wards and perceptions of aggression.

The aim of this study was to determine student nurses' attitudes towards professional containment methods used in psychiatric wards and its relation to their perception of aggression. We employed a cross-sectional descriptive design to evaluate nurses' attitudes. Participants included 120 student nurses who were enrolled in psychiatric nursing during their fourth (final) year of education. The 'Attitude to Containment Measures Questionnaire' and 'The Perception of Aggression Scale' were used for assessments. Student nurses exhibited positive attitudes toward 'intermittent observation', 'Pro re nata Medication' and 'Psychiatric Intensive Care Unit', respectively. The least approved method was 'net bed'. The data showed a negative correlation between approval of 'Intra-Muscular Medication' and 'mechanical restraint' with the perception that aggression was dysfunctional/unacceptable. Student nurses who believed that professional containment methods were effective also perceived aggression as less functional/acceptable. These results emphasize the importance of health care perceptions of aggression towards patients and their experience with containment measures.

Providing a motivational interviewing (MI) informed intervention in conjunction with a cannabis drug urine screening for PICU service users: a feasibility project

Purpose – The purpose of this paper is to provide a description of a small, early-stage feasibility project that used a motivational interviewing (MI) informed intervention on a psychiatric intensive care unit (PICU). Design/methodology/approach – The paper describes a MI informed intervention implemented on a PICU for service users who use cannabis. The intervention was evaluated using a feedback questionnaire post intervention. Due to the small number of service users (n=5) in the first cohort there is limited narrative and quantitative data available. Findings – The project raised awareness for staff of the potential usefulness of applying MI informed interventions in a PICU setting. All participants stated the intervention should continue to be offered after the project. The intervention needs to be further developed with the possibility of it being used on an acute open ward environment with a larger cohort and consider the use of a randomised-controlled trial approach to validate the results. Resear...

Treatment of clozapine-induced priapism by goserline acetate injection

Clozapine (Denzapine) is a treatment for resistant schizophrenia. Among the serious but rare side effects of clozapine are agranulocytosis and priapism. We hereby present the case of a 30-year-old man with a diagnosis of schizophrenia who has spent nearly 12 years of his adult life on various psychiatric in-patient units including open wards, secure units, psychiatric intensive care units and rehab wards. Diagnosed at the age of 15, he only responded to clozapine at the age of 18. Whilst being on clozapine he developed priapism in June 2010 and needed emergency surgical treatment in the form of surgical decompression. He again responded only to clozapine and fortunately he did not redevelop priapism; however, he was readmitted in February 2011 due to relapse, and he remained resistant to other antipsychotics. He was rechallenged with clozapine and recovered, but unfortunately redeveloped priapism which required emergency surgical and medical intervention (goserline acetate and tinzaperin injection). In order to relieve the recurrent priapism, he agreed to continue clozapine and goserline acetate injection. This decision was made by the patient in a compos mentis state. As far as we are aware, this is the first time goserline acetate has been reported as a successful treatment for clozapine-induced priapism.

Creating a high quality consultant led psychiatric intensive care unit multidisciplinary team ward round

Ward round is an integral platform for patients and the multidisciplinary team to communicate, assess and plan treatment. With such a key process, it is vital that the effectiveness of the ward round is maximised and that reliable follow of information is addressed. This can be achieved using lean methodology.Aim: To improve the quality of ward rounds, particularly reliability and patient experience.Method: This is a quantitative quality improvement study that used a plan-do-study-act cycle, including process mapping. The improvements were measured by an objective patient survey, staff survey and a checklist.Results: Process mapping identified the use of templates for the ward round plan, nursing and medical summaries. There was an increase in the reliability of ward round relating to flow of information measured by the checklist. Patient experience improved, rated by both patient and staff surveys, after series of changes were put in place.Conclusions: Checklists in the form of templates improved the reliability of information flow for patient treatment. If the multidisciplinary team is clear about what information and tasks are necessary, there will be a more reliable assessment. With the implementation of the plan template, more treatment plans are fully comprehensive enabling the consistent delivery of high quality of care.

Gender differences in referral pathways and admissions to a psychiatric intensive care unit in a county psychiatric hospital in the UK

Gender differences in referral pathways and admissions to a psychiatric intensive care unit in a county psychiatric hospital in the UK

Arzneimittelinteraktionen in der Psychiatrie

In daily practice of psycho-pharmacotherapy most patients are under polypharmacy which may result in potentially harmful drug-drug interactions. Therefore, we investigated if the risk of drug-drug interactions can be reduced by a consultant clinical pharmacist for the physicians on psychiatric wards. Drug-drug-interactions and adverse drug reactions of patients on 2 psychiatric intensive care units were investigated retrospectively in 2008 and 2009. Before the second investigation period, a special training was performed and during this period a pharmacist supported the physicians regarding drug therapy. After the introduction of a pharmacist on the ward and 2 teaching lessons relevant drug interactions were reduced by 78 % (p < 0.001), the number of all interactions by 44 % (p < 0.001). The total number of drug interactions decreased by the training sessions, which were offered shortly before starting the second observation period, from 3.4 interactions/patients in 2008 to 2.2 interactions/patients in 2009 (p < 0.04). A clinical pharmacist on the ward can contribute to a higher drug therapy safety in psychiatric wards. An interdisciplinary approach can relieve the physicians' daily work. The drug therapy can be improved by continuous teaching sessions about drug interactions.

1777 – Is management of borderline personality disorder in female psychiatric intensive care unit (PICU) appropriate?

Introduction There are above 170 PICUs in the UK, most of them being gender mix or male only. There is no specific data available about management of patients diagnosed with Borderline Personality Disorder (BPD) in PICUs. Objective Review of sociodemographic, clinical, outcome characteristics, care pathways and financial implications when managing BPD population in Female PICU. Aims To measure rates of compliance with NICE guidelines using such criteria as: comprehensive care plan provided on admission to PICU and at discharge from PICU; patient being involved in discussion about discharge plans; specialist assessment / treatment started before admission to Female PICU was continued during the admission; referral for psychological therapies was considered/made during stay in Female PICU; prescribing practice by referring and admitting teams; availability of specialist Personality Disorders (PD) services locally. Methods Retrospective cross sectional review of patient records. Results 76% of patients are admitted to Female PICU with a comprehensive multi-disciplinary care plan. 80% of patients transition from ECH was discussed carefully with the patient beforehand. Specialist assessment/treatment started before admission to ECH was continued during the admission 100%. Most of the patients would receive treatment by various psychotropic meds prior and during the admission. Referrals to psychological therapies were considered for 19% of patients. There is a lack of specialist PD services. Conclusions BPD is the most costly population in comparison with other patient groups in Female PICU which requires multidisciplinary team input, specialist services involvement, better adherence to NICE guidelines, support and training for MDT.

2187 – Migration and acute mental disorders in italy. a comparison study in a psychiatric intensive care unit

First-generation immigrants from developed countries appear to be particularly at risk of being diagnosed with a mental disorder after migration. Nevertheless, in Europe immigrated people appear less likely than their native counterparts to access community mental health care. Inequity in treatment may lead to enhanced severity of the disease and consequent emergency referrals. The aim of this study was to explore demographic and clinical characteristics in immigrants patients compared to Italianborn patients admitted in a Psychiatric Intensive Care Unit (PICU) for an acute mental disorder. One hundred first-generation immigrant patients were consecutively recruited and compared to 100 age-, genderand diagnosis-matched Italian-born patients. Subjects were diagnosed according to DSM-IV-TR and rated on the Clinical Global Impression - Severity Scale and the Global Assessment of Functioning. Medical history and demographic information were collected with a study-specific form and were abstracted from medical records. The majority of patients were admitted to the PICU for an acute psychotic or manic episode. There were no differences in socio-demographic characteristics, in clinical severity scores and global functioning scores between immigrant and Italian-born patients. Despite no differences in age or diagnosis, immigrant patients were significantly more likely to be at the first psychiatric contact (32% vs 15%; p=0.007). Our results suggest a role of migration in the development of acute psychotic or manic episodes. Moreover, limited access for immigrants to community mental health services may lead to longer duration of untreated illness, increased disease severity and consequent emergency referrals.

1724 – Management of borderline personality disorder: compliance with nice CG 78 in the female psychiatric intensive care unit (PICU), elizabeth casson house, bristol, UK

A modest body of research has emerged documenting the characteristics of 170 PICU populations in the UK (2006). No specific data is available about Crisis Management of patients diagnosed with Borderline Personality Disorder (BPD) in Female PICUs. To offer the first service evaluation project in the UK of the BPD group in PICU and to review compliance with the NICE guidelines, ‘Borderline Personality Disorder: Treatment and Management’, 2009. To measure rates of compliance with NICE guidelines as a gold standard. Retrospective cross sectional review of patient records. The project included data of 46 admissions (from 2007 to 2010). Ninety-seven percent of patients were White British. The median length of involvement with mental health services prior to the first admission to ECH was 12 years. Seventy percent of patients showed mixed engagement with services. All patients presented with complex needs, all were detained under the Mental Health Act. The commonest primary reason for admission was self harm or threatening behavior. Seventysix percent of patients were provided with the copy of the multi-disciplinary care plan at the time of admission. Antipsychotic polypharmacy and prescription of antidepressants was reduced during the admission. In 80% of admissions discharge planning was discussed with the patient and documented. In 54% of discharges the care coordinator was involved and at discharge 26% of patients were informal. Specific target criteria in the NICE guidelines were not complied with fully. For 85% of admissions the initial purpose of admission was fully achieved.