Psychiatric Intensive Care Unit Research Articles

Can mental health clusters be replaced by patient typing?

Introduction: Psychiatric intensive care units (PICUs) are well defined, but there is poor clarity surrounding the types of patient treated. Clustering as a way of describing need is standard. Clinical patient typing has been suggested as an alternative but without examination of usefulness. This paper compares mental health clustering with clinical patient typing within a PICU. Methods: Following development of a clinical patient typing measurement, length of stay of 100 consecutive transfers from a PICU were measured. Similarities between clinical typing and clustering were assessed graphically and by McNemar's test for marginal homogeneity. Length of admission and transfer delay were analysed using ANOVA and Fisher's least significant difference method. Results: There was no evidence of a consistent relationship between clustering and patient typing. There were significant differences between different patient types in length of stay, transfer delay and facilities to which patients were transferred. There was no difference when patients were separated by clusters. Conclusions and implications for clinical practice: Clinical patient typing outlines different groups of patients managed within a PICU better than established methods of clustering. It should be taken into consideration as a method to clinically assess patient need.

Being Subject to Restrictions, Limitations and Disciplining: A Thematic Analysis of Individuals' Experiences in Psychiatric Intensive Care

ABSTRACTThe aim of this study was to describe individuals' experiences of being hospitalized in psychiatric intensive care units (PICUs). Four participants who had previously been admitted in a PICU were interviewed using open-ended questions. The data were analyzed using thematic analysis. Analysis resulted in a synthesis of the various ways patients experienced limitations: (1) Descriptions of Being Limited in the Environment, (2) Descriptions of being Limited in Interactions with Staff, (3) Descriptions of Being Limited in terms of Access to Information, and (4) Descriptions of Having Limited Freedom and Autonomy. Hospitalization is experienced as a life-changing event that shows a kaleidoscopic view of limitation. We stress that the conceptualization of limitation must be considered due to its historical origins, sociopolitical aspirations, and philosophy of care. Thus, nurse practitioners and nursing leaders are advised to put the patient's experience at the center of care, and to involve and integrate patients throughout the recovery process.

The 'revolving door': a study of factors involved in readmissions to a women's psychiatric intensive care unit

The 'revolving door': a study of factors involved in readmissions to a women's psychiatric intensive care unit

Creating change: implementation of an inpatient behavioural activation programme on a psychiatric intensive care unit

Creating change: implementation of an inpatient behavioural activation programme on a psychiatric intensive care unit

The patient pathway outcomes of a female psychiatric intensive care unit

The patient pathway outcomes of a female psychiatric intensive care unit

Reducing physical violence and developing a safety culture across wards in East London

Violence is the biggest cause of reported safety incidents at East London NHS Foundation Trust. Evidence suggests the utility of structured risk assessment, discussion of violence in ward community meetings and the use of restraint and seclusion in psychiatric wards. The Tower Hamlets Violence Reduction Collaborative brought together six wards with the aim of reducing violence by 40% by the end of 2015. A collaborative learning system was used to test a bundle of four interventions on the four acute admissions wards and two psychiatric intensive care units. A 40% reduction in physical violence was seen across the six wards. Physical violence reduced from 12.1 incidents per 1000 occupied bed days in 2014 to 7.2 in 2015. Across the four general acute admissions wards there was a 57% reduction in physical violence. Key elements of the system that have been addressed through this work have been developing a more predictive approach, and developing a more open and shared experience of violence and aggression on the wards.

Reducing restrictive practice: Developing and implementing behavioural support plans

The importance of reducing restrictive practices in mental health settings is an issue of national importance. This article details the development and implementation of bespoke behavioural support plans at a large London mental health trust. The tool was developed and piloted by staff on a male psychiatric intensive care unit (PICU), caring for patients with complex mental and physical health needs. These patients present with challenging and acutely disturbed behaviour which cannot be managed in an open setting. The behavioural support plans are based on a biopsychopharmacosocial approach in conjunction with an appraisal of the patient's current environment and past incidents, to examine contributing factors to the patient's behaviour. This information is used to form a management plan, including primary, secondary and tertiary interventions, thus proactively reducing tertiary restrictive practices such as restraint, rapid tranquilisation and seclusion. The plans are now used trust-wide with patients who have complex needs. As a result of the success of this intervention, a second pilot is now underway, where behavioural support plans have replaced traditional care planning.

Acceptability and use of coercive methods across differing service configurations with and without seclusion and/or psychiatric intensive care units.

AimsThe aim of this study was to compare across different service configurations the acceptability of containment methods to acute ward staff and the speed of initiation of manual restraint.BackgroundOne of the primary remits of acute inpatient psychiatric care is the reduction in risks. Where risks are higher than normal, patients can be transferred to a psychiatric intensive care unit or placed in seclusion. The abolition or reduction in these two containment methods in some hospitals may trigger compensatory increases in other forms of containment which have potential risks. How staff members manage risk without access to these facilities has not been systematically studied.DesignThe study applied a cross‐sectional design.MethodsData were collected from 207 staff at eight hospital sites in England between 2013 ‐ 2014. Participants completed two measures; the first assessing the acceptability of different forms of containment for disturbed behaviour and the second assessing decision‐making in relation to the need for manual restraint of an aggressive patient.ResultsIn service configurations with access to seclusion, staff rated seclusion as more acceptable and reported greater use of it. Psychiatric intensive care unit acceptability and use were not associated with its provision. Where there was no access to seclusion, staff were slower to initiate restraint. There was no relationship between acceptability of manual restraint and its initiation.ConclusionTolerance of higher risk before initiating restraint was evident in wards without seclusion units. Ease of access to psychiatric intensive care units makes little difference to restraint thresholds or judgements of containment acceptability.

A retrospective study describing the characteristics of one Mental Health Trust's admissions under sections 47 and 48 of the Mental Health Act 1983.

Sections 47 and 48 of the Mental Health Act 1983 allow prisoners to be transferred from prison to an appropriate health-care setting in order to be treated. There is an awareness that delays exist when transferring prisoners to hospital. However, literature regarding the delay in returning these patients from hospital is limited. The admissions from prison to a Psychiatric Intensive Care Unit (PICU) in South West London were compared to non-offenders on the PICU in order to compare the average length of stay for both groups and the time taken for the discharge from PICU once felt clinically appropriate. The study also compared demographic profiles, reason for admissions, psychiatric diagnosis and index offences. Over six years, there were 18 admissions from prison to a PICU. The control group comprised 37 non-offenders admitted to the same PICU. On average the prison group took longer to be deemed clinically ready for discharge and, even once clinically ready, then took longer to be discharged. The average length of stay in PICU was 77.83 days for prisoners, and 16.46 days for non-offenders. All 55 admissions were between 1 January 2008 and 31 December 2014. The offender pathway and the difference in the length of stay between prisoners and non-offenders in a PICU warrants further exploration. Possible recommendations to reduce the length of stay of prisoners include improved information sharing between prisons and hospital, and clearer guidelines regarding the level of security required.

Factors associated with use of psychiatric intensive care and seclusion in adult inpatient mental health services.

Within acute psychiatric inpatient services, patients exhibiting severely disturbed behaviour can be transferred to a psychiatric intensive care unit (PICU) and/or secluded in order to manage the risks posed to the patient and others. However, whether specific patient groups are more likely to be subjected to these coercive measures is unclear. Using robust methodological and statistical techniques, we aimed to determine the demographic, clinical and behavioural predictors of both PICU and seclusion. Data were extracted from an anonymised database comprising the electronic medical records of patients within a large South London mental health trust. Two cohorts were derived, (1) a PICU cohort comprising all patients transferred from general adult acute wards to a non-forensic PICU ward between April 2008 and April 2013 (N = 986) and a randomly selected group of patients admitted to general adult wards within this period who were not transferred to PICU (N = 994), and (2) a seclusion cohort comprising all seclusion episodes occurring in non-forensic PICU wards within the study period (N = 990) and a randomly selected group of patients treated in these wards who were not secluded (N = 1032). Demographic and clinical factors (age, sex, ethnicity, diagnosis, admission status and time since admission) and behavioural precursors (potentially relevant behaviours occurring in the 3 days preceding PICU transfer/seclusion or random sample date) were extracted from electronic medical records. Mixed effects, multivariable logistic regression analyses were performed with all variables included as predictors. PICU cases were significantly more likely to be younger in age, have a diagnosis of bipolar disorder and to be held on a formal section compared with patients who were not transferred to PICU; female sex and longer time since admission were associated with lower odds of transfer. With regard to behavioural precursors, the strongest predictors of PICU transfer were incidents of physical aggression towards others or objects and absconding or attempts to abscond. Secluded patients were also more likely to be younger and legally detained relative to non-secluded patients; however, female sex increased the odds of seclusion. Likelihood of seclusion also decreased with time since admission. Seclusion was significantly associated with a range of behavioural precursors with the strongest associations observed for incidents involving restraint or shouting. Whilst recent behaviour is an important determinant, patient age, sex, admission status and time since admission also contribute to risk of PICU transfer and seclusion. Alternative, less coercive strategies must meet the needs of patients with these characteristics.

Virtual communication about psychiatric intensive care units: Social actor representatives claim space on Twitter.

Psychiatric intensive care units (PICU) provide care for those with the worst phases of mental illness. What defines a PICU is often decided locally at hospitals. The aim of the present study was to explore and describe a contemporary discourse on how PICU are socially constructed from virtual discussions. An explorative and descriptive study design was applied for this qualitative inquiry using discourse methodology. The data were collected in Twitter's search string and consists of 215 Twitter postings. A framework of social actor representatives that form the discourse was established and presented in three categories: (i) hospital and agencies communicating about PICU; (ii) health-care professionals communicating about PICU; and (iii)service users and relatives communicating about PICU. Hospitals, agencies, and health-care professionals hold great power and responsibility for informing the public about PICU. Transparent and informative tweets could turn the mystery of PICU into more specific, positive portrayals.

Impact of Sudden Expansion of Catchment Area on Admissions to a Psychiatric Intensive Care Unit.

The closure of a neighboring psychiatric intensive care unit (PICU) provided an opportunity to evaluate the number of PICU beds required per head of population and to explore how referrals to the PICU are prioritized. Data were collected and analyzed for admissions to our PICU in the year before and the year after the closure of the other unit. Admissions increased (in year 2) by 42%, although there was no significant increase in the use of restrictive nursing interventions. There was, however, a shift in patients' characteristics, which differed between males and females. The closure of the other PICU was uneventful, suggesting that the new arrangement of one bed per 100,000 population is potentially safe and feasible. Furthermore, we demonstrated that the threshold for referring patients to the PICU was adjusted, and the length of stay on the PICU was reduced (in males only) in order to adapt to the reduction in the number of PICU beds.

An exploration into occupational therapists' use of creativity within psychiatric intensive care units

An exploration into occupational therapists' use of creativity within psychiatric intensive care units

Exploring consumer functioning in High Dependency Units and Psychiatric Intensive Care Units: Implications for mental health occupational therapy

Consumers admitted to High Dependency Units (HDUs) or Psychiatric Intensive Care Units (PICUs) experience very significant functional difficulties. These can make it challenging to deliver targeted occupational therapy interventions. This study was established to analyse previously collected data to better understand consumer functioning in HDUs and PICUs. The Hyperacute Screening Tool (HST) includes descriptors of increasing functional skills in three domains of functioning (task performance, social performance and task initiation). Data were extracted from 360 HSTs from 70 individuals admitted to a male HDU and a PICU in a mental health facility in metropolitan Sydney and analysed using the Rasch analysis program Facets. The hierarchy of category descriptors in each domain of the HST was correctly ordered, suggesting that the pattern of regaining functional abilities in the HST is accurate. Results suggested that there may be some conceptual overlap between adjacent categories and that the pattern of regaining functional abilities as described in the HST may not be applicable to a minority of individuals. This study provides the first description of functional abilities of consumers admitted to an HDU and PICU. Results were used to develop an initial conceptualisation of 'stages' of regaining functional abilities and a set of initial guidelines to support targeted occupational therapy interventions. This study will contribute to a better understanding of the functional abilities of individuals admitted to HDUs and PICUs and will support the development of optimal occupational therapy interventions in these settings.

Illustrating and evaluating the psychosexual symbolic meaning of the coprophilia through the film of Salò, or The 120 Days of Sodom

Coprophilia is a rarely discussed phenomenon although not uncommon in psychiatric intensive care units, inpatient learning disability services and on wards for older people. It evokes intense emotional reactions in those who witness and who are exposed to it. This paper gives a definition and a current diagnostic overview of this unusual phenomenon. It sums up the medical and psychoanalytic approaches, then makes an effort to illustrate and evaluates the psychosexual symbolic meaning of coprophilia through the film of Salò, or The 120 Days of Sodom.

Routine clinical measures in a newly commissioned psychiatric intensive care unit (PICU): predictors of favourable outcomes

Routine clinical measures in a newly commissioned psychiatric intensive care unit (PICU): predictors of favourable outcomes

A mirror image study of the utility of long acting aripiprazole

Aims and backgroundAblify Maintena (AM) is a long acting injection of aripiprazole that received marketing authorisation in the UK in January 2014. It is costly compared to first generation antipsychotics (FGAs) LAIs and there are no robust trials comparing AM with FGAs. We examined the effectiveness and use of AM in a mental health trust.MethodsWe identified all patients prescribed AM in North Staffordshire (population: 470,000) since launch and examined records for demography, diagnosis, bed and medication use. We examined the effectiveness of AM using a mirror image design.ResultsThirty patients received AM in a time frame allowing a 1-year follow-up. Sixty-nine percent were male and the mean age was 39 years. Over half were detained under the 1983 Mental Health Act and 30% were inpatients on a psychiatric intensive care unit when AM was started. Twenty-eight patients had a psychotic diagnosis. There was a significant reduction in bed occupancy (63 v 6 days, P = 0.0001) and admissions (1.6 v 0.5, P = 0.0001). The median dose was 400 mg. Lack of effectiveness/poor adherence with prior treatments were the main reason for starting AM in 84%. Eighty-six percent of patients clinically improved on AM. Blood parameters were in the normal range.DiscussionWithin the limitations of the methodology, our results show a reduction in psychiatric bed use in the year following AM initiation on an intention to treat basis. The reduction in bed use equates to a minimum annual saving of £14,250 per patient. AM at the median study dose costs £2645 per year.Disclosure of interestThe authors have not supplied their declaration of competing interest.

Sleep patterns as a predictor for length of stay in a psychiatric intensive care unit

Systematic evaluations of the relationship between sleep patterns and length of stay in psychiatric intensive care units (PICUs) are lacking. The aims of the present study were to explore if sleep duration or night-to-night variations in sleep duration the first nights predict length of stay in a PICU. Consecutive patients admitted to a PICU were included (N=135) and the nurses registered the time patients were observed sleeping. In the three first nights, the mean sleep duration was 7.5 (±3.2)h. Sleep duration the first night correlated negatively with the length of stay for patients with schizophrenia. The mean difference in sleep duration from night one to night two were 3.3 (±3.0)h and correlated with length of stay for the whole group of patients, but especially for patients with schizophrenia. Patients of all diagnostic groups admitted to a PICU had pronounced intra-individual night-to-night variations in sleep duration. Stabilizing night-to-night variations of sleep duration might be a major goal in treatment.

Achieving violence and restraint reduction in an IPCU

This article reports on the culture and practice changes that have evolved in an intensive psychiatric care unit (IPCU) since starting its journey with the Scottish Patient Safety Programme (Mental Health) in 2012. Significant, sustained reductions in patient violence and use of restraint have been experienced which has had a positive impact on the physical and psychological safety of patients and nursing staff within IPCU.

Markers of inflammation as risk predictors of lethal outcome in patients diagnosed with delirium.

Delirium is an acute or subacute, and most frequently reversible syndrome of higher cortical functions disturbances that is manifested as generalized disorder. If not prevented, it is associated with various adverse outcomes. The aim of this study was to determine the connection between the markers of inflammation and lethal outcome in patients diagnosed with delirium, hospitalized in the psychiatric intensive care unit. This retrospective study included 120 patients hospitalized in the psychiatric intensive care unit in whom examination of differences in inflammation markers was done. The examinees have been divided into two groups: the case group of 40 patients who died during the hospitalization, and the control group of 80 examinees who were discharged with the diagnosis Post delirium status. The following variables were taken into account: age, gender, clinical diagnosis of infection (pneumonia and urinary tract infection), laboratory parameters (total of white blood cells, granulocytes, monocytes, C-reactive protein − CRP) and type of delirium (withdrawal or organic). The average age of patients was 50.3 ± 13.1 years. The patients who survived delirium, were on the average 10.5 years younger than the deceased (p < 0.001). More than half (57.5%) of the deceased had pneumonia. There was a statistically significant correlation between pneumonia and lethal outcome in the patients with delirium (p < 0.001). The examinees with lethal outcome had significantly higher median CRP levels than the group of examinees who survived (75.6% ± 54.0 vs 30.3 ± 42.5 ng/L, p < 0.001). Aiming to better and more precise diagnostics of this complicated and still unclear neuropsychiatric syndrome it would be useful to consider introduction of more precise diagnostic algorithms in every unit of intensive care. That would significantly reduce the number of delirium diagnosis overlook, decrease complication of clinical features and would also reduce the unfavorable outcome rate, therefore the total cost of treatment.