Psychiatric Intensive Care Unit Research Articles

Identifying predictors of adverse outcomes after termination of seclusion in psychiatric intensive care units.

Seclusion is a restrictive practice that many healthcare services are trying to reduce. Previous studies have sought to identify predictors of seclusion initiation, but few have investigated factors associated with adverse outcomes after seclusion termination. To assess the factors that predict an adverse outcome within 24 h of seclusion termination. In a cohort study of individuals secluded in psychiatric intensive care units, we investigated factors associated with any of the following outcomes: actual violence, attempted violence, or reinitiation of seclusion within 24 h of seclusion termination. Among the seclusion episodes that were initiated between 29 March 2018 and 4 March 2019, we investigated the exposures of medication cooperation, seclusion duration, termination out of working hours, involvement of medical staff in the final seclusion review, lack of insight, and agitation or irritability. In a mixed-effects logistic regression model, associations between each exposure and the outcome were calculated. Odds ratios were calculated unadjusted and adjusted for demographic and clinical variables. We identified 254 seclusion episodes from 122 individuals (40 female, 82 male), of which 106 (41.7%) had an adverse outcome within 24 h of seclusion termination. Agitation or irritability was associated with an adverse outcome, odds ratio 1.92 (95% CI 1.03 to 3.56, P = 0.04), but there was no statistically significant association with any of the other exposures, although confidence intervals were broad. Agitation or irritability in the hours preceding termination of seclusion may predict an adverse outcome. The study was not powered to detect other potentially clinically significant factors.

Exploring Social Interactions in the Context of Justice System Involvement: Perspectives of Patients and Psychiatric Nurses.

Psychiatric nurses who work with people who are involved with the justice system experience ethical and moral tension arising from their dual role (care and control). This is known to significantly affect the development of a therapeutic relationship between nurses and patients. (a) better understand how justice system involvement affects people living with mental disorders and the nurses who work with them; (b) explore the influence of judiciarization on social interactions between these actors. Grounded theory (GT) was used as the qualitative methodology for this research. Semi-structured interviews were conducted with participants. The study was carried out in three different units of a psychiatric institution: Psychiatric Intensive Care Unit, Emergency Department, and Brief Intervention Unit. A sample of 10 patients and 9 psychiatric nurses was recruited (n = 19). Theoretical sampling was used to recruit participants. We followed the iterative steps of qualitative GT analysis (open coding, axial coding, constant comparison, and modelization). Three main themes emerged from the qualitative analysis: (a) Experience of Justice System Involvement, (b) Crisis, (c) Relational Aspects and Importance of the Approach. These results will inform nurses and healthcare providers about the impacts of justice system involvement on people living with mental illness and how clinical practices can be better adapted to this population with complex health needs.

Treating taboo thoughts on a psychiatric intensive care unit: a four-phase mixed methods single case experimental design.

Well-designed evaluations of psychological interventions on psychiatric intensive care units (PICUs) are a rarity. To evaluate the effectiveness of cognitive behaviour therapy for intrusive taboo thoughts with a patient diagnosed with bipolar affective disorder admitted to a PICU due to significant ongoing risk of harm to self. This was a four-phase ABC plus community follow-up (D) mixed methods n=1 single case experimental design. Four idiographic measures were collected daily across four phases; the baseline (A) was during PICU admission, the first treatment phase (B) was behavioural on the PICU, the second treatment phase (C) was cognitive on an acute ward and the follow-up phase (D) was conducted in the community. Four nomothetic measures were taken on admission, on discharge from the PICU, discharge from the acute ward and then at 4-week follow-up. The participant was also interviewed at follow-up using the Change Interview. Compared with baseline, the behavioural and the cognitive interventions appeared effective in terms of improving calmness, optimism and rumination, but the effects on sociability were poor. There was evidence across idiographic and nomothetic outcomes of a relapse during the follow-up phase in the community. Eleven idiographic changes were reported in the interview and these tended to be unexpected, related to the therapy and personally important. Single case methods can be responsive to tracking the progress of patients moving through in-patient pathways and differing modules of evidence-based interventions. There is a real need to implement robust outcome methodologies on PICUs to better evaluate the psychological aspects of care in this context.

Facilitating a hearing voices group on acute and psychiatric intensive care units to promote acceptance and hope: preliminary learning and reflections

Purpose Hearing voices can be a debilitating and traumatic experience, and psychiatric hospitals can feel unsafe and overstimulating to voice hearers. Research suggests this may prolong a service user’s admission time and lead to an unhelpful experience. Therefore, a hearing voices group (HVG) was developed to create a safe space where voice hearers could share their story with others with lived experience and access support. Design/methodology/approach The group was developed by the first author under the supervision of the inpatient psychology lead. Both a practice-based and expert by experience-based approach were considered during the development of the group structure. The group also aligned with the Hearing Voices Network and the Trust’s values. A questionnaire was developed to evaluate the effectiveness of the group using six five-point Likert scale questions and three open questions to collect the data, which was then analysed. Findings The themes from the qualitative data showed that staff and ward-based promotion of the group were paramount to ensuring patient engagement. The results also showed that voice hearers found the group therapeutic, and some found the coping skills shared to be beneficial and effective. Research limitations/implications A large percentage of women (76%) reported that they had attended a HVG before. This was not the case for service users from the male unit and psychiatric intensive care unit. This result is considered to reflect the fact that women in that unit had the opportunity to attend more than once during their admission, rather than that they had accessed these groups in other settings or in the community. Therefore, in the future, it would be useful to change this question to “have you attended any other HVGs in the past, prior to this admission?”, which might be more appropriate for data collection. Originality/value To the best of the authors’ knowledge, this is the original work of the first author, who is an expert by experience and an assistant psychologist. The results suggest that HVGs can be beneficial for patients in acute and intensive mental health care and highlight some necessary adaptations and the importance of adopting an MDT approach in promoting therapeutic groups.

Delays in transferring patients from prisons to secure psychiatric hospitals: An international systematic review.

Transfer to a psychiatric hospital of prisoners who need inpatient treatment for a mental disorder is an important part of prison healthcare in the UK. It is an essential factor in ensuring the principle of equivalence in the treatment of prisoners. In England and Wales, delays in transferring unwell prisoners to hospital were identified by the 2009 Bradley Report. There has been no subsequent systematic review of progress in so doing nor a corresponding appraisal of transfer arrangements in other parts of the world. To conduct a systematic review of international literature about transfers of mentally unwell individuals from prison to hospital for the treatment of mental disorder since 2009. Eight databases were searched for data-based publications using terms for prison and transfer to hospital from 1 January 2009 to 4 August 2022. Inclusion criteria limited transfer to arrangements for pre-trial and sentenced prisoners going to a health service hospital, excluding hospital orders made on the conclusion of criminal hearing. In England, four articles were identified, all showing that transfer times remain considerably longer than the national targets of 14days (range, 14days to >9months); one study from Scotland found shorter mean transfer times, but more patients had been transferred to psychiatric intensive care units than to secure forensic hospitals. There were only two studies that investigated prison to hospital transfers for mental disorder from outside the UK and only one reported time-to-transfer data. Findings from this literature review highlight failures to resolve transfer delays in England and provide little evidence about the problem elsewhere. Given the lack of data, it is unclear whether other countries do not have this problem or simply that there has been no research interest in it. A possible confounding factor here is that, in some countries, all treatment for prisoners' mental disorders occurs in prison. However, the principle that prisons are not hospitals seems important when people need inpatient care. Prospective, longitudinal cohort studies are urgently needed to map transfer times and outcomes.

Providing Patients Caffeinated Coffee in PICUS

Caffeine is a legally available, widely consumed psychoactive substance with mild central nervous system stimulant properties. There is sufficient caffeine in a cup of coffee to have a stimulant effect. Caffeine can adversely affect some mental health symptoms, notably sleep and anxiety. Effects would be worse if consumed excessively. This survey aimed to describe the pattern of provision of caffeinated coffee to patients admitted to UK adult psychiatric intensive care units (PICUs) in order to inform local practice. All NHS adult PICUs across the UK were contacted to establish what type of coffee they routinely provided to their patients. Two thirds of PICUs provided only decaffeinated instant coffee to their patients. However, a minority provided caffeinated coffee in an unregulated manner, including three units which did not routinely offer decaffeinated coffee. National guidance to inform and direct the practice of providing or restricting the consumption of drinks containing psychoactive substances on a PICU may be beneficial.

Activity PRN: Exploring Meaningful Occupation 'As and When Required' on a Psychiatric Intensive Care Unit

Background: Occupational deprivation and barriers to meaningful and purposeful activity are key issues for patients admitted to psychiatric intensive care units (PICUs), resulting in occupational alienation. To increase the frequency of engagement in meaningful occupations, an intervention named 'Activity PRN' was developed. Method: A quasi-experimental study was completed, measuring the number of ad hoc activities and the frequency of activity engagement on a PICU ward over a period of six months. Therapeutic programme sessions were excluded as this study measured 'as and when required' activities. Data were collected from 18 patients admitted to the ward over a period of three months prior to the intervention start, and from 22 patients in the following three months during the intervention. Patients were supported to choose personally meaningful activities, which were then risk-assessed, and resources and activity locations were organised. Activity PRN cards were used to communicate their activity choices to ward staff, and facilitate activity engagement. Results: Data comparison showed greater provision of, and engagement in, meaningful activities as a result of the intervention. It was found that the terms 'Activity PRN' and 'PRN activities' were used commonly within the ward and hospital. Conclusion: Activity PRN was used as a successful intervention to reduce occupational deprivation and promote occupational justice on the ward. Further study is required to measure the clinical validity of Activity PRN within inpatient mental health units.

The Characteristics of Patients Admitted to a Forensic Psychiatric Intensive Care Unit in Australia

Background: Psychiatric intensive care units (PICUs) house some of the highest acuity patients within the mental health system. Little is known about patient characteristics and adverse events occurring in these settings and this study aimed to examine clinical, demographic and offending characteristics and correlates of problem behaviours for patients admitted to the first forensic PICU in Australia. Aims: To identify common characteristics held by patients admitted to one high secure forensic PICU in Australia. Method: Retrospective file review occurred for patients admitted between March 2019 and May 2020, during which 96 male patients were admitted. Results: Mean (range) age was 37.3 (21–76) years, and when admitted most patients were: single (n = 80; 83.3%), homeless (n = 52; 54.2%), had not completed high-school education (n = 60; 62.5%), had histories of trauma (n = 38; 39.6%) and antisocial behaviour (n = 40; 41.7%) in adolescence and presented with personality disorder (n = 23; 24.0%) and substance abuse (n = 93; 96.9%). Frequent problem behaviours, particularly aggression (n = 65; 67.7%), were encountered and rates of seclusion (n = 62; 64.6%) were high. Segregation in prison prior to admission and co-morbid personality disorder were associated with increased likelihood of aggression or self-harm respectively occurring. Conclusion: With high mental illness acuity and significant behavioural risk complicated by multi-vulnerability, forensic PICUs need specialist environments, models of care and high level relational and de-escalation staff expertise to maintain safety and promote recovery.

Study protocol for virtual leisure investigating the effect of virtual reality-delivered stress reduction, entertainment and distraction on the use of coercion and need-based medication and patient satisfaction at a closed psychiatric intensive care unit - a mixed-methods pilot clinical trial

IntroductionThe environment at a psychiatric inpatient ward can lead to emotional distress and behavioural deviations in vulnerable individuals potentially resulting in conflicts, increased use of need-based medication and coercive actions,...

Implementation of a case formulation to reduce restrictive interventions on a psychiatric intensive care unit: quasi-experimental single case evaluation - CORRIGENDUM.

Implementation of a case formulation to reduce restrictive interventions on a psychiatric intensive care unit: quasi-experimental single case evaluation - CORRIGENDUM.

Implementation of a case formulation to reduce restrictive interventions on a psychiatric intensive care unit: quasi-experimental single case evaluation.

Despite the use of case formulation being encouraged for in-patient psychiatric care, there have been no previous examples and evaluations of this type of work on a psychiatric intensive care unit (PICU). To evaluate whether a schema-informed formulation with a patient diagnosed with emotionally unstable personality disorder (EUPD), autism spectrum disorder (ASD) and mild learning difficulties was effective in reducing the use of restrictive interventions. A biphasic n = 1 quasi-experimental design with an 8-week baseline versus an 8-week intervention phase. The restrictive outcomes measured were use of physical restraint, seclusion, and intramuscular rapid tranquilisation. The formulation was developed through eight one-to-one sessions during the baseline period, and was implemented via six one-to-one sessions during the intervention phase and discussion at the ward reflective practice group. The intervention encouraged better communication of schema modes from the patient and for staff to then respond with bespoke mode support. Incidents involving need for seclusion, restraint and rapid tranquilisation extinguished. The need for making access to psychological input a routine aspect of the care in PICUs and the necessity for developing a methodologically more robust evidence base for psychological interventions on these wards.

Seclusion Reviews: Audit of Medical Documentation in a Psychiatric Intensive Care Unit

AimsSeclusion is a restrictive intervention used when a patient presents with risks that cannot be safely managed in their current environment. The Mental Health Act 1983 Code of Practice (MHA CoP) provides clear recommendations for both frequency and content of medical seclusion reviews, with compliance previously audited within Cheshire and Wirral Partnership NHS Foundation Trust (CWP). Following the initial findings however, change was not implemented. A new audit has therefore been commenced to reassess baseline practice and identify areas requiring improvement.MethodsThe MHA CoP audit tool outlines the following timeframes for assessment: initial medical review within 1 hour, 4-hourly medical reviews until first internal multidisciplinary review, twice daily medical seclusion reviews with at least 1 by the Responsible Clinician. Documentation should evaluate: physical and mental health, medication adverse effects, observation level, prescribed medication, risk to others and self, need for ongoing seclusion. Data were collected retrospectively for all episodes of seclusion occurring in a CWP Psychiatric Intensive Care Unit during August 2022.Results5 seclusion episodes related to 4 patients, ranging from 1 night to 15 days in duration. Regarding medical review frequency, 20% were seen face-to-face within 1 hour of seclusion commencing and 75% were seen 4-hourly until their internal multidisciplinary review. Mental health was more consistently commented on than physical health (97% vs 61% respectively), whilst medication was reviewed in 69% of assessments. Rationale for continuing seclusion was provided in 72%, referring to risk to others in 54%. Adverse medication effects and observation level were the least documented parameters (2%), followed by risk to self (7%).ConclusionAssessment time was often not explicitly stated and was substituted with time of documentation, meaning reviews may have occurred earlier than accounted for. The on-call doctor does cover multiple sites overnight, potentially contributing to delays in attending unforeseen time-sensitive tasks. Trust policy dictates constant visual observation must be maintained throughout seclusion and this is therefore not routinely subject to review or adjustment. Overall interpretation of the qualitative information was fairly subjective in a low number of seclusion episodes, however there was a notable lack of recording adverse medication effects and risk to self. Findings will be presented at junior doctor induction whilst a quick reference sheet is designed prior to reaudit. CWP's seclusion policy specifies medical review frequency, but does not outline expected content of documentation. There is scope to extend local policy and align with the MHA CoP.

Improving Screening and Standardising Interventions for Patients With Above Normal Body Mass Index (BMI) Admitted to a Male Psychiatric Intensive Care Unit (PICU): A Quality Improvement Project

Aims/hypothesis1.To increase the proportion of patients having their BMI documented on admission to the PICU.2.To improve rates of standardised interventions when abnormalities in BMI found.Among patients admitted to PICU, there is lack of consistency in monitoring of BMI and in offering interventions for those with abnormal BMI. We expect an improvement in both the parameter with the quality improvement project. Background: Service users admitted to PICU have severe mental health illnesses, and are known to have several high risk cardiometabolic parameters including excessive weight. In addition, they are often treated with medications known to cause weight gain. Without effective management, this is likely to cause increased morbidity and mortalityMethodsInitial baseline data were collected by reviewing patient notes.We then tested interventions to improve weight and BMI screening process on the PICU. We used the Plan-Do-Study-Act (PDSA) methodology over 2 cycles. In the first cycle, we engaged the nursing staff to improve screening on admission, including training to overcome the glitch in the electronic form that prevented automatic BMI calculation. In the second cycle, we introduced a protocol to ensure consistent interventions were offered to patients with abnormal BMI. The interventions offered were referral to dietician, referral to PICU gym instructor and MDT discussion about lifestyle changes and medication to manage weight.Data were collected after each PDSA cycle to monitor change.ResultsBaseline: 47% of PICU patients had their BMIs recorded on admission. 69% of those patients that met the overweight criteria were offered an intervention.After the first PDSA cycle, 91% of patients had their BMIs recorded. 71% of those patients that met the overweight criteria were offered an intervention.After the second PDSA cycle, all the consenting patients had their BMIs recorded. 100% of those patients that met the overweight criteria were offered all the interventions in the protocol but not all agreed to engage with the interventions.ConclusionAs a result of this quality improvement project there has been an improvement in screening for BMI on admission to PICU and in the standardised interventions offered to those with high BMI. The next steps will be to implement this across the other wards and to improve patients’ engagement with the interventions.

A Service Evaluation and Improvement Project: Outcomes of Referrals From Prison to the Male Psychiatric Intensive Care Unit (PICU) in Kent

AimsAims: The project aims to evaluate the referrals from prison services for admission to our PICU from June 2020 to October 2021. Hypothesis: We expect referrals to come from multiple sources with variable timeframes for assessment. For those admitted to PICU, we expect delays in transfer out of PICU with increased PICU length of stay. We believe this to be secondary to lack of an established protocol for this pathway. Background: Our single 12 bedded male PICU in the trust has seen increased demands on its beds for prisoners requiring admission to mental health services. While PICU beds can meet the low secure requirements for prison transfers, they cannot function as forensic low secure beds due to their role within Acute services. With the increased number of referrals and the lack of a clearly defined pathway for these prison transfers, there was a risk of erosion of PICU philosophy aiming for discharge at the point when intensive care was not required, i.e increased length of stay.MethodsData were collected for all referrals from prison services to the male PICU between June 2020 and October 2021, recording the demographics, clinical information and timeframes for assessment. For those admitted to the PICU, percentage meeting the PICU criteria, admission-discharge pathways, serious untoward incidents and delays in transfer were recorded.ResultsThere were 22 referrals from prisons, of which 11 (50%) were admitted to the male PICU. The referrals came from multiple sources with poor coordination between the PICU, forensic and prison services with delays in assessment. 100% of the admissions met criteria for PICU. There were 2 serious incidents related to security levels of the environment. The pathway out of PICU included prison, forensic services and acute wards. Over half the patients were downgraded to non-restricted detentions and stepped down to acute beds. There was a delay in transferring out of PICU in 36% of the patients leading to increased length of stay.ConclusionIn conclusion, the data support our initial concerns that there is a need for a protocol guiding the transfer of prisoners to our PICU for treatment. This has led to discussions to develop such a protocol with close collaboration between prisons, forensic services and PICU. We hope this will lead to a much smoother process from having a single point of referral, timely assessments and decisions making, better defined exit pathways with less delays in transfer from PICU.

Isolation and restraint in units for difficult patients and in psychiatric intensive care units

The units for difficult patients (UMD) and the intensive psychiatric care units (Usip) are psychiatric services that are not successively sectorized, created to meet the needs of intensive care in a closed environment and sometimes of a forensic nature. These two systems are used to care for patients whose clinical condition often makes it too complex to maintain them in sector psychiatric units, and many of their operating rules differ. This is not the case for seclusion and restraint measures and the application of the law governing these measures.

Soothing in units for difficult patients and in psychiatric intensive care units

In the units for difficult patients (UMD) and the intensive psychiatric care units (Usip), patients whose mental pathologies have or could generate violent acts which can go as far as committing homicide are taken care of. If, during the psychiatric care of these patients, isolation and restraint measures can be put in place as a last resort, in general it is the symptomatological and behavioral appeasement of these persons that is sought in an alternative way.

Management of medically assisted withdrawal from alcohol in acute adult mental health and specialist addictions in-patient services: UK clinical audit findings.

Medically assisted alcohol withdrawal (MAAW) is increasingly undertaken on acute adult psychiatric wards. Comparison of the quality of MAAW between acute adult wards and specialist addictions units in mental health services. Clinical audit conducted by the Prescribing Observatory for Mental Health (POMH). Information on MAAW was collected from clinical records using a bespoke data collection tool. Forty-five National Health Service (NHS) mental health trusts/healthcare organisations submitted data relating to the treatment of 908 patients undergoing MAAW on an acute adult ward or psychiatric intensive care unit (PICU) and 347 admitted to a specialist NHS addictions unit. MAAW had been overseen by an addiction specialist in 33 (4%) of the patients on an acute adult ward/PICU. A comprehensive alcohol history, measurement of breath alcohol, full screening for Wernicke's encephalopathy, use of parenteral thiamine, prescription of medications for relapse prevention (such as acamprosate) and referral for specialist continuing care of alcohol-related problems following discharge were all more commonly documented when care was provided on a specialist unit or when there was specialist addictions management on an acute ward. The findings suggest that the quality of care provided for medically assisted withdrawal from alcohol, including the use of evidence-based interventions, is better when clinicians with specialist addictions training are involved. This has implications for future quality improvement in the provision of MAAW in acute adult mental health settings.

Impact of COVID‐19 on rate of admissions in the Humber Teaching NHS Foundation Trust in Yorkshire

Impact of <scp>COVID</scp>‐19 on rate of admissions in the Humber Teaching <scp>NHS</scp> Foundation Trust in Yorkshire

Consistency of Violence: Implications for Effective Inpatient Psychiatric Care

Instances of violence and aggression in acute psychiatric settings are common and highly distressing for service users and staff. They also incur financial costs. This study aimed to identify the proportion of service users at risk of consistent violence/aggression enactment. It also aimed to analyse associated service use to explore the potential need for specialised, targeted approaches. Five years’ worth of data were extracted from 2016 to 2020 on inpatient stays across South London and Maudsley NHS Foundation Trust (SLaM) acute adult wards and Psychiatric Intensive Care Units (PICUs). Service users were divided into cohorts based on relative number of violent/agressive incidents enacted. Differences in frequency of acute service use during the period 1st January-31st December 2020 were analysed. In total, 2524 service users had at least one inpatient stay during 2020. 679 were recorded as having enacted at least one incident of violence or aggression. Just 4% of all service users accounted for 50% of all violence/aggression enactment. Results further showed strong evidence of group differences between violence cohorts in the following domains: internal transfers, occupied bed days, admissions and Place of Safety (PoS) referrals. There was weaker evidence for group differences in referrals to Home Treatment teams (HTTs) and Psychiatric Liaison Teams. A small proportion of service users disproportionately account for the majority of violent and aggressive incidents and higher levels of violence and aggression are associated with more acute service use. The provision of targeted, personalised interventions for this cohort may reduce the enactment of violence and aggression, leading to improved quality life and a reduction in financial expenditure.

Modelling admission lengths within psychiatric intensive care units

ObjectivesTo examine whether discharge destination is a useful predictor variable for the length of admission within psychiatric intensive care units (PICUs).MethodsA clinician-led process separated PICU admissions by discharge destination into...