Psychiatric Intensive Care Unit Research Articles

Characterization of Psychotropic PRN Medications in a Canadian Psychiatric Intensive Care Unit.

Pro re nata (PRN) antipsychotics and benzodiazepines are routinely used for the rapid stabilization of acutely agitated patients. Despite the popular use of PRN medications in mental health units, primary literature supporting efficacy and safety is poor, and there is no single universally accepted practice guideline. PRN psychotropic medications have the potential to cause adverse effects when used inappropriately. Our objective was to characterize the prescribing, administration, and documentation practices of PRN psychotropic medications in a psychiatric intensive care unit. We conducted a retrospective chart review of patients admitted to a 12-bed psychiatric intensive care unit between June and September 2018. All PRN antipsychotic and benzodiazepine orders, administrations, documentation practices, and attempted nonpharmacological strategies were assessed for each order and patient. Descriptive statistics were used to analyze data. Thirty-two patients with a total of 123 physicians' orders and 1,179 PRN administrations of antipsychotics and benzodiazepines were reviewed. Of the total administrations, 720 (61%) were combinations with at least two psychotropic agents. Forty-one (33%) physicians' orders had a prescribed indication, and 559 (47%) administrations had an attempted nonpharmacological method prior to PRN administration. Eight patients (25%) had antipsychotic PRN orders, which exceeded the total daily maximum dose. Three adverse drug effects were attributed to PRN administration. Areas of improvement that we identified included documentation practices of effectiveness of administered PRNs, prescriptions to include clear indications and dosage within the 24-hour maximum limits, and documentation of nonpharmacological methods utilized.

Sexual and reproductive health needs assessment & interventions in a female psychiatric intensive care unit

AimsTo assess the sexual and reproductive health (SRH) needs of women admitted to a psychiatric intensive care unit (PICU), and acceptability of delivering specialist SRH assessments/interventions in this setting. Secondary aims were to explore the barriers to access and the feasibility of providing SRH assessments and interventions in the PICU.MethodA retrospective analysis of fifteen months’ activity data found that only 25 SRH referrals had been made across 205 PICU admissions. This low referral rate of 12% likely reflected pathway barriers and was unlikely to represent the actual clinical need in female PICU patients. A bi-monthly SRH in-reach clinic and a nurse led SRH referral pathway were implemented on the PICU over a seven-month period. Within a quality improvement framework, a staff training needs assessment was performed, training delivered, a protocol developed, staff attitudes explored, and patient and carer engagement sought.ResultA quality improvement approach streamlined SRH assessments on the PICU and resulted in 42% of women being assessed and a 3.5-fold increase in uptake. At least 30% of the women in the PICU had unmet SRH needs identified and proceeded to a specialist appointment. This amounts to a minimum 2.5-fold increase in SRH unmet need detection.The most common SRH needs were complex gynaecological issues (such as period problems, pelvic pain, vaginal discharge), STI advice/testing and contraception advice/options. 21% of women initiated SRH interventions, and 14% completed all the interventions required for their needs. The most common interventions were in the areas of contraception advice/family planning and STI advice/testing.Staff confidence on assessing SRH topics was identified as a barrier to access with a positive shift noted after bespoke SRH training was implemented and a protocol introduced: on a scale of 0-10 (with 10 being high), 81.3% of staff rated their confidence 8 or above in relation to discussing contraception/sexually transmitted infections (pre-training: 25.0%), and 93.8% in relation to discussing risky behaviours (pre-training: 18.8%). All 11 patient and carer participants felt it was important to have a forum to talk about SRH and 8 (72.7%) agreed it was important in the PICU.ConclusionResults identify that SRH needs for PICU admissions are greater than previously realised. Staff highlighted the acceptability and importance of SRH care, if interventions are appropriately timed and the patient's individual risk profile considered. Providing a nurse led referral pathway for an SRH in-reach clinic is acceptable, feasible and beneficial for PICU patients.

Physical health monitoring before commencing regular antipsychotics in a Psychiatric Intensive Care Unit (PICU) - A Quality Improvement project

AimsTo compare the practice in a PICU setting against the standard practicing guidelines before commencing antipsychotics with regards to: 1.Physical examination2.ECG3.Baseline blood investigations4.Physical health conditions5.Family history of medical conditions.MethodData were collected from the PICU, Black Country Healthcare NHS Foundation Trust which covers four different hospital sites. 37 patients were admitted in PICU from 1st March 2020 to 30th September 2020, out of which 30 were included. 6 case notes were not available and one patient was admitted twice, thus case notes for only one admission was included in data collection.The standard guidelines for PICU outline that each admitted patient should have physical examination, vitals monitoring and baseline investigations including routine blood tests and ECG within first 24 hours. The data were collected as per standards retrospectively within two weeks from case notes in health records. Investigations were accessed through electronic information system for current inpatient admission and 12 months prior to the admission to the PICU.ResultMean age of the sample (n = 30) was 34.26 years. 37% of patients had physical comorbidities and a family history of medical conditions was documented for only 3% of cases. A large proportion of inpatients (53%) refused to have blood investigations before treatment and only 13% of blood investigations were completed before commencing treatment. Only 7% of patients consented to an ECG prior to commencing treatment. 27% of patients had a physical examination, including vitals, before starting treatment, a further 37% had just their vitals taken within 24 hours of admission and 20% refused any form of physical examination during their inpatient admission. 7% of cases had complications due to a lack of investigation.ConclusionAlthough there are standard guidelines for the PICU setting, it has been noted that these guidelines aren't always implemented. Multiple factors have a role to play such as: non-consenting patients, inaccessibility of previous records, initial assessment forms being incomplete including assessment of mental capacity and lack of follow-up with physical investigations by both primary care and secondary mental health services. As per findings, a few recommendations were proposed to meet the standards.

Audit of Documentation of Forensic History on Admission Form in a Psychiatric Intensive Care Unit.

To study the documentation of relevant components of forensic history on admission form for male patients admitted in psychiatric intensive care unit (PICU)/OAK ward of Phoenix Care Center. Clinical audit. Psychiatric intensive care unit/OAK ward of Phoenix Care Center, from August 2019 to July 2020. Charts of all patients admitted in PICU from August 2019 to July 2020 were analysed, and admission forms were reviewed for documentation of relevant parameters of forensic history. A structured tool was made after literature search, which included drug and alcohol history, history of assaults, protection/barring orders, number of previous PICU admissions, previous charges, pending charges, use of depot medications and previous encounters with police without pending charges. A total of 50 patients were admitted during the given time period. Drug and alcohol history was documented in 98% of the cases, previous charges were documented in 88% of the cases, protection/baring order was documented in 62% of the cases, while previous encounter with the police without being charged was documented in only 32% of the cases. Drugs and alcohol and previous charges were documented in most of the cases, but documentation of protection/baring order and encounter with the police without being charged was a neglected area, which should be worked upon in future. Key Words: Admission form, Forensic history, Medical audit.

Reducing levels of Violence in the Psychiatric Intensive Care Unit (PICU) - a multidisciplinary quality improvement project

AimsOur aim: To reduce the number of Level 1* violent incidents in Ward 4 by 30% by April 2020*Level 1 is defined as “Behaviour involving force, which causes or is intended to cause physical harm to others; but excludes assault on objects, threats or verbal abuse”Ward 4 is Belfast Health and Social Care Trust's only PICU, with a total of 6 beds. Our project took place on the background of a recent move to a new purpose-built inpatient unit, as well as a trust-wide initiative to address levels of violence across inpatient psychiatry services.MethodWe divided our project into 3 main areas:Patient factorsStaff factorsEnvironmental factorsWe identified and implemented a number of change ideas, using Plan-Do-Study- Act methodology, regularly meeting to review progress and plotting our data on a run chart.Key patient interventions included a “Mutual Respect” exercise and regular “Community Meetings”.Staff interventions included use of Safety Crosses, Daily Safety Briefings and the Broset Violence Checklist (BVC).Environmental factors were continually assessed and escalated as appropriate.We raised awareness of our project and gained feedback by creating a dedicated notice board, providing a staff information session and including it as an agenda item at ward meetings.Our project measures were identified as:Outcome: Number of level 1 violent incidents occurring per weekBalancing: Number of incidents in other categories; Patient satisfactionProcess: Staff safety rating; Engagement with interventionsResultUnfortunately, we were unable to meet our initial goal and there continued to be considerable variation in the number of weekly incidents.We believe this was attributable to several factors, including the level of acuity within the ward during the project timeframe. It was noted that a relatively small number of patients contributed to a large proportion of the total incidents. Our results, therefore, did not reflect the success of interventions with other patients on the ward.Despite this, we noted improvements in terms of patient and staff engagement with the project, including subjective reports of staff safety during shifts.ConclusionThe unpredictable and complex nature of the PICU setting cannot be under-estimated and this ultimately impacted on achieving our intended outcome.We do feel, however, that the project has had a positive impact and we hope we can build on this progress over the coming months.Further interventions are being explored, including personalised daily activity schedules and attempts to reduce levels of continuous observations.

A survey of the level of knowledge and understanding of members of the inpatient team on the role of the physician associate on the general adult psychiatric wards

AimsPhysician Associates (PAs) are healthcare professionals with a general medical education background, having completed a two-year postgraduate degree. Whilst the number of PAs employed in healthcare trusts continues to increase, the number working in mental health settings remains small.Mersey Care NHS Foundation Trust employed two PAs two years ago. In August 2019, a third PA was recruited to work at Clock View Hospital, a general adult inpatient unit.This survey aims to establish what level of understanding different members of the inpatient teams across the inpatient wards have of the tasks PAs are permitted to undertake and those they are not.MethodA survey was designed, listing 37 tasks, e.g. completing an admission clerking. For each task, the participant was asked whether a PA is allowed to complete it or not, with three options provided – “can carry out the task”, “cannot carry out the task” and “do not know.” A score of + 1 was awarded if the correct answer was provided, –1 for an incorrect answer and 0 if the respondent didn't know. The highest possible score for a completed survey was + 37 points; the lowest possible score was –37 points.A sample of survey respondents was identified from the three general adult inpatient wards at Clock View Hospital and the Psychiatric Intensive Care Unit (PICU), comprising: senior doctors, junior trainees, Ward Manager, Deputy Ward Manager, Band 5 nurse and Assistant Practitioner.ResultTwenty-four members of staff completed the survey – 3 senior doctors, 4 junior trainees, 4 Ward Managers, 4 Deputy Ward Managers, 5 Band 5 nurses and 4 Assistant Practitioners. The respondents were distributed equally across the three general adult wards and the PICU. The highest survey score was 36 out of 37 (a Consultant); the lowest was 18 (a junior trainee). The lowest mean score was variable across the different grades of staff, with Consultants scoring highest at 29 and Assistant Practitioners and Ward Managers both scoring lowest at 25. There was little variability in mean score (only 2 points) across the three wards and PICU.ConclusionThe results from this survey demonstrate that different members of the inpatient team have a good understanding of what tasks PAs are and are not permitted to. There is still a need to provide further education to inpatient staff to ensure they utilise the PA at Clock View Hospital appropriately and that the PA is able to develop his skill set.

Audit of patients absent without leave from a psychiatric intensive care unit

AimsWe aimed to reduce the number of patients absent without leave (AWOL) by carrying out an audit of processes around granting leave for those patients and the action taken when they absconded. We also wanted to determine factors which might be associated with patients absconding.BackgroundNile ward is a 14-bedded male psychiatric intensive care unit (PICU). All patients admitted to the ward are under section 2 or 3 of the Mental Health Act. Patients who are AWOL may pose a risk of harm to themselves or others. The Royal College of Psychiatrists’ Quality Network for PICUs has developed applicable standards, which include criteria on developing a leave plan, actions to take when patients are AWOL and involvement of carers.MethodPatients who went AWOL during a six month period in 2019 from ward records. The electronic medical records for identified patients were reviewed to assess whether the following eight criteria were met: risk assessment documented; leave conditions specified; consultation with the multi-disciplinary team; crisis card provided to patients or families; risk management plan enacted when AWOL; relevant authorities informed; incident form completed; relatives/carers involved in patient's care if they consented. In reviewing the notes, factors that might have been associated with an increased risk of AWOL were also assessed in order to inform risk assessment.ResultSix patients were identified who went AWOL during the six month period in question. For six of the criteria, all of patients' cases met the audit standards. Five patients' did have involvement of relaties/carers if they consented, but in one case no details were available for making contact. All patients lacked documented details of crisis numbers being provided before they went on leave. Preliminary findings that might be associated with an increased risk of AWOL are differing views between the patient and the treating team on the care plan and concerns about mental state.ConclusionThe audit showed many of the standards are met. However, a quality improvement intervention is planned to ensure all audit standards are met, in particular around providing a crisis card to patients and these findings will be presented on the poster, if accepted. Further research is needed into factors which might be associated with an increased risk of absconsion in PICU.

Nile Ward PICU violence reduction quality improvement project

AimsTo reduce incidents of inpatient violence and aggression at Nile Ward Psychiatric Intensive Care Unit (PICU), St Charles Hospital by at least 30% between December 2019 and December 2020. Reducing inpatient violence is a major quality improvement (QI) priority for CNWL NHS Foundation Trust.MethodAs a Psychiatric Intensive Care Unit, Nile Ward looks after male patients suffering from severe mental illness (SMI). This usually includes patients presenting with high levels of violent and aggressive behaviour. Prior to this QI project, there were high levels of patient assaults towards staff and other patients. This required a lot of medication use, including rapid tranquilisation, restraint and the use of seclusion. This QI project was started to allow the Nile MDT to explore ways to reduce serious incidents on the ward in the least restrictive manner.We implemented a number of change ideas within this project. Our change ideas included: 1. A new risk management tool : ‘Ragging', a daily risk assessment tool, was created to assess patients’ risk of violence and aggression to allow signposting of appropriate interventions to safely manage risk. 2. A brand new Staff Photo board : New photos of all permanent and bank staff displayed in the ward with no hierarchy of positions. 3. A new Patient Feedback board : Patient experience, comments and feedback displayed in common areas of the ward which are regularly updated. 4. Mutual Expectations between Staff and Patients: A set of expectations created in co-production with patients displayed in the communal areas of the ward to be followed by both staff and patients. 5. Gardening sessions : One of our newer change ideas during the COVID-19 pandemic was to provide a safe, socially distanced space for patients to be involved in growing and caring for the Nile Ward garden with our activities co-ordinator. 6. Optimisation of Physical Exercise : Focus on physical activity through garden fitness sessions and 1-1 fitness sessions in the gym. This was another change idea commenced during the COVID-19 pandemic. These sessions occur throughout the day with our fitness instructor and enable our patients to focus on their physical health & fitness. 7. Improved Ward Environment : Gym equipment were upgraded and the appearance of the ward gymnasium was enhanced using quality art created in co-production with patients.ResultThere was a 43% reduction in the number of violent incidents in the ward following QI interventions. The details of the results will be depicted in pictorial form in the poster.ConclusionOur patients are able to recover in a safe environment with a reduced level of violence and aggression resulting in patients receiving less rapid tranquilisation and restrictive interventions. We have had fewer assaults on staff which has made our staff feel safer to work in a busy PICU. Staff feel more confident in their role through the use of the new risk assessment tool . Patients and staff alike have given positive feedback to the changes implemented in this QI project, with violence being successfully reduced by 43%. We hope that our QI project can be used as an example to show how QI methodology can enable Violence Reduction within mental health services.

Audit on resuscitation equipment in Carseview Centre (NHS Tayside)

AimsPsychiatric hospitals are well equipped to manage patients with complex psychiatric needs, however due to their community setting when a rare medical emergency occurs it is not unusual for a small delay whilst staff search for equipment on the ward or even go to other wards for equipment. The aim of this audit is to ensure that our psychiatric wards in Carseview Centre are well equipped to respond to patients becoming medically unwell and put our nurses and doctors in a position to safely stabilise the patient until furthur help arrives.MethodWe collected data from 3 inpatient adult wards, 1 intensive psychiatric care unit and 1 learning disability unit and compared their resuscitation trolley equipment with local NHS Tayside Emergency Equipment Protocol in January 2020. Following data collection we fed back to the wards about our results and discussions were held between doctors, charge nurses, pharmacists and resuscitation officers to determine whether missing equipment were neccesary in the community setting and to see if there were updates that required for our local protocol to better reflect current practices as it had not been reviewed since 2012. Following multiple meetings we amended our local protocol to better reflect what was . A list of recommendations was also made to improve patient safety.We then collected data again in January 2021ResultFolloing our first data collection we found that the resuscitation trolleys tended to not have ligature packs and masks were generally not by the oxygen cylinders. Hypoglycaemic dextro-tablets were also not readily available. The Learning disability units also did not have an emergency resuscitation trolley.Following our discussions and amendment of the protocol this was finalised in November 2020 and was dissemindated towards the wards and we waited 2 months for the changes to take effects and recollected our data. There continued to be equipment that was incomplete/missing on each individual ward, but none that were consistent throughout the whole hospital site. All the recommendations that were made for the 1st data collection had been done.ConclusionOverall we felt that the emergency trolleys were better equipped in line with the updated protocol compared to the previous audit cycle. The overall pattern of missing equipment was inconsistent and the recommendation was for staff to copmlete checks to address missing/incomplete items when found. Our local protocol also recommends that all ward should stock ‘additional items’ (nebuliser masks and non-rebreather masks), which majority had however were difficult to locate, which could delay patient care.We will continue to repeat data collection cycles and feedback to our wards to ensure patient safety is not compromised.

Developing a dashboard for use in a forensic and intensive care psychiatric unit: a quality improvement project

AimsDashboards provide a visual summary of relevant data to track performance against key indicators over time. They are used in healthcare to monitor the quality of patient care and to identify potential quality improvement projects. There is little published evidence of them being used in mental health services, especially in forensic psychiatric care.This project aims to design a dashboard for use in a forensic and intensive psychiatric care unit, by specifying measures and ideal features it would include.To develop a model for a quality dashboard for useTo decide which measures would be reported on the dashboardTo find reliable methods of assessing said measuresTo explore staff preferences as to how the dashboard would display data, and how they would like the information to be disseminatedTo use blank data to design a mock dashboard interface for feedbackMethodA literature search was conducted on healthcare dashboards and quality improvement projects taking place on low-secure psychiatric wards similar to the Blair unit. Potential outcome measures and methods of assessing them were researched. Staff thoughts on the dashboard, and which measures they would like to see included, were explored in interviews and using a surveyResultBlank data were fed into excel to create example graphs for a mock dashboard. The results section details: measures to be included, such as staff turnover rate, absences, and patient satisfaction levels; how they can be assessed; and specific features of the dashboard, such as the capability to track trends in selected quality indicators over a period of time. Further development of this project out with the 4 week development timeframe will require cooperation from IT services and unit management staff.ConclusionMany staff suggestions, whilst valuable measures, were more suitable for use in a clinical or nursing dashboard, rather than a quality dashboard. COVID-19 factored into reasons why staff requested certain measures, and also meant that less staff were available to be contacted about the project. This project has limitations based on the four-week timeframe, but could be further developed by staff on the unit if desired.

An audit to assess the measurement of Body Mass Index (BMI) and referral to the dietetics service following admission to the general adult inpatient wards in Mersey Care NHS Foundation Trust

AimsThis audit aims to establish whether patients have their BMI measured and recorded following admission to the general adult inpatient wards in Mersey Care NHS Foundation Trust and whether, in those with a BMI >30 kg/m2, or >28 kg/m2 in those with weight-related comorbidities, they are referred to the dietetics service for input.BackgroundObesity has an increased prevalence in those with mental disorder. There are many factors that influence this, e.g. sedentary lifestyle and poor dietary intake. Medication prescribed to treat mental disorders may increase risk of weight gain. Patients with severe mental illness are at increased likelihood of developing weight-related comorbidities, particularly type II diabetes mellitus.Many patients with severe and enduring mental illness do not regularly access primary care services. Admission to the psychiatric ward therefore provides an opportunity to address, not only the patient's mental health issues, but also any physical health issues.MethodA list of all inpatients on the eight general adult wards was obtained on 3rd of December 2020. Inpatients on the Psychiatric Intensive Care Unit were also incorporated, providing a final sample of 148 inpatients.An audit tool was designed, to collect demographic data for each inpatient – gender, age, ethnicity, psychiatric diagnosis, as well as BMI on admission and, if applicable, whether a referral to the dietetics service was made.ResultOf the 148 inpatients, 91 were male, 57 female. Patient age ranged from 19 to 71 years. The majority were of “white British” ethnicity. The most common mental disorder diagnosis was schizophrenia (35 patients). For 14 of the 148 inpatients, no BMI was measured on admission. In the 134 inpatients that had BMI measured, 74 were in one of the “overweight”, “obese”, “very obese” and “morbidly obese” categories. Thirty-four patients met the criteria for requiring referral to the dietetics service. Of these, four were not referred, five were offered referral but declined, 17 referrals were made for other reasons, e.g. BMI <18 kg/m2, and one patient was referred despite no BMI being recorded.ConclusionCurrent practice across the general adult inpatient wards in the trust indicates a proportion of patients do not have BMI recorded following admission. This may result in a valuable opportunity to address obesity being lost. There is a need to emphasise to ward staff the importance of recording BMI as part of the admission physical health screen and of the criteria for referring an inpatient to the dietetics service.

Admission patterns in a psychiatric intensive care unit in Ireland: a longitudinal follow-up

AimsThis observational study aims to describe the course of the admission and clinical characteristics of admissions to the PICUs in the Phoenix Care Centre, Dublin, Ireland. The authors hypothesised that the length of stay (LOS) would be shorter in male patients as compared to females.MethodThis retrospective cohort study was carried out at the Phoenix Care Centre Dublin, Ireland. Informed consent was not sought as this was a retrospective chart study involving anonymised clinical data which was collected as part of routine clinical care and no items of information were reported that would enable the identification of any subject. We described primary outcomes using frequencies, percentages, mean and standard deviations, median and interquartile ranges (IQR). Between groups comparisons were made using x2 tests for categorical variables; t-tests, ANOVA tests, or Kruskal-Wallis tests, for continuous variables; All analyses were two-tailed, and a P-value ≤ 0.05 was considered statistically significantResultOver the study period from Jan 2014 to Jan 2017 inclusive, there were 96 admission episodes to the PICU. The mean age of admitted cases was 37.1 (SD = 11.3) years (range 18–63 years). The mean length of stay (LOS) was 59.3 (SD = 61.0) days (median 39.5 days). All patients were admitted under the Mental Health Act legislation. We identified assault as the primary risk factor for pre-admission 62% (n = 62) to the PICU. Antipsychotic polypharmacy was used in 61% (n = 55) of the admission. The mean daily antipsychotic dosage was 139.4 % (SD = 65.1) of BNF maximum daily dose. A diagnosis of acute psychotic disorder (B= -1.027, p = 0.003, 95% CI: –1.691 to –0.363) was associated with reduced LOS in PICU. Majority of admissions 43% (n = 39) had a diagnosis of schizophrenia, followed by Bipolar affective disorder BPAD 21% (n = 21), schizoaffective disorder 18% (n = 18), and acute psychotic disorder 9% (n = 9).ConclusionPsychiatric Intensive Care Unit is an essential service for the severely ill psychiatric patients and is a progressively developing sub-speciality. An important finding from our study describes the cohort of patients admitted being predominantly male, younger-aged, single, with a diagnosis of schizophrenia, legally detained, and from an Irish background. The primary indication for a referral is the risk of assault, showing the need for the intensive and secure treatment model that a PICU can provide.

Are the rapid tranquilisation nice guidelines adhered to, in patients with agitated/aggressive behavior? a QIP

AimsTo explore whether the NICE guidelines for rapid tranquilisation are adhered to in the Psychiatric intensive care unit (PICU/ Tryweryn).MethodData were collected by core trainees. Standards were taken from NICE guidelines NG10. All patients who had received rapid tranquilisation, that were in PICU from August 2019 to February 2020 were considered in this a.ResultDuring the first PDSA, we discussed with the staff in the ward regarding the protocol. Prior to actually starting the second audit, the adherence was noted to be low. However following persistence and having created a protocol jointly with the ward manager, we could see the difference. The staff were appreciated for their efforts in maintaining 100% adherence. The same was intended to be continued with some positive reinforcement from the auditing team. Over the first 2 months, 12 patients received Rapid Tranquilisation. Out of these 12, we randomly selected 4 patients to find the adherence of the NICE guidelines to be 100 per cent. The predictions regarding the adherence to protocol showed that the PDSA was successful.During the second PDSA, the adherence was 100% again. The adherence to the protocol has been followed for not just the sample that was selected, but for the entire set of patients who received the Rapid Tranquilisation. Following this QIP, we formatted the proforma which included the services to be provided/ actions to be taken, Post Rapid Tranquilisation physical health monitoring and response to medication.ConclusionThe utilisation of de-escalation techniques and behavioural support plans that was person-centred in turn brought down the rate of Rapid Tranquilisation successfully. Thus placing our PICU as having the least restraints in the UK in 2019 (Second least 3/ month). Our PICU was awarded the prestigious Nursing Times Team of the Year Award for their pioneering work.Following this QIP, we then formatted the proforma for Rapid Tranquilisation which included the services to be provided/ actions to be taken, Post Rapid Tranquilisation physical health monitoring and patients response to medication. The PICU will continue to maintain this 100% standard and we would then consider extending the Audit to both Open wards and PICU in entire North Wales.

An evaluation of the prevalence of weight-related comorbidities in patients following admission to the general adult inpatient wards in Mersey Care NHS Foundation Trust

AimsThis audit aims to evaluate the prevalence of any weight-related comorbidities in patients following their admission to the general adult inpatient wards in Mersey Care NHS Foundation Trust.BackgroundObesity has an increased prevalence in those with mental disorder. There are many factors that influence this, e.g. sedentary lifestyle and poor dietary intake. Medication prescribed to treat mental disorders may increase risk of weight gain, particularly most of the second generation antipsychotics. Patients with severe mental illness are at increased likelihood of developing weight-related comorbidities - essential hypertension, ischaemic heart disease, hyperlipidaemia and type II diabetes mellitus.Many patients with severe and enduring mental illness do not readily or regularly access primary care services. Admission to the psychiatric ward therefore provides an ideal opportunity to address, not only the patient's mental health issues, but also any physical health issues.MethodA list of all inpatients on the eight general adult wards was obtained on 3rd of December 2020. Inpatients on the Psychiatric Intensive Care Unit were also incorporated, providing a final sample of 148 inpatients.An audit tool was designed, to collect demographic data for each inpatient – gender, age, ethnicity, psychiatric diagnosis, as well as the presence of any cardiovascular comorbidities and, if so, what were they and how many were present.ResultOf the 148 inpatients, 91 were male, 57 female. Patient age ranged from 19 to 71 years. The majority were of “white British” ethnicity. The most common mental disorder diagnosis was schizophrenia (35 inpatients), followed by schizoaffective disorder (22 inpatients). Twenty-one of the 148 patients had at least one weight-related comorbidity recorded. Only 2 of the 21 inpatients with a diagnosis of one or more weight-related comorbidity had a recorded BMI in the “healthy” range. The gender split for the presence of weight-related comorbidities was almost equal. The most common comorbidity recorded was type II diabetes mellitus. Most patients with a weight-related comorbidity had only one recorded, but three patients had two comorbidities recorded, and one patient had three recorded.ConclusionA significant proportion of patients admitted to the general adult inpatient wards in the trust have a weight-related comorbidity. Admission to hospital provides an ideal opportunity to review the management of any such comorbidity and optimise this as required. There is a need to ensure there is a strong focus on, not only the patient's mental health issues, but also his / her physical health status.

Re-audit of use of seclusion in a tier 4 adolescent psychiatric intensive care unit

AimsTo re-audit seclusion practices within a Tier 4 Adolescent PICU provision in London, originally audited in 2018. To ensure restrictive practices are only used in exceptional circumstances for short term risk management. To evaluate whether practice has improved following introduction of incidence reduction strategies and identify any further areas of development.BackgroundThis Tier 4 Adolescent PICU provides treatment of up to 16 high risk and unwell adolescents with severe and enduring mental health illnesses. Seclusion should be a short term risk management strategy with subsequent review of the care plan and treatment. It should be used for the shortest time possible. Following the audit in 2018, three strategies were implemented to reduce restrictive practice: (1) daily nursing safety huddles, (2) weekly Incidence Reduction meetings, and (3) ongoing QI project on restrictive practice.MethodData were collected from all patients requiring seclusion between January and December 2019 (n = 18), which included 46 incidents. Data were collected from RiO computer records, extracting details of patient demographics, reasons and context of seclusion, risk reduction steps prior, length of seclusion, monitoring, and modifications to care plans.ResultAverage length of stay in seclusion was 20h, reduced from 30h previously. Over half of patients requiring seclusion had symptoms of psychosis, consistent with the original audit. Majority of incidents involved assault to staff (80.4%) as indication for seclusion, compared to 50% previously. In 58.7% of cases, verbal de-escalation was followed by further risk reduction with oral medication. Overall, rapid tranquillisation was required in 45.7% of incidents. Restraint was used in 84.8% of incidents, always in combination with at least one other management strategy.Just under half of seclusions were monitored and documented in line with Trust guidelines, however, there was significant improvement in documentation of consultant reviews within 24h from under 70% to over 90%. Care plan modification rates improved from 63% to over 95%.ConclusionMajority of seclusion incidents were due to violent acts by young people presenting with psychotic features/disorder. This reflects the complex nature of psychosis and the substantial need for research to reduce restrictive practice in such cases.Ongoing review of data relating to seclusion will continue to inform and improve practice. This re-audit demonstrates improvement in various areas after implementation of strategies to reduce restrictive practice – importantly, average time in seclusion, documentation of 24 hour consultant reviews and focus on non-pharmacological risk reduction approaches in care plan modifications.

Admission patterns in a psychiatric intensive care unit in Ireland: a longitudinal follow-up.

This study aims to describe the course of admission and clinical characteristics of admissions to a psychiatric intensive care unit (PICU) in the Phoenix Care Centre (PCC), Dublin, Ireland. This retrospective chart study was conducted at the PCC, Dublin, Ireland. The cohort included all admission episodes (n = 91 complete data) over a three-year study period between January 2014 and January 2017. The mean age of admitted cases was 37.1 (s.d. = 11.3; range 18-63). The mean length of stay (LOS) was 59.3 days (s.d. = 61.0; median 39.5 days). All patients were admitted under Mental Health Act legislation. Antipsychotic polypharmacy was used in 61% (n = 55) of the admissions. A diagnosis of acute psychotic disorder (B = -1.027, p = 0.003, 95% CI: -1.691, -0.363) was associated with reduced LOS in PICU. Our study describes the cohort of patients admitted asbeing predominantly male, younger-aged, single, having a diagnosis of schizophrenia and being legally detained. The primary indication for referral is risk of assault, which highlights the need for the intensive and secure treatment model that a PICU can provide.

The comparative analysis of clinical and social characteristics of patients with schizophrenia and organic mental disorders receiving care in partial inpatient units

The article presents the results of a comparative analysis of the clinical and social characteristics of patients with schizophrenic spectrum disorders (SSD) and organic mental disorders (OMD) who received care in day hospitals and intensive psychiatric care units (Moscow). During the study, a random sample of 487 discharge epicrises was studied, of which 392 (80,49%) were patients with SSD and OMD, who were subjected to further analysis. The study revealed gender differences and low rates of labor and family adaptation in both nosological groups of patients. The highest percentage of patients observed on a long-term basis in neuropsychiatric dispensaries and the rate of hospitalization in a round-the-clock inpatient unit were among the patients with diagnoses of schizophrenic spectrum disorders who were treated in intensive psychiatric care units. There were significant differences in the routing of patients depending on the pathology: district psychiatrists more often refer patients with a diagnosis of schizophrenia to the intensive psychiatric care unit in order to prevent hospitalization and patients with organic mental disorders - to day hospitals for therapy selection and medical and social rehabilitation, while doctors of the round-theclock hospital – vice versa (in order to continue treatment or follow up in out-of-hospital conditions). There was also a circulation of patients between the intensive psychiatric care unit and the day hospitals. Isolated episodes of compliance violations were noted. Indicative indicators such as hospitalization in a round-the-clock psychiatric inpatient unit within a year after the discharge from partial inpatient units was low and was usually due to severe continuous forms of the disease and the formation of therapy resistance in patients. Day hospitals and departments (offices) of intensive psychiatric care in general effectively perform the functions of inpatient unit substitution.

Sexual and reproductive health (SRH) needs of women admitted to eileen skellern ward (ES1) psychiatric intensive care unit (PICU)

IntroductionPICU inpatients are likely to be at increased risk of having unmet SRH needs due to barriers to accessing services. Since May 2018, an in-reach SRH assessment has been available to all psychiatric inpatients on ES1 ward, if referred. Analysis of referrals over 15 months identified only 24 had been made during this time.ObjectivesTo assess the SRH needs of women admitted to ES1 PICU, the feasibility of providing a SRH in-reach clinic, and the acceptability of delivering a nurse lead referral programme.MethodsA bi-monthly SRH in-reach clinic and a nurse led SRH referral pathway were implemented on ES1 over a seven-month period. A staff training needs assessment was performed followed by training, a protocol was developed, staff attitudes were explored, and patient engagement was sought.ResultsA total of 41% (32/77) of patients were referred, which was a 29% increase. 53.1% (17/32) of the total referrals had a true SRH need, equating to a 10% increase and 22% (17/77) of all PICU admissions. 90% of referrals were made by nursing staff. A staff focus group (n15) highlighted the acceptability and perceived importance of offering SRH care in PICU, if interventions were appropriately timed and the patient’s individual risk profile was considered.ConclusionsResults identify that SRH needs for PICU admissions are greater than previously realised. Providing a nurse led referral pathway for an SRH in-reach clinic is acceptable, feasible and beneficial for PICU patients. This project has resulted in service improvements including offering asymptomatic STI testing to all PICU admissions.DisclosureNo significant relationships.

The characteristics of patients requiring readmission to an Australian forensic psychiatric intensive care unit

IntroductionPsychiatric intensive care units (or PICU’s) emerged to manage high acuity patients outside the justice system. Studies have sought to better understand characteristics of those admitted to forensic or civilian PICU’s. Few, in contrast, have explored the frequency and contributors to readmission. The following study was conducted on Apsley unit, a Forensic PICU based in Melbourne, Australia, and seeks to understand the differences which would allow early identification of patients likely to require readmission and the provision of targeted interventions.ObjectivesExamine rates of and contributors to forensic PICU readmission over a 6-month period.MethodsA retrospective audit was conducted to collect clinical, problem behaviour (and strategies to manage), forensic history and demographic information for consecutively admitted patients to an 8-bed forensic PICU between March-September 2019.ResultsData analysis is ongoing. Interim analysis found that 96 patients were admitted during the 6-month study period: 74 (77.1%) had a single admission; 22 (22.9%) required readmission. Almost all were admitted from prison (96.9%), most had a psychosis diagnosis (80.2%) and substance abuse history (96.9%), and many had a personality disorder (24.0%) and history of adolescent antisocial behaviour (46.5%). Patients requiring readmission were significantly more likely to have been previously under compulsory mental health treatment (95.5% vs 75.3%, p=.039) and have a Positive Behaviour Support Plan developed during admission (85.7% vs 54.8%, p=.010).ConclusionsInterim analysis highlighted the multicomplexity for forensic PICU patients alongside the occurrence of problem behaviour during admission and history of compulsory treatment as indicators of increased risk for re-admission.

Characteristics and outcomes of patients admitted to the first psychiatric intensive care unit in Egypt.

BackgroundPsychiatric intensive care units (PICU) have become an essential part of psychiatric hospital design worldwide, there are few published data about their effectiveness.AimIn this study, the characteristics and outcomes of 50 Egyptian patients admitted to the first PICU in the Middle East region between April 2015 and October 2018 were retrospectively examined.SettingThe study was conducted at the Institute of Psychiatry, Ain Shams University.MethodsData on patients in PICU at the Institute of Psychiatry, Ain Shams University, were collected retrospectively and analysed and included information on previous psychiatric contact, diagnoses, causes of admission and outcomes. Continuous and categorical variables were subjected to statistical analyses.ResultsThe majority of patients in PICU were of female gender, having a diagnosis of schizophrenia. The most common reason for admission to the PICU is the management of delirium, followed by catatonia. The average length of patients’ stays in PICU ranged from half a day to 16 days. Immediate outcome differed where the majority of patients (47 patients, 94%) were discharged to the inpatient psychiatric ward.ConclusionThis study reviewed practice in the first PICU in Cairo, Egypt, over 3 years, showing the importance of ongoing evaluations of patient populations in providing the best clinical practice; the typical PICU patient is likely to be: female, suffering from schizophrenia or bipolar affective disorder (BAD). The most common reason for PICU admission is for the management of delirium followed by catatonia.