National Survey of Psychiatric Intensive Care, Low Secure and Locked Rehabilitation Services: NHS patient characteristics

Aims: To update the benchmark from the 2006 National Survey, comparing users of NHS psychiatric intensive care (PICU) and low secure (LSU) services, and to define 'locked rehabilitation' (LRU) patient characteristics.<br/> Method: A cross-sectional census day questionnaire (November 2016) with a six month follow-up ending in May 2017.<br/>Results: 104 NHS units responded: 73 PICU, 644 patients; 17 LSU, 190 patients; 14 LRU, 183 patients. The typical PICU patient is younger, employed, stays for shorter periods, is more likely to suffer delayed discharge and mood disorder, have complex needs, have had mental health admissions in the last 12 months, be on 1:1 or higher observations, and have fewer antipsychotic and physical health medications but more benzodiazepines. The typical LSU patient is an out of area transfer, least likely to have been admitted for self-harm or non-concordance, and is of Black Other ethnic origin. The typical LRU patient is less likely to be married or have a long-term partner, has the lowest complex needs, but is most likely to have had physical examination and investigations.<br/>Discussion: There has been a rise in PICU and LSU patients from the Black and Minority Ethnic (BAME) population. Length of stay (LoS) for PICU and LSU patients has doubled; there are lower rates of delayed transfers of care.<br/>Conclusions : Our findings demonstrate that PICU and LSU services are providing care to the right patients as they were conceptualised in national guidance, and provide a benchmark for LRU patients.

The evaluation of a highly specialist inpatient psychologist working with patients with high risk presentations in an acute mental health inpatient setting

Objective: To evaluate the function and impact of a highly specialist psychologist working with high risk patients in an acute mental health inpatient setting. The impact was examined on outcomes such as risk related incidents, re-admission, average length of stay, and use of restrictive practice.<br/> Method: A mixed methods service evaluation of a pilot project was undertaken to examine the impact of the specialist psychologist role on these outcomes over a 17-month period. Demographic and clinical data was collected for 18 patients who were seen by the psychologist. Routinely collected clinical data examining risk incidents, re-admission rates, average length of stay, and use of restrictive practice, were also used to evaluate outcome across the evaluation period (at baseline and six-month follow-up).<br/> Results: The specialist psychologist provided input to patients' care and undertook a variety of direct and indirect work and training. Examination of descriptive routine clinical data indicated a slight reduction in risk related incidents, readmissions, and average length of stay after the introduction of the psychologist role, however these were not statistically significant.<br/> Conclusion: These initial findings suggest the potential for outcome improvement, but further, more robust research is required to see if such a role can have a significant impact on outcomes.

Capacity to consent to admission of patients detained under Section 5(2) of the Mental Health Act

Background: Little is known regarding capacity to agree to admission of informal patients later detained under Section 5(2) of the UK Mental Health Act.<br/> Aim: To evaluate how frequently such capacity is assessed and to discover associations related to length of time from admission until imposition of Section 5(2).<br/> Method: Patients detained under Section 5(2) on acute inpatient general adult and old age psychiatric wards in one UK location between June 2016 and March 2018 were identified. Their admission records were scrutinized.<br/> Results: Capacity was assessed in 97 of 124 patients. Fewer assessments were performed immediately prior to admission, especially upon patients admitted from residential settings. On admission, medical staff assessed for capacity less than non-medics, but found an individual lacked capacity more frequently. Time until detention was less upon a first admission, in absence of pre-admission capacity assessment, when medical staff assessed, or when any inpatient clinician detected incapacity.<br/> Conclusion: Routine capacity assessment immediately prior to and at psychiatric admission should be formalized and offers potential to reduce use of Section 5(2), unlawful detention and negative sequalae.

LIGATURE RECORD: improved capture of risk information in CAMHS PICU using a mnemonic-style documentation aid

Psychiatric risks associated with ligature-tying present significant management challenges for inpatient multidisciplinary teams (MDT). Accurate and detailed clinical information capture following incidents involving ligatures is necessary to inform future risk management. A documentation tool is presented whichhas been demonstrated to improve the accuracy of recording of clinical risk information following inpatient ligature incidents in the child and adolescent mental health service (CAMHS) psychiatric intensive care unit (PICU) setting. The LIGATURE RECORD tool provides a highly useable prompt for information capture of 14 important data elements identified as relevant to MDT risk formulation.The effectiveness of the LIGATURE RECORD tool was audited following its introduction in PICU in May 2020. Contemporaneous incident reports and progress note entries were examined with an improvement in the frequency of reporting of all 14 domains seen, with near-100% completeness where the prompt was used directly as a template. Particular improvements were seen in recordingof non-narrative elements such as circumstantial information and important negative reports. Formal and informal feedback from clinical staff indicated good usability and high rates of adoption of the tool.

What is the impact of staff wearing uniforms in psychiatric inpatient settings?

Background: Uniform has traditionally been worn in psychiatric inpatient and other mental health settings, but there has been a move to non-uniform in recent years. Some services have made the change back to uniform, raising questionsabout the potential impact on patients and staff.Aim: To review the impact of uniform within a psychiatric inpatient or mental health setting.Method: Databases were searched for articles exploring the impact of uniform use using specified search terms. Articles were assessed for suitability with inclusion and exclusion criteria, critically appraised, then analysed for themes using thematic analysis.Results: 17 papers were included in the review. Thematic analysis identified five main themes and 29 subthemes. Main themes were Attitudes and interactions, A freer environment, Are you both nurses?, The ‘ideal self’ and There are more important things. A critical appraisal of the articles suggested issues with validityand reliability, which are discussed.Discussion: Studies identified that wearing non-uniform facilitated positive changes in both patients and staff. This raises the potential negative impact of uniform on both patients and staff, and the role of power imbalance in these settings is discussed. Further themes around identification of staff out of uniform were considered.Implications for practice: The use of uniform in mental health and psychiatric inpatient settings should be considered carefully, due to the potential negative impact, whilst also recognising the importance of staff identification and supporting professional identity.

Impact of length of stay in psychiatric intensive care on the episode trajectory

Background: Length of stay (LOS) on admission to psychiatric intensive care in the UK varies widely, with few studies examining the relationship of LOS to clinical outcomes. Data from two South London male PICUs delivering care with the contrasting philosophies of rapid turnover versus slower stepdown were investigated to determine if additional LOS correlated with clinical benefit.Method: Data on admissions to the PICUs were collected over six months and assessed for outliers and then for variance using Levene’s test. The variables were compared using independent samples t-tests. Pearson correlations were alsocalculated for the major variables.Results: Mean LOS was 8.4 days higher on PICU 1 (p = 0.026) and readmission rates to hospital 6 months post discharge were 27% higher on PICU 1 (p = 0.025). There were no strong correlations between LOS on either PICU and the other five variables examined.Conclusion: It was intuitive to expect better outcomes in the PICU with a slower turnover where complex patients could receive an extended period of re-evaluation of pharmacological treatments and engagement with services and could achieve a fuller recovery from the episode. However, this group had no reduction in LOS following step-down to the wards, readmission rates to PICU during in the index episode or re-hospitalisation six months following discharge. The PICU with a policy of rapid-turnover, concentrating on reducing acuity and risk and rapid step down, was equally effective on the measures evaluated.

The safety of medication in patients who have recently received a Taser shock

There remains controversy as to whether Tasers can adversely affect cardiac rhythm. It is well established that antipsychotics can adversely affect cardiac rhythm. Therefore the question arises whether it is safe to prescribe and administer an antipsychotic to a person who has recently received a Taser shock. This article addresses this issue and makes recommendations for practice.

Reducing delays in the transfer of patients from psychiatric intensive care units (PICU) to acute inpatient services: a quality improvement project

Aim: To investigate the delays in the transfer of care of patients from psychiatric intensive care units (PICU) to acute care inpatient wards.Background: Few studies have focused on the characteristics of patients requiring transfer from PICU or delays in transfer of care from PICU to inpatient beds. The efficient transfer of patients from a PICU is essential to provide a dynamic service, promote patient recovery, enable safe, timely discharges and reduce stay in unnecessarily restrictive settings.Method: A 3-month prospective study was performed on two PICUs (Brooklands and Willow), investigating delays to transfer from PICUs to open wards. Days and percentage of discharges was also examined.Following collection of the initial data cycle, Brooklands implemented a ‘traffic light’ tool to identify delays. Following implementation, the project was repeated one year later.Results: A total of 122 patients were analysed for delays in the transfer of care from PICU to acute open wards. Brooklands PICU demonstrated a prolonged delay to transfer of patients, prompting implementation of a delayed discharge tool, the ‘traffic-light’ system. Brooklands PICU subsequently demonstrated a statistically significant improvement in the days to transfer.Conclusions: This quality improvement project adds to the limited research base for delays in the transfer of PICU patients and is the first study to implement a delayed discharge tool within a PICU. Further research is required on the transfer of patients from PICUs, examining barriers for these delays and the impact of this on patients within PICU.