Therapeutic role of a psychiatric intensive care unit in acute psychosis

Changes over time of the diagnostic and therapeutic characteristics of patients of a psychiatric intensive care unit in Austria

OBJECTIVE

The aim of this repeated cross-sectional study was to compare patients from a psychiatric intensive care unit (PICU) over ≫30 years regarding their diagnostic and therapeutic characteristics.

METHOD

Three samples including 100 consecutive inpatients each from the Viennese PICU were submitted to a chart review: sample no. 1 from the years 1985/86, no. 2 from 1995/96 and no. 3 from 2007/08.

RESULTS

Changes in referral modes were associated with a decrease of patients with substance induced disorders and an increase of patients with affective disorders over time. The rate of admissions after accidents and suicides was stable. The use of cranial MRI increased, while intravenous psychopharmacotherapy and parenteral nutrition decreased. Involuntary admission occurred in 43% and in 37% of patients physical restraints were necessary. We saw a shift from tricyclic antidepressants to SSRIs and SNRIs from sample 1 to 3. Likewise, we observed the emergence of atypical antipsychotics and a reduction of use of typical neuroleptics mainly from sample 2 to 3. The percentage of patients receiving benzodiazepines increased over time, while the mean dosage of benzodiazepines decreased. 7% of patients received electroconvulsive therapy.

CONCLUSIONS

The changes over time in our samples reflect the medical progress made during the last decades. Future studies should focus on evaluation of efficacy of psychiatric intensive care using standardized measurements.

Psychiatric intensive care units, a design for living

The psychiatric intensive care unit (PICU) is now at the cutting edge of acute psychiatric care. Very little guidance has been produced to ensure that the PICU structure and design is able to meet the complex demands put upon it. The creation, development and relocation of a PICU has taken place within the Severn NHS Trust. We describe the experience gained from a recently commissioned unit together with a review of the relevant literature. Recommendations are offered for core features and design.

A nurse-led psychiatric intensive care unit

Severn NHS Trust has recently commissioned a psychiatric intensive care unit (PICU) which became operational on 18 July 1994. Although the number of PICUs is increasing and their services are greatly valued, they are often fraught with problems. A model for the development of PICU services is described. It includes admission criteria, overall clinical organisation of the PICU, discharge criteria and a discussion. The model described is based on the hypothesis that the primary role of the PICU is to deal with clinical nursing problems rather than medical problems. The discussion points out some of the instrumental components necessary for the successful development of PICU services.

Seclusion and Psychiatric Intensive Care Evaluation Study (SPICES): combined qualitative and quantitative approaches to the uses and outcomes of coercive practices in mental health services

Background

Seclusion (the isolation of a patient in a locked room) and transfer to a psychiatric intensive care unit (PICU; a specialised higher-security ward with higher staffing levels) are two common methods for the management of disturbed patient behaviour within acute psychiatric hospitals. Some hospitals do not have seclusion rooms or easy access to an on-site PICU. It is not known how these differences affect patient management and outcomes.

Objectives

To (1) assess the factors associated with the use of seclusion and PICU care, (2) estimate the consequences of the use of these on subsequent violence and costs (study 1) and (3) describe differences in the management of disturbed patient behaviour related to differential availability (study 2).

Design

The electronic patient record system at one trust was used to compare outcomes for patients who were and were not subject to seclusion or a PICU, controlling for variables, including recent behaviours. A cost-effectiveness analysis was performed (study 1). Nursing staff at eight hospitals with differing access to seclusion and a PICU completed attitudinal measures, a video test on restraint-use timing and an interview about the escalation pathway for the management of disturbed behaviour at their hospital. Analyses examined how results differed by access to PICU and seclusion (study 2).

Participants

Patients on acute wards or PICUs in one NHS trust during the period 2008–13 (study 1) and nursing staff at eight randomly selected hospitals in England, with varying access to seclusion and to a PICU (study 2).

Main outcome measures

Aggression, violence and cost (study 1), and utilisation, speed of use and attitudes to the full range of containment methods (study 2).

Results

Patients subject to seclusion or held in a PICU were more likely than those who were not to be aggressive afterwards, and costs of care were higher, but this was probably because of selection bias. We could not derive satisfactory estimates of the causal effect of either intervention, but it appeared that it would be feasible to do so for seclusion based on an enriched sample of untreated controls (study 1). Hospitals without seclusion rooms used more rapid tranquillisation, nursing of the patient in a side room accompanied by staff and seclusion using an ordinary room (study 2). Staff at hospitals without seclusion rated it as less acceptable and were slower to initiate manual restraint. Hospitals without an on-site PICU used more seclusion, de-escalation and within-eyesight observation.

Limitations

Official record systems may be subject to recording biases and crucial variables may not be recorded (study 1). Interviews were complex, difficult, constrained by the need for standardisation and collected in small numbers at each hospital (study 2).

Conclusions

Closing seclusion rooms and/or restricting PICU access does not appear to reduce the overall levels of containment, as substitution of other methods occurs. Services considering expanding access to seclusion or to a PICU should do so with caution. More evaluative research using stronger designs is required.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

The Developing Role of Occupational Therapy in Psychiatric Intensive Care

Occupational therapy has an established role in the delivery of mental health services. Psychiatric Intensive Care Units (PICUs) are a development found in many psychiatric inpatient facilities and their numbers are increasing. The introduction of occupational therapy to a recently established PICU is examined. A comparison is made between PICU and forensic client groups, and the developing need for PICUs as a distinct service and the client group they serve are described. An example of successful service delivery of occupational therapy in a PICU is offered, and the challenges to the therapist working in this demanding and rewarding setting are outlined.

Psychiatric intensive care units: a literature review

BACKGROUND

Psychiatric Intensive Care Units (PICU) have been part of most inpatient psychiatric services for some time, although information about their functioning and outcome has not previously been collated.

AIM

To conduct a systematic literature review to assess the current state of knowledge about such services.

METHOD

A search of electronic databases was undertaken, followed by obtaining additional references from items obtained.

RESULTS

Over 50 papers in English containing some empirical data were identified. Most studies were retrospective. Typical PICU patients are male, younger, single, unemployed, suffering from schizophrenia or mania, from a Black Caribbean or African background, legally detained, with a forensic history. The most common reason for admission is for aggression management, and most patients stay a week or less. Evidence of the efficacy of PICU care is very poor.

CONCLUSIONS

Most research so far has been small scale, and more substantial work using better methodologies is clearly required.

P.r.n. medication use in a psychiatric high-dependency unit following the introduction of a nurse-led activity programme

This paper describes the introduction of a daily activity programme with clients who require psychiatric intensive care in two locked high-dependency units (HDUs). To evaluate the programme, a crossover study between the two units was undertaken with a convenience sample of clients. Baseline data of pro re nata (p.r.n.) medication dispensed to patients were collected for a period of 2 weeks from both locked units before the introduction of the programme. The programme was conducted for a period of 1 month in alternate locked units. Both non-intervention and active programme data were collected throughout the 6-month period of the study. Findings from the study demonstrated that an activity-based nursing intervention was effective in reducing the number of p.r.n. medications dispensed in a HDU compared with control conditions. The effects were statistically significant in one of the units and absent in the other. This study shows that a purposeful activity programme for severely disturbed psychiatric clients in a HDU setting can be effective in reducing disturbed behaviour and therefore the need for p.r.n. medication.

Mental health nursing practice in acute psychiatric close-observation areas

The provision of evidence-based therapeutic nursing care in close-observation units or psychiatric intensive care units, has been identified as a problem internationally. These areas of nursing practice have been the subject of considerable discussion particularly in relation to the management of aggression, violence, involuntary treatment, and seclusion. This study used a participatory action research framework to identify qualitative and quantitative measures of activity in the area. Quantitative data collected included rates of critical incidents, the use of prn medication, and the use of seclusion. These data were used as base-line data and were predicted as a measure of change. Qualitative data, collected by interview and focus groups, were used to reveal the experience of patients, relatives, and nurses in a close-observation area. Analysis of this data revealed three main themes: design and environment, lack of activity and structured time, and nursing care. The importance of this study is in demonstrating the multiple problems that exist in the provision of care in close-observation areas and the corresponding need for fundamental changes.

Close-observation areas in acute psychiatric units: a literature review

Close-observation areas in Australian inpatient psychiatric units are locked areas usually within an open ward. Despite patient acuity, and the inherent difficulties in this area, little has been written that addresses either the processes or goals of containing patients, the role of nurses, or the skills involved. This paper examines the literature related to close-observation areas and argues that they are highly demanding of expert psychiatric nursing skills. Nurses need to advocate for humane, well-resourced areas, staffed with highly skilled nurses in order to fulfil the obligations of the national nursing and mental health service standards and to reduce the deleterious effects of hospitalization on patients.

Mental health intensive care: the nurses' experience and perceptions of a new unit

This paper describes a qualitative research study which explored the practices and views of nurses working on a new mental health intensive care unit. A review of the literature identified the main aspects of intensive care provision: (1) physical security, (2) characteristics of the patient group, (3) staff-patient ratios. (4) therapeutic environment and (5) multi-agency involvement. Twenty-one periods of participant observation helped form the questions for a semi structured in-depth tape recorded interview in which 11 out of a total of 16 trained nurses took part. The information is categorized and the discussion is informed by observation of practice. The nurses perceived the following as the main issues: that the physical environment is inadequate for security; that the patient group appears to have the common characteristic of being unwanted in other clinical settings; that the staff-patient ratio is inadequate and that their vision of the nature of a therapeutic environment is vague.

Clinical and administrative consequences of a reduced census on a psychiatric intensive care unit

The Psychiatric Intensive Care Unit at the FDR VA Hospital is a specialized ward designed to assess and treat suicidal and assaultive patients. Since its creation in 1983, over 1600 admissions have taken place. The authors have previously reported that patients referred for aggressive behavior had a statistically significant higher recidivism rate, as well as a statistically significant longer length of stay. The unit went through several changes in response to externally perceived needs and available resources. When the census cap was decreased, the referral pattern changed and the patients were even more likely to be aggressive. Length of stay decreased dramatically leading to a unit with a significantly higher turnover rate. Clinical and administrative concerns are also discussed.

The concept of recovery and secondary prevention in psychotic disorders

The concept of recovery is embedded in the current classification of functional psychosis, an unfortunate fact which has obscured important therapeutic and preventive opportunities for patients and their relatives. A range of theoretical perspectives is reviewed which could be drawn upon to extend research, and develop and evaluate new forms of intervention in this area. The major tasks facing patients and their families at different stages of illness are described, and a series of principles is then proposed to guide the clinical care of recovering psychotic patients.

Decrease of depression during stroke and amputation rehabilitation

Clinical observation had suggested that mild depression occurs after admission for acute medical treatment and then decreases during further hospitalization for rehabilitation treatment. The Geriatric Depression Scale (GDS) was given on admission and discharge to 14 stroke and 17 amputee rehabilitation patients. Each of the two groups showed decreasing GDS scores from beginning to end of the rehabilitation admission. Suggested reasons included: (1) the gradually diminishing effects of stroke and amputation as life crises during the 1-2 month admission, (2) effects of physical improvement on mood and affect, (3) milieu effects of the medical ward, and (4) tendencies for all psychopathology scale scores to decrease on retest.

Antipsychotic effect of milieu in the acute treatment of schizophrenia

We studied 35 patients meeting DSM-III criteria for schizophrenia, paranoid or undifferentiated type, chronic with acute exacerbation. All were treated in hospital, 13 on a psychiatric intensive care unit, and 22 on an open ward. The former unit is a more structured and less stimulating one. We found those patients treated on that ward to show greater improvement in BPRS ratings during the first 2 days of hospitalization compared to the open-ward group, despite similar doses of medication being utilized. Additionally, this improvement was noted to occur among BPRS items comprising a psychotic subscale.