Little is known about the types of patients admitted to medium secure psychiatric intensive care units, which cater for some of the most mentally disordered and dangerous patients. Only one retrospective study has profiled this subgroup (Dolan & Lawson, 2001).

Using a pre-coded proforma, the study prospectively profiled patient characteristics over a year, for those who were admitted or transferred to the unit. It was predicted that patients detained under Section 3 of the Mental Health Act, 1983 (Civil section) would be overrepresented and present with more management problems.

Information on 24 patients was gathered. Patients detained under Section 3 featured heavily in the cohort and were more difficult to manage, though this did not reach statistical significance. All patients had a criminal history, particularly of violence. Serious adverse incidents on the ward were relatively infrequent. A small number of patients were responsible for the majority of adverse incidents.

The cohort demonstrated serious risk signatures and forensic histories. Management problems may not necessarily reflect underlying mental disorder. There was a trend towards violent offending and co morbid substance misuse. The unit was an effective environment. The study was limited due to low numbers of patients and a lack of comparable populations.

Background: Psychiatric intensive care units (PICUs) initially developed in a haphazard fashion. In the UK, in an attempt to standardise quality of services, guidance for PICUs was published in 2002. Subsequently there has been a paucity of information outlining compliance with standards within different units.

Aims: To describe adherence to a subset of national standards in the care of 332 patients admitted consecutively to seven English PICUs.

Methods: Prospective, multi-centre patient case note analysis and staff questionnaire for each patient admitted.

Results: There was significant variation in different PICUs’ compliance with standards. Seventeen percent of patients were deemed not to meet basic criteria for admission to PICU. Pre-admission assessment and identification of treatment aims were poorly adhered to. Inappropriate mix of gender within patients occurred following 33% of admissions.

Conclusions: Implementation of national standards varies between different PICUs according to local policy and interface between acute wards and PICUs. This highlights the importance of, and challenge for, a national accreditation scheme.

Background: In acute psychiatry, seclusion has traditionally been used to manage people at risk of harming themselves or others. However, being secluded can be traumatising and cause harm to service users and staff. In North America, sensory modulation strategies and a focus on early identification of aggression warning signs and tailored responses have significantly improved care and reduced seclusion use.

Methods: A six-month pilot of the use of sensory modulation strategies and a brief sensory and risk assessment tool (Safety Tool) was implemented on a 30-bed acute psychiatric unit. Indicators of the impact on seclusion use were audited from service users’ files with feedback collected from clinical staff.

Results: Safety Tools for 43 psychiatric intensive care service users were audited. They required significantly longer hospitalisation (mean=39.4 days) than was the average for the unit (mean=19.0 days). Whereas 65% had been previously secluded, only 26% were secluded after completing a Safety Tool. Most staff had completed or read a Safety Tool with 76% saying it should become part of standard care.

Conclusion: Findings support the significant role that sensory assessment and engagement can play in improving service user care in acute psychiatry.

Aims: To describe the methods of self harm incidents in a low secure unit population and to identify and compare the clinical characteristics of patients displaying inpatient self harming behaviours with those who do not display such behaviours.

Method: A retrospective case control study was conducted. Details about the inpatient self harming incidents were collected from an incident database. Clinical characteristics of those who displayed inpatient self harming incidents (cases) and those who did not display such behaviours (controls) were compared. Analysis was performed to establish statistical significance on the observed differences.

Results: 80 admissions resulted from 78 patients during a 6½ year period. 21% of patients presented with inpatient self harming behaviours. 57% of the incidents were caused by 13% of patients. Clinical characteristics such as white ethnic background, histories of self harm, physical or sexual abuse, childhood conduct problems and lack of educational qualifications and having a diagnosis of schizoaffective disorder were more likely to be associated with inpatients self harming in low secure settings. Sexually inappropriate behaviours and a diagnosis of schizophrenia were less likely to be associated with this group.

Conclusion: The majority of self harm incidents are caused by a minority of patients. Most of the clinical characteristics associated with the low secure inpatient self harming patients are similar to those observed in other psychiatric inpatient settings.

Background: Refugees and asylum seekers may have other feelings and expectations about the future than immigrants do. The aim of this study was to explore and analyse the expectations for the future among populations of immigrants, asylum seekers and refugees admitted to Norwegian acute psychiatric departments.

Method: In a prospective study in the period 2005 to 2008, data were collected from two acute psychiatric departments.

Results: There were 48 immigrants, 24 refugees, and 21 asylum seekers. A significantly higher proportion of asylum seekers than refugees had nightmares (p = 0.04), feelings of guilt (p = 0.04) and feelings of hopelessness (p = 0.04). A significantly higher proportion of asylum seekers than immigrants had sleeping problems (p = 0.03), nightmares (p = 0.03), feelings of hopelessness (p = 0.03) and reduced appetite (p = 0.04). Significantly more asylum seekers than refugees maintained that life would change for the better over time (Z = 2.0; p = 0.04). More refugees than asylum seekers indicated problems judging life ten years from now (Z = 2.1; p = 0.04).

Conclusion: Being an asylum seeker seems to incur greater distress and higher negative expectations for the future. Preventive strategies should be created to improve refugees’ and asylum seekers’ life in exile. Priority and speed in processing of asylum cases should be given higher priority.

Background: Seclusion in psychiatric inpatient settings is contentious, and services attempt to minimize its use. Many studies compare seclusion rates before and after the introduction of an intervention, but few control for the effect of external factors such as legislative constraints and patient characteristics.

Aims: To evaluate the effect of a programme designed to manage acute arousal.

Method: Seclusion rates in a six-month period incorporating a programme to manage acute arousal were compared with the previous six months. The intervention focused on formal assessment of arousal levels and an escalating set of actions by nursing staff.

Results: Seclusion rates in the two periods were comparable, both before and after controlling for patient characteristics. Duration of seclusion events appeared to be heavily influenced by local legislative constraints.

Conclusions: A programme designed to reduce seclusion showed no difference from baseline after taking various factors into account. This may have been at least partly because most seclusion events occurred early in an admission. Many patients arrive on the unit already requiring seclusion, and any impact of a ward programme on them is limited. Since seclusion is a comparatively uncommon event, and attributable to a minority of patients, appropriate analytic methods are required.

Introduction: Quality of life is an important measure of results in psychiatry in general, and in the treatment of schizophrenia in particular. The metabolic syndrome has a strong prevalence in schizophrenia, and can have an impact on quality of life.

Objective: To compare the perceived quality of life of a sample of schizophrenic patients with and without metabolic syndrome.

Methods: Cross-sectional observational study, including 136 patients (49 with metabolic syndrome) admitted in 2004 to a short-term hospitalization psychiatric unit with a diagnosis of schizophrenia or schizoaffective disorder validated using the SCID-I. Metabolic syndrome defined according to NCEP-ATP III criteria. Quality of life assessed using the EuroQol 5D. Simple associative, and multivariate analysis (logistic regression) were performed.

Results: In the schizophrenic patients studied, metabolic syndrome is associated with age (p = 0.035), pension beneficiary (p = 0.005), antipsychotics treatment (p = 0.017), years of evolution (p = 0.008), and also with a lower score on the EuroQol 5D ‘health state today’ (p = 0.035) and ‘mobility’ (p = 0.011) dimensions. Multivariate analysis (logistic regression) shows that quality of life is mainly associated with age (OR = 3.2), metabolic syndrome (OR = 2.6) and mobility problems (OR = 2).

Conclusion: When treating schizophrenic patients, we should take into account comorbidity with metabolic syndrome, since the latter, in addition to representing a significant cardiovascular risk factor, can also affect, added to treatment issues, illness factors and other social and environmental variables, the patient’s quality of life.

Introduction: Psychiatric intensive care units (PICU) are small wards, designed for the most difficult-to-manage patients. They have higher levels of nursing and other staff, are often locked, and sometimes have facilities for seclusion. Although PICU staff are often confronted with aggressive behavior, resulting in higher usage of coercive measures, there is need to increase understanding of the necessary infrastructure and treatment policy for successfully reducing seclusion and restraint.

Aim: To investigate whether patients transferred to a newly developed PICU, focused on the effective and non-coercive management of disruptive behavior, are secluded and restrained less than during earlier stays in a psychiatric unit.

Method: The effect of the newly developed PICU on reducing seclusion was evaluated in eight patients, six of whom had been diagnosed with a severe form of borderline personality disorder. The number of days in seclusion during the period before admission to the PICU was compared to the number of days in seclusion after admission to the PICU.

Results: After patients’ admission to PICU, the use of seclusion was almost completely eliminated, falling from 40% of admission days spent in seclusion before transfer to the PICU to 0.1% during their stay at the PICU.

Conclusion: When a special non-coercive infrastructure and treatment policy is applied at a PICU, seriously disturbed patients can be treated without coercive measures.

Specific concerns have been raised about seclusion use within mental health services. However, it has been reported that one of the potential consequences of reduced seclusion use is an increase in assaults on either clinical staff or patients. In a high secure hospital a number of measures were implemented as part of a clinical governance programme. These measures will be described. Data on all episodes of seclusion and adverse incidents over a five year period was analysed. The results demonstrate a progressive and sustained reduction in seclusion use with over a sixty percent reduction in the number of seclusion episodes. We found no increase in adverse incidents in conjunction with the reduction in seclusion use. The results of this analysis demonstrate that reductions in seclusion use are achievable, without an increase in assaults on clinical staff or patients, when it is identified as both a managerial and clinical priority, supplemented by robust performance monitoring and effective clinical governance arrangements.

An evaluation of the Extra Care Area (ECA) in a medium secure psychiatric facility for women is described. A retrospective case note audit over an 18 month period concluded that the ECA was used infrequently for the most disturbed service users who had previously been frequently secluded. Ongoing self harm and aggression in ECA was a feature of some cases raising the possibility that admission may be counter productive for some, particularly when it is combined with a lack of occupational stimulation. Service users valued the opportunity for reflection in a low stimulus environment and there were no repeat admissions. A number of initiatives to improve multidisciplinary care planning, documentation, therapeutic engagement and service user involvement to reduce risk have been actioned. Of particular importance is the need to begin ‘discharge planning’ at the first point of entry to avoid prolonged stays, isolation from peers and dependence on both individual staff attention and a special status living arrangement.

This commentary outlines the need for a PICU accreditation system, its development and initial use. The development of a framework that includes clinical outcomes in conjunction with accreditation to measure quality of care is discussed.

Psychiatric patients suffer high rates of mortality and morbidity. One of the major reasons for this is the high prevalence of physical health problems in psychiatric patients. Psychiatrists have tended to pay less attention to, and receive less training in, the management of the physical health of their patients with this role largely being left to general practitioners. Though there is an increasing awareness of long term physical morbidities in psychiatric patients, the literature on acute physical morbidity is sparse. In this article we aim to emphasise the importance of recognising serious physical illnesses that could arise in the acutely unwell psychiatric patient.

The scope of this article is not to provide a comprehensive list of physical complications and management strategies but to provide the psychiatrist with a conceptual framework to assist with the management of co-morbid physical and psychiatric illness.

Although psychiatric intensive care is a relatively new speciality, it has been well defined. The use of lean management techniques in association with accurately defining services lends itself well to treating patients in an effective and efficient manner. This paper summarises the development of lean management, its use in health services, and its early application within psychiatric intensive care units (PICUs) when examining quality of care provided. It then discusses its possible function in conjunction with robustly describing needs of patients within psychiatric intensive care and how this further enhances patient care by grouping these needs into different types.