Transcript Psychiatric Intensive Care

Psychiatric Intensive Care
Zahoor Syed
History
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Historically psychiatry has been judged by its
management of the furiously mad (Turner 1996)
King of Babylon was put to pasture after he started to
behave like a wild animal. (book of Daniel)
Wild man wandering naked amidst the tombs, having
broken the chains that bound him (New Testament)
750 yrs ago the first asylum for mental patients formed
at the Priory of St Mary of Bethlem in London
Mental Treatment Act 1930 introduced the concept of
informal admissions
Mental Health Act 1959 laid down strict guidelines for
involuntary patients
1950s saw introduction of chlorpromazine
PICU function evolved as a pragmatic solution to the
PMPs encountered on the open wards
History
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Idea of PICU came from USA
Rachlin 1973 – open door policy
cannot provide adequately for the
treatment needs of all psychiatric
patients
First PICU in England was opened in
St James’s Hospital Portsmouth
Psychiatric intensive care
Care in a highly staffed unit for
those who are mentally ill and
behaviourally disturbed. In a secure
setting by a MDT
 Management of risk associated with
mental illness
 Three aspects of risk to be
considered
Seriousness Immediacy Duration
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PICU
Three features need to be present.
1 Intensive levels of care delivered by
professionals (both quantitative &
qualitative)
2 More facilities
3 More security
PICU
Psychiatric intensive care is for patients
 compulsorily detained usually in secure
conditions
 acutely disturbed phase of a serious mental
disorder
 associated loss of capacity for self control,
 corresponding increase in risk, which does not
enable their safe, therapeutic management
and treatment in a general open acute ward
PICU
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Care and treatment offered must be patientcentred, multidisciplinary, intensive,
comprehensive, collaborative and have an
immediacy of response to critical situations
Length of stay must be appropriate to
clinical need and assessment of risk but
would ordinarily not exceed eight weeks in
duration
Psychiatric Intensive Care is delivered by
qualified staff according to an agreed
philosophy of unit operation underpinned by
principles of risk assessment and
management
PICU
Detention
in
a
locked
environment
constitutes a fundamental loss of freedom
for an individual. PICU and low secure staff
need to work collaboratively with referring
services to ensure that admission is
appropriate to the individual’s needs. There
should be no more restrictions on a
person’s freedom than is warranted by his
or her clinical condition.
Management of acutely disturbed patient
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Assessment prior to admission and
management plan
Prepare for patient arrival
staff nos, C&R team, medication, bed
room
Observation levels
Safe environment
good visibility, alarms and consistent staff
response, minimal movable objects,
activities
Assessment
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Follow rules to reduce risk to staff
and those visiting the unit
When interviewing a patient, inform
colleagues
Conduct joint medical and nursing
assessment
Carry your alarm
Sit at a safe distance and close to
the exit
Call police if necessary
Factors indicating increased risk of violence
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Male
Young
Previous violence towards others or self
Previous forensic history
Antisocial or impulsive personality traits
Substance misuse
Poor compliance
Presence of precipitants
Association with a sub culture prone to violence
Evidence of social restlessness
Access to potential victims identified in MSE
Predicting potential for immediate violence
Primary characteristics
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H/O aggression, forensic history, overtly
aggressive acts
Hostile, threatening verbalisation, boasting of
prior abuse
Suspicious, paranoid
Delusions of control
Hallucinations with violent content
Poor impulse control
Non verbal expression of hostile intent
Refusal to communicate
Unclear thought process
Possession of weapon
Predicting potential for immediate violence
Secondary characteristics
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Inappropriate / unrealistic demands
Fear, anxiety, pain and anger
Exacerbation of psychosis
Inability to verbalise feelings
Previous substance abuse
Related factors
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Hypomanic excitement
Confusional state
Psychiatric or psychological motivation for
problem behaviour
Violent incidents
Precipitants
Enforcement of ward rules
Denial of patient’s requests
Confrontational staff
Staff factors
Staff stability, Staff training, Poor leadership,
Inadequate staff
Environmental factors
No fresh air, lack of privacy, overcrowding,
unpredictable routines, overstimulation, authoritarian
conditions, hidden corners, access to weapons, too hot
or cold, uncared for environment.
Medical Causes
Head injury (SDH), DT, Intoxication, meningitis,
encephalitis, hypoglycaemia, wernicke’s
encephalopathy, TLE, Neoplasia, dementia, overdose
with prescribed drugs ( anticholinergics)
Management of acutely disturbed behaviour
Prevent violence by de- escalation
techniques
 Safe distance
 Easy access to alarms and escape route
 Stay calm
 Avoid sudden movement
 Explain your intentions clearly and
confidently
 Engage the patient in conversation
 Try to reason
 Consider other interventions
De-escalation Techniques
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De-escalation is a complex interactive
process in which a patient is redirected
towards a calmer personal space
( Stevenson 1991)
Important skill for health care
professionals
Three components of effective face to
face de-escalation
Assessment of the immediate situation
Communication skills
Tactics aimed at problem solving
Assessment of the immediate situation
Situation
Appraisal
Anger
Inhibitions
Aggression
Communication
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Non- verbal communication
principles
position your body at an angle
Avoid authoritarian or defensive body
postures
Communicate at the same height as the
patient
Facial expression should reflect what you
say verbally
Comfortable proximity during
communication ( 1 metre, increase 3 fold
if escalating verbal aggression)
Avoid touch
Eye contact
Communication
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Verbal communication
Calm, warm and clear tone of voice
Personalise yourself and build rapport
Ask for specific acts avoiding long statements
Avoid personal confrontation
Deal with the problem and avoid being selective with
your attention to the issues the patient is verbalising
Avoid passing the buck
Avoid using jargon
Highlight the impact of patient’s behaviour
Reinforce your position as a helper
Remain astute to the progress made as there are limits
to what can be achieved verbally
Tactics
Win – lose equation (Le Poole 1987)
Win
Win
Negotiation
Pt. need
Lose
Win
Tactics
Debunking
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Process of debunking pts need to make his point by
use of aggression.
Accepting the content of pt’s grievance
unconditionally.
Transactional analysis( Berne 1964)
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Understanding different contexts (ego states) within
which interaction takes place.
3 ego-states are parental, adult and childhood.
Ensure the ego state within which the de-escalator is
interacting is complementary to the pt’s ego state
Aligning goals
- Find a common ground
ACT model
Assessment
Systematic assessment of situations variables
and their response to de-escalation
De- escalator
Tactics
Problem solving
Reducing level of aggressive
response
Communication
Capturing pt’s attention
Focus on presenting problem
Use of restraint
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The act of laying hands on another without their
consent is in some circumstances assault and is
viewed as an infringement of civil liberties
When is such action acceptable or justifiable?
To prevent imminent harm to the patient or
others when all other options have failed
To allow administration of compulsory treatment
when clinically justified and legally sanctioned
(Hopton 1995)
Mechanical
Manual
C&R
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Developed in 1970 as a method for
restraining prisoners in a safe manner
using techniques that were legally
sanctioned.
Relies on various holds to immobilise the
individual.
Central to the practice is the 3 person
team.
SCIP (Strategies for Crisis Intervention &
Prevention)
Rapid Tranquilisation
- RT is use of psychotropic medication to control
agitated, threatening or destructive behaviour
(Ellison et al 1989)
- Pts needing RT fall in 2 groups (Pilowsky et al
1992)
Those who require repeated injections due to
persistent refusal of oral medication and resulting
aggressive behaviour
Those who require only one or two injections
early on in their treatment
- Hospital policy on RT should include
Indications, consideration of non pharmacological
interventions, assessment and monitoring of the
risks associated with RT
Rapid Tranquilisation
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Staff should be aware of procedures for RT
Ensure safety of staff and pts
Enough staff should be available
Ask for help from other wards
If not enough staff available…
Voluntary application of restrain
Review case notes to check contraindications
Establishing differential diagnosis should not delay
intervention
Continue to observe patient and justify use of
medication
Choice of drug
Check vital signs before and after.
Facilities for resuscitation and Flumazenil should be
available
Watch for ↓ RR, ↑pulse and cyanosis.
Rapid Tranquilisation
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Trust policy available on
nww.enline.cambsmh.nhs.uk
Prescribing considerations include
psychotic symptoms, medical co- morbidities,
previous response to medication, existing
medication
Choice of medication
Benzodiazepine alone
Antipsychotic alone
Combination
Olanzapine
Aripiprazole
Zuclopenthixol Acetate (Clopixol Acuphase)
Objectives
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Treat mental illness as you would in other
settings
Clear cut management plan
Good enough dose for long enough period
Avoid poly pharmacy
Be mindful of risks if above BNF dose limit
Frequent reviews
Avoid boredom
Move the patient as soon as ready
The Cavell Centre
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PFI – 102 beds
Phase 1 – OPMH Opened Nov 2008
Phase 2 – LD & AMH 21st May 2009
PICU – Poplar ward
1st patient in 22 June 2009
Capacity – Max 8 Male
6 En-suite Bedrooms, 2 step down
Patient Profile
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Age – 18 to 125
Gender – Male
MH Act – Must be detained
Presentation – extreme levels of aggression &
hostility, high risk of suicide, self harm, harm
to others, absconding
Treatment Plan – Not expected to require PICU
for more than 4-6 weeks
Exclusions – organic brain injury, requires low
secure, requires high secure, manageable on
open ward, primary substance misuse
Aspirations
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Close Support of Acute Care System
Liaison with George McKenzie House
Promote & Maintain Skills within Acute
system
Lead Specialist Provision
Lead Inter-professional Training Facility
Financial Achievements
Thanks