Transcript Document

Psychiatric Intensive Care
Stephen Dye
Presentation
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Introduction
History and Development
Standards
Disturbed Behaviour
Research
Quality
Historical Development
Graham Young
Butler Report (1975)
Regional Secure Units (12 -18 months)
Reed Report (1992)
Historical Development
Graham Young
Butler Report (1975)
Regional Secure Units (12 -18 months)
Reed Report (1992)
NAPICU (1996)
Hotbeds Publication (1997)
Beer, Paton, Pereira, 1997 survey of 110 units
Admissions
•107 from other wards in
Trust
•89 from Prisons
•24 from RSU’s/SH
•13 from Police (section
136)
•84 from Community
•47 only detained patients
•63 also informal patients
Beer, Paton, Pereira, 1997 survey of 110 unitsn
MDT
•29 Multi Consultant led
•51
Consultants had no specific
PICU role
•55 No SR/staff grade
•14
No junior doctors
•58 Only SHOs, no Registrars
•32
No OT
•46 No pharmacist input
•50
No psychologist input
•49 No social worker
•98 No other therapies eg art
Historical Development
PICU Textbook (2000)
Natl Min Standards (2002)
Governance Network (2004)
Journal (2005)
Advisory Service (2006)
PICU Textbook 2nd Edition (2008)
“Psychiatric Intensive Care is for patients compulsorily detained usually in secure
conditions, who are in an acutely disturbed phase of a serious mental disorder. There is
an associated loss of capacity for self control, with a corresponding increase in risk,
which does not enable their safe, therapeutic management and treatment in a general
open acute ward.”
Admission Criteria
1. Acute Mental Illness
2. Detained under Mental Health Act
3. Either:
a) Externally directed aggression
b) Internally directed aggression
c) Unpredictability
d) Absconding behaviour
1. Core Interventions*
2. MDT Working*
3. Physical Environment*
4. Service Structure – Personnel
5. User Involvement*
6. Carer Involvement
7. Documentation
8. Ethnicity, Culture and Gender
9. Supervision
10. Liaison with other agencies
11. Policies and Procedures*
12. Clinical Audit and Monitoring*
13. Staff Training*
14. PICU / Low Secure Support
Services
New Studies / Audits
National / Regional Surveys
Individual Units
Multi Unit Audits / Surveys
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Including BPRS measurements,
disturbance levels, medication and some
standards
New Studies / Audits
UK 1997
Survey
“PICUs”*
(%) (n=110)
UK National
Survey PICUs#
(%) (n=170)
UK National
Survey Low
Secure Units#
(%) (n=137)
Consultant
covering PICU /
LSU only
26
20
27
Occupational
Therapist
71
48
58
Clinical
Psychology
54
24
50
Social Worker
55
21
46
* Beer et al 1997
#
Pereira et al 2006
Staffing
New Studies / Audits
UK 1997
Survey
“PICUs”*
(%) (n=110)
UK National
Survey PICUs#
(%) (n=170)
UK National
Survey Low
Secure Units#
(%) (n=137)
57
57
52
Referral
Protocol
76
90
Pre Admission
Assessment
61
82
Risk Asst
Protocol
92
99
Admit Informal
Patients
* Beer et al 1997
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Pereira et al 2006
Policies / Protocols
Need for New Stds?
No real evidence of impact of Standards
Plethora of other guidance since 2002
Little evidence of actual clinical practice
• Mode of admission
• How care is escalated / de-escalated to
meet patient need
• Planning for discharge
• User and carer involvement
• Appropriate use of clinical area
• Organisation of processes
• Information throughout the patient
journey
What therapeutic and managerial interventions, actions and processes
contribute to the patient’s journey and demonstrate a safe, effective,
cost efficient pathway which delivers a high quality service?
Ingredients to deliver high quality care
• Well trained and motivated MDT
• User and Carer centred ethos responsive
to feedback
• Good & Consistent leadership in a well
managed organisation
• Physical environment fit for purpose,
modern, good order
• Clear lines communication particularly for
referral & discharge
• Clear criteria admission & discharge
accepted and followed
Ingredients to deliver high quality care
• Low Seclusion
• Low Restraint
• Low Rapid Tranquillisation
• Rare Staff / Patient injury
• Best Recruitment, Retention, Sickness
• Positive Feedback from Patients / Carers
• Difficult to validate........Only a few PICUs –
no benchmarking
• Limited proof to validate arguments
• Examples given may not be transferable
• Outlined Pt Pathway but didn’t feel
psychiatry lends itself to this (“not reflect the
complexities”)
Violence
The short-term
management of
disturbed/violent
behaviour in in-patient
psychiatric settings
and emergency
departments
Clinical Guideline
25
February 2005
2. Between Unit Comparisons
Medication
27
2. Between Unit Comparisons
Medication
Use of Acuphase
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Higher BPRS Admission
Predicted by
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Violence in PICU
Property damage in PICU
Male gender
Unit 4
Unit 5
Seclusion
The supervised confinement of a patient
in a room which may be locked to
protect others from serious harm. Its
sole aim is to contain severely disturbed
behaviour which is likely to cause harm
to others.
Code of Practice 15.43
Seclusion
Applebaum (1999)
142 deaths 1988 – 1998 USA
UK – Orville Blackwood
1991
David Bennett – 1998
(inquiry 2003)
Patient Behaviour
Aggression & Sexually Inappropriate Behaviour
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Tooke & Browne, 1992
Physical Assaults on Staff / Patients
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Only 1/3 of episodes (Morrison & Lehane, 1996)
Disruptive Behaviour disturbing the ward environment
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Betemps, 1993
Negative experience vs Necessary?
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Meehan, 2000
“Containment Strategies”
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Bowers
Ward Characteristics
Staffing levels, Education, Experience
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Craig & Ray, 1989
Unit Layout
Crowding
Patient Mix
Attitudes & Culture
Policies
Education
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Plaskey & Coakley, 2001
Creative Interventions
Non Behavioural
Characteristics
Race
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Soloff & Turner, 1981 – disproportionate black pts
Soloff 1985 – no significance
Browne 1997 – Black pts > seclusion, > RT
Gender
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M > F – Swett, 1994
Age
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Soloff 1985 – younger > older
Between Unit Comparisons
Physical Interventions
Factors Associated with seclusion / restraint
Pre-selected variables
Those significant – logistic regression model
 Age
 Gender
 Ethnicity
 Recent Behaviour prior to admission
 Behaviour in PICU
 Admission and 2/52 BPRS
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Between Unit Comparisons
Physical Interventions
Factors Associated with seclusion / restraint
Factors significant in logistic regression model
Seclusion
Violence in PICU
Property damage in PICU
Restraint
Violence in PICU
Property damage in PICU
2 week BPRS
Younger Age
No evidence that presence or use of seclusion
decreased the use of, or time spent within
restraint
Multi-centre assessment of psychiatric
intensive care unit (PICU) patient
characteristics, treatment and outcome
Brown et al, 2008
1. Typical PICU Patient
Sociodemographic, background and psychiatric history
35 yr old caucasian male
Unemployed, no
significant relationship
Diagnosis of chronic
psychotic illness (most
likely Sz) with substance
and/or alcohol misuse
History of violence and
property damage
Often history of DSH but
serious attempt rare
1. Typical PICU Patient
Circumstances of Admission
Detained under Section 2 or 3 of MHA
Transferred from acute hospital ward
Before admission:
 42% used illicit drugs and 31% drank
alcohol harmfully
 58% were violent to person and 47% to
property
 19% DSH
 25% absconding from acute ward
40
1. Typical PICU Patient
Treatment (Medication)
He will receive at least 1 antipsychotic
 no antipsychotic 10%
 no IM medication 51%
% of patients receiving
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1. Typical PICU Patient
Treatment (Medication)
23% received more than one antipsychotic
simultaneously
 Symptomatic / behavioural control 55%
 Cross tapering oral medication 21%
 Switching from oral to depot 19%
He will receive an oral Benzodiazepine (80%)
Not likely to receive a mood stabiliser (29%) or
antidepressant (17%)
10 patients (3% received no psychotropic
medication)
42
1. Typical PICU Patient
Outcome
Mean length of stay 35 days, median 18 days (1 315 days)
Mean delay in transfer of 8 days (0 - 255 days)
Transferred to acute psychiatric hospital ward
Significant improvement in mental state - mean
fall in BPRS 17.6 points
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1. Typical PICU Patient
Outcome - BPRS
BPRS
BPRS hostility cluster
BPRS factor V
Mean BPRS Score
70.0
60.0
50.0
40.0
30.0
20.0
10.0
0.0
Admission
2 weeks
Transfer
44
2. Ethnic Minority Patients
27% patients from ethnic
background (8% general
population)
18% Black - African or
Caribbean origin (2%
general population)
Caucasians and Asian
under represented
Very few differences in
history or recent behaviour
except higher rate of
reported recent violence
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2. Ethnic Minority Patients
These patients were:
 Significantly less likely to be given
leave
 Stayed in PICU longer (45.4 vs 31.3
days)
 Waited longer for transfer (13.5 vs 6.4
days)
Despite:
 Similar BPRS scores during PICU stay
 Similar rates in challenging behaviour
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3. Female patients
2 units admitted only males
28.5% females in other
PICUs
More likely to be in
significant relationship, less
substance misuse, more
DSH
Greater proportion with
Personality Disorder
Very few differences in
treatment, behaviour or
outcome
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4. Long stay patients
18% patients stayed longer than NMS
guidelines of 8 weeks
Of those staying longer than 8 weeks:
 Male
 African or Caribbean ethnicity
 Slightly younger (32 yrs)
 More likely to be on Forensic Section
of MHA
 Higher BPRS score on admission (74.4
vs 56.5) and 2 weeks (61.9 vs 46.1)
48
1. PICUs developed locally
2. Local policies and different practices
3. Recent attempts to standardise
practice (NMS), NICE, Accreditation
4. Few studies - suggest continued
variation
5. Little evidence of actual clinical
practice in UK PICUs, but improving
6. Quality Agenda