Literature comparing the quality of care on psychiatric intensive care units and acute wards is sparse, but a review has found differences in key areas e.g. violence, drugs and alcohol.

This study compares the response to questionnaires completed by patients, carers and qualified nursing staff from PICUs and acute wards as part of the Accreditation for Inpatient Mental Health Services (AIMS) process.

There were few differences between the standards of care on PICUs and acute wards according to patients, carers and qualified nurses. Patients reported a more negative experience of care on PICUs than trained nurses, and in particular rated low standards on accessing records and counselling. Carers reported inadequate involvement in risk assessment an assessment of their needs. Nurses generally gave positive views of standards of care.

The challenging environment of the PICU does not appear to be compromising quality of care. There is however still room for improvement for both acute wards and PICUs in key areas, including full involvement of patients and carers and imparting information.

The use of additional sedative psychotropic medication to calm agitated or aggressive patients is known as rapid tranquillisation (RT). Several studies of RT practice have been conducted in psychiatric intensive care units (PICUs) and acute psychiatric settings.

We carried out a cross-sectional survey of the use of parental sedation in an English secure hospital using data from medication charts and case notes.

We studied the medication charts of 316 patients and found 203 incidents (all involving intramuscular route) of parenteral sedation involving just 35 patients. The vast majority (30; 85.7%) of those administered parenteral sedation were female and most (23; 65.7%) had emotionally unstable personality disorder. The most common indication was self-harm (44; 21.7%). In 24 (11.8%) instances the patient had requested an injection. A single drug was administered in 159 (78.3%) cases. The most commonly administered drug was lorazepam (152 cases) followed by haloperidol (69) and olanzapine (21). Case note documentation was frequently inadequate and in very few cases was there evidence of physical monitoring.

The use of parenteral sedation was rather different from that previously described in PICUs. Hospital policy and NICE guidance were not always being followed. Measures to rectify these deficits are being taken.

There is limited research on the attitudes of nursing staff towards psychiatric intensive care units (PICUs) for general adult populations, and none examining attitudes in older adult PICU populations. The aim of this study was to examine these attitudes in one Scottish health board region.

A semi-structured questionnaire was distributed to nursing staff working in general and older adult psychiatric admission and PICU wards.

Of 138 responders, PICUs were considered necessary by 96.4%, with 93.5% agreeing on the need for a separate older adult PICU. PICU staff had more influence on discharges from the PICUs compared to non-PICU staff. The main reasons for admission to PICU services were physical violence and absconding, and for refusing admission were acute ward containment and medication issues, with few differences between the general adult and older adult PICUs.

There were more similarities than differences in nursing attitudes between the general adult and older adult PICUs but many staff feel inadequately trained and supported. The combination of service-user reports, the demographic shift to an aging population and the increase in mental health detentions in the older adult population suggest a need to consider age-appropriate psychiatric intensive care services.

Rapid tranquillisation (RT) is a high risk clinical intervention in terms of potential physical health complications. There has been no published work in the UK to survey nationally whether standards for post RT physical monitoring (as set out in organisation's RT documents) are being adequately audited.

To review current auditing of RT practice in England, with particular emphasis on examination of post RT physical monitoring.

A scrutiny of evidence provided by English NHS mental health trusts to illustrate auditing of adult RT documents.

Fifty-eight mental health trusts in England were contacted. Less than one-third could provide evidence of an audit of post RT physical health monitoring. These audits were variable with respect to what aspect of physical health monitoring they focused on. When results of all audits were combined, it revealed a concerning finding that basic physical observations and investigations were not performed consistently following RT.

The current paucity of trust audits of post RT physical monitoring and the poor practice observed in those audits could reflect a lack of clarity in both trust and national guidelines, as well as poor clinical practice. Given the risks to a patient's physical health associated with RT it is essential to ensure high quality care in this area.

Interpersonal effectiveness and social competence are central issues in treatment engagement and recovery for women with a diagnosis of personality disorder or schizophrenia in secure psychiatric settings.

To assess the effectiveness of a manualized group cognitive behavioural treatment for women admitted to a secure inpatient unit.

Thirty four patients were divided into treatment completers and non completers on the basis of rates of attendance. Pre-post measures covered interpersonal problems, self efficacy, company, relationships and risk behaviours.

Completers show significant pre-post changes on all measures, in contrast to non completers. Completers were younger and more likely to have experienced psychotherapy in the past.

Results provide confirmatory evidence for the value of training in interpersonal and communication skills training for women in secure care. The failure of one third of patients to complete treatment raises issues about the timing and applicability of treatment for some patients.

To describe the characteristics of patients admitted over one year to two psychiatric intensive care units in one large mental health trust. To establish the number of admissions, reasons for admission, incidents on the PICU, bed days and destination after discharge. Differences in gender for these factors were explored. Secondary questions were whether patient factors predicted aggressive incidents or predicted requiring long term care.

The electronic notes for one year of admissions to the PICUs in one trust were examined; sociodemographic and clinical details were recorded. Reasons for admission and incidents on the PICU were coded. Data was analysed to establish significant sociodemographic or clinical differences within the cohort.

Men were much more likely to require PICU but women stayed longer. There was a trend for women to go on to long term secure placement. Aggression and sexually inappropriate behaviour were common but there were no demographic predictors of aggression. The only predictor of requiring long term placement was having been a long time on the PICU.

There is evidence that women and men use the PICU differently, with women staying longer. Further research is needed to see if this is a national trend.

This paper presents the psychometric properties, including factor structure, internal reliability and relative validity of a 16-item questionnaire measuring patients’ relative activation with milieu activities while hospitalised in an acute psychiatric inpatient unit.

24 hours after admission, and before discharge, psychiatric inpatients (N = 132) completed a set of validated self-reports and the pilot questionnaire, the Checklist of Unit Behaviors (CUB). The CUB outlines items that reflect the extent to which the patient avoided or engaged with the treatment milieu within the previous 24 hours. Factor analysis, bivariate correlations and repeated-measures t-tests were used to analyse the data.

Factor analysis identified two factors for the CUB: (1) Behavioural Approach; and (2) Behavioural Avoidance. Psychometric properties were satisfactory (Approach, Cronbach's α = 0.93; Avoidance, Cronbach's α = 0.79). Over the course of treatment, CUB-Approach increased (p < 0.001) and CUB-Avoidance decreased (p < 0.001). The construct validity of the CUB was supported through correlations with measures of positive and negative affect.

The CUB demonstrates strong psychometric properties, quantifying patients’ behavioural activation in the treatment milieu. Daily use of the CUB provides clinically useful information that has the potential to improve patient care and treatment planning.

Despite not being underpinned by a strong evidence base, rapid tranquillisation is frequently the intervention of choice for dealing with violent and aggressive behaviour in psychiatric hospitals. This is the second of a two-part review of recommendations set out in UK trusts' adult rapid tranquillisation documents. In this article we focus on the drugs recommended, their routes of administration and clinical parameters influencing their use.

A review of adult rapid tranquillisation documents currently in use in NHS or HSC trusts providing adult mental health services in the UK.

A total of 45 rapid tranquillisation documents met the inclusion criteria and were examined. Sixteen drugs were recommended, via four separate routes of administration. Beyond the use of oral and IM lorazepam, haloperidol and olanzapine there was no consensus as to which drugs should be used for rapid tranquillisation in adults. Eleven clinical decision-making parameters were identified that influenced the selection of drugs for IM administration. However, the wide variation and sometimes absence of advice surrounding these parameters was concerning.

The results of this review demonstrate that there is a need to rationalise rapid tranquillisation and develop consensus guidelines that allow for evidence based decision-making tools.

Delirium is a severe and complex neuropsychiatric disorder and because of its diverse aetiology is often poorly managed. The refeeding syndrome is a well known cause of delirium, characterized by metabolic disturbances elicited during reintroduction of nutrition after a period of starvation. Although a common complication, it is often not recognized by clinicians.

A 53-year-old man presented at the emergency department with psychomotor agitation, irritability and disorientation in time. Apart from previous alcohol abuse he had no documented medical history. Examination led to detection of an intracranial haemorrhage, which could explain cognitive dysfunction. After admission, his level of consciousness gradually improved and he resumed eating and drinking. However, a deterioration of his mental status occurred after three days.

Blood analysis revealed a severe hypophosphataemia indicating refeeding syndrome. After a new dietary regimen and aggressive supplementation of electrolytes his mental state improved rapidly. Following correction of phosphate plasma concentration, no further episodes of severe confusion or disorientation were observed.

This case report illustrates that clinicians in both psychiatric and general intensive care must be aware of the numerous causes of delirium that can be present concurrently. Refeeding syndrome may be overlooked initially when more alarming causes of a delirium are noticed.