Patients can be referred at any time of day or night for acute care in an inpatient setting in a psychiatric hospital. The time of arrival at an acute psychiatric care unit has not previously been studied. We studied all referrals (1323) of 1027 individual patients to our unit in 2005 according to time of arrival at the unit.

Between 08.00 and 16.59 51.6% arrived, between 17.00 and 00.59 39.1%, and between 01.00 and 07.59 in the morning 9.3%. Mean length of stay was lowest for patients arriving at night. 637 referred patients were female and 686 male. This was not different from the representation in the catchment area population. Females had longer mean stays than men, 11.3 versus 9.4 days, but more men than women were referred during the year. 19.4% of referred patients ended their stay within the first day; two referrals lasted for more than 100 days. Patients referred between 01.00 and 07.59 ended their stay within one day in 39.0% of cases, and within seven days in 76.4% of cases.

Almost half of all patients arrived when all therapists except the doctor on duty, who is in training, had left the unit.

Aims: To describe the pattern of aggressive incidents, compare clinical characteristics of aggressive and non aggressive inpatients and determine predictors of inpatient aggressive behaviours in a low secure mental health unit population.

Method: Clinical data were extracted from inpatient records and a critical incident database for a low secure unit population. Clinical variables between those with inpatient aggressive behaviours (inpatient aggressors) and those without inpatient aggressive behaviours (inpatient non aggressors) were compared. Statistical analysis was carried out on the differences to establish predictors of inpatient aggression.

Results: 80 admissions resulted from 78 patients during a 6½ year period. 44% of patients presented with inpatient aggressive incidents. 64% of aggressive incidents resulted from 15% of patients. 54% of aggressive incidents were directed towards staff, 16% towards property and 15% towards other patients. 8% and 4% contributed to disturbed behaviour (non-directed aggression) and sexually inappropriate behaviour respectively. Most aggressive incidents are perpetrated by males and directed towards staff though a larger proportion of females (compared to males) were aggressive. On univariate analysis, clinical variables of more than one previous psychiatric admission, auditory hallucinations and delusions of control and persecution were significantly higher in patients displaying inpatient aggression. Logistic regression analysis identified the former two as predictors of inpatient aggression.

Conclusion: In a low secure inpatient population, the majority of aggressive incidents are perpetrated by a minority of patients. Clinical variables such as history of more than one previous psychiatric admission and psychopathological symptoms such as presence of auditory hallucinations and delusions of control and persecution can influence inpatient aggression.

Background: Psychiatric intensive care units (PICUs) have become a standard part of UK mental health services. They treat patients who may be very unwell and who are usually compulsorily detained. There is little published data about the clinical activity of such units to provide an evidence base for clinical governance.

Aim: To describe the socio-demographic characteristics, mental state and outcome of treatment for 332 patients admitted consecutively to seven English PICUs.

Method: Prospective, multi-centre case note analysis.

Results: PICU patients were predominantly Caucasian males, in their mid thirties, with complex needs and chronic psychotic illness often complicated by substance misuse. Most were admitted because of perceived risk of violence to others. Whilst most admissions appeared to be broadly in line with Department of Health guidelines some patients experienced an excessive length of PICU stay. Patients from particular BME groups were over-represented.

Conclusions: PICUs appear to deliver effective treatment but are not always the least restrictive environment as envisaged by the Department of Health. Further work is needed to evaluate treatment interventions and develop valid measures of quality of care.

This longitudinal audit aimed to determine the ethnic groups and other characteristics of patients referred to a Low Secure Unit in South East London over a period of 9 years between 1997 and 2005. The data provide a picture of the characteristics of those most likely to be referred to a Low Secure Unit, and highlights an over-representation of Black Caribbean and Black African people. Discussion is provided for this latter finding.

Background: People with severe mental illness are at increased risk of developing serious physical health problems, including metabolic syndrome, cardiac and respiratory diseases.

Aims: To audit the admission physical examinations carried out on patients admitted to a male psychiatric intensive care unit.

Method: A retrospective audit of 100 sets of case notes. After the first 45 case notes had been audited, the results were presented at a clinical meeting and an action plan formulated. A further 55 cases were then audited.

Results: Overall, 70 patients had an admission physical examination and 25 (36%) of these were abnormal. In 11 (16%) cases medical intervention was required, occasionally urgently and in 5 (7%) the abnormalities detected impacted on psychiatric diagnosis or management. In the re-audit there was no significant improvement in the proportion of patients having an admission physical but better documentation as to why one was not done and more patients had had a physical by discharge.

Conclusion: Physical examination on admission is an integral part of patient assessment and may identify underlying physical illness that may require urgent intervention and/or impact on psychiatric diagnosis or management. Clinical audit provides a means of detecting and rectifying absent admission physicals.

Background: Rapid tranquillisation is used when control of agitation, aggression or excitement is required. Throughout the UK there is no consensus over the choice of drugs to be used as first line treatment. The NICE guideline on the management of violent behaviour involving psychiatric inpatients conducted a systematic examination of the literature relating to the effectiveness and safety of rapid tranquillisation (NICE, 2005). This paper presents the key findings from that review and key guideline recommendations generated, and discusses the implications for practice of more recent research and information.

Aims: To examine the evidence on the efficacy and safety of medications used for rapid tranquillisation in inpatient psychiatric settings.

Method: Systematic review of current guidelines and phase III randomised, controlled trials of medication used for rapid tranquillisation. Formal consensus methods were used to generate clinically relevant recommendations to support safe and effective prescribing of rapid tranquillisation in the development of a NICE guideline.

Findings: There is a lack of high quality clinical trial evidence in the UK and therefore a ‘gold standard’ medication regime for rapid tranquillisation has not been established.

Rapid tranquillisation and clinical practice: The NICE guideline produced 35 recommendations on rapid tranquillisation practice for the UK, with the primary aim of calming the service user to enable the use of psychosocial techniques.

Conclusions and implications for clinical practice: Further UK specific research is urgently needed that provides the clinician with a hierarchy of options for the clinical practice of rapid tranquillisation.

Aims: To conduct a survey investigating the provision of psychiatric intensive care within NHS medium secure units in England and Wales, gaining preliminary information about PICU size and clinical structure, and using this information to inform a discussion regarding PICU provision in medium security.

Method: A postal survey was conducted.

Results: A total of 30 MSUs were identified. The three groups of MSU differed significantly in size. Half of the MSUs surveyed either had a PICU or were developing one. There was a great variation in clinical service structure.

Discussion: There appears to be a growing trend for the provision of intensive care within medium security. Possible explanations for this movement are discussed. Reasons for PICUs not being developed are also explored. Forensic psychiatry needs to consider whether the national standards are appropriate for medium security. Further research is required to understand the reasons for the changing practice that we have identified, to develop a base of knowledge to inform service structure and to investigate the effects of different structures on clinical outcomes.

Aims: Evaluation of users’ perspectives on ward meetings on a low secure challenging behaviour unit with high levels of morbidity as a means towards increasing their sense of empowerment.

Method: Semi-structured questionnaire designed and administered by a user to all users on the unit over the period of June–Aug 2004 and review of ward meeting minutes over the same period.

Results: 60% response rate. Issues were analysed and issues of importance highlighted and changes made.

Conclusion: On challenging behaviour wards with very high morbidity and long stays, involving the users actively in ward meetings and addressing concerns with feedback is empowering and can be therapeutic. This study highlights this need.

This commentary aims to explore the benefits of having a designated, specialised clinical lead on the psychiatric intensive care unit (PICU). It discusses the problems, disadvantages and risks of not having such leadership, especially where a multiple consultant psychiatrist model is employed. The impact of clinical leadership on specific aspects of work on the PICU is examined including multidisciplinary team working, patients’ clinical time and safety, decision making, resource expertise, delayed discharges, and staff stress levels. Reference is made to standards in the literature which show that departure from designated leadership on the PICU is unsatisfactory.