There is considerable variability in the ethos of the various adolescent in-patient units in Britain. Currently, there are few services within NHS settings able to manage acute behavioural disturbance in adolescents despite the prevalence of psychiatric disorder in this population group. Due to this variation, individual units around the country have developed their own bespoke services for managing disturbance. These services are given different names although may be operating with similar models. However, there is little consensus on these definitions, resulting in services with similar titles providing differing levels of service and varying capacity to manage violence or aggression. We attempt to define patient populations in need of such services and suggest a nomenclature for defining such services that could be universally adopted. We also describe the five-year review of admissions of one adolescent psychiatric intensive care unit and suggest how well its name fits with our proposed model.

We have used a remifentanil-based anaesthetic for patients undergoing major abdominal surgery who would normally have gone to the intensive care unit in this hospital. Avoiding intensive care unit admission was considered an advantage as a shortage of intensive care unit beds was leading to the cancellation of operations. We first used remifentanil as part of a safety and efficacy study. The aim was to see if the rapid and complete awakening obtained when using this drug would allow us to avoid the need for admission to an intensive care unit and use a high dependency unit instead. This was shown to be practicable. In comparison with a group of patients matched retrospectively for the type of operation before remifentanil was used there was a reduction in the length of time (mean ± SD) patients’ lungs were ventilated (612 ± 417 vs. 9.9 ± 28.9 min P<0.0001). There was no saving in cost (£808.71±£187.06 vs. £795.27±£253.49). When remifentanil was used routinely (after the safety and efficacy study), there were significant reductions in the time to tracheal extubation (612±417 vs. 4±10 min P <0.0001) and costs (808.71I vs. 392.10 I P <0.0001) compared with other patients in whom it was not used. Patients waiting for a liver transplant were also being cancelled when a donor organ became available because of the shortage of intensive care unit beds. Based on our other experience with remifentanil, we used a similar anaesthetic technique for these patients. It proved possible to extubate the trachea in 12 of 15 patients at the end of the operation. No patient needed re-intubation. The need for intensive care and therefore cancellation of surgery was reduced. In contrast, only one patient's trachea was extubated immediately after surgery in the group of patients anaesthetized before the introduction of remifentanil. A remifentanil-based technique in combination with a change in organization has therefore enabled us to avoid admission to the intensive care unit for these patients.