Background: Psychiatric intensive care units (PICU) are a potentially expensive component of inpatient services, and exists to care for those patients who cannot be easily contained on ordinary acute wards. However, to date there is little evidence on their efficacy.

Methods: Using data from a previous study of 136 acute psychiatric wards in England (City-128) we examined whether ordinary acute wards having access to a PICU had lower rates of adverse incidents, and modelled behaviours associated with PICU transfer rates.

Results: Controlling for other factors, wards with greater ease of PICU access did not have lower rates of adverse incidents. PICU provision is related in complex ways to the use of seclusion. PICU transfers were associated with seclusion, manual restraint and other severe containment measures, and were triggered by aggression, drug use and absconding.

Conclusions: Transferring patients to a PICU may not be an effective means of reducing adverse incidents on acute wards and may not have appreciable cost benefits. However, PICUs may still produce a range of valued outcomes such as injury reduction, more effective and efficient treatment, greater feelings of security on acute wards, and care for patients within the criminal justice system. Larger and more detailed evaluations using longitudinal data are required.

Objective: To examine the distribution of length of stay (LOS) in acute psychiatric units.

Method: Analysis of one year of LOS data from twelve acute psychiatric units in New South Wales, Australia.

Main findings: LOS had a complex distribution, with a ‘head’ of discharges within a day, a ‘body’ of discharges that approximated an exponential distribution and a ‘tail’ made up of a small group of patients discharged after very long admissions. There were substantial differences between units in the proportions of discharges classified as being in the head and the tail of the LOS distribution. With regards to the traditional measures of central tendency, the median LOS was affected by the proportion of patients discharged within a day, and the mean LOS was strongly influenced by small numbers of very long stay patients.

Conclusions: A graphic representation of logarithmically transformed LOS values might assist in understanding the LOS of individual acute psychiatric units. A modified median LOS, calculated after the removal of patients staying less than a day, was found to be a simple and reliable measure that can potentially provide a more meaningful measure of LOS than the mean or the median LOS.

Background: People with severe mental illness are at an increased risk of physical health problems including diabetes.

Aims: To identify the proportion of patients with diabetes in specialist secure psychiatric care, establish current practice in diabetes care and management, and clarify the role of the psychiatric medical team versus the on-site general practitioner.

Method: Hospital-wide data collection from electronic and paper case notes of all identified diabetic patients. Audit standards were based on current National Institute for Clinical Excellence guidelines.

Results: 64 out of 548 patients (11.7%) were identified with a diagnosis of diabetes. 18 (28%) of these patients had an individual care plan to address their diabetic management and risk. The majority of patients had regular blood glucose and HbA1c monitoring.

Clinical implications: Patients should receive regular structured education sessions, regular feedback about their own management, and individual care plans that include the management of common and potentially life threatening complications. These are essential components of providing good quality diabetes care. Clinical audit may provide a means of identifying and rectifying problems in relation to diabetes care in long-stay psychiatric inpatients.

Background: The highly prevalent comorbidity of substance use disorders and psychiatric disorders represents challenges concerning diagnosis and treatment in acute psychiatric wards.

Aims: To study the feasibility of the first Norwegian version of the Psychiatric Research Interview for Substance and Mental Disorders (PRISM) in an acute psychiatric ward.

Methods: 61 consecutively admitted substance abusing patients, presenting with mood symptoms, psychotic symptoms, or both, were interviewed. Assessments included variables concerning the way the interviews were carried out.

Results: 51% of eligible patients were interviewed. The main reason for non-inclusion was short stay on the ward. Median interview time was 155 minutes and median number of interview sessions was three.

Conclusion: It was possible to use the PRISM in a busy acute psychiatric ward. Patients mainly had positive reactions to this extensive interview.

Recent changes in the practice of inpatient psychiatry have minimized the emphasis on psychodynamic principles in the treatment of hospitalized patients. The concepts of transference and countertransference have taken a secondary role to rapid diagnosis, treatment and discharge. This paper explores the impact of countertransference on physician decision-making and clinical care through two case histories illustrating how countertransference can impact the assessment, treatment and management of the psychiatric inpatient. The authors discuss the concept of countertransference, its effect on physicians and hospital staff and strategies for recognizing and minimizing the impact of countertransference.

Background: Staff working on psychiatric intensive care units (PICUs) are routinely exposed to aggression or threats of aggression from the patients they care for. This phenomenon is identified as an ongoing factor that influences both work performance as well as staff sickness, and as such requires understanding and management.

Aims & method: This study utilized questionnaires assessing the extent to which PICU staff thought violence was a problem and how safe and supported they felt. Semi-structured interviews were conducted with five nurses to gather in-depth information on the factors involved in perceptions of safety and support.

Results: The analysis indicated that as a whole, staff feel safe and supported by their immediate team. Interview analysis produced two main domains and ten sub-domains of experiences that contribute to managing threats, these being grouped in either personal or systemic factors. It particularly highlighted that although patient aggression is a concern, the perception of threat most directly relates to beliefs about a lack of support from other teams and senior management, not the patients themselves.

Conclusions: More research and attention is needed on systemic factors in the management of threatening patients.

Objective: To explore, using a naturalistic design, the efficacy of typical and atypical antipsychotics in the management of behavioural disturbance in people with psychiatric disorders.

Method: Prospective naturalistic study of 15,278 incidents of behavioural disturbance perpetrated by 1,059 patients, over a two year period.

Results: Typical and atypical antipsychotics did not differ in terms of their efficacy, overall. In terms of specific agents, haloperidol and quetiapine tended to show equal efficacy, with olanzapine being somewhat less effective on two of three outcome measures.

Conclusions: Overall, atypical antipsychotics were as effective as typical agents in the management of acute behavioural disturbance in a mental health setting. Further work is required to determine the relative side effect burden of those agents.

Background: A proposal to introduce metal cutlery onto a PICU in order to create a more homely environment prompted staff concerns about safety.

Aims: Based on the premise that past behaviour is a strong predictor of future behaviour, we undertook a pilot audit of history of weapon use as a measure to guide decision making on weapons security on our PICU.

Methods: Retrospective case note audit of 30 PICU patients to determine historical rates of weapon use. Secondary measures included level and type of weapon use, and mental disorder. 30 ‘non PICU pathway’ general ward patients were sampled as a ‘control’.

Results: 19/30 patients on the PICU had a history of weapon use, compared to 7/30 on the general ward. There were 23 recorded incidents in the PICU sample and 7 on the general ward.

Conclusions: The majority of the PICU sample had a history of weapon use, often recent, including improvised and bladed weapons, at times of acute disturbance and non-compliance with medications. Comparison with the non-PICU group indicates that the measure had good construct validity as rates in this group were significantly lower. Therefore history of weapon use could be a useful measure in guiding decision making about security protocols on PICU, however, further research is required.