Ward round is an integral platform for patients and the multidisciplinary team to communicate, assess and plan treatment. With such a key process, it is vital that the effectiveness of the ward round is maximised and that reliable follow of information is addressed. This can be achieved using lean methodology.

Belgium has a large capacity of psychiatric beds as compared to most other European countries and is on the verge of reducing this capacity. An accompanying augmentation of assertive community treatment strategies alongside acute crisis resolution has already begun. The latter function has been implemented in recently developed psychiatric intensive care units. Whether this development will result in improved care for psychiatric patients and in a reduction in cost for the government remains unanswered. Outcomes research in psychiatric intensive care is ongoing in the United Kingdom but this is not the case in Belgium. In this commentary we suggest that this moment of change is a perfect time for initiating research on psychiatric intensive care units in Belgium preferably in close collaboration with experienced staff in the United Kingdom.

Aim and method: To review antipsychotic prescribing practice using selected recommendations from the 2006 Royal College of Psychiatrists’ (RCPsych) consensus statement on the use of high dose antipsychotic medication. A clinical audit of antipsychotic prescribing for patients from two periods, February to October 2005 and February to October 2006, who were discharged from Hollywell PICU at Hillcrest and had received one or more antipsychotic medications whilst an inpatient there.

Results: The proportion of patients receiving a single antipsychotic increased from 9 (31%) in 2005 to 22 (55%) in 2006 and the proportion prescribed high dosages of antipsychotics declined, 10 (33%) in 2005 vs. 3 (8%) in 2006. The number of high dose combination prescriptions also declined, 4 (13%) in 2005 vs. 1 (3%) in 2006.

Clinical implications: The audit illustrates the potential for individual variation in prescribing practice in the PICU environment. It suggests that the Royal College of Psychiatrists’ 2006 consensus statements on antipsychotic prescribing can be used to both benchmark clinical practice and promote evidence based prescribing.

This commentary outlines the need for a PICU accreditation system, its development and initial use. The development of a framework that includes clinical outcomes in conjunction with accreditation to measure quality of care is discussed.

Background: Psychiatric intensive care units (PICUs) initially developed in a haphazard fashion. In the UK, in an attempt to standardise quality of services, guidance for PICUs was published in 2002. Subsequently there has been a paucity of information outlining compliance with standards within different units.

Aims: To describe adherence to a subset of national standards in the care of 332 patients admitted consecutively to seven English PICUs.

Methods: Prospective, multi-centre patient case note analysis and staff questionnaire for each patient admitted.

Results: There was significant variation in different PICUs’ compliance with standards. Seventeen percent of patients were deemed not to meet basic criteria for admission to PICU. Pre-admission assessment and identification of treatment aims were poorly adhered to. Inappropriate mix of gender within patients occurred following 33% of admissions.

Conclusions: Implementation of national standards varies between different PICUs according to local policy and interface between acute wards and PICUs. This highlights the importance of, and challenge for, a national accreditation scheme.

Background: Psychiatric intensive care units (PICUs) provide care for patients who may demonstrate agitation and aggressive tendencies. Such behaviour has traditionally been managed using interventions such as seclusion and/or physical restraint. There is little published data about the use of these measures within different PICUs. This paper attempts to provide such evidence as a base for clinical governance.

Aims: To describe patterns of seclusion and restraint usage within the care of 332 patients admitted consecutively to seven English PICUs.

Method: Prospective, multi-centre patient case note analysis.

Results: Within the four units that utilised seclusion in the study period, it was used on 16% of patients who had been admitted. All seven units used control and restraint and 28% of admitted patients were formally restrained at some point during their admission. There was no significant difference in mean duration of restraint or proportion of patients who were restrained between the units that used seclusion and those that did not. Use of seclusion was significantly associated with patient violence and property damage in PICU. Restraint usage was also significantly associated with patient violence and property damage but also with higher two week BPRS scores and a younger patient age.

Conclusions: It appears that PICUs manage disturbed behaviour differently, either dependent upon facilities or local policies. In attempting to reduce the use of seclusion and restraint, a multi-faceted approach must be taken both locally and nationally. PICU clinicians and service users should be integral within this.

Although psychiatric intensive care is a relatively new speciality, it has been well defined. The use of lean management techniques in association with accurately defining services lends itself well to treating patients in an effective and efficient manner. This paper summarises the development of lean management, its use in health services, and its early application within psychiatric intensive care units (PICUs) when examining quality of care provided. It then discusses its possible function in conjunction with robustly describing needs of patients within psychiatric intensive care and how this further enhances patient care by grouping these needs into different types.

Objective: A paucity of research exists on the types of patients admitted to psychiatric intensive care units (PICUs), which is important in terms of identifying patient needs, training and service provision. Questions have also been raised as to whether or not ethnic minorities are overrepresented in these units.

Method: A literature review using MeSH headings from a wealth of databases was performed to identify such studies. In addition studies on ethnic minority overrepresentation in psychiatric care were also identified.

Results: Under a dozen studies were identified, mainly from the UK and Australia. Study designs tended to be basic and heterogeneous, but this was reflected in the nature of the study and the data gained. A typical PICU patient emerged, namely a young schizophrenic detained male, belonging to an ethnic minority (if in an inner city), known to mental health services with previous informal, detained and PICU admissions, admitted due to violence and often possessing a forensic history. If a complex need existed, it was usually substance misuse. The inpatient stay tended to be for less than two months and discharge was usually to an acute ward. Ethnic minorities were overrepresented in PICU care.

Conclusions: The literature review highlighted a paucity of good-quality studies in this field. The establishment of a national association of intensive care units as well as national guidelines can only improve services. The reason for ethnic minority over-representation on these units is still far from clear.

Current western involuntary hospitalisation legislation is based on legal philosophy and the freedom of the individual. Legislation based on medical philosophy, which focused on the need for care has been deposed. Formerly, doctors had greater authority, but with this came the difficulty of balancing the opposing agendas from various quarters. This role has been adopted by Mental Health Tribunals. Eventually, doctors accepted the new system, which in some ways made their lives easier. They continue to be concerned that the emphasis on freedom leaves some non-dangerous disorganized patients without care.

Background: Low Secure Mental Health Services provide care for highly disturbed psychiatric patients. Little is known about the characteristics of such patients in the UK.

Aims: To perform the first UK wide survey developing a national data set of low secure services.

Method: A cross-sectional census day postal survey design was employed.

Results: A total of 307 units were identified this comprised 170 Psychiatric Intensive Care Unit (PICU) housing 1,242 patients and 137 Low Secure Units (LSUs) treating 1,583 patients. The majority of patients in Low Secure care were male, white, single, unemployed and with a diagnosis of schizophrenia. Complex needs, violence and forensic histories were common. There was a clear overrepresentation of black ethnic patients.

Conclusions: Patients in Low Secure Services shared many characteristics. However, there were important differences between PICU and LSU patients. The overrepresentation of black ethnic groups is concern that requires NHS action to ensure that the specific needs of black patients are met.

Background: Low Secure Mental Health Services provide care for highly disturbed psychiatric inpatients. Little is known about the provision of such services in the UK.

Aims: To perform the first UK wide survey developing a national data set for Low Secure Services.

Method: A cross-sectional census day postal survey design was employed.

Results: A total of 307 units were identified in the UK, this was comprised of 170 Psychiatric Intensive Care Units (PICUs) housing 1,242 patients and 137 Low Secure Units (LSUs) treating 1,583 patients. The survey achieved a 98% response rate. PICUs on average had more qualified staff and were more medically oriented than LSUs. PICUs offer a time limited, medically oriented treatment strategy with a higher number of qualified nursing staff then LSUs. Whereas, LSUs placed more of an emphasis on long-term therapeutic treatment and rehabilitation.

Conclusions: Although there were a variety of names, Low Secure Services were organised into two main categories of unit: the PICU and the LSU. These names should be adopted nation-wide as standard. There is need for a national strategy relating to the way PICUs and LSUs are developed.