Reducing the use of seclusion to deal with challenging behaviour is a priority in secure services for women. This study describes the concurrent introduction of a series of initiatives based on recovery principles and the full involvement of patients in their risk management plans.

Following change implementation, the first 19 patients who had completed one year of treatment were matched with 19 patients who had completed their first year of treatment before change.

A significant decline in both the number of seclusions and risk behaviour post-change was complemented by improved staff ratings of institutional behaviour, increased treatment engagement and a reduction in time spent in medium security. Staff and patients differed in terms of their ratings of the most effective strategies introduced. Patients favoured the Relational Security item of increased individual engagement and timetabled Behaviour Chain Analysis sessions. Staff viewed on ward training and use of de-escalation techniques as most effective.

Findings confirm results from mixed gender forensic mental health samples that seclusion can be successfully reduced without an increase in patient violence or alternative coercive strategies. Limitations of the study are discussed along with the need for future evaluations to address issues of fidelity and utilise vigorously designed case studies.

Little is known about how different groups of health-care workers compare to each other and to the general public in their opinions about involuntary admission and treatment. In the present study, 1,094 people in Norway responded to a questionnaire containing three cases with patients suffering from schizophrenia. They were asked in which cases they would admit involuntarily and treat involuntarily with neuroleptics. An overwhelming majority would coerce when the patients were violent. Between a third and a half would coerce when the patients had problems coping with activities of daily life, or when the patients were in an early schizophrenic development with few symptoms. In all the cases, significantly more would accept involuntary admission than involuntary treatment with neuroleptics. The results suggest that health-care workers' attitudes to coercion in psychiatric care are in line with the attitudes of the general public. Prior experience with coercion, female sex, not having a college/university education, having a profession other than social worker, and not currently being employed in the psychiatric services, were positive predictors of willingness to coerce.

It has become evident that Psychiatric Intensive Care Units (PICU) accept aggressive, violent patients often with criminal histories and personality disorders. This paper aims to document the effects that this patient group can have on a PICU and the significant role that psychotherapy can offer this complex patient group. The conclusions have been drawn from psychotherapeutic work on a PICU (Pathways on Tagore, NELMHT). Such patients present unique therapeutic and emotional challenges to staff. As a result staff need to recognise and address these issues. This paper identifies and discusses a number of central themes, challenges and practical skills that may be important in enabling the successful treatment of such patients within a PICU setting.

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.

Rapid Tranquillisation (RT), defined as “the use of psychotropic medication to control agitated, threatening or destructive psychotic behaviour”, is a last resort pharmacological intervention. The withdrawal of the widely used droperidol in 2001 due to concerns over QTc prolongation may have increased the variability in RT practice across the UK. This paper reports on a UK wide survey of the practice of RT by psychiatrists. The survey pre-dated publication of NICE guidance on management of distributed behaviour. 257 questionnaires were received (response rate 22%). In comparison with previous surveys of this type, the overall quality of prescribing and monitoring has improved, although some apparently idiosyncratic practice remains. The majority of psychiatrists expressed concerns about prescribing and monitoring RT and would welcome an easy to use algorithm and associated training package. Findings are discussed in terms of training implications and BNF recommendations for high dose prescribing.

Aims and method: To measure the numbers of staff and patients experiencing physical assault, and identify the perception of staff and patients regarding alcohol and drug related violence on Psychiatric Intensive Care wards (PICUs), acute adult wards and forensic wards. Postal questionnaires were received from 2761 individuals. They yielded quantitative and qualitative data. Further information arose from discussion groups of staff at feedback events.

Results: Nurses on PICUs (61%) were more likely to report assault than those on acute wards (45%) or forensic wards (33%). Patients on PICUs (25%) were significantly more likely to report assault than those on acute wards (14%) but not forensic wards (23%). Nurses were more likely than patients to report that drugs and alcohol had caused violence on their ward. Nurses on PICUs and forensic wards thought drug use was more likely to cause violence than alcohol. Compared with PICUs, more nurses considered that violence was due to alcohol and drugs on acute wards but not on forensic wards. Many nurses on PICUs carried out personal searches but few had received training in this.

Conclusion: Nurses on PICUs appear to be at particularly high risk of violence. Reducing the availability of illegal drugs on PICUs and improvement of staff training could be important means of reducing violence.

Aims: To compare the clinical characteristics of patients who absconded and those who did not abscond; and to show the types of absconding behaviour in a low secure challenging behaviour mental health unit.

Method: A retrospective case control study was conducted. Details of the absconding incidents were collected from an electronic incident database. Clinical predictors of patients who absconded (cases) and those who did not (controls) were compared. Statistical analysis was performed to determine statistical significance of the observed differences.

Results: 80 admissions resulted from 78 patients during a period of 6½ years. 22% of the inpatients absconded from the unit. 84% of the incidents occurred while patients were utilising their unescorted leave. Only one patient escaped from the building. No serious incidents resulted from any of the abscondings. On univariate analysis, the following predictors were more likely to be statistically associated with patients who absconded from the unit: a history of absconding behaviour and a history of substance misuse or dependence. A history of non-compliance with treatment, a history of sexually inappropriate behaviour and a history of childhood conduct problems showed a trend towards statistical significance.

Conclusion: The clinical characteristics of patients who abscond from low secure units show similarities with those who abscond from other psychiatric inpatient settings.

Declaration of interests: None.

Background: Rapid tranquilisation (RT) is one of the highest risk clinical procedures currently undertaken by mental health services, yet it is underpinned by a surprisingly weak evidence base. The evidence base is weaker still when applied to post RT monitoring.

Aims: To review current clinical monitoring practice contained within adult RT documents in the UK.

Method: A review of adult RT documents currently in use in NHS or HSC trusts providing adult mental health services in the UK.

Findings: A total of 44 RT documents were examined. A picture of wide ranging practice was observed that prevented us from undertaking a full analysis of the data collected. Even when analysis was confined to the intramuscular route, there were concerning differences between documents in: when monitoring was initiated; what was being monitored; and the frequency and duration of this monitoring.

Conclusions and implications for clinical practice: There is a fundamental need for consensus in this high risk practice. The College of Mental Health Pharmacists, Royal College of Nursing and Royal College of Psychiatrists should have a key role in fashioning this consensus in both practice and policy.

Background: Seclusion in psychiatric inpatient settings is contentious, and services attempt to minimize its use. Many studies compare seclusion rates before and after the introduction of an intervention, but few control for the effect of external factors such as legislative constraints and patient characteristics.

Aims: To evaluate the effect of a programme designed to manage acute arousal.

Method: Seclusion rates in a six-month period incorporating a programme to manage acute arousal were compared with the previous six months. The intervention focused on formal assessment of arousal levels and an escalating set of actions by nursing staff.

Results: Seclusion rates in the two periods were comparable, both before and after controlling for patient characteristics. Duration of seclusion events appeared to be heavily influenced by local legislative constraints.

Conclusions: A programme designed to reduce seclusion showed no difference from baseline after taking various factors into account. This may have been at least partly because most seclusion events occurred early in an admission. Many patients arrive on the unit already requiring seclusion, and any impact of a ward programme on them is limited. Since seclusion is a comparatively uncommon event, and attributable to a minority of patients, appropriate analytic methods are required.

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.

Rapid tranquilization (RT) is a procedure used in an inpatient setting to deal with acute behavioural disturbance not manageable by other means. The 2gether NHS Foundation Trust has an RT policy which incorporates the National Institute of Clinical Excellence (NICE) guidance on best practice which breaks down into eight domains.

The aim of this audit was to scrutinize practice in relation to this policy.

The audit team sampled 50 Prevention and Management of Violence and Aggression (PMVA) incidents that occurred over a four month period at Wotton Lawn Hospital and the Montpellier Low Secure Unit in Gloucester. PMVA is a method of organized restraint involving a team of three staff used to administer parenteral RT as well as managing disturbance. Data was collected using an audit proforma.

This audit demonstrated adherence to the majority of standards in the RT policy in most incidents. However, there was a significant non-compliance in two areas: appropriate physical observations being carried out after an RT incident and administration of RT in a private area. It may be that standards were in fact met but that there was no evidence for this in the documents examined.

The authors believe that clinical practice can be improved by effective training of staff that emphasizes the need to meet standards and the importance of contemporaneous documentation following an RT incident. They have disseminated the results of this audit to appropriate clinical leads and trainers.

The audit will be repeated in 12 months’ time.

Giving medicines to quickly calm the severely agitated patient, in order to reduce the risk of imminent and serious violence to self or others, is referred to as rapid tranquillisation (RT).

Despite national guidelines on the management of violence, several Royal College of Psychiatrists guidelines, consensus statements, best practice guidelines, and numerous reviews of the evidence, there is no current consensus as to the first line pharmacological agent in RT.

Over the last few years there have been a number of new medicines for RT, new formulations, and new evidence. The discontinuation of droperidol injection led to more widespread use of haloperidol. The maximum dose of haloperidol has decreased, baseline ECGs are now recommended, and it is no longer licensed for IV administration. These developments have led to changes in RT practice.

In order to safely use the new medicines and new formulations it is imperative that all staff involved in prescribing and administration should be familiar with the practical use of these medicines. This includes methods of preparation and administration, specific side effects and monitoring requirements, as well as their own responsibilities in regard to these medicines.

Though only engaged in by a minority of sufferers, self-harm and violence can nevertheless occur within the context of a variety of mental illnesses, from personality disorder to affective disorders, to schizophrenia and other psychoses. Violence to the self (both with and without suicidal intent) and others are not uncommon occurrences on psychiatric wards. This paper explores the utilisation of a new mindfulness centred therapeutic protocol based on acceptance and commitment therapy for the management of self-harm and violence. The protocol was piloted on three patients with a history of high levels of violence to self or others on a psychiatric intensive care unit in London. An outline of acceptance and commitment therapy is provided, together with a detailed description of the protocol for the intervention itself, and some of the outcomes achieved. Recommendations for further adaptations, studies and clinical trials are considered.

Seclusion of psychiatric inpatients is used as a last resort in managing disturbed behaviour. Research on factors contributing to its use is limited. The aim of this study was to examine the effect of a change in unit size and other variables, such as time of day and nursing workload, on the rates of use of seclusion in an intensive care inpatient psychiatric unit. Rates of seclusion were examined in randomly selected nursing shifts across three time periods; one before and two after a change in the size of the unit. Effects on seclusion rates of size, shift and four nursing workforce variables were explored using multivariate analysis. Unit size, shift and nurse hours together explained 23% of the variance in seclusion use. Of particular significance was the change from a 20 bed unit to two separate 10 bed units. The findings have implications for the organisation of inpatient psychiatric units. Smaller units may allow better management of disturbed behaviour.

Background: Physical illnesses are more prevalent among patients with serious and enduring mental illnesses. This is mainly due to the association between mental and physical illnesses, complications of the mental illness itself and as a side effect of medication. Medical problems can be overlooked by psychiatrists due to several reasons. More research and audit of the existing services are necessary to establish the physical needs of patients with complex mental health problems.

Aim: To give an account of the causes of excessive mortality and physical morbidity among patients with serious mental health problems.

Method: Review of the worldwide literature.

Results: Physical problems are more common and the standardised mortality rate (SMR) is higher in psychiatric patients compared to the general population. The main causes are association between mental and physical illnesses, lifestyle including lack of physical activity, smoking and poor dietary habits, metabolic syndrome, diabetes mellitus and other cardiac risk factors. There is a close association between treatment with antipsychotic medication and weight gain, diabetes mellitus, sudden death, cardiac and endocrine complications such as QT prolongation and also hyperprolactinemia.

Conclusion: The paper highlights the importance of monitoring physical problems in patients with serious and enduring mental illnesses. Good practice points include help with smoking cessation, psycho-education about healthy lifestyle, close liaison between carers and professionals, the importance of taking baseline investigations before commencing antipsychotics, a shared care approach with primary care, early identification of the risk factors for physical illnesses and regular monitoring of physical health. Also important are social interventions such as appropriate accommodation and structured day, leisure and sporting activities.

At least twenty-five years have passed since the term ‘psychiatric intensive care unit’ (PICU) was imported into the UK and Western Europe from the United States. During that time the concept of psychiatric intensive care has continued to develop, with a number of important milestones.

Background: Previous studies have shown that as well as being an effective antipsychotic, clozapine reduced aggressive and violent incidents. Most of the studies measured the length of time the patients were on clozapine, or the dose of the clozapine when the effectiveness was evaluated.

Method: A retrospective audit was designed to see the effectiveness of clozapine in reducing incidents in a low-secure challenging behaviour unit. The number of incidents was calculated pre and post the date when clozapine serum level reached the therapeutic level of 0.35μg/l. Then, the number of incidents per month (incidents/month ratio) before and after reaching the therapeutic level was calculated.

Results: The number of incidents per month was reduced by over 75%. Before serum clozapine level reached 0.35μg/l the number of incidents/month/patient was 1.22 and after reaching 0.35μg/l, it was 0.26 (p=0.004).

Conclusions: The use of clozapine reduced the number of adverse incidents by 75%. The monitoring of serum levels was found to be clinically useful.

Background: The physical environment of a Psychiatric Intensive Care Unit (PICU) or Low Secure Unit (LSU) is one of its defining aspects. The National Minimum Standards for General Adult Services in PICUs and Low Secure Environments published by the Department of Health (2002) outlines the standards to be followed regarding design of PICUs and LSUs. Till date, no comprehensive national data exists about the standard of physical environment of these units.

Aim: To determine whether current physical environment of PICUs and LSUs are adequate to meet the therapeutic needs of patients in England.

Method: An inventory was sent to all NHS PICUs and LSUs (in England).

Results: A total of 231 units were identified as either PICUs or LSUs. Out of these, 164 valid returns were received. Sixty PICU units (62.5%) and 43 LSU units (63.5%) were good or acceptable. Thirty six PICU units (37.5%) and 25 LSU units (36.5%) failed on several issues. Analysis of the data showed that to bring the PICU/LSU Estate to a good standard is anticipated to cost approximately £140million.

Conclusion: The Department of Health has allocated funding of £30 million to be distributed amongst all the 28 Strategic Health Authorities. A further funding of £130 million has also been released to address places of safety and for upgrading PICUs and LSUs to meet the National Minimum Standards.

Declaration of Interest: The project was funded by the Department of Health.