Psychiatric intensive care units (PICUs) were designed to create a safe and controlled environment for the management of acutely disturbed psychiatric patients on a short-term basis, with high staffing levels and a limited number of beds. Admission and discharge criteria are usually clearly defined and the majority have locked doors (Reference Michalon and RichmanMichalon & Richman, 1990; Reference Hyde and Harrower-WilsonHyde & Harrower-Wilson, 1996). The average length of stay ranges from 2.6 days (Reference Hafner, Lammersma and FerrisHafner et al, 1989) to 30 days (Reference Citrome, Green and FostCitrome et al, 1994), although Rachlin (Reference Rachlin1973) reported that 20% of his patients stayed over 2 months.

The majority of PICUs reported in the literature provide care and treatment for non-offender patients with mental illness who cannot be managed in open wards. In the UK, intensive care for mentally disordered offenders is provided by the secure psychiatric services. Problems in the movement of patients through different levels of security, however, has led to the development of PICUs in some medium secure facilities. As far as we are aware this is the first report on the characteristics and outcomes of a cohort admitted to a PICU in a medium secure unit (MSU) in Britain.

The study

Using a precoded form, data were extracted from case notes on the characteristics and outcomes of 73 patients who were admitted to a PICU in a MSU in the North-West of England between its opening in July 1994 and April 1998. The five bed PICU, which was set up and run by nursing staff, was an annex to one of the three wards in the 60-bed MSU — Edenfield Centre. Unlike other ward areas, the PICU did not have a designated seclusion room. Staff to patient ratios were a minimum of 1:1, unlike other ward areas where staff to patient ratios were much lower. The unit was intended as a crisis facility to deal with patients with challenging behaviours who could not be managed on less staffed wards, but were unlikely to require maximum security because of the likely brevity of their disturbed behaviour. Assessments for transfer to and from the PICU were made by nurses from the relevant areas, and patients requiring PICU care at its inception were considered unsuitable for unescorted leave. The unit did not have explicit admission or discharge criteria in terms of patient characteristics, but was seen solely as a facility for managing disturbed behaviour.

Data were collected on the demographic details, medical/psychiatric history and criminal history of all subjects. Details pertaining to the current admission, for example, presenting problems (index offence), management problems and outcome following the PICU admission, were examined. Psychiatric diagnoses were based on DSM-III-R criteria (American Psychiatric Association, 1987).

Findings

During the study period 73 patients (one-third of the MSU population at that time) were admitted to the PICU. These patients accounted for 78 PICU admission episodes. Five patients were admitted on two occasions. The sample characteristics are shown in Table 1. The majority were male, Caucasian, single and referred from prison. The mean age of the sample was 33.2 years (s.d.=9.2). Most patients (48, 66%) were detained under Part III of the Mental Health Act (MHA) 1983 and the legal category of mental illness (65, 89%). Twenty (27%) patients were on hospital orders with restrictions (Section 37/41, MHA 1983).

Table 1. Characteristics of the sample

Demographic	n=73 (%)
Gender (male)	59 (81)
Caucasian	37 (61)
Afro-Caribbean	16 (27)
Asian	8 (13)
Married/cohabiting	13 (18)
Source of referral	n=73 (%)
Prison	37 (51)
District general hospital	18 (25)
Community	17 (23)
Maximum security	1 (1)
Offences	n=73 (%)
Assault	23 (32)
Arson	9 (12)
Homicide	8 (11)
Acquisitive	8 (11)
Sex offences	6 (8)
Motoring	3 (4)
Primary diagnosis	n=73 (%)
Psychosis	56 (77)
Affective disorder	10 (14)
Personality disorder	5 (7)
Neurosis	1 (1)
Asperger's syndrome	1 (1)
Secondary diagnosis	n=34 (%)
Brief reactive psychosis	4 (11)
Affective disorder	8 (21)
Neurosis	2 (5)
Personality disorder	9 (24)
Substance abuse	27 (71)
Dementia	1 (3)
Learning difficulties	1 (3)
Eating disorder	1 (3)
Physical disability	n=21 (%)
Respiratory problem	6 (29)
Cardiovascular	5 (24)
Epilepsy	4 (19)
Musculoskeletal	4 (19)
Skin/wound problems	3 (14)
Brain damage	3 (14)

Outcomes

Discussion

As far as we are aware this is the only study reporting on a PICU in a forensic setting, perhaps because most MSUs have sufficient staffing and security measures to deal with difficult or challenging patients and these units are a rarity.

The majority of admissions to the PICU were as a result of a significant deterioration in mental state/behaviour and most cases were eventually successfully transferred to less secure environments on the unit. On the surface this suggests that for the most part the unit operated as a crisis facility for patients with acute disturbance. However, our finding that one-third of MSU patients were admitted to the PICU and relatively few (five) cases were repeat admissions by the same individuals points to the PICU being used in an unintended manner. This may well reflect the lack of clear admission criteria at its inception. The mean length of stay was considerably longer than is reported in non-offender PICUs and could be explained by the forensic nature of the population and the observed relationship between incident rates and length of stay.

Contrary to the admission policy for the unit we note that 10% of cases (particularly female patients and those with physical health care needs) were placed on the PICU because it provided a safe environment, that is, high levels of staffing and observation. This phenomenon probably reflects the lack of appropriate facilities elsewhere (in less secure environments) on the MSU. At the time of study there were no single sex wards or suitably staffed ward areas for those with physical health needs on the unit and our findings highlight the need for such specialist services.

In terms of the immediate outcomes following discharge from the PICU, the majority of cases were relocated on the unit without much difficulty when beds became available — the latter being the most significant rate-limiting factor. Perhaps because of the bed crises inter- or intra-disciplinary arguments were rare and it was accepted that admission and discharge from the PICU could not be based on strict operational criteria. Despite this we were surprised by the number of cases (11) that were discharged directly from the PICU to the community and district services without pre-discharge relocation to less intensively nursed areas on the MSU. In all of these cases patients had shown striking improvements in mental state and behaviour with treatment and discharge directly from the PICU clearly occurred because of a lack of available beds elsewhere on the unit. These patients were also (contrary to PICU policy) having unescorted leave in the community, which highlights the difficulties of running the PICU in a strict sense when there are insufficient beds to meet a variety of patients' needs.

In conclusion, this study demonstrates the difficulties in running a PICU in a true sense in a MSU when there are no clear criteria for admission and discharge and there is a shortage of beds on the MSU as a whole. Since this study the PICU has closed, the ward is now a female only facility, a physical health care nurse has been appointed and a pre-discharge hostel ward opened.