Policy EDM

P3-02

ADMISSION, CARE, UTILISATION and DISCHARGE in PSYCHIATRIC INTENSIVE CARE UNITS

M I LLENN UM MIL L E N N IIU M

A New

A New

BEGINNING

MENTAL HEALTH in SOUTH AUSTRALIA

EMERGENCY DEMAND MANAGEMENT

Policy & Procedure Series

human services

2002-2005
November 2002

ADMISSION, CARE, UTILISATION and DISCHARGE in PSYCHIATRIC INTENSIVE CARE UNITS

A new

MILLENNIUM BEGINNING
A new

MENTAL HEALTH in SOUTH AUSTRALIA

EMERGENCY DEMAND MANAGEMENT

Policy & Procedure Series

2002-2005
DEPARTMENT OF HUMAN SERVICES Mental Health Services and Programs EDM P3-02 NOVEMBER 2002

Contents

Introduction Policy statement Principles Admission Criteria Priorities Minimum standards Procedures Contingency Planning Referral Bed utilisation Discharge Policy monitoring and review Abbreviations

3 3 4 6 6 6 7 9 9 10 10 11 12 12

This policy is one of the Emergency Demand Management policies that include EDM P1-02 Mental Health Emergency Demand Management - Best Practice for SA EDM P2-02 Admission, Care, Utilisation and Discharge in Acute Mental Health In-Patient Units EDM P3-02 Admission, Care, Utilisation and Discharge in Psychiatric Intensive Care Units EDM P4-02 Mental Health Emergency Demand Management for Children and Young People EDM P5-02 Mental Health Emergency Demand Management Contingency Planning EDM P6-02 Restraint and Seclusion in Health Units (including Mental Health Situations) EDM P7-02 Emergency Transport of Mental Health Consumers from Country Locations EDM P8-02 Emergency Demand Management and Assessment and Crisis Intervention Service Department of Human Services 2002. It may be reproduced in whole or in part for work, study or training purposes subject to the inclusion of an acknowledgement of the source and no commercial use or sale. National Library of Australia Cataloguing-in-Publication A new millenium, a new beginning : mental health in South Australia emergency demand management : policy and procedure series 2002-2005 ISBN 0 7308 9206 9 (EDM P3-02) 1. Mental health policy - South Australia. 2. Crisis intervention (Mental health services) - South Australia. I. South Australia. Mental Health Services and Programs. 362.2099423 A full copy of this policy and others in this series can be obtained from www.dhs.sa.gov.au/mental-health-unit/ or by contacting the Mental Health Services and Programs Branch Tel. (08) 8226 6286 or E-mail mentalhealthfeedback@dhs.sa.gov.au 2

Introduction

This policy is concerned with access to and provision of treatment for people who have been assessed as requiring admission to a psychiatric intensive care unit (ICU).
It is one policy in the Mental Health Emergency Demand Management policy series, and should be read in conjunction with the policy for acute mental health inpatient units - EDM P4-02 Admission, Care, Utilisation and Discharge in Acute Mental Health In-Patient Units. Brentwood, the ICU facility at Glenside Campus, will continue as a psychiatric intensive care facility until replacement tertiary specialist units at the Royal Adelaide Hospital (RAH) and the Flinders Medical Centre (FMC) are completed.

Policy statement

Psychiatric intensive care in-patient services provide short-term back up and support to other mental health services, for the management of individuals with complex, high acuity and severe behaviour disturbances.
All reasonable care alternatives within the consumer's mental health service should be trialled for as long as possible before consideration of referral to psychiatric ICU. Any person admitted to psychiatric ICU will have a primary mental health service that is responsible for care prior to and following ICU care. In most instances, people will not be admitted directly to or discharged from psychiatric ICU. Generally, consumers from forensic services will be managed by forensic services. Those services will need to develop contingency plans for occasions when ICU services might not be available.

Principles

Principles of good practice assist with the delivery of consistent, high quality psychiatric ICU services. Psychiatric ICU services will: National Standards for Mental Health Services criteria examples

1 2 3 4

Demonstrate the highest standard of skill and knowledge in psychiatry and mental health nursing that pertains to its group of consumers.

9.17 The MHS regularly identifies

training and development needs of its staff.

9.18 The MHS ensures that staff participate in education and professional development programs. 2.4 Staff are regularly trained to
understand and appropriately and safely respond to aggressive and other difficult behaviours. Develop and facilitate growth in knowledge and skills about 11.5.7 All services provided by the brief interventions at times of peak distress and disturbance in MHS are planned and delivered on psychiatric illness or disorder. the basis of the briefest appropriate duration of contact consistent with best outcomes for the consumer. Provide the highest standard of brief psychiatric assessment and treatment for all consumers admitted.

11.4.1 Treatment and support provided by the MHS reflect best available evidence and emphasise positive outcomes for consumers. 11.3.6 The assessment is conducted
using accepted methods and tools.

Provide a safe, secure environment for the implementation of 2.2 Treatment and support offered by such assessment and treatment. the MHS ensure that the consumer is protected from abuse and exploitation.

2.3 Polices, procedures and resources are available to promote the safety of consumers, carers, staff and the community. 11.4E.14 The MHS provides a
physical environment for inpatient care that ensures protection from harm, adequate indoor and outdoor space, privacy and choice.

Provide a service that promotes and strengthens the role of families and carers in assisting with recovery from acute episodes of psychiatric illness or disorder.

5.3 The MHS encourages, and provides opportunities for, the consumer to involve others in their care. 11.4E.8 The MHS ensures that the
consumers visitors are encouraged.

5 6 7

1.5 The right of the consumer not to

have others involved in their care is recognised and upheld to the extent that it does not impose imminent serious risk to the consumer or other person(s). Provide support and/or interventions for other mental health services at times when a consumer's level of distress and disturbance is too great for that services resources/skills/knowledge.

8. The MHS is integrated and

coordinated to provide a balanced mix of services which ensure continuity of care for the consumer.

Contribute to the promotion and maintenance of co-operative 8.1.5 The MHS has documented relationships with other mental health services, with referring policies and procedures which are general practitioners and with the private sector. used to promote continuity of care across programs, sites, other services and lifespan.

8.2.1 The MHS is part of the general

health care system and promotes comprehensive health care for consumers, including access to specialist medical resources.

Admission

Criteria
Psychiatric ICU will provide brief, specialist, tertiary-level psychiatric intensive care services to the following group of consumers over the age of 18 years. A person who is: detained under the Mental Health Act 1993 (SA); AND experiencing an acute episode of psychiatric illness or disorder; AND exhibiting psychiatric symptoms complicated by severe behavioural disturbance; AND medically stable; AND unable to be managed safely in an open ward setting; AND has exhausted the resources of closed units at 1G, Cramond and Morier wards.

Reportable event

Persons under 18 years of age will be managed according to the policy EDM P4-02 Mental Health Emergency Demand Management for Children and Young People. Admission of a person under the age of 18 years to an adult psychiatric ICU will be a reportable event, in which the Director, Mental Health Services and Programs, Department of Human Services is notified and mandatory review undertaken.

Priorities
When there are more consumers who meet admission criteria than beds available, the following priorities will be used to establish admission: 1. Consumers in hospital emergency departments or medical wards. 2. Consumers in the care of community mental health teams. 3. Consumers in care of specialist mental health in-patient service, including a forensic service.

Minimum standards

Minimum standards will assist services to provide consistent and equal treatment, objectively assess
performance and identify areas for continuous improvement. It is expected that all mental health services will meet the standards within agreed implementation timeframes. 1. 2. Psychiatric ICU will provide tertiary level complex intervention for consumers who meet the admission criteria. Every consumer in psychiatric ICU will receive the triad of: Highly specialised nursing interventions designed to relieve distress and de-escalate disordered behaviour. Evidence based pharmacological management including combinations of anti-psychotics and benzodiazepines as appropriate to relieve distress and achieve a low level of sedation. Education and support for them and their carer or family about their illness and strategies that they or their carer or family can undertake to achieve self-management of some symptoms. Purpose designed protocols for pharmacological management will be available to assist and guide clinicians. Protocols will specify the preferred drugs, the dosages and the timeliness of their use. Protocols will be prepared by the Psychiatric Intensive Care Drugs and Therapeutics Subcommittee of the Glenside Hospital Drugs and Therapeutics committee. Those protocols will be approved by the Director, Psychiatric ICU and DHS Mental Health Services and Programs. Consultant psychiatrists may elect to use alternative medication protocols provided that their reasons for so doing are documented in the consumer clinical file. Registrars may not use alternative protocols unless specifically permitted to do so by a consultant psychiatrist. All staff working in psychiatric ICU will participate in regular update training in aggression prevention, de-escalation and management strategies, and records of attendance will be kept. Every nurse will have attended one up-date session every six months; and every registrar, consultant psychiatrist and allied health staff member will attend at least annually. Registrars on six-month rotation will be required to attend at least once during the rotation. The policy EDM P6-02 Restraint and Seclusion in Health Units (including Mental Health Situations) defines protocols which specify reasons for use and initiation, manner of use, supervision and reporting of restraint or seclusion. In addition to the procedures specified in that policy.

3.

4.

5.

6.

7.

7.1 Any consumer who requires greater than eight hours continuous seclusion in any 24-hour period will receive a consultation by a psychiatrist (by telephone if necessary). 7.2 Any consumer who has required greater than 12 hours total seclusion or restraint during a psychiatric intensive care episode will receive a second opinion assessment from a psychiatrist who is different from the treating psychiatrist.

7.3 If there is more than 24 hours total seclusion or restraint in three days, the matter will be referred for discussion to the Glenside Hospital Patient Care Committee. 8. Every consumer will have a Statement of Rights provided verbally and in writing (with appropriate language translation where necessary) at the time of their admission, and again verbally (and in writing if requested) daily during their stay as their level of distress lessens and their capacity to understand the information increases. 9. Visits by family members and carers will be encouraged to occur as often as practical during a consumers stay. Any restriction on family or carer visits for any reason will be documented in the consumer file and will be referred to the Patient Care Sub-Committee for discussion.

Reportable event

10. Should any consumer require more than five days in psychiatric ICU the Clinical Director, Glenside Campus will be notified on the next working day and a review undertaken. 11. There will be as much documented evidence as possible on use of standardised and objective assessment of a consumers progress in psychiatric ICU, using constructive recovery strategies.

Procedures

Contingency planning
Every mental health service will have systems in place to ensure that, at times of higher than usual demand, bed availability is maximised. Contingency planning for mental health is described in detail in the policy EDM P5-02 Mental Health Emergency Demand Management Contingency Planning. It should be an extremely rare occurrence where a psychiatric intensive care consumer is waiting for a bed in a hospital emergency department or medical ward. A more settled consumer from an acute mental health in-patient unit will be transferred to a general hospital medical bed, in order to make a bed available temporarily for a consumer waiting for intensive care admission. The following procedure will be used specifically when there are insufficient available beds in psychiatric ICU. A decision will be made at noon (1200 hours) each day as to whether contingency planning is required. This will be done by consultation between the Brentwood Assessment Team (BAT) and the local mental health service (Directors nominee) requesting a psychiatric ICU admission. Following this discussion, BAT will then prioritise consumers waiting for admission to psychiatric ICU, and those most ready for early discharge from psychiatric ICU. Information will be conveyed by BAT to the local mental health service, about likely waiting times in order that alternative care plans can be implemented. If necessary, BAT will alert the Director Psychiatric ICU of the need to implement the psychiatric ICU contingency plan. If activated, the plan will comprise the following steps: 1. 2. All consumers currently in psychiatric ICU will be urgently reviewed. Those most likely to be ready for discharge to another mental health service will be identified. All mental health services will review current in-patients in their units and discharge consumers wherever possible (according to general contingency planning rules in policy EDM P5-02) in order to create a place for a person requiring discharge from psychiatric ICU to the acute in-patient unit. Any mental health service that identifies a consumer requiring a psychiatric ICU bed will make every effort possible to create a vacancy in their unit for a person who can be discharged from psychiatric ICU, so that the identified consumer needing psychiatric ICU can be admitted. Any consumer waiting for a psychiatric ICU bed will have in place an interim psychiatric intensive care plan that comprises: An up-to-date Risk Assessment. A strategy for de-escalation of distress and disturbance which includes: appropriate one-to-one nursing care titrated medication regime psychological support to minimise distress. Every possible consideration of options to facilitate admission to the acute Mental Health in-patient unit while waiting for an intensive care bed.

3.

4.

Referral
Only a registrar (or consultant psychiatrist) who has personally reviewed the consumer and determined that all steps have been taken to manage the person in a less intensive environment can refer a consumer to psychiatric ICU. The following documentation should accompany the person being referred wherever possible; however, on occasions, verbal referral followed by faxed information will be accepted. A formal risk assessment. A recent comprehensive Mental State Examination (MSE). A review of medical status to ensure medical stability. Generally it is not appropriate to refer a consumer to a psychiatric ICU if they have delirium or severe intoxication, however this should be considered on a case-by-case basis. The referral to psychiatric ICU is done via the BAT, in negotiation with the Director, Psychiatric ICU. The role of the BAT in the referral process is to: Confirm that the mental state examination and the risk assessment have been completed. Discuss and document previous treatment and its effect, before requesting a psychiatric ICU bed. Determine the immediate needs the consumer will have upon admission including religious, cultural and language requirements. Discuss with the referring doctor the likely length of stay and discharge arrangements. In most circumstances discharge will be expected within three days of admission. Make contact with families or carers to provide information about psychiatric ICU and to negotiate any role they may wish to have in transport and admission of the consumer to psychiatric ICU, in order to reduce consumer stress and trauma. Determine priorities for admission between consumers when more than one meets the admission criteria, and there are insufficient beds to admit all at the same time. Offer advice to referring doctors for temporary management of the consumer when a bed in psychiatric ICU is not available. On occasions, if appropriate, a BAT member will travel to the referring site to offer assistance and advice regarding alternatives to referral to psychiatric ICU.

Bed utilisation
1. All consumers in psychiatric ICU will be reviewed by a psychiatry registrar and/or a consultant psychiatrist at least once in every 24-hour period including during weekends and public holidays. This review should occur where possible prior to noon (1200 hours) each day. All consumers in psychiatric ICU will have a formal risk assessment completed at least once in every nursing shift. All consumers in psychiatric ICU will have their potential discharge date specified upon admission and reviewed daily prior to noon (1200 hours). All mental health services will be notified daily of all consumers of the services who are occupying beds in psychiatric ICU, together with potential discharge dates. This notification will occur as close as possible to 0800 hours.

2. 3. 4.

10

5. 6. 7.

No consumer will stay in psychiatric ICU more than 24 hours beyond the individual optimum discharge date. Any consumer who is thought likely to be ready for discharge within 24 hours may be discharged earlier if appropriate and if there is a higher priority consumer awaiting admission. All consumers, their carers and families and their mental health service will be informed of the likelihood of discharge up to 24 hours earlier then planned.

Discharge
1. 2. 3. Discharge will always be to the care of a specific mental health service that will assume responsibility for further planning and care for the consumer. Discharge will occur within 24-hours of the criteria for admission no longer applying. It is the responsibility of the primary mental health service to ensure there is a bed available to accept a consumer ready for discharge from psychiatric ICU, as soon as possible, and at least within 24 hours of being informed of their readiness for discharge. It is the responsibility of the primary mental health service to ensure there is a bed available immediately to accept a consumer ready for discharge from psychiatric ICU, if there is a consumer of that service waiting for admission to psychiatric ICU. It would be rare that a consumer would be discharged directly to the community mental health team from a psychiatric ICU. Psychiatric ICU will ensure that a comprehensive summary of issues, care and treatment, and of serial risk assessments will accompany the consumer at the point of their discharge, and the consumers GP will be advised, unless the consumer specifically directs that this not occur. Psychiatric ICU staff will endeavour where possible to facilitate the family member or carer accompanying the consumer to their discharge destination in order to minimise the trauma associated with relocation.

4.

5. 6.

7.

11

Policy monitoring and review

The Emergency Demand Management policy series will be complemented by a State-wide key performance indicator (KPI) strategy. The key policy objectives will be translated into a set of quantifiable indicators that will be used at a State level to measure progress toward achieving the policy objectives.
Health services, as part of the quality improvement processes, are also expected to continually monitor progress during policy implementation, to identify areas for improvement, set in place actions to ensure compliance with the policy series. The DHS Mental Health Services and Programs will review the Emergency Demand Management policy series in December 2005.

Abbreviations

BAT DHS EDM FMC ICU KPI MHS MSE RAH

Brentwood Assessment Team Department of Human Services Emergency Demand Management Flinders Medical Centre Intensive Care Unit Key Performance Indicator Mental Health Service Mental State Examination Royal Adelaide Hospital

12