M I L L E N N I U MA New

A New

BEGINNING

ADMISSION, CARE,UTILISATION andDISCHARGE inPSYCHIATRICINTENSIVE CARE UNITS

2002-2005

MILLENNIUM

P3-02Policy EDM

h u m a n s e r v i c e s

November 2002

MENTAL HEALTH inSOUTH AUSTRALIAEMERGENCY DEMAND MANAGEMENT

Policy & Procedure Series

A new

M I L L E N N I U MA new B E G I N N I N G

ADMISSION, CARE,

UTILISATION and DISCHARGE

in PSYCHIATRIC INTENSIVE

CARE UNITS

2002-2005DEPARTMENT OF HUMAN SERVICESMental Health Services and Programs

EDM P3-02NOVEMBER 2002

MENTAL HEALTH in SOUTH AUSTRALIAEMERGENCY DEMAND MANAGEMENT

Policy & Procedure Series

Introduction 3

Policy statement 3

Principles 4

Admission 6Criteria 6Priorities 6

Minimum standards 7

Procedures 9Contingency Planning 9Referral 10Bed utilisation 10Discharge 11

Policy monitoring and review 12

Abbreviations 12

2

Contents

This policy is one of the Emergency Demand Management policies that include EDM P1-02 Mental Health Emergency Demand Management - Best Practice for SAEDM P2-02 Admission, Care, Utilisation and Discharge in Acute Mental Health In-Patient UnitsEDM P3-02 Admission, Care, Utilisation and Discharge in Psychiatric Intensive Care UnitsEDM 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 LocationsEDM P8-02 Emergency Demand Management and Assessment and Crisis Intervention Service

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

National Library of Australia Cataloguing-in-Publication

A new millenium, a new beginning : mental health in South Australia emergencydemand 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 healthservices) - South Australia. I. South Australia. Mental Health Services and Programs.

362.2099423

© Department of Human Services 2002. It may be reproduced in whole or in part for work, study ortraining purposes subject to the inclusion of an acknowledgement of the source and no commercialuse or sale.

This policy is concerned with access to and provision of treatment for people who have beenassessed 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 beread 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 facilityuntil replacement tertiary specialist units at the Royal Adelaide Hospital (RAH) and the FlindersMedical Centre (FMC) are completed.

3

Introduction

Policy statement

Psychiatric intensive care in-patient services provide short-term back up and support to othermental health services, for the management of individuals with complex, high acuity and severebehaviour disturbances.

All reasonable care alternatives within the consumer's mental health service should be trialled foras long as possible before consideration of referral to psychiatric ICU.

Any person admitted to psychiatric ICU will have a primary mental health service that isresponsible for care prior to and following ICU care. In most instances, people will not beadmitted directly to or discharged from psychiatric ICU.

Generally, consumers from forensic services will be managed by forensic services. Those serviceswill need to develop contingency plans for occasions when ICU services might not be available.

4

National Standards for Mental HealthServices criteria examples

Demonstrate the highest standard of skill and knowledge inpsychiatry and mental health nursing that pertains to itsgroup of consumers.

Develop and facilitate growth in knowledge and skills aboutbrief interventions at times of peak distress and disturbance inpsychiatric illness or disorder.

Provide the highest standard of brief psychiatric assessmentand treatment for all consumers admitted.

Provide a safe, secure environment for the implementation ofsuch assessment and treatment.

9.17 The MHS regularly identifiestraining and development needs of itsstaff.

9.18 The MHS ensures that staffparticipate in education andprofessional development programs.

2.4 Staff are regularly trained tounderstand and appropriately andsafely respond to aggressive andother difficult behaviours.

11.5.7 All services provided by theMHS are planned and delivered onthe basis of the briefest appropriateduration of contact consistent withbest outcomes for the consumer.

11.4.1 Treatment and supportprovided by the MHS reflect bestavailable evidence and emphasisepositive outcomes for consumers.

11.3.6 The assessment is conductedusing accepted methods and tools.

2.2 Treatment and support offered bythe MHS ensure that the consumer isprotected from abuse andexploitation.

2.3 Polices, procedures and resourcesare available to promote the safety ofconsumers, carers, staff and thecommunity.

11.4E.14 The MHS provides aphysical environment for inpatientcare that ensures protection fromharm, adequate indoor and outdoorspace, privacy and choice.

Principles of good practice assist with the delivery of consistent, high quality psychiatric ICU services.

Psychiatric ICU services will:

Principles

1

23

4

5

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

Provide support and/or interventions for other mental healthservices at times when a consumer's level of distress anddisturbance is too great for that service’sresources/skills/knowledge.

Contribute to the promotion and maintenance of co-operativerelationships with other mental health services, with referringgeneral practitioners and with the private sector.

5.3 The MHS encourages, andprovides opportunities for, theconsumer to involve others in theircare.

11.4E.8 The MHS ensures that theconsumer’s visitors are encouraged.

1.5 The right of the consumer not tohave others involved in their care isrecognised and upheld to the extentthat it does not impose imminentserious risk to the consumer or otherperson(s).

8. The MHS is integrated andcoordinated to provide a balancedmix of services which ensure continuityof care for the consumer.

8.1.5 The MHS has documentedpolicies and procedures which areused to promote continuity of careacross programs, sites, other servicesand lifespan.

8.2.1 The MHS is part of the generalhealth care system and promotescomprehensive health care forconsumers, including access tospecialist medical resources.

5

67

6

Admission

Criteria

Psychiatric ICU will provide brief, specialist, tertiary-level psychiatric intensive care services to thefollowing 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.

Persons under 18 years of age will be managed according to the policy EDM P4-02 Mental HealthEmergency Demand Management for Children and Young People. Admission of a person under theage 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 mandatoryreview undertaken.

Priorities

When there are more consumers who meet admission criteria than beds available, the followingpriorities 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.

Reportableevent

7

Minimum standards

Minimum standards will assist services to provide consistent and equal treatment, objectively assessperformance and identify areas for continuous improvement. It is expected that all mental healthservices will meet the standards within agreed implementation timeframes.

1. Psychiatric ICU will provide tertiary level complex intervention for consumers who meet the admission criteria.

2. 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 andbenzodiazepines 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.

3. 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.

4. Protocols will be prepared by the Psychiatric Intensive Care Drugs and Therapeutics Sub-committee 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.

5. 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.

6. 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.

7. 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.

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.

8

7.3 If there is more than 24 hours’ total seclusion or restraint in three days, the matter will be referredfor 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 consumer’s stay. Any restriction on family or carer visits for any reason will be documented in theconsumer file and will be referred to the Patient Care Sub-Committee for discussion.

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 consumer’s progress in psychiatric ICU, using constructive recovery strategies.

Reportableevent

9

Contingency planning

Every mental health service will have systems in place to ensure that, at times of higher than usualdemand, bed availability is maximised. Contingency planning for mental health is described in detailin the policy EDM P5-02 Mental Health Emergency Demand Management Contingency Planning. Itshould be an extremely rare occurrence where a psychiatric intensive care consumer is waiting for abed in a hospital emergency department or medical ward. A more settled consumer from an acutemental health in-patient unit will be transferred to a general hospital medical bed, in order to make abed available temporarily for a consumer waiting for intensive care admission.

The following procedure will be used specifically when there are insufficient available beds inpsychiatric ICU.

A decision will be made at noon (1200 hours) each day as to whether contingency planning isrequired. This will be done by consultation between the Brentwood Assessment Team (BAT) and thelocal mental health service (Director’s nominee) requesting a psychiatric ICU admission. Followingthis discussion, BAT will then prioritise consumers waiting for admission to psychiatric ICU, and thosemost ready for early discharge from psychiatric ICU. Information will be conveyed by BAT to thelocal mental health service, about likely waiting times in order that alternative care plans can beimplemented. If necessary, BAT will alert the Director Psychiatric ICU of the need to implement thepsychiatric ICU contingency plan. If activated, the plan will comprise the following steps:

1. 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.

2. 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.

3. 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.

4. 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.

Procedures

Referral

Only a registrar (or consultant psychiatrist) who has personally reviewed the consumer anddetermined that all steps have been taken to manage the person in a less intensive environment canrefer 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, culturaland 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 negotiateany 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 andadvice 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.

2. All consumers in psychiatric ICU will have a formal risk assessment completed at least once in every nursing shift.

3. All consumers in psychiatric ICU will have their potential discharge date specified upon admission and reviewed daily prior to noon (1200 hours).

4. 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.

10

5. No consumer will stay in psychiatric ICU more than 24 hours beyond the individual optimum discharge date.

6. 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.

7. 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. 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.

2. Discharge will occur within 24-hours of the criteria for admission no longer applying.

3. 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.

4. 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.

5. It would be rare that a consumer would be discharged directly to the community mental health team from a psychiatric ICU.

6. 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 consumer’s GP will be advised, unless the consumer specifically directs that this not occur.

7. 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.

11

BAT Brentwood Assessment Team

DHS Department of Human Services

EDM Emergency Demand Management

FMC Flinders Medical Centre

ICU Intensive Care Unit

KPI Key Performance Indicator

MHS Mental Health Service

MSE Mental State Examination

RAH Royal Adelaide Hospital

Abbreviations

12

The Emergency Demand Management policy series will be complemented by a State-wide keyperformance indicator (KPI) strategy. The key policy objectives will be translated into a set ofquantifiable indicators that will be used at a State level to measure progress toward achieving thepolicy objectives.

Health services, as part of the quality improvement processes, are also expected to continuallymonitor progress during policy implementation, to identify areas for improvement, set in place actionsto ensure compliance with the policy series.

The DHS Mental Health Services and Programs will review the Emergency Demand Managementpolicy series in December 2005.

Policy monitoring and review