Stephen Dye

PEER REVIEWED JOURNAL PAPER (2nd author)
Aims To assess the impact of a changed ward environment upon levels of inpatient arousal and aggression on a National Health Service psychiatric intensive care unit.
Method A retrospective service evaluation comparing seclusion episodes, duration of close observation, recorded aggressive incidents and data from the Nursing Observed Illness Intensity Scale (NOIIS) on a psychiatric intensive care unit for two three-month periods either side of a move… Show more

PEER REVIEWED JOURNAL PAPER (2nd author)
Aims To assess the impact of a changed ward environment upon levels of inpatient arousal and aggression on a National Health Service psychiatric intensive care unit.
Method A retrospective service evaluation comparing seclusion episodes, duration of close observation, recorded aggressive incidents and data from the Nursing Observed Illness Intensity Scale (NOIIS) on a psychiatric intensive care unit for two three-month periods either side of a move from an old, temporary building to a new, purpose-built ward. The ward environments were also objectively assessed and compared using the Environment Assessment Inventory (EAI).
Results A statistically significant reduction in episodes of seclusion, total seclusion hours and aggressive incidents, as well as a reduction in levels of agitation from the NOIIS data on the new ward compared to the old ward. The EAI scores showed important qualitative improvements on the new ward.
Conclusions This study supports the hypothesis that the physical environment of a psychiatric intensive care unit has a significant impact on levels of arousal and aggression. Established measures of ward environment should be applied to the development and improvement of psychiatric wards.
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PEER REVIEWED JOURNAL PAPER (2nd author)
Over the next year there will be a major change in the way mental health services are funded within the UK. Block contracts will be dismantled and the future will be populated by clusters of patients along pathways that are costed for and agreed upon locally between commissioners (who will pay for the pathway) and service providers (who will deliver what is specified within the agreed pathway) (Department of Health, 2011). However, will these pathways… Show more

PEER REVIEWED JOURNAL PAPER (2nd author)
Over the next year there will be a major change in the way mental health services are funded within the UK. Block contracts will be dismantled and the future will be populated by clusters of patients along pathways that are costed for and agreed upon locally between commissioners (who will pay for the pathway) and service providers (who will deliver what is specified within the agreed pathway) (Department of Health, 2011). However, will these pathways lead to gold or be muddied by confusion within a maze of complexity due to variations of ill defined care? This paper highlights potential difficulties with the proposed arrangements and gives possible solutions. Show less

PEER REVIEWED JOURNAL PAPER (3rd Author)
Background
Rapid tranquillisation (RT) is a high risk clinical intervention in terms of potential physical health complications. There has been no published work in the UK to survey nationally whether standards for post RT physical monitoring (as set out in organisation's RT documents) are being adequately audited.

Aim
To review current auditing of RT practice in England, with particular emphasis on examination of post RT physical… Show more

PEER REVIEWED JOURNAL PAPER (3rd Author)
Background
Rapid tranquillisation (RT) is a high risk clinical intervention in terms of potential physical health complications. There has been no published work in the UK to survey nationally whether standards for post RT physical monitoring (as set out in organisation's RT documents) are being adequately audited.

Aim
To review current auditing of RT practice in England, with particular emphasis on examination of post RT physical monitoring.

Method
A scrutiny of evidence provided by English NHS mental health trusts to illustrate auditing of adult RT documents.

Results
Fifty-eight mental health trusts in England were contacted. Less than one-third could provide evidence of an audit of post RT physical health monitoring. These audits were variable with respect to what aspect of physical health monitoring they focused on. When results of all audits were combined, it revealed a concerning finding that basic physical observations and investigations were not performed consistently following RT.

Conclusions and Implications for Clinical Practice
The current paucity of trust audits of post RT physical monitoring and the poor practice observed in those audits could reflect a lack of clarity in both trust and national guidelines, as well as poor clinical practice. Given the risks to a patient's physical health associated with RT it is essential to ensure high quality care in this area.
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PEER REVIEWED JOURNAL PAPER (1st author)

Aims and Method

To describe the use of Community Treatment Orders (CTOs) and outcomes for patients placed under CTOs within the first eight months of usage in Suffolk. Retrospective and prospective examination of health records was performed in order to collect sociodemographic and clinical measurements with a specific data collection tool.

Results

All patients studied suffered a major psychotic mental illness with a… Show more

PEER REVIEWED JOURNAL PAPER (1st author)

Aims and Method

To describe the use of Community Treatment Orders (CTOs) and outcomes for patients placed under CTOs within the first eight months of usage in Suffolk. Retrospective and prospective examination of health records was performed in order to collect sociodemographic and clinical measurements with a specific data collection tool.

Results

All patients studied suffered a major psychotic mental illness with a significant proportion having history of alcohol or substance misuse difficulties as well as contact with judicial services. Implementation of CTO was associated with increase in engagement, decrease in number of admissions and increased time spent outside hospital.

Clinical Implications

This small localised study indicates supervised community treatment can have benefits for some patients. The challenge is now to examine its practice and to receive meaningful feedback from those who are subject to it.

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PEER REVIEWED JOURNAL PAPER

Background: PICUs traditionally manage patients who can display disturbed behaviour. Recent guidance has advocated patient engagement in outlining preferences regarding management strategies should they display such behaviour.

Aim: To audit the use, within one PICU, of a mechanism that formally records individual patient preference in management of episodes of acute disturbed behaviour.

Method: Two sets of fifteen retrospective case note analyses… Show more

PEER REVIEWED JOURNAL PAPER

Background: PICUs traditionally manage patients who can display disturbed behaviour. Recent guidance has advocated patient engagement in outlining preferences regarding management strategies should they display such behaviour.

Aim: To audit the use, within one PICU, of a mechanism that formally records individual patient preference in management of episodes of acute disturbed behaviour.

Method: Two sets of fifteen retrospective case note analyses in an audit cycle.

Results: Initial findings revealed that advance statements were completed by eight of the fifteen patients admitted (53%). Patients’ wishes were followed for two thirds of patients following incidents needing interventions. Following changes to practice, although only minimal improvement occurred in patients completing advance statements, they were completed sooner after admission and, despite more incidents needing interventions, patients’ wishes following episodes of disturbed behaviour were followed in two thirds of those who completed an advance statement.

Conclusion: Use of advance statements regarding management of disturbed behaviour can be introduced in PICUs and this should be advocated.
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PEER REVIEWED JOURNAL PAPER (1st author)

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… Show more

PEER REVIEWED JOURNAL PAPER (1st author)

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.
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PEER REVIEWED JOURNAL PAPER (1st Author)

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.

PEER REVIEWED JOURNAL PAPER (2nd author)

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… Show more

PEER REVIEWED JOURNAL PAPER (2nd author)

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. Show less

PEER REVIEWED JOURNAL PAPER (3rd author)

Aims and method To describe the psychotropic medication given to 332 patients admitted consecutively to seven English psychiatric intensive care units (PICUs) by prospective, multicentre case-note analysis.

Results Overall, 104 (32%) patients received rapid tranquillisation or zuclopenthixol acetate by intramuscular injection; 72 (23%) received more than one regular antipsychotic drug simultaneously. It was reported that 20 patients… Show more

PEER REVIEWED JOURNAL PAPER (3rd author)

Aims and method To describe the psychotropic medication given to 332 patients admitted consecutively to seven English psychiatric intensive care units (PICUs) by prospective, multicentre case-note analysis.

Results Overall, 104 (32%) patients received rapid tranquillisation or zuclopenthixol acetate by intramuscular injection; 72 (23%) received more than one regular antipsychotic drug simultaneously. It was reported that 20 patients received high-dose antipsychotic medication, which was probably an underestimate. The use of these interventions varied significantly between different units.

Clinical implications Potentially risky treatments such as forcible intramuscular medication are a standard part of PICU activity. Further work is needed to clarify the reasons behind the differences in prescribing practices between different PICUs.
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PEER REVIEWED JOURNAL PAPER (1st author)

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… Show more

PEER REVIEWED JOURNAL PAPER (1st author)

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.
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