Out of harm's way: developing the PICU

'Back then the more ill you were the worse deal you got. You got no meaningful activities, no soft furnishings and a backside full of drugs,' recalls Roland Dix, psychiatric intensive care unit (PICU) and secure rehabilitation consultant nurse at Gloucestershire Partnership trust's Greyfiars unit, of the regime in operation when the unit was built in 1992. Now Greyfriars is internationally renowned for its innovative practices and for being one of the first nurse-led units of its type.

Its development is testament to the transformation in psychiatric intensive care for the most distressed and unwell. These are patients who present too much of a challenge for general wards and need a more secure environment; PICUs are locked and service users cannot come and go as they please.

PICUs did not begin to emerge until after the 1992 Reed report on mentally disordered offenders. It recommended that there should be separate premises for patients who were too ill for general inpatient acute wards and needed a secure environment, but were not offenders.

While the development of community-based teams to help service users experiencing crises and acute illness has allowed general inpatient psychiatric units to concentrate on providing care for the most unwell, this care is not specialised enough for some service users. As in general healthcare, there are some who are too ill to stay on a general ward.

There are now around 350 PICU beds in England, but practitioners say the standards under which they operate vary considerably.

'Achieving consistency of care is a key issue for PICUs, but depends on the level of commitment from trust managers, clinicians and commissioners,' says North East London Mental Health trust PICU lead consultant psychiatrist Dr Stephen Pereira.

Dr Pereira, who is also chair of the National Association of Psychiatric Intensive Care Units (NAPICU), co-authored the national minimum standards for PICUs in 2002. They include areas such as access to outside space and an environment that allows for privacy and dignity.

Oxfordshire and Buckinghamshire Mental Health Partnership trust consultant PICU psychiatrist Dr Stephen Dye says PICUs should have access to a multi-disciplinary team. 'There should be a feeling of calm and space. When someone is acutely unwell this can make all the difference.'

Before the guidelines were published, there was no overall strategy for such units. As a result, says Andy Johnston, NAPICU executive secretary and director of Four Seasons Health Care's Huntercombe Hospital in Roehampton, a range of approaches has developed. But even now providers are not obliged to follow the standards.

'In one place you might have had two beds blocked off, while in another you would have a whole unit for psychiatric intensive care,' he says.

The death of psychiatric healthcare assistant Eshan Chattam, who was beaten to death in June 2003 by a patient in a poorly designed PICU at South West London and St George's Mental Health trust's Springfield Hospital, was a tragic reminder of the dangers an inappropriate PICU environment can present.

Mr Chattam's death prompted the Department of Health to ask the National Institute for Mental Health in England and NAPICU to survey the physical condition of PICUs. Although the survey in its entirety remains unpublished, some of its findings were released and revealed startling gaps in the quality of PICU environments.

Seclusion facilities

One in 10 units, for example, were not in single-storey accommodation and more than one in four of those were not on the ground floor, even though access to outside space is considered crucial. Around 25 per cent of units did not have garden space, only 35 per cent had en suite facilities and 35 per cent did not have single-sex facilities.

Almost half did not have seclusion facilities and 55 per cent did not have dedicated section 136 facilities - 'appropriate places of safety' for people who have been detained under the Mental Health Act.

Environmental problems can hinder the running of even the most forward-thinking units. At Gloucestershire Partnership trust's Greyfriars unit, consultant nurse Roland Dix says that despite its reputation for innovatory practice, its physical environment is dated. He says the 1992 unit was built at a time when 'there was very little intention of trying to engage with patients'.

'We have to adapt and live with that environment the best we can.'

At the end of last month the trust had to close its six-bed Barnsley PICU because of cuts, but is hoping to gain government funding soon for a purpose-built 10-bedded unit. The DoH released£30m in 2005 specifically for PICUs and£130m this year for PICUs, the supply of section 136 areas and updating acute inpatient units.

NAPICU's Mr Johnston says this is significant investment. 'Some units need a lot of work and others need improvement in certain areas,' he says. 'There is still a lot to achieve.'

What a PICU is actually providing is another area of difficulty. PICU practitioners are agreed they should provide fairly short-term, intensive, high-level support for the most distressed and unwell. But the units can run the risk of being used as de facto low secure units, which should themselves be used to provide longer-term care.

As a result, PICU beds are often blocked by people who should be getting cared for elsewhere. Dr Pereira says this is caused by a lack of low secure units for those with complex needs and challenging behaviour who need long-term care, as opposed to low-secure provision for those who are stepping down from medium-secure care.

'The provision of low secure, challenging behaviour beds to PICU beds is about one to 10 when it should be four or five to 10. Of every two neighbouring mental health trusts, there should be at least one low secure unit,' he adds.

Dr Pereira estimates that around 30 per cent of PICU beds are occupied inappropriately. He also points out that of the 80 per cent of prisoners who have mental health problems and need specialist mental healthcare, many could be cared for in low-secure units.

PICUs also report that beds are often taken up by service users referred from the prison system. Having to work with both the DoH and the Home Office can delay sending patients to forensic units. Both this and the absence of a longer-term low-secure facility can lead to service users staying on in a PICU for months, when some units aim for stays of just a few weeks.

Sound relations

Within a trust, there can also be a tendency for any patient who has a long history of admissions to psychiatric inpatient care always to be sent to the PICU first. 'In my own experience PICUs are often expected to be the panacea to cure all ills. They get a lot of inappropriate referrals,' says Mr Johnston. 'If the PICU is the only locked ward in a trust it is expected to take in anyone with complex needs. PICUs have to make clear that they are part of a wider service.'

South London and the Maudsley trust's Ladywell unit manager Derek Nichol says the key to appropriate referrals and keeping lengths of stay short is strong relationships with referring wards. Referrers to the Ladywell's PICU are told the expected length of stay is 17-30 days.

'We aim for a very short stay as a PICU is supposed to give intensive, short-term treatment, whereas a lot of intensive care units are treated as if they are challenging behaviour units or even medium-secure units,' says Mr Nichol.

'When someone needs an ICU it is an emergency, whether they are coming from a ward or the community. To get someone in quickly the referrer has to understand that they will have to be willing to get them out quickly too.'

The 10-bed unit is fortunate in that, with the exception of two beds rented by another locality, it serves the trust's Lewisham locality wards, which are all housed in the Ladywell unit, too. Mr Nichol says this means ward staff can come and see how service users are progressing, which aids discharge planning. On the rare occasion that the length of stay is longer than the target duration, it is often down to the PICU and referring ward not knowing each other and not having the opportunity to develop a relationship.

The needs of specific populations, based on gender or age, are also being considered by trusts. Female-only PICUs are rare but are beginning to emerge. In light of worries that putting women in male-dominated units can compromise their safety, many PICUs opted some years ago to stop admitting women altogether.

Care provision for service users younger and older than working age may also become of increasing concern. The development of early-intervention services to target young people with psychosis has increased the number of people having their first psychotic episode being admitted to a PICU, as specialist adolescent secure units are few and far between. Equally, the numbers of over-65s who need care beyond what an older people's service can generally provide are poorly catered for, but likely to increase in line with an ageing population.