Psychiatric Intensive Care Unit Operational Policy

Transcription

1 Psychiatric Intensive Care Unit Operational Policy

2 Psychiatric Intensive Care Unit (PICU) Operational Policy Document Type Clinical Policy Unique Identifier CL-052 Document Purpose To set out the operational arrangements and procedures to be followed by staff when working in the Psychiatric Intensive Care Unit. Document Author Kerry Beaumont, Acting Inpatient Lead Sven Rouse, PICU Manager Target Audience All staff working on or visiting the PICU. Responsible Group Clinical Policies Group Date Ratified 28 th November 2012 Version Update 18 th March 2013 Expiry Date 28 th November 2015 The validity of this policy is only assured when viewed via the Worcestershire Health and Care NHS Trust website (hacw.nhs.uk.). If this document is printed into hard copy or saved to another location, its validity must be checked against the unique identifier number on the internet version. The internet version is the definitive version. If you would like this document in other languages or formats (i.e. large print), please contact the Communications Team on or PICU Operational policy Page 1 of 28

3 Version History Version Circulation Date Job Title of Person/Name of Group circulated to Brief Summary of Change Version 1 26/03/2012 Acting Inpatient Lead PICU Manager Review, update and initial drafting of revised document. Version 2 12/04/2012 Clinical Policies Administrator Trust template applied, reformatting sections, and minor typographical amendments. Version 3 18/04/2012 High Risk Manager PICU Manager PICU Deputy Managers Acting Inpatient Lead PICU RMO, Consultant Psychiatrist Clinical Lead Acute Lead Lead OT Document structure changed and simplified to reflect comments from consultation. Sections moved from main body of text into appendices. Version 3 01/05/2012 Clinical Policies Administrator Further formatting and amending document structure/order. Minor amendments. Care Pathway Appendices updated. Version 4 05/07/2012 Clinical Policies Group Sections 1, 2, 3, and 4 re-drafted to remove repartition and improve document flow. Minor rewording and amendments. References added. Version 5 12/09/12 Clinical Policies Group No further comments Version 6 18/03/13 Clinical Policies Administrator Watermarks added to Forms PICU Operational policy Page 2 of 28

4 Accessibility Worcestershire Health and Care NHS Trust have a contract with Applied Language Solutions to handle all interpreting and translation needs. This service is available to all staff in the trust via a free-phone number ( ). Interpreters and translators are available for over 150 languages. From this number staff can arrange: Face to face interpreting; Instant telephone interpreting; Document translation; and British Sign Language interpreting. Training and Development Worcestershire Health and Care NHS Trust recognise the importance of ensuring that its workforce has every opportunity to access relevant training. The Trust is committed to the provision of training and development opportunities that are in support of service needs and meet responsibilities for the provision of mandatory and statutory training. All staff employed by the Trust are required to attend the mandatory and statutory training that is relevant to their role and to ensure they meet their own continuous professional development. PICU Operational policy Page 3 of 28

5 Contents Page 1. Introduction 5 2. Psychiatric Intensive Care Unit Approach to Care 5 3. PICU Referrals 5 4. PICU Assessments 6 5. Criteria for Admission 6 6. Criteria for Exclusion 7 7. Behaviours requiring PICU 7 8. Alternative Interventions to admission 8 9. Admission Process Reviews Transfer Process Shift Management Security Withholding Patient s Correspondence Guidance for visiting Absent without Leave (AWOL) Standard Operating Procedures Staff Development and Training References 15 Appendices 1 PICU Admission Criteria 16 2 PICU Referral and Assessment Form 17 3 Integrated Pathway Flow Chart 19 4 Out of Area Referral Flow Chart 20 5 Restricted and Controlled Items List 21 6 Environmental Check List 22 7 Guidance on Withholding Patient s Correspondence 25 PICU Operational policy Page 4 of 28

6 1. Introduction a. The Adult Mental Health Service Delivery Unit provides inpatient services across 6 sites in Worcestershire, with a total of 110 beds including a 9 bedded Psychiatric Intensive Care Unit (PICU). This Unit provides expert, supportive, short term, individualised care for patients who are in an acutely disturbed phase of a serious mental disorder, resulting in increased risks that require them to be treated in a controlled environment for a brief period of time. b. Although PICU is a structured physical environment it should not be regarded purely as a locked ward, a secure unit or a challenging behaviour unit. Is designed for short-term care for periods of weeks rather than months. National guidance states that length of stay must be appropriate to clinical need and risk assessment but would not ordinarily exceed eight weeks in duration. (DH, 2002) c. The unit is an important and integral part of the patient pathway which reflects the Trust s vision of care that requires a fundamental respect for and courtesy towards the individual and respecting their individual needs. Therapeutic management is assessed and based on specialist intensive interventions and not containment. d. The Unit provides therapeutic intervention with the emphasis on safety, individualised care, professional rapport and staff development. Quality auditing processes will ensure positive service development. 2. Psychiatric Intensive Care Unit Approach to Care a. The service, predominantly nurse led, provides expert, supportive and individualised care for patients whose acute episode of mental illness results in disturbed behaviour with increased risks requiring admission to a safe specialist environment for a short period of time. It fosters a holistic model of care, providing a thorough and ongoing assessment of each patient s psychological, physical and social needs, offering individualised care based upon these assessments. b. Therapeutic interventions are provided in line with the Mental Health Policy Implementation Guide, National Minimum Standards for Psychiatric Intensive Care Units (DoH 2002) by a multidisciplinary team (MDT) which also has an advisory role to other Acute Mental Health Inpatient wards within Worcestershire. c. The therapy is delivered through the provision of a daily structure and a range of effective clinical interventions which seek to balance the therapeutic needs of the patient with the need for support and security, whilst minimising their dependence upon staff within the unit. Patients are encouraged to take an active role in planning their care and treatment pathway, within the constraints of the Mental Health Act, whilst maintaining their own safety and that of those around them. d. Patients are encouraged to maintain close contact with friends and relatives in accordance with their own wishes, whilst maintaining the overall safety and security of the unit and those within it. 3. PICU Referrals a. The PICU operates a referral-based service and accepts referrals from a number of sources. Each referral is considered for admission by an Assessment Team following a referral. The Criteria for PICU Admission are included as Appendix 1. The PICU will accept referrals from Band 5 nurses or an equivalent MDT member or Responsible Clinician (RC) of any the Trust s acute mental health wards and the Assessment and Home Treatment Teams. For Out of Area treatments referrals can be made by a qualified member of the team. In such cases is important that host Commissioners are involved. PICU Operational policy Page 5 of 28

7 b. When referrals are made, the team that require the bed should fill in the PICU Referral and Assessment Form (Appendix 2). The PICU team will then make an assessment based upon the information provided. The team may wish to assess the patient themselves or be present to offer advice, facilitate an MDT meeting or if there are no bed spaces support the admitting team in giving medication or other interventions deemed necessary. When the patient is out of county clearly this is impractical, and the decision will be based upon discussions between professionals. c. All sections of the Referral Form must be completed with particular regard to the rationale for referral. This referral will include information on the following headings: Reason for Referral; Assessment of Mental and Behavioural State On Interview; Risk Assessment; and Recommendations. 4. PICU Assessments a. Every referral is assessed as soon as possible to identify problematic behaviours and risks associated with them and to clarify with the patient what is happening and how they feel about any incidents. The assessment will also ensure that the patient meets the admission criteria to PICU. This practice is necessary in order to address the following priorities: Appropriate use of PICU beds; Prevent delayed discharge and increase efficiency; Reduce de-skilling amongst team members from the general mental health inpatient wards; and Ensure that the levels of disturbance and or dangerousness presented by a referral can be managed safely. b. The waiting time for an assessment will depend on the perceived urgency of the situation. It is expected that referrals from Trust facilities will be assessed within one working day. The PICU Assessment Team will contact the referrer and agree a mutual convenient time for the assessment. The Assessment Team will also be able to give advice over the telephone. This may be appropriate if it is not felt an assessment is indicated (by either the general adult or PICU service). c. The PICU offers a 24 hour a day emergency service. Anyone referred for admission to the unit should meet one or more of the admission criteria. Decisions relating to an emergency out of hours admission are made by the PICU nursing team in consultation with the on call medical staff and the Mental Health Act assessment team as appropriate. d. The assessment will include an interview with the patient and the Multidisciplinary Team providing care at that time. Once identified, suggestions as to the most appropriate action to deal with these problems will be given to the referring team. Possible outcomes of an assessment are admission to the PICU (which will occur in a planned manner as soon as possible) or advice given to the referring team with or without arrangements to re-assess the patient. e. If a significant delay in admission is expected, interim management advice will be given. If part of the advice is to refer the patient elsewhere, the treating team will perform this referral. PICU Operational policy Page 6 of 28

8 f. If the assessment team is unable to agree a plan, they should seek assistance from senior members of the Adult Acute Mental Health Service e.g. the Service Manager, Ward Manager or Consultant Psychiatrist. 5. Criteria for admission a. In line with the national minimum standards (DH 2002), Patients will have a pre-admission assessment by the PICU Assessment Team prior to admission. Individuals will generally be from within Adult Mental Health Services however assessment will always be based on clinical need. Patients will only be admitted if they display a significant risk of aggression, absconding with an associated serious risk, suicide or vulnerability in the context of a serious mental disorder. Individuals who are detained under the appropriate completed assessment/treatment section of the Mental Health Act under provisions of Section 2, 3, 35, 36, 37/41, 38, 47/49 or 48. It has been demonstrated that multidisciplinary management strategies in the referring acute mental health ward have not succeeded in containing the present problems. This should include the use of high level observations for a period of at least 24 hours and the use of PRN or utilising the Rapid Tranquillisation Policy. There must be mutual agreement between the referrer and the PICU assessment team on the positive therapeutic benefits expected to be gained from the time limited admission including clear rationale for assessment and treatment. 6. Criteria for exclusion a. In line with the national minimum standards (DH, 2002) there are categories of patient who should not be treated within a PICU. The patient is assessed as presenting too high a degree of risk for a PICU environment and may require admission to forensic services. Restricted patients (Section 37/41 and 47/49), unless there is provision to transfer them to an acute ward if warranted by their clinical condition. Patients who could/would present a grave and immediate risk if they were to abscond. Such individuals would possibly require a more secure environment such as that provided by a Low Secure or Medium Secure Unit. Primary diagnosis of substance misuse and where the behaviour is a direct result of substance misuse and not an exacerbation of mental illness. Primary diagnosis of dementia. Primary diagnosis of learning disability. Where the patient s physical condition is too frail to allow safe management within the PICU. b. Although there are no strict age limits regarding admission (in keeping with the National Service Framework for the Care of Older People), individuals whose general physical level of functioning, emotional maturity or physical condition preclude admission to a PICU will not be admitted. Careful consideration must be given to the safety and care of patients at either end of the age spectrum and the appropriateness of a PICU. PICU Operational policy Page 7 of 28

9 c. Individuals with a primary diagnosis of a personality disorder, whose behaviour is unlikely to be modified by brief intensive care and treatment. Unless urgent necessity in in-patient areas within the Trust dictates otherwise and the admission to PICU is for an agreed time limited plan and discharge plans are in place. 7. Behaviours requiring PICU a. Problem behaviour will fall under one, or more of the following headings: Externally directed aggression towards people or property resulting in significant risk to others or extreme aggression; Internally directed aggression resulting in a significant risk of suicide and current management measures are proving unsuccessful and if the patient is likely to respond to intensive therapy within a PICU setting; Absconding Patients in which the consequences of persistent absconding are serious enough to warrant treatment in a PICU. PICUs do not provide security for security s sake and there will always be a primary clinical reason for admission; and Unpredictability that potentially poses a significant risk to self or others and requires further assessment. b. It may be possible under exceptional circumstances to offer direct entry into the PICU for those individuals who have a history of consistently requiring this level of care and security. The multidisciplinary team should identify these individuals, including representatives from the PICU team, during the discharge planning/section 117 meeting, prior to discharge from hospital. Factors must be formally identified which would indicate direct entry into the PICU facility in any potential future relapses. 8. Alternative Interventions to PICU Admission a. The PICU will aim to co-operate with the acute mental health inpatient wards to make best use of the resources available ensuring that the safety of the Unit is not compromised. b. A flexible and creative problem solving approach will be adopted to ensure the maximum benefit to the patient. The referral process will not be considered complete if the assessors are unable to agree a plan. In such cases the assessing staff will seek assistance from senior clinical staff to resolve the situation. Such assistance might include: Offering advice and information on medical and nursing interventions and care planning. Offering advice on the specific management of problematic behaviour. Agreement on further reviews of a developing problem and possible re-assessment where indicated. Release of staff where feasible to initiate plan. Supporting applications for referral to other specialists units. 9. The Admission Process a. It is the responsibility of the admitting nurse to ensure that the following procedure is followed and documented: Welcome the patient and orientation to the Unit, offer drink where appropriate. Check Section papers. If accompanied by police and handcuffs are being used these can be removed in this area. PICU Operational policy Page 8 of 28

10 Property search and documentation. b. When the patient is brought through to the main part of the PICU the following processes can begin to be undertaken. Patient should be searched using the metal detector wand Commence 72 hour nursing assessment, including initial assessment of risk. Update NCRS. Inform relatives of transfer (having considered the time of the admission) visiting times and property that is restricted within PICU, ensuring that they give a rationale. Request a copy of the patient s Care Programme Approach (CPA) from the care coordinator if these have not accompanied the patient Commence CPA for new patients. Add patient to shift detail board. Set level of observation required (as per Observation Policy). Mental Health Administrator is to be informed of patient s admission. Request old notes and drug charts/discharge summaries. c. For each patient admitted the nursing assessment will commence. The admitting nurse and unit medical staff, in consultation if appropriate, will prescribe a treatment plan for the first 72 hours. While it is good practice for risk to be assessed by the multi-disciplinary team, it is not good practice for medical staff to prescribe nursing observation. The admitting nurse should hold responsibility for determining appropriate observation, according to the observation policy. The admitting nurse will ensure that all staff on duty are made aware of the initial treatment plan. 9.1 Pathway for admission Out of Hours a. There will, on occasions, be individuals who are placed upon the unit without a prior PICU assessment. Possible scenarios in which this may occur are: When agreed by both PICU staff and acute adult staff that an individual would need direct admission. This may have been identified previously within the patient s care plan. When the level of disturbance is so severe that on-call doctors and the nurse in charge of PICU deem it necessary that the patient is placed within an intensive care environment. b. In a situation where there is disagreement between professionals regarding the appropriateness of a PICU admission the On Call Senior Manager will make the decision. The On Call manager will explain this decision in writing to the ward manager, the Responsible Clinician and the Inpatient Lead Nurse. This will be used as form of learning, auditing and training for future scenarios. c. It should be acknowledged that direct admission to the PICU has implications for the patient regarding their risk history. d. If this occurs then the patient will be placed on the PICU and the assessment team will formally assess the patient for 72 hours. 9.2 Allocating a Named Nurse a. The admitting nurse will organise for the completion of the 72 hour assessment in accordance with duty rosters and a named nurse will be allocated. It is good practice to PICU Operational policy Page 9 of 28

11 allocate the patient to a nurse who has nursed them previously and has a good relationship with them. Attention must be given to allocation in relation to gender and patients preferences. b. It is the responsibility of ALL staff when returning from off duty to read admission details and treatment plans of the new patient. 9.3 Continuing Nursing Intervention a. After the initial treatment plan and the appointment of the Named Nurse, the process of enabling the patient to return to the locality ward has begun. Interventions will be in line with Trust policies and will reflect the Core Interventions from the National Minimum Standards for PICU (DH 2002). b. Following allocation, the Named Nurse, and Associate workers will conduct a more indepth assessment. All new and reviewed treatment plans will be presented at each handover during the day it was initiated or reviewed. The named nurse will coordinate with other team members. 9.4 Carers, Relatives and Family a. On admission, if no advanced directive is available the named nurse must establish with the patient which family member, carer or relative they wish to be contacted in case of crisis. The named nurse will establish all contact numbers for that identified individual. At this time in the admission process the family member, carer or relative must be asked by the named nurse of any specific risk issues relating to the individual that they are concerned about or aware of. 9.5 Interventions 10. Reviews a. A comprehensive range of therapeutic interventions are available for patients during their admission. These groups will be delivered on a rolling programme by a qualified member of nursing staff. Diversionary activities will form part of the wards programme of interventions and may be delivered by either a qualified or unqualified member of staff. b. Patients will be allocated a nurse for 1:1 each shift. The allocation of 1:1s will be the responsibility of the Nurse in Charge and they will ensure that this is recorded on the ward for patients to view. 1:1s will be documented and highlighted as such in the medical notes. c. Patients will meet with their named nurse or associated nurse at least three times a week. The purpose of this will be to review care plans, complete the pre patient review and generally review progress on the ward/deliver specific interventions. d. Patients will be expected to engage in activities and therapeutic interventions as per their agreed plan of care. e. The wards will audit that 1:1s and activities have taken place on monthly basis. a. During the week (Mondays to Fridays) there will be a daily review of each patient carried out, on the unit, by the nursing team. There will be a weekly MDT meeting to review all patients in detail. During weekends and at bank holidays the on-call doctor will provide medical support to the unit. This would include face-to-face review of any patient who may be a cause for concern, as identified by the nurse in charge. b. All appropriate professionals will be invited to attend, plus any carer family member or relative friend requested by the patient with a specific time to attend the review and to be informed of any changes in the plan. If relatives, family members or carers cannot attend the clinical review then the named nurse will make contact and give a clinical update. PICU Operational policy Page 10 of 28

12 11. Transfer Process a. Transfer planning is essential to the smooth and efficient operation of a PICU and should begin prior to admission to the unit. All too often, patients can show evidence of dependence on the unit and this presents difficulties when moving back to open wards. The transfer of patients is essential to maximise efficiency and prevent blockages of beds and relies upon good working relationships and communication with other Trust services and units. It is acknowledged that the effective use of beds is dependent upon an atmosphere of cooperation. Patients should not be discharged from the PICU, the exception to this being if the patient is in a position to discharge themselves perhaps if they have been re-graded as informal via the Mental Health Review Tribunal, wish to leave and the team have no grounds to detain them further. In these cases the 7 day follow up protocol should be utilised. b. Clear transfer indicators and criteria should help alleviate potential problems when the patient returns to the acute mental health inpatient ward Transfer to acute mental health inpatient wards a. Within the routine management of patients on PICU, clinical review and CPA meetings will take place. These will adhere to Trust policy and it is expected that all relevant professionals involved in the patients care will attend these meetings. b. Once a patient has been assessed by PICU medical and nursing staff and subsequently identified as being near to transfer back to an acute mental health inpatient ward environment the PICU staff will contact the referring ward to arrange a meeting to discuss appropriate handover arrangements. The PICU expects the referring ward to respond promptly ( depending on the acute bed status) to any requests for transfer back once the PICU multi-disciplinary team has assessed the need for intensive care is no longer required. c. Locating an appropriate bed on an acute mental health inpatient ward is the responsibility of the referring acute mental health inpatient ward team usually with assistance from the bed manager; actual physical transfer arrangements are the responsibility of the PICU staff. d. Once a patient has been identified as no longer requiring PICU then the transfer should take place as swiftly as resources will allow. A transfer summary will complied and part of the transfer documentation Unexpected or urgent transfers a. It is acknowledged that, given the demands on such a service there will be occasions when pre-planned transfer is not possible. It is therefore expected that through close communication with other wards, the bed manager and nursing and medical staff, efficient transfer of patients can be achieved. Effective bed management will ensure that if there is not a vacancy on the unit to accommodate an urgent admission, individuals will have previously been identified who could potentially be transferred back to the referring team should the need arise Transfer to other Wards or Units a. Inevitably some patients will not be able to be returned to acute mental health inpatient ward. These are the patients who potentially block PICU beds. Hopefully good preadmission assessment by PICU staff will have identified such patients and suggested appropriate alternative arrangements at that time. Inevitably, given the nature of the client group that PICU manage, some patients will be identified after admission to PICU. They fall mainly into two categories: PICU Operational policy Page 11 of 28

13 i. Those needing increased security; and ii. Those needing an extended period of Enhanced/Low Secure care. b. Should PICU require the input of Forensic Services, appropriate referrals will be arranged and advice taken. c. The decision that an individual requires longer term Enhanced/Low Secure care should not be taken lightly as it potentially consigns the patient to an extended period in hospital. There may also be a delay in transfer, thus further extending the stay on the PICU. The decision should be taken in consultation with provider teams and appropriate specialist services following a Care Programme Approach (CPA) meeting. Once this decision has been reached, appropriate referrals will be made. 12. Shift Management a. The number of staff on duty on the PICU depends upon the clinical needs of the Unit, including the observational status of those patients resident at the time and the perceived management problems of the overall patient population. Minimum staffing levels for a full population are set at 5 staff on both early and late shifts and 4 staff at night. It is the responsibility of the PICU Manager to ensure safe minimum staffing levels required to ensure effective management of the unit. b. All clinical staff will be trained in the MAPA. c. In order to promote individual patient care the following Shift Management System has been implemented within the PICU. A Shift Co-ordinator holds the responsibility for shift management. This may be any grade of RMN, or Student Nurse in education with an allocated RMN taking responsibility. Where the Shift Co-ordinator is a junior member of staff, they will be closely supervised and supported by the senior nurses on duty. d. The duties and responsibilities of the Shift Co-ordinator include: Checking that all staff expected to be on duty have arrived; reporting to the unit manager/bleep holder if any additional staff are required. Receive handover from the previous shift Co-ordinator. Checking or delegating the checking all resuscitation equipment, reporting any faults immediately to ECT Manager and Assistant Resuscitation Officer (internal 33211) on and make provisions for repair and replacement. Adding the Named Nurse s name to the whiteboard displayed on the unit as soon as they are appointed to a patient. Ensuring that any patient who does not have a Named nurse s or associate worker on duty, is allocated a nurse to deliver prescribed care for that shift. Prioritising resources and the skill mix to ensure all patients needs are met. Allocate a nurse to every patient during every shift and record this clearly on the whiteboard displayed on the unit. Facilitating staff break times. Ensuring that the in-coming shift is adequately staffed Handover between Shifts a. Information about each patient will be handed over by the shift coordinator where possible. Generally information will be handed over starting from the 48 hours prior to the commencement of the shift for which they are taking handover. PICU Operational policy Page 12 of 28

14 13. Security b. All oncoming staff should be present during handovers for presentation of new and reviewed care plans. All new patients will be subject to comprehensive presentation at handovers, including mental state and Care Plans. c. A minimum of two members of staff will remain in the clinical area during the handover period. This may need to be increased dependent upon the needs of any shift. The Shift Co-ordinator is responsible for this decision. d. Shift Co-ordinators are highlighted on the unit duty rota. If no one is highlighted, the off going shift Co-ordinator is responsible for appointing one before the new shift takes over. e. All new members of the unit staff will be subject to a comprehensive local induction programme following handover Staff and Visitors Access to the PICU a. Access to the PICU for all staff working on the unit, other Trust staff and all other visitors professional and non professional will be through the main unit entrance. Swipe card access is on different levels in relation to PICU staff and Trust Staff. All staff that have Trust swipe cards will be able to access the unit and resources within the air lock. Access to the PICU from this point will only be for designated staff that have swipe card access. All staff will leave personal belongings in the lockers provided in the staff room. No personal items are allowed on the PICU i.e. mobile telephones, wallets etc. Visitors to the PICU will be met by a nurse in the air lock. Visiting professionals and relatives will use the lockers provided within the air lock for leaving personal belongings. Visiting professionals and relatives using the visitors room will be escorted into the room from the air lock and that door will then be locked. The patient will be brought into the room from the PICU. At no point will both doors will be unlocked at the same time. It is the Nursing staff s responsibility for locking and unlocking the doors to the visitor s room. b. Items not accepted on the PICU are listed in Appendix Staff Alarms and Fire Keys a. The monitoring board for the attack alarm is situation in the staff base. b. At the commencement of each shift staff will be allocated an alarm for the duration of the shift by the nurse in charge. These will be tested at the commencement of each shift and handed over at the end of each shift. All alarms will be accounted for before any member of staff leave the unit at the end of a shift. c. Every visitor to the PICU will be given an attack alarm by the nurse in charge. d. All staff have their own allocated set of keys. e. Bank/agency staff will be allocated keys at the commencement of the shift, this is to be documented and their return accounted for Fire and Safety a. The PICU will have a system of automatic fire detection. If there is a fire within the PICU PICU Operational policy Page 13 of 28

15 fire alarms will sound continuously within the unit. This will activate the alarm which gives an intermittent tone to inform other wards and areas that there is a fire on the PICU. b. When the fire alarm sounds staff will proceed with a horizontal evacuation within the unit which will lead to patients and staff being evacuated into the secure garden areas. c. All external fire doors will fail open after four minutes with the exception of the air lock door which will be key controlled by a member of staff. The fire keys will be part of the access allocation that staff receive when they commence duty and every member of staff on duty will have a fire key attached to keys and personal alarm. d. There will be no manual break glass points within the PICU and all call point systems will be key operated Internal and external Security a. The monitoring and recording equipment for all the external security will be situated in the ward manager s office. b. The cameras are situated to provide the maximum coverage to ensure that the PICU external area is safely maintained. c. The Environmental Checklist (Appendix 6) is to be completed as indicated every shift. 14. Withholding patient s correspondence a. Please refer to Appendix 7 for guidance 15. Guidance for Visiting a. The Unit visiting times are: Monday to Friday.. 6:30 pm to 8:30pm; and Weekends and Bank Holidays... 2pm to 4pm and 6:30pm to 8:30 pm. b. Visiting may be possible outside these times in special circumstances, but only by prior arrangement with the unit staff. c. There are two visiting rooms on the Unit and visitors are asked to remain in these designated areas in order to promote privacy and dignity for all on the Unit. Usually no more than 2 visitors will be permitted at one time but this is at the discretion of the nursing staff and exceptions can be made. d. Visitors are not permitted to smoke on the Unit and must use designated smoking areas off the Unit. e. Both the patient and the Nursing staff have the right to refuse or stop a visit at any time if it is felt that it is detrimental to the patients or visitors health and well being, or the safety of the Unit. f. Due to the nature of the Unit, children under the age of 16 are not permitted to visit. Arrangements can be made for children to visit the Elgar Unit dependant upon a risk assessment. 16. Absent Without Leave (AWOL) a. A patient will be considered Absent Without Leave under the following circumstances: i. They are subject to detention under the requirements of the Mental Health Act and have left the Unit without the explicit and written authorisation of the unit RC or agreement with the Unit team, if the terms of Section 17 require so; or ii. They are on Section 17 leave and have not returned at the appropriate time and are PICU Operational policy Page 14 of 28

16 considered to be a risk to themselves or others. The particulars and physical characteristics section of the AWOL form must be completed upon admission and kept in the patient s notes. b. When a patient has gone AWOL the relevant policy must be followed. 17. Standard Operational Procedures a. The expectation is that all staff will follow Trust policies, procedures and protocols/guidelines which can be found on the Trust Intranet site. b. Particular attention is drawn to the following key Trust policies which all staff must be familiar with, understand and implement are: Rapid Tranquilization Policy. Incident Reporting Policy. Medicines Policy. Serious Incidents Policy. Care Programme Approach Policy. Policy for Managing Actual or Potential Aggression. Supervision Policy. Policy on management of use and possession of drugs. Seclusion and Long Term Segregation Policy. Fire Safety Policy. Observation Policy. Absent without Leave, Absent and Missing Inpatient Policy and Guidance. Safeguarding Adults Protection Procedures. Safeguarding Children and Young People Policy. Policy Covering the Arrangements for the Voluntary or Compulsory Admission and Treatment of Young Persons (age 16-18) to Adult Mental Health In-patient Wards, including the Requirements for the Notification of Such Admissions to the Care Quality commission. Infection Control Policy. 18. Staff Support, Development and Training a. By their very nature PICUs can be turbulent, constantly changing and stressful environments to work in therefore, a systematic approach to staff support is imperative. These structures offer support and an opportunity to explore practice issues within both formal and informal forums. All staff have access to a forum in which they feel safe expressing their views. b. Staff within PICU have access to the following formal and informal meetings and supervision, which promote best practice and support staff in their work Induction, Preceptorship and Mentorship Programme a. All new staff undergo the Unit Induction Training Pack. This process will assist new staff in orientation to the intensive care environment and enhance their understanding of the unit, service and the Trust. PICU Operational policy Page 15 of 28

17 b. All students seeking placement on the unit will have a mentor identified prior to commencement of their placement. It is expected that students will arrange a meeting with their identified mentor prior to commencing their placement and discuss the unit s operation and philosophy. This is also a useful time to address any existing anxieties the students may be experiencing and agree shifts etc Line Management Supervision a. All staff will engage in LMS on a monthly basis. The LMS tree will be displayed in the staff base of the unit informing the lines of supervision. The areas identified within LMS for professional development will be included in the individual s Staff Appraisal and Development Review Clinical Supervision a. All staff have access to clinical supervision in accordance with the Trust s Clinical Supervision Policy. The clinical supervision relationship is more about continuous profession support with practice issues. Each member of staff will meet each month with an identified clinical supervisor. There is a record kept of the issues discussed of which the supervisee keeps as a record for their professional development as evidence of progressing practice Staff Training Needs a. PICU staff are required to have a core set of competencies which are identified within the Unit training matrix. There is a staff development pathway which is applicable to PICU for both qualified and unqualified staff. All training should be identified within individuals SADRs, service plan and head of service plan References a. Department of Health. Mental health policy implementation guide: National minimum standards for general adult services in Psychiatric Intensive Care Units (PICU) and Low Secure Environments. May PICU Operational policy Page 16 of 28

18 Appendix 1 Criteria for PICU Admission The patient is detained under an appropriate section of the MHA 1983 prior to admission. The patient will only be accepted for PICU admission if their clinical presentation included one or more of the following: a) Serious and significant risk to harm to others. b) Serious and significant risk of harm to self. c) Risk of absconding which could result in risk of harm to others, self or deterioration in mental state. d) Unpredictability in the patient s presentation which makes it difficult to accurately assess mental state. e) Mutual agreement between referrer and PICU regarding positive clinical benefits expected to be gained from PICU admission. Does the patient fit the PICU criteria? Yes Trust PICU bed available? No Yes Referring clinical team need to re-assess risk, management and treatment interventions/plans Facilitate transfer to PICU No Can patient be managed on any other in-patient resource? No Yes What extra resources or services need to be in place? Clinical rationale for extra resources or service demands is appropriate to the patient s needs. Request for out of county bed Describe what resources are needed to meet clinical and patient s needs. What services can the proposed unit/placement deliver that local services cannot? Complete out of county checklist and forward with required documentation to Audit Service manager and commissioners for approval. Care Co-ordinator and PICU to maintain regular contact with out of area PICU. Illustrate clinical benefits of the proposed transfer and provide an exit strategy. Transfer back to PICU as soon as a PICU Operational policy Page 17 of 28 bed is available.

19 Appendix 2 PICU Referral and Assessment Form Patient s Full Name: Date: Referred by: Location: Needs Assessment Up to date CPA Documentation enclosed as follows: Completed and present in clinical file Completed. Care Coordinator to send within 72 hours Not completed Risk Assessment Care Plan Carers Assessment Current Medication: from Prescription Card Regular: PRN (used regularly) Depot - Date last administered Reason for referral to PICU PICU Operational policy Page 18 of 28

20 Source of Admission to Hospital: Emergency/Planned Admission: Source of Referral: Ward: Name of referrer: CMHT: CR/HT: OAT: Referring R.C.: Referring Keyworker: Care Co-ordinator: Address: MHA Section: Date of Renewal: Consent to Treatment Expiry Date: Action Suggested (Referrer): Action Suggested (Assessment Team): Suggested Outcome: Agreed Outcome: Signed Assessment Team: Signed Referrer: Date: Date: Discussed at Referral Meeting: PICU Operational policy Page 19 of 28

21 Appendix 3 Integrated Pathway Flow Chart Out of Hours Emergency Patient detained under Section 2 or 3 Emergency Referral Agreement between PICU, the assessment team and acute ward staff in relation to pathway. In the case of a dispute or disagreement the 2 nd Level Senior Manager on-call will make the decision where to admit the patient Patient placed on PICU Patient assessed by PICU staff for 72 hours Usual Patient Pathway Admission to adult acute ward Admission to PICU Regular liaison Transfer back to Admission with PICU Ward when discharge criteria are fulfilled with the provision of further liaison PICU Operational policy if required Page 20 of 28

22 Appendix 4 Integrated Care Pathway; Out of Area Bed Pathway for Admission Referral Accepted? Yes No Contact referring team with rationale for clinical decision Internal External No Bed Available? Yes Bed Available? Advise Trust of need to access bed elsewhere Yes Fax referral documentation to referrer No Advise Trust of use of OAB Referral Accepted? No Advise referrer of clinical rationale and reasons Inform Finance of Out of Area Bed (OAB) admission Patient admitted or transferred to OAB? Yes Referring clinical team arrange transport, escort and transfer to PICU Referring clinical team invited to attend clinical reviews Patient is ready to transfer back to referring clinical team If referring clinical team is unable to attend clinical reviews then weekly updates are sent PICU staff is to arrange transport, escort and transfer back to referring team Inform Trust of the termination of OAB Please refer to PICU Operational Policy for more detailed guidance Inform Finance of discharge PICU Operational policy Page 21 of 28

23 Appendix 5 Restricted and Controlled Items List The following items are not allowed under any circumstances: Alcohol. Drugs of any nature. Medicines not prescribed. Canned drinks or food (contents of soft canned drinks can be poured into a beaker). Coat hangers. Lighter fuel. Metal combs. Syringe needles. Photographic equipment. Rope or string. Weapons - real or replica. Large rings. Tools other than those allowed for activities. Any items in addition to the above considered dangerous or detrimental to the individual. Some items may be permitted under supervision. This is not is an exhaustive list and all items brought on to the unit will be individually risk assessed. Items may need to be added to this list at any time if deemed appropriate by the team. Examples of such items are as follows: Controlled items The following items are allowed only under staff supervision. When not in use these items will be kept in your locker; Aerosols. Shaving razors. Shaving foam or gel. Pens. Glass bottles and jars. Sharp implements dependent upon the item. Mobile phones. Items allowed on leave only The items below must be handed back to staff on return to the unit; Mobile phone. Lighters or matches. Plastic carrier bags. Items of clothing subject to risk assessment; Shoe and boot laces. Scarves. Belts. CDs and DVDs For safety reasons these items are subject to controlled restricted access. You can have a maximum of two DVDs or CDs in your possession at any one time. PICU Operational policy Page 22 of 28

24 Appendix 6 Psychiatric Intensive Care Unit Environmental Checklist Date: 09:00 11:00 13:00 15:00 17:00 19:00 21:00 23:00 00:00 Corridors Bedroom Toilet Activity Room Quiet Room and TV Lounge Banned Items Anti Barricade Bolts Courtyard All Perimeter Doors Kitchen Fridge Temp (Kitchen) Fridge Temp (Clinic Room) Laundry Check Passes and spare Keys. Cupboard is Locked Staff Initial PICU Operational policy Page 23 of 28

25 What to Look For Courtyard Bedrooms Plastic Bags Excess Linen Banned items Medication (hoarded) Are fixtures secure Anti barricade bolts are down Check fences for any deposited drugs any risk items stones, sharps Ensure doors are secure and locked Corridors Fire exits clear Remove linen piles Fixtures secure Activity room. Door is locked. Fixtures secure Banned items Cupboards are locked Empty bins Check wires are not missing Quite room and lounge Return remote control Banned items all doors are secure Anti barricade bolts are down Kitchen Discard out of date food Regen food warmer working generally tidy Record fridge and freezer temp Empty Bins Fixtures secure PICU Operational policy Page 24 of 28

26 Bedroom 1 Sign: EACH ROOM TO BE CHECKED DAILY Removal of Contraband Items Room Clean and Tidy Remove Electrical EARLY LATE NIGHT EARLY LATE NIGHT goods by 00:00 Additional Comments Time: Bedroom 2 Sign: Time: Bedroom 3 Sign: Time: Bedroom 4 Sign: Time: Bedroom 5 Sign: Time: Bedroom 6 Sign: Time: PICU Operational Policy Page 25 of 28

27 Bedroom 7 Sign: Time: Bedroom 8 Sign: Time: Bedroom 9 Sign: Time: PICU Operational policy Page 26 of 28

28 Appendix 7 Guidance on Withholding Patient s Correspondence Mental Health Act 1983, SECTION 134 (Patients Correspondence) Key Issues a. When required, correspondence will be appropriately managed from patients detained under the Mental Health Act and stored in an appropriate safe place. What correspondence can be withheld from dispatch. What correspondence cannot be withheld from dispatch. What information must be kept in relation to withheld mail for dispatch. The role of the MHA administrator. Powers of the MHA Commission. Definition of Section 134 Under Section 134 (1) a postal packet addressed to any person by a patient detained in a hospital under this Act and delivered by the patient for despatch may be withheld if the recipient has requested that communications addressed to him/her by the patient should be withheld. This request must be in writing to the Hospital Managers (MHA Administrator). Definition of a Postal Packet A postal packet includes a letter, postcard, printed packet or parcel. Restrictions to informal patients correspondence There are no restrictions on informal patients correspondence. Correspondence where the powers of 134 do not apply a. The powers of Section 134 do not apply to correspondence sent by detained patients to the following persons: i. Any government minister or MP; ii. iii. iv. Court of Protection; Health Service Commissioner; Mental Health Review Tribunal; v. Health Authority; vi. vii. viii. ix. Mental Health Act Commission; Hospital Managers; The patients legal adviser; or The European Commission of Human Rights. b. The withholding of postal packets from the Post Office addressed to a detained patient applies only to Special Hospitals (Section 134 (1)(b). PICU Operational policy Page 27 of 28

29 Procedure for withholding Patients Mail If a request has been received in writing it must be sent to the MHA Administrator. The Responsible Clinician and Clinical Team must be informed. An entry must be made to this effect in the case notes. The patient must be informed of the decision. Any mail sent for despatch by the patient must be given to the MHA Administrator on behalf of the Hospital Managers and will be placed in an appropriate place of safety. A register will be kept by the Mental Health Administrator giving details of: i. The fact that the package or item has been withheld. ii. iii. iv. The date and the grounds on which it was withheld. The name of the appointed person who withheld it. The description of the item withheld. The nominated person to withhold patient mail will be the Mental Health Act Administrator. The nominated persons appointed to inspect post will be the Mental Health Act Administrator, Ward Manager, the Clinical Manager and Adult Service Manager. If a packet has been opened and inspected a notice must be inserted stating: i. That the packet had been opened and inspected ii. iii. iv. That nothing has been withheld The name of the person who opened the packet, the name of the witness The name of the hospital. Mental Health Act Commission powers Under Section 121 (7) of the Mental Health Act 1983 the Mental Health Act Commission has the power to review any decision to withhold a packet under Section 134 of the Act. PICU Operational policy Page 28 of 28