To identify the pharmacological management of acutely disturbed behaviour in patients requiring rapid tranquillisation (RT) on a psychiatric intensive care unit (PICU). Socio-demographic and clinical characteristics were also identified in these patients.

A retrospective cohort examination was carried out of 24 patients receiving RT, average age of 38.8 years (7 women and 17 men), admitted to the PICU between 1 January 2011 and 31 December 2011. Patient records and hospital incident reporting system were used to obtain relevant data for analysis.

The majority of patients were detained (95%); suffering from schizophrenia (45.8%); bipolar disorder (25%) and substance misuse disorders (12.5%). Verbal aggression (58.3%) and threatening behaviour (29.2%) were the most common factors leading to RT. Fourteen patients (58.3%) were medicated with a combination of haloperidol and lorazepam; nine (37.5%) with zuclopenthixol acetate only; and one (4.2%) with a combination of zuclopenthixol and promethazine.

Haloperidol in combination with lorazepam was the most common medication utilised for RT. Nevertheless, zuclopenthixol acetate alone, or combined with other drugs, was used in over 40% of cases. This finding is in considerable variation with recommended guidelines.

Rapid tranquillisation (RT) is a procedure that carries both medication and non-medication related risks. It has also recently been targeted by the NHS Litigation Authority, with an entire risk management standard devoted solely to this intervention. In this study, we aim to quantify the risk associated with RT, by looking at medication patient safety incidents (PSIs) reported by all NHS healthcare providers over the course of one year.

Medication PSIs relating to RT that occurred between 1 August 2010 and 31 July 2011 were extracted from the National Reporting and Learning System (NRLS) and analysed.

The number of PSIs extracted from the NRLS was low and no incidents related to adverse effects or harm encountered post administration of RT. These results are not generalisable as this study describes one search strategy of what is a fragmented system for reporting RT related PSIs.

This study indicates that the task of examining RT related PSIs in their entirety would be neither easy not simple. There needs to be a more relevant, reliable and robust system for reporting incidents related to RT.

The HCR-20 is one of the most popular structured clinical judgement tools used in forensic settings; yet, there are no published tools to assess the quality of its use. This study used the CAI-V, a tool to assess the competency of those carrying out risk assessment, to develop a quality tool for the use of HCR-20.

The audit was carried out between July 2012 and July 2013 on all patients resident in St Andrew’s Essex, a low secure unit. The results of the first audit led to an action plan for clinical improvement, subsequently re-audited a year later.

Most of the HCR-20 ratings scored in the competent range in both audits, but the greatest weakness was identified in the treatment planning section. The re-audit showed improvement, but there remained areas for development.

The audit highlighted broad areas of improvement like the need for full multidisciplinary involvement, more attention to formulation, and the need for greater consultation and information gathering from outside professionals and family members. The quality tool developed could be adapted to the requirements of any service, and used accordingly.

In recent years, policy in Australia has endorsed recovery-oriented mental health services underpinned by the needs, rights and values of people with lived experience of mental illness. This paper critically reviews the idea of recovery as understood by nurses at the frontline of services for people experiencing acute psychiatric distress.

Data gathered from focus groups held with nurses from two hospitals were used to ascertain their use of terminology, understanding of attributes and current practices that support recovery for people experiencing acute psychiatric distress. A review of literature further examined current nurse-based evidence and nurse knowledge of recovery approaches specific to psychiatric intensive care settings.

Four defining attributes of recovery based on nurses’ perspectives are shared to identify and describe strategies that may help underpin recovery specific to psychiatric intensive care settings.

The four attributes described in this paper provide a pragmatic framework with which nurses can reinforce their clinical decision-making and negotiate the dynamic and often incongruous challenges they experience to embed recovery-oriented culture in acute psychiatric settings.

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.

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).

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.

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.

PRN (as required) medication is commonly used in inpatient psychiatry but little is known about staff opinions concerning its use.

To explore views about PRN medication among nurses and psychiatrists working in PICUs or secure care at a charitable hospital.

A structured questionnaire with visual analogue scales was used to examine staff views about PRN medication. Participants were: 21 PICU nurses, 20 nurses working on medium secure admission units (MSAUs) and 27 psychiatrists. Inquiry was made about preferences and avoidance of PRN drugs and when PRN administration becomes rapid tranquillisation (RT).

Nurses working in PICUs and MSAUs held similar views about PRN medication. Nurses were more in favour of PRN medication than psychiatrists, whereas psychiatrists felt more strongly that PRN sedation was sometimes over-used. PICU staff favoured promethazine whereas non-PICU staff preferred lorazepam/lorazepam and haloperidol combined. There was no consensus as to when PRN administration becomes RT.

Nurses hold more positive views about PRN sedation than psychiatrists. Despite the ECG requirement, many staff favour haloperidol. The NICE definition of RT was not quoted by most participants. RT and PRN medication is a grey area which deserves further exploration.

Rhabdomyolysis is a potentially life-threatening syndrome that can develop from various causes. This study was undertaken to analyse the clinical spectrum and to evaluate the prevalence of various aetiologies in psychiatric patients with rhabdomyolysis.

We retrospectively analysed the medical charts of 87 patients. For them, serum creatine kinase (SCK) activity higher than 1500 IU/l was defined as rhabdomyolysis. The causes of increased SCK activity were assessed.

The annual incidence of rhabdomyolysis during 2007–2012 was 0.8–1.45%. In 59 men and 28 women (17–87 years old; median 50.9 years), no relation was found between age and the highest value of SCK activity. Their SCK activities were 1544–186 500 IU/l (median 3566 IU/l), but 45% had SCK activity higher than 5000 IU/l. Men were at greater risk than women. Major aetiologic factors were medical drugs, excessive physical activity, and psychogenic polydipsia. Patients with psychogenic polydipsia and alcoholism had higher SCK activity. Acute kidney injury (AKI) occurred in 8 men (9.1%). Five patients died, but only one died of rhabdomyolysis.

Most psychiatric patients with rhabdomyolysis were asymptomatic. The increase in SCK activity subsided spontaneously without specific treatment.

There is an abundant literature on the unfavourable attitudes held by staff working in mental health care settings towards patients with borderline personality disorder. The aim of this study was to assess whether attendance at a training session about the neurobiological underpinnings of borderline personality disorder could improve knowledge and produce positive attitudinal change within staff members working in a low secure inpatient setting.

Staff knowledge and attitudes (Mental Health Locus of Origin, Empathic Concern and Perspective Taking) were assessed at baseline, post-training attendance and at an eight-week follow up.

Attendance at the training session was associated with significant increases in theoretical knowledge, Perspective Taking and Locus of Origin scores. However, there were no changes observed in Empathic Concern scores.

This research suggests that a relatively brief training session, that utilises the neurobiological framework, can be effective in facilitating knowledge and attitudinal change for those working with borderline personality disorder. The implications of the findings are discussed along with suggestions for further research.