Psychiatric patients who need to be (in)voluntarily admitted to a psychiatric ward due to a crisis situation deserve the highest quality of treatment and care. Today, only few studies have been done which assessed quality and effects of (in)voluntary admissions, despite several already existing models of psychiatric intensive care units. In general, the aim of each admission is to treat patients effectively, in a humane and safe way, with as little coercion as possible and to try to keep the duration of stay as short as possible.
Given the fact that most patients who need an (in)voluntary admission have behavioural problems due to severe psychiatric symptomatology, providing high quality treatment and care is extremely challenging for clinical staff. This requires a multidisciplinary team (psychiatrists, nurses, psychologists, consumers) of sufficient size, and specific training in for example crisis management, acute medication, and handling aggression and suicidal behaviour. Apart from skilled and sufficient staff, a specific architectural environment is needed for providing optimal treatment facilities.
In the Netherlands, we developed a specific model for inpatient treatment of acute psychiatric patients, called High & Intensive Care (HIC). In the HIC model, elements of the recovery as well as the medical model have been combined. Staff and treatment modalities that were included in the HIC model were chosen from a list of existing practice- and evidence based methods, which were described earlier based on a literature survey (Voskes et al. 2012). The choice for including specific ingredients into the HIC model was done by a multidisciplinary group of Dutch experts, including consumers and representatives of family organisations. In addition to the requirements for staff and treatment modalities, specific architectural demands were formulated according to healing environment principles, including for example one person bedrooms, large and light living rooms and the availability of an outdoor space for patients.
Treatment ingredients of the HIC model include methods such as ‘’The first five minutes’’, describing the attitudes and behaviour of staff during the first five minutes of admission to the ward. When arriving on the ward, staff members try to make the patient to feel as comfortable as possible, thereby aiming at a reduction of anxiety and feelings of aggression and alienation. Making contact with the patient and significant others is key. In addition, frequent risk assessment using observation scales three times a day, during each shift (Sande et al. 2013), provides staff with timely information about potential risks for agitation and violence on the ward. This enables staff members to act proactively and prevent escalation.
On the HIC ward, there is a separate intensive care unit (ICU) for patients who have severe behavioural problems. On the ICU these patients can be taken care of on a one-to-one basis as long as needed. Finally, in extreme circumstances of patients having very severe behavioural problems a seclusion room can be used. The seclusion room can be used for a maximum of 24 hours and each patient is supervised constantly.
Coercion, including acute involuntary medication or seclusion, is used only when no other treatment options remain available. In the Netherlands, acute involuntary medication is seen as a legitimate measure in case patients pose a danger to themselves or others on the ward. Seclusion and involuntary medication are seen as equal measures in terms of violation of patient’s autonomy. Therefore, when deciding on using acute involuntary medication or seclusion in an emergency situation on the ward, the potential harm or benefits have to be weighted. Every time coercion (seclusion and medication) is used, this has to be documented and these data are discussed regularly among the staff members of the HIC. Yearly, the use of coercion has to be communicated with the National Dutch Health Care Inspectorate for quality assessment purposes.
The ingredients of the HIC model are put together into a HIC model fidelity scale, which is currently being validated. We hope to use the HIC model fidelity scale to study the associations between (ingredients of) the HIC model and outcome parameters such as the number of aggression incidents, coercive measures, patient satisfaction and length of stay.
The HIC model is well received in the Netherlands, by professionals, user organisations, management and insurance companies, because it provides a well described model which potentially offers the best care available. This has lead to a wide spread implementation of the HIC model in the Netherlands. The HIC model can be studied scientifically, since the model is summarized in a model fidelity scale, including available treatment options, staff availability, and architectural aspects. Therefore, in the future the HIC model can be optimized based on scientific data.