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Within acute mental health care, the year started normally enough with the usual challenges and successes that punctuate mental health inpatient care Language rarely used in acute mental health services became the content of daily conversations Like many mental health services around the world, the UK inpatient mental health service is profoundly dependent upon the skills and contribution of staff members from the BAME community Using familiar methods of observing the movement of ultraviolet (UV) visible material between people to determine contact contamination has been explored in detail under controlled conditions

Background: Restraint is widely practiced within inpatient mental health and is considered a higher risk procedure for patients and staff. There is a sparsity of evidence in respect of the efficacy of Personal Protective Equipment (PPE) used during restraint for reducing risk of infection. Methods: A series of choreographed restraint episodes were used to simulate contact contamination in research participants playing the roles of staff members and a patient. For comparison, one episode of simulated recording of physical observations was taken. UV fluorescent material was used to track the simulated contact contamination, with analysis undertaken using established image registration techniques of UV photographs. This was repeated for three separate sets of PPE. Outcomes: All three PPE sets showed similar performance in protecting against contamination transfer. For teams not utilising coveralls, this was dependent upon effective cleansing as part of doffing. There were similar patterns of contamination for restraint team members assigned to specific roles, with hands and upper torso appearing to be higher risk areas. The restraint related contamination was 23 times higher than that observed for physical observations. Interpretation: A second layer of clothing that can be removed showed efficacy in reducing contact contamination. PPE fit to individual is important. Post-restraint cleansing procedures are currently inadequate with new procedures for face and neck cleansing required. These findings leave scope for staff to potentially improve their appearance when donning PPE and engaging with distressed patients. Funding: The evaluation was funded by Gloucestershire Health and Care NHS Foundation Trust. Conflict of Interest: None. Ethical Approval: The evaluation design did not involve any patients or patient related data and therefore is considered part of standard procedure and equipment evaluation not requiring ethical approval. Valid consent to take part in the evaluation was provided by all involved.

The British Association for Psychopharmacology and the National Association of Psychiatric Intensive Care and Low Secure Units developed this joint evidence-based consensus guideline for the clinical management of acute disturbance. It includes recommendations for clinical practice and an algorithm to guide treatment by healthcare professionals with various options outlined according to their route of administration and category of evidence. Fundamental overarching principles are included and highlight the importance of treating the underlying disorder. There is a focus on three key interventions: de-escalation, pharmacological interventions pre-rapid tranquillisation and rapid tranquillisation (intramuscular and intravenous). Most of the evidence reviewed relates to emergency psychiatric care or acute psychiatric adult inpatient care, although we also sought evidence relevant to other common clinical settings including the general acute hospital and forensic psychiatry. We conclude that the variety of options available for the management of acute disturbance goes beyond the standard choices of lorazepam, haloperidol and promethazine and includes oral-inhaled loxapine, buccal midazolam, as well as a number of oral antipsychotics in addition to parenteral options of intramuscular aripiprazole, intramuscular droperidol and intramuscular olanzapine. Intravenous options, for settings where resuscitation equipment and trained staff are available to manage medical emergencies, are also included.

Weapons and other items with potential to cause harm are usually prohibited in mental-health hospitals and other psychiatric facilities. Detecting such prohibited items (PIs) can be problematic, particularly if concealed, and metal detectors are commonly used to search for such items. Our study compared two types of metal detection: continuous wave detection (CWD) by hand-held metal detector (HHMD) and magnetic anomaly detection (MAD) by a static pole device. In the study, real and dummy PIs were hidden on test subjects and in a simulated body cavity. The results showed MAD to be significantly superior to CWD in detecting small concealed PIs containing ferrous metal. The MAD pole found 100% of the real PIs on the test subjects and in the simulated body cavity. The CWD HHMD found only 5.2% of the real PIs, and these were limited to those on the test subjects, as it detected none in the simulated body cavity. In addition, the time taken to search by MAD pole was shorter than time taken to search by CWD HHMD.

We review key recent research and guidance for staff working with acutely disturbed psychiatric patients. Assessment of aggressive patients and their situation should enable full risk assessment, which may ideally involve the use of advance directives. We discuss appropriate use of the Mental Health Act 1983 and consider benefits and adverse effects of rapid tranquillisation. We present a simple protocol for oral or intramuscular rapid tranquillisation. Staff using physical restraint should be properly trained and consider sensitively issues of the patient's diginity, gender and the most appropriate location for restraint to occur. Simple precautions can improve safety when working with potentially disturbed patients. Staff need support during and after the management of an aggressive incident.

The treatment of acutely disturbed patients is a stressful area of psychiatric practice. Castleet al(1994) found that MRCPsych Part II trainees expressed a general dissatisfaction with training in the management of violence, and in our experience junior trainees are even less confident in the treatment of the disturbed patient. A survey by Cunnane (1994) found that no consensus exists among consultant psychiatrists on which drug treatment is most appropriate for the management of the aggressive, acutely disturbed psychotic patient. There was uncertainty as to optimal management, low expectation of quick results, unwillingness to express an opinion and the use of drug cocktails of dubious rationale.

Introduction Throughout the ages, virtually all complex societies have found the need for containment and control of behaviour by physical means. Indeed, it is difficult to imagine a world without prisons, police and the periodic need for society to impose its collective standard of behaviour on individuals. While most people share a degree of comfort with the notion of physical intervention to maintain law and order, its use under the justification of mental health ‘care’ is deeply troubling to many, with some arguing it has no place at all (Davis 2004). The first words in any discussion about restraint must include the methods of avoiding the need for its use wherever possible. De-escalation, negotiation and the development of trusting relationships have been covered in detail elsewhere in this volume and the reader is advised to consider these issues as an essential first step. The focus here will be confined to the activity of restraint, assuming that due attention has already been paid to the methods of avoiding the need for its use. Restraint and physical intervention: the questions In mental health care, the use of restraint, both mechanical and inter-personal, has a long and chequered history. In recent years, the use of restraint has come under increasing scrutiny. In the UK and the USA, death during restraint has been increasingly reported (Appelbaum 1999; Paterson et al. 2003).

The psychiatric intensive care unit (PICU) is now at the cutting edge of acute psychiatric care. Very little guidance has been produced to ensure that the PICU structure and design is able to meet the complex demands put upon it. The creation, development and relocation of a PICU has taken place within the Severn NHS Trust. We describe the experience gained from a recently commissioned unit together with a review of the relevant literature. Recommendations are offered for core features and design.

Severn NHS Trust has recently commissioned a psychiatric intensive care unit (PICU) which became operational on 18 July 1994. Although the number of PICUs is increasing and their services are greatly valued, they are often fraught with problems. A model for the development of PICU services is described. It includes admission criteria, overall clinical organisation of the PICU, discharge criteria and a discussion. The model described is based on the hypothesis that the primary role of the PICU is to deal with clinical nursing problems rather than medical problems. The discussion points out some of the instrumental components necessary for the successful development of PICU services.