people Guideline Document Number # QH-GDL-365-2:2012 Guideline for the operation of High Dependency Units (HDUs) in Mental Health Services Custodian/Review Officer: Executive Officer, Mental Heath Alcohol and Other Drugs Branch Version no:2 ‘Applicable To: al authorised mental health services in Queensland ‘Approval Date: 14 August 2012 Effective Date: 14 August 2012 Next Review Date: 31 July 2014 Executive Director, Mental Health Alcohol and Other Drugs Branch ‘Approving Officer: Name: Associate Professor Jagmohan Gihota ‘Supersedes: Guidelines for Operation of Mental Health High Dependency Units (HDU) in Queensland. Key Words: mental health, high dependency unt, safety ‘Accreditation References: National Standards for Mental Health Services (NSMHS): Standard 1 ~ Rights and Responsibilties Standard 4 ~ Diversity Responsiveness Standard 5 ~ Promation and Prevention Standard 6 - Consumers Standard 7 - Carers Standard 8 - Governance, leadership ‘and management Standard 9 Integration Standard 10 ~ Delivery of Care EQUIPS: 1.1.1; 11.2; 1.1.3; 1 148; 124; 122) 13.4; 1 214; 2 32 1841;1.9.1; 95.1;981, ® Queensland Government 1. Purpose This Guideline provides recommendations regarding best practice around the management and operation of High Dependency Units (HDUs) in mental health services. 2. Scope This Guideline applies to all Hospital and Health staff and employees (permanent, temporary and casual), including contractors and volunteers working in treatment settings where specialist mental health services are delivered. 3. Related documents Policy and Standards: * Mental Health Services Policy: _ National Standards for Mental Health Services 2010 Procedures, Guidelines, Protocols + Mental Health Act 2000 Resource Guide + Implementation Standards for Safety + Implementation Standards for Delivery of Care + National Standards for Mental Health Services 2010 + Queensland Plan for Mental Health 2007-2012 + Mental Health Visual Observation Guideline Forms and templates Version No, 2012 Page 1 of 5Queensland Health: Guideline for the operation of High Dependency Units (HDUs) in Mental Health Services 4. High Dependency Units in Mental Health Services The provision of more intensive clinical care is on occasion necessary within mental health inpatient units for the effective management of acutely unwell consumers. This provision of care may take a number of forms including but not limited to increased mental health visual observations, access to a low stimulus environment and the scope for delivery of intensive care should it be clinically indicated. An intensive care area is a separate potentially lockable area within a mental health inpatient facility, designed to provide for the safe management of consumers requiring a higher level of individual care. Intemationally the term Psychiatric Intensive Care Unit (PICU) has been adopted, but in Australia this has led to confusion with Paediatric Intensive Care Units. Consequently the preferred nomenclature may need to avoid reference to PICU. Individual services should agree locally on their preferred name but some may prefer to continue to use the term High Dependency Unit. The following guidelines are intended to provide mental health services (MHS) with a framework for the operation of these units. They do not replace professional judgement on a case-by-case basis. MHS are to consider best practice for their service and develop local protocols that reflect this. In order to facilitate adaptation of the guidelines to meet local service needs and the needs of the individual, specific definitions of level of care and time frames have not been included. 4.4 Guiding Principles + Consumers are managed in the least restrictive environment, based on clinical need that considers their safety and the safety of others, + An individual's basic human rights (privacy, dignity and confidentiality) are recognised and met. + MHS have clearly defined processes for the provision of safe HDUs. + Services have a designated lead clinician with authority to make decisions regarding all aspects of the HDU operation. + The delivery of care and treatment must be consumer-centred, multi-disciplinary, comprehensive, collaborative and timely. Length of stay should be commensurate for clinical need and identified risks. 4.2 General Issues HDUs are considered part of an acute inpatient mental health facility. Secure Mental Health Rehabilitation Units (SMHRU) and High Secure Inpatient Services (HSIS) may also include a capacity for an HDU in their design. In such cases these guidelines will equally apply. HDUs provide safe management for consumers requiring intensive mental health care. When these needs cannot be met due to the severity or the duration of the consumer's condition, access to a SMHRU or HSIS may be required. This should only occur after all Version No.: 20; Effecive From: August Page 2 of 5 QueenslandGovernment 2012 Printed copies are uncontrolledQueensland Health: Guideline for the operation of High Dependency Units (HDUs) in Mental Health Services appropriate management options within the MHS have been tried and following discussion at a senior level. To facilitate this, individual units are encouraged to develop protocols with their receiving SMHRU and HSIS. HDUs, when locked, are not considered seclusion (providing the consumer is not confined alone), however must be staffed at all times. 4.3 Environment All acute inpatient mental health facilities will have a designated intensive care area. This area may have the potential to be locked and ideally be separated from the open ward. There are no set requirements on the number of intensive care beds, but it is recommended that a minimum of 10-15% of acute inpatient beds be allocated for this purpose. The HDU environment is important and efforts should be made to ensure the milieu is conducive to desired clinical outcomes. Ideally there will be adequate communal space, access to personal space with appropriate maintenance of privacy and access to an outdoor area. There should be ease of access to the seclusion rooms as clinically indicated. Mental health facilities are to have a policy on smoking that includes and considers consumers confined to the HDU. This Policy is to respect consumers’ and staffs’ right to a smoke free environment, if it is to permit consumers in HDU to smoke. 4.4 Safety Personal duress alarms will be available to staff working in the area. These must alert other clinical staff to an emergency and its location. The duress alarm system should be clearly understood by all staff, including agency and non-HDU staff. There should be clear procedures for staff to follow with regards to alarms. Testing of the system is to occur regularly. 4.5 Admission Criteria Admission to an HDU is based on current clinical need and made in the context of a treatment plan which identifies the consumer's diagnosis, clinical needs, treatment goals and expected outcomes. Explanation of the decision to admit a consumer to an HDU should be given to both the consumer and their caret/next of kin if the consumer has consented as clinically indicated. Voluntary consumers will not be routinely managed in an HDU care setting; should this be clinically required, informed consent must be obtained and clearly documented. 4.6 Management in HDU While a staff member will always be present in the HDU it should not be assumed that the Version No.: 20; Effecive From: August Page 3 of 5 QueenslandGovernment 2012 Printed copies are uncontrolledQueensland Health: Guideline for the operation of High Dependency Units (HDUs) in Mental Health Services consumer is always being observed e.g. consumers in bed or in the bathroom. The minimum requirement for visual observation in an HDU is at 15 minute intervals. Visual observations may be undertaken more frequently depending on the clinical needs of the consumer (refer to the Visual Observation Guidelines for further information). Surveillance cameras in HDUs should not be used for the purpose of mental health visual observations. In keeping with the philosophy of least restrictive environment, consumers are to have access to outdoor areas, structured activities and ward based activities as soon as clinical needs allow. The consumer's mental state, risk screen and treatment plan is to be reviewed daily, this review is to be clearly documented. Consultant psychiatrist review should occur at a minimum twice weekly and include review of the consumer's current treatment plan. Planning for reintegration into the open ward should commence on admission to the HDU. The timing of transfer from the HDU to the open ward is a clinical decision, based on a comprehensive review of all available clinical information and considering a graduated approach where necessary. The consumers’ right to maintain familial and interpersonal relationships is supported, however processes will be in place that safely balance and consider the rights of all consumers with the rights of visitors and staff. The Mental Health Act 2000 allows for searches of consumers and their environment in an Authorised Mental Health Service if a doctor or senior registered nurse reasonably believes that the consumer is in possession of something harmful. Please refer to the Guideline: Searches in Authorised Mental Health Services. 4.7 Staffing The selection of staff who work with acutely unwell consumers is important. In staffing these areas, consideration must be given to the skill mix, gender mix, level of staff experience and the staff/consumer ratio required. The staff/consumer ratio should remain dynamic depending on the clinical needs of the consumers. 4.8 Qu ity Activities MHSs are encouraged to establish local processes, collect data and identify clinical indicators that can be used to monitor the practices in HDUs. This data should be reviewed on a regular basis to ensure ongoing best practice. In addition, there should be processes for: + responding to (and reporting of) critical incidents; and + debriefing and counselling of both consumers and staff following critical incidents. Version No.: 20; Effecive From: August Page 4 of QueenslandGovernment 2012 Printed copies are uncontrolledQueensland Health: Guideline for the operation of High Dependency Units (HDUs) in Mental 5. Defi Health Services ion of Terms Definitions of key terms are provided below. Term Definition / Explanation / Detalls Source High Dependency Unit A separate potentially lockable area within a mental health inpatient facility, designed to provide for the sate Guidelines for the Operation of Mental ‘management of involuntary patients requiting a higher | Health High level of individual care, Dependency Units in Queensland Authorised Mental Health | A mental health service declared under section 495, | ‘Mental Health Act Service (AMHS) Mental Health Act 2000. To be an authorised mental | 2000 service or a public hospital if there Is no authorised ‘mental health service readily accessible for a persons examination or assessment. 8. Guideline Revision and Approval History Version | Modified by No. Amendments authorised by | Approved by 2 Penny Dale and Catherine | Robert Troy Dr Bill ‘Scott-Richardson Acting Mental Other Kingswell, Executive Director | Health Alcohol and Drugs Branch Version No.: 2. }, Etfecive From: August Page 5 of 5 Printed copies are uncontrolled