A short-term service for those who are most severely ill, the intensive care unit provides twenty-four-hour nursing care and monitoring to help stabilize patients so that they can return to the day hosflital for definitive treatment.

The Intensive Care Unit Laura Rood

Established in 1981, the intensive care unit (ICU) is perhaps the most traditional part of the treatment system at the Massachusetts Mental Health Center in that it is the service that most closely resembles a con- ventional inpatient psychiatric unit. Yet in its relationship to the other components of hospital care at the center, the ICU has several unique features, described in this chapter.

Before the introduction of the day hospital/inn model, inpatient care at the center was divided into two services, to which patients were ran- domly assigned on admission. The services had virtually identical pro- grams and staffs, with residents and other trainees working on each unit. The program of care included evaluation, diagnosis, and treatment; room and board; and containment. The milieu was designed for long-term stays, and patients were expected to progress through a series of restric- tions in the effort to gain privileges and eventual discharge.

When the state fiscal crisis in 1981 forced the center to reevaluate its system of services, we realized that although all our hospitalized patients required evaluation, diagnosis, and treatment, many did not need containment or twenty-four-hour care after the initial period of illness. They remained on the inpatient service because they continued to need room and board. It made sense, therefore, to differentiate these functions so that our limited resources could be used more efficiently and patients could be treated in the least restrictive settings possible.

M. F. Shore and J. E. Gudeman (ds.). Serving the Chronically M~nlal ly 111 m an Urban Sptting New Directions for Mental Health Services, no. 39. San Francisco: Jossey-Bass, Fall 1988. 41

42

These observations became the foundation for our day hospital/inn model of care.

Under the new system, the ICU acts as a backup to the day hospitals and other services at the center; i t is not a receiving unit. All patients are admitted to a day hospital and assigned to one of its treatment teams. On admission, approximately 80 percent of patients are judged to be in need of twenty-four-hour observation and nursing. These patients are imme- diately transferred to the ICU. Once stabilized, they return to the day hospital. The treatment team follows them from one service to the other.

The Setting

Although the Massachusetts Mental Health Center has always considered itself an open-door hospital, the ICU has a locked door. The threshold for admission is so high that all patients transferred to the unit need containment and close observation. Before the reorganization of services, each inpatient unit had an unlocked door that was watched by a staff member. Staffing constraints no longer permit that approach, and so the door is locked. Because of the large number of trainees and visitors, however, we generally think of the ICU as an open-door unit that is sometimes locked. In this respect, i t could be considered a minimum- to medium-security unit.

Occupying an L-shaped wing of the main building, the ICU looks very much like a psychiatric unit in a general hospital. One enters a large dayroom that has a nurses’ station and a reception desk. Smoking is confined to one room on the unit, so that the dayroom and the patients’ rooms are free of smoke. The bedrooms are to the left of the dayroom, along with the seclusion area and a room for activities and watching television. To the right is the room where patients can smoke, as well as an area for storage of clothing and linen.

To receive accreditation from the Joint Commission on the Accredita- tion of Hospitals, as well as Title XVIII and XIX certification, the unit must meet certain design requirements, which can present problems for patient care and maintenance. For example, most of the bedrooms have separate bathrooms attached, an arrangement that complicates routine safety checks. In addition, the more disturbed patients sometimes clog toilet and sink drains with large amounts of paper or clothing, making it difficult to maintain the plumbing.

Both interior and exterior space constraints pose special problems for the ICU. The Massachusetts Mental Health Center is in a congested urban area, where there are no grounds for patients to wander or cool off. The hospital has long since outgrown the building that was constructed in 1912 to house its programs. The gymnasium is now used for a social program, and the swimming pool has been closed because of mainte-

nance problems. Insufficient space for physical exercise and recreation has a profound effect on the acute care of patients who have severe psychiatric disorders. The ICU staff must work especially hard to pro- vide activities on the unit that help engage patients and channel their aggressive drives.

The Patients

The criteria for admission to the ICU are rigorous. The only patients transferred to the unit are those who pose a danger to themselves or to others, are so incapacitated that they cannot care for themselves, or require twenty-four-hour nursing to monitor medication or physical con- ditions. About 75 percent of these patients have a diagnosis of bipolar disorder or schizophrenia. Approximately 44 percent of the patients are admitted to the center involuntarily. Court-ordered evaluation is per- formed on the ICU only if a patient has been charged with a violent crime.

The ICU is designed to be a short-term unit. The average length of stay is about three weeks, but certain patients-those with organic brain syndrome, mental retardation combined with violent behavior, medical as well as mental illness, or chronically psychotic violent behavior-may require longer stays. Since the center has no backup state hospital, such patients have tended to remain on the ICU for extended periods. Realiz- ing that patients with these disorders frequently require more specialized and extended treatment than the ICU is designed to offer, the hospital recently opened a separate eighteen-bed unit for their care.

Ten beds at the center (on the ICU and at the Fenwood Inn) are reserved for the comprehensive evaluation and treatment of patients who are homeless. These patients receive limited medical care, in addition to psychiatric treatment. We also provide evaluation services for extremely difficult patients throughout the state, although we are somewhat limited by our catchment-area responsibilities.

Like most state institutions whose primary mission is to serve patients with major mental illness, we have many repeat admissions (only about 25 percent are first admissions). Nevertheless, patients who become known to us through multiple hospitalizations tend to stay on the ICU for very short periods and are treated primarily in the day hospital, stay- ing at the Fenwood Inn at night, if necessary.

The Program

The ICU program of care is medically oriented, offering a place for eval- uation and diagnosis of acute mental illness. Much of the program is concerned with containment of the acute phase of illness, so that the

44

patient can return to the d a y hospital as soon as possible for definitive treatment. The day-hospital team assigned to a patient on admission follows that patient to the ICU, and the primary clinician works closely with the nursing staff to provide optimal care.

The nursing staff is responsible for the management of patients on the ward, deciding which groups they should attend and what degree of restriction is required. As a guideline for making such decisions, we believe that patients should be allowed maximum freedom, unless they are extremely dangerous or indicate that they cannot tolerate such free- dom. For example, all patients are expected to leave the unit for meals and in-hospital activities, unless they are in seclusion or under restraint. Patients also have full privileges on the ward, so long as there is no pressing reason (for example, extreme suicidality) to retract them. We allow patients to keep all personal belongings except glass objects and matches. On the other hand, all patients are checked at fifteen-minute intervals, no matter how long they have been hospitalized, and many are on five-minute checks. In this way, we can observe the patients closely without subjecting them to undue restrictions.

In keeping with the needs of our patients, the program on the ICU is carefully structured. The day begins and ends with a meeting of all patients. The purpose of the morning meeting is to help the patients decide what they would like to accomplish that day. These plans may range from activities as basic as taking a shower to participation in the day hospital’s program. The evening meeting, generally cochaired by a patient who has volunteered for the job, provides a chance for each patient to review the day’s activities. The two daily meetings help the patients set and accomplish goals for themselves. They also provide the staff with important information. For example, can a particular patient sit still for thirty minutes without being disruptive, attend to basic needs, or think through plans for the next minute, hour, or day?

Structured activities are offered throughout the day by three staff members under the supervision of a registered occupational therapist. These activities are scheduled from 8:30 A.M. to 8:30 P.M., seven days a week, with a total of approximately sixty activities available during the week. Figure 1 shows the schedule for a typical day. Medications are given throughout the day, although we aim for once- or twice-daily dos- ages to encourage compliance.

Each patient has a staff member assigned as an advocate. The advo- cate helps the patient throughout the stay on the ICU, providing assis- tance with grooming, room maintenance, banking, and so forth. The advocate also documents the patient’s daily progress and participates in treatment planning. Any ICU staff member may act as a patient advo- cate, and all advocates receive weekly supervision from a registered nurse on the staff.

45

7:OO A.M.

8:30 A.M.

9:oo A.M.

1o:oo A.M.

11:30 A.M.

12:00 P.M.

12:30 P.M.

1:30 P.M.

2:oo P.M.

2:30 P.M.

3:OO P.M.

3:30 P.M.

5:OO P.M.

7:OO P.M.

8:oO P.M.

Figure 1. Daily Schedule for Patients on the ICU

Wake up, clean common area, breakfast Morning meeting Shave, shower (bedroom doors locked) Projects Break Lunch (bedroom doors open) Rest Medication group (bedroom doors locked) Community meeting (discuss issues such as ward rules, food) Social time Visiting hours begin (bedroom doors open) Games group Supper Group walk Evening meeting

Violent Behavior

One cannot talk about psychiatric intensive care without addressing vio- lence and how to deal with it. Verbal intervention, good ward structure, and active defusing of a tense ward go a long way toward preventing violence. If a patient assaults someone or damages property, however, more restrictive intervention is generally required. The means of inter- vention may depend on the patient’s disorder. For example, in the case of a violent psychotic patient, we may intervene first by using additional antipsychotic medication. For a violent patient with a character disorder, space restriction may be the first choice.

In keeping with our effort to use the least restrictive measures possi- ble, we have a low rate of seclusion and restraint on the ICU, averaging half an hour per patient per month. The nursing staff assesses the need for such interventions. All other means of controlling violent behavior must be exhausted first, and the choice of restraint must be whatever will cause the least harm and do the most good for the particular patient. Often, if chemical restraint is used, the initial laying on of hands has a calming effect, allowing the patient to take medication by mouth; if not, an intramuscular injection is administered. Only if a patient continues to be combative will we resort to seclusion (placing the patient alone in a locked room) or physical restraint (placing one to four limbs under

46

restraint). A patient who is in seclusion or under restraint must be indi- vidually monitored for safety. The ICU implemented its one-to-one mon- itoring policy several years ago, on the assumption that anyone disturbed enough to require such extreme intervention should have individual care. Shortly after we introduced one-to-one monitoring, the Massachusetts state legislature passed a law requiring it. We believe that this approach makes good sense, especially considering the number of patients who die in seclusion or under restraint.

Seclusion and restraint are used only until the patient has regained self-control, a period that may be minutes or hours. Once the patient is in control, he or she is encouraged to look at the escalating events that resulted in destructive or self-destructive behavior. Staff members need to go through a parallel process of debriefing, letting the adrenaline subside, and returning to work.

The Massachusetts Mental Health Center holds a semimonthly semi- nar on violence for all staff members, where methods of verbal and nonverbal intervention are discussed. Since violent behavior is a common topic on psychiatric wards, we believe it is important to provide continual training and up-to-date information on all intervention techniques, particularly those that help prevent violence. Seclusion and restaint, after all, cannot prevent an assault that has already occurred.

Refusal of Treatment

We try to establish an alliance with the patient, to promote compliance with medication regimens and enhance treatment. In Massachusetts, a patient who refuses medication and is deemed incompetent must have a court-appointed guardian who makes the decision to accept or refuse treatment on the patient’s behalf, using the principle of substituted judg- ment. Unfortunately, this process can delay treatment by weeks or even months. Medication is certainly not the only treatment offered on the ICU, but for some patients it may make the difference between long and short stays.

Staffing

Since the ICU is basically a nursing and behavior-monitoring unit, nurses and mental health assistants predominate on the staff. The day shift consists of two registered nurses, five mental health assistants, one occupational therapist, and an occupational therapy assistant. The staff- ing pattern is the same in the evening, except that this shift does not include an occupational therapist. One registered nurse and four mental health assistants care for patients on weekends. Although physicians, psychologists, and social workers are assigned to the day hospitals, and

47

not directly to the ICU, they still follow their patients throughout hospi- talization, including their stays on the ICU.

The high employment rate and the nursing shortage have made recruitment and retention of staff members a major concern of the unit. A large university in the area recently closed its nursing school, and other nursing programs have experienced large declines in enrollment. In response to the shortage, the Massachusetts Mental Health Center has stepped up its efforts to recruit nurses, particularly for the ICU.

One of the main problems in hiring and retaining ICU staff members is the work schedule on the unit, which differs from the schedule for the rest of the hospital. The day hospitals run on a forty-hour, five-day work week, but the ICU has a rotating schedule of day, evening, and weekend shifts, making it less attractive to many would-be employees. We have recently been able to adjust salaries on the ICU to compensate for the disruption of shift work and the higher level of stress on the unit. We have also introduced “flex time” and participatory scheduling, which give staff members a greater voice in determining their work schedules. As the center plans for a new building over the next few years, low-cost housing and health facilities are being considered as additional ways to attract new staff members.

The quality of working life on the ICU remains a central concern and probably always will, by virtue of our mission to take care of patients when they are most severely disturbed. The high level of stress on the unit makes staff meetings particularly important. A weekly meeting of all staff members provides a forum for discussing tensions, concerns, and problems with patients. In addition, the nurses and mental health work- ers have separate meetings to address issues related to their specific jobs.

Stress-reduction workshops are offered to ICU staff and are well attended. We also try to make i t possible for staff members to attend the many case conferences and other educational offerings at the center.

In summary, the ICU is an exciting part of the Massachusetts Mental Health Center’s program of care. Ours is perhaps the most challenging mission at the hospital: to provide the best, least restrictive psychiatric treatment to society’s most vulnerable members-the indigent severely mentally ill. Despite its fast pace and demanding work, the unit is rich in opportunities for learning. Moreover, the rewards of seeing very sick patients recompensate are enormous.

Laura Rood, R.N., is director of the intensive care unit at the Massachusetts Mental Health Center and instructor in psychiatry at Haruard Medical School. She earned her B.S. and M.S. degrees from Boston University and has worked at the center since 1978.