Mental health intensive care units

Guideline number: QH-GDL-499:2022

Effective date: 27 June 2022

Review date: 27 June 2025

Supersedes: N/A first issue

On this page:

1. Purpose
2. Scope
3. Related documents
4. Indicators for transfer to MHICU
5. Transfer of care to MHICU
6. Care within MHICU
7. Transition from MHICU
8. Governance and quality improvement
9. Definitions
10. Document approval details
11. Version control

1. Purpose

This guideline provides recommendations regarding caring for consumers requiring more intensive clinical care within a designated mental health intensive care unit (MHICU) which is located within an acute mental health inpatient unit (AMHIU).

A MHICU is a designated, lockable area designed to facilitate the care of consumers who cannot be safely managed in a less contained environment and require more intensive mental health care. MHICUs are often referred to as high dependency units, as in previous guidelines, or psychiatric intensive care units. For the purposes of this document, the term MHICU will be used as the generic name.

This guideline does not provide operational guidance, nor offer recommendations regarding staffing ratios or other resourcing matters.

2. Scope

This guideline applies to all AMHIUs with MHICUs.

This guideline applies to all Queensland public health system employees (permanent, temporary and casual) and all organisations and individuals acting as its agents (including visiting medical officers and other partners, contractors, consultants and volunteers).

3. Related documents

Legislation and standards

• Mental Health Act 2016 (QLD)
• Hospital and Health Boards Act 2011 (QLD)
• Human Rights Act 2019 (QLD)
• National Safety and Quality Health Service Standards 2017
• National Standards for Mental Health Services 2010

The Queensland public sector must consider the impact on the human rights of individuals when making decisions and ensure that any decision is compatible with the Human Rights Act 2019 (Queensland) (HR Act). This guideline must be implemented in a way that is consistent with the rights outlined in the HR Act. Queensland Health staff have obligations under the HR Act to make decisions and act in ways that are compatible with human rights.

Staff must also work in accordance with professional practice standards and scope of practice relevant to their profession.

Guidelines, policies and procedures

This document should be read and applied in conjunction with other related Queensland Health documents.

Queensland Health guidelines:

• Therapeutic visual observation for mental health alcohol and other drugs services guideline, 2020
• Sexual Health and Safety Guidelines for Mental Health Alcohol and Other Drugs Services, 2016
• Recognising and managing potential environmental hazards in Queensland public mental health and alcohol and other drug inpatient units, 2016
• Managing ligature risks in Queensland public mental health alcohol and other drug inpatient units, 2016

Chief Psychiatrist policies:

• Treatment and care of patients
• Treatment and care of minors
• treatment criteria, assessment of capacity, less restrictive way and advance health directives
• Seclusion
• Physical Restraint
• Clinical need for medication
• Searches and security
• Management of complaints and right to a second opinion

Mental Health Alcohol and Other Drugs Branch, resource guide:

• Comprehensive Care Resource Guide and associated documentation, 2020.

4. Indicators for transfer to a MHICU

Indicators for transfer to a MHICU may include:

• deterioration requiring increased frequency of review and more intensive monitoring and intervention
• higher level need for intervention and support, including physical health needs
• acute severe behavioural disturbance which places the consumer or others at imminent risk of serious harm, including by aggressive behaviour and serious self-harm
• significant suicide risk or repeated severe self-harm
• repeated attempts to leave the AMHIU without authority (involuntary patients receiving treatment and care under the Mental Health Act 2016)
• where further risk assessment is required due to the consumer’s historic risk profile, including forensic history or risk of harm toward others. For example, this may include classified patients being admitted to the AMHIU
• increased vulnerability due to personal characteristics (for example chronological and developmental age, gender, history of trauma) or mental or physical state
• consumers requiring care in a low stimulus environment.

5. Transfer of care to a MHICU

Transfer to a MHICU is appropriate where care cannot be provided safely and effectively in less restrictive settings. It should only occur after less restrictive approaches have been considered and if possible trialled.

Transfer of care to and from a MHICU requires safe and effective communication processes relating to transfer and consideration of optimal continuity of care by the multi-disciplinary team.

The consumer, their family and carer or nominated support person, should receive an explanation for the transfer to a MHICU, including information on what to expect and what parameters would lead to transfer from/out of a MHICU. Information should be shared with the family, carer or nominated support person as soon as possible depending on circumstances, and wherever possible prior to the transfer.

Planning for transition from a MHICU should begin at the point of admission into the MHICU and should involve clear indicators for transition out of the MHICU and interventions that may support successful transition.

6. Care within a MHICU

General principles

• An individual’s basic human rights (privacy, dignity and confidentiality) are recognised and met.
• Care within a MHICU should be provided by the entire multi-disciplinary team to achieve identified treatment and support goals, consistent with Comprehensive Care: Partnerships in Care and Communication.
• Care within a MHICU should recognise and respond to principles of trauma-informed care and ensure personalised care meets cultural and spiritual needs.
• Care within a MHICU should be time limited and as brief as possible.
• Voluntary consumers will not routinely be cared for in a MHICU. Transfer of a voluntary consumer to a MHICU should occur only when clinically necessary and informed consent should be obtained and documented.

Therapeutic interventions within a MHICU

• The MHICU environment is to be as therapeutic as possible, whilst maintaining safety for consumers and staff.
• Consumers should have access to the full suite of mental health care interventions, as far as clinical needs allow, which may include access to outdoor areas, structured and unit-based activities.
• Close attention and surveillance by staff are necessary to provide care, including to monitor the safety of consumers and the environment and to maintain a therapeutic milieu. This includes monitoring potentially harmful items within a MHICU, or that may be brought into a MHICU, consistent with Queensland Health guidelines:
  • Recognising and managing potential environment hazards in Queensland public mental health and alcohol and other drug inpatient units, and
  • Managing ligature risks in Queensland public mental health alcohol and other drug inpatient units.
• As part of ensuring the safety of the MHICU environment and minimising the risk of potentially harmful items being brought into a MHICU, staff should ensure that a consumer has been searched prior to entry to the unit. This may either be on entry to the AMHIU, or on entry to the MHICU within the AMHIU. Refer to the Chief Psychiatrist policy, Searches and Security for further information on conducting searches under the Mental Health Act 2016.
• The minimum frequency of therapeutic visual observation within a MHICU is 15 minutes (intermittent level). For detailed guidance on therapeutic visual observations refer to the Queensland Health guideline, Therapeutic visual observation for mental health alcohol and other drug services.

7. Transition from a MHICU

• Planning for transition from/out of a MHICU should identify clear and specific indicators for transition and interventions that may support successful transition.
• Assessment of the point at which a person may safely transfer from a MHICU to less intensive levels of care is a clinical decision to be made by the multi-disciplinary team, based on a comprehensive assessment of risks and benefits.
• At the time of transition from a MHICU, consumers should be given the opportunity to debrief and discuss any concerns in order to:
  • enable open discussion about the consumer’s experience in the MHICU and allow the consumer to ask questions about their care
  • provide an opportunity to identify strategies that may assist in preventing the need for transfer to a MHICU in the future. This may include a written plan or list of strategies that can be shared with and utilised by the consumer, their support person/s and staff
  • identify the consumer’s wishes for any future transfers to a MHICU which can support the preparation of an advance health directive.

8. Governance and quality improvement

Services are encouraged to establish local processes and collect data and identify clinical indicators that can be used to monitor practices and outcomes when providing care in a MHICU.

9. Definitions

10. Document approval details

Document custodian: Director, Clinical Governance Unit, Mental Health Alcohol and Other Drugs Branch

Approval officer: Chief Psychiatrist, Mental Health Alcohol and Other Drugs Branch

Approval date: 27 June 2022

11. Version control