Models of care and practice for the inpatient management of highly acute mental illness and acute severe behavioural disturbance

Highly acute mental illness and acute severe behavioural disturbance (ASBD) are two of the most challenging problems faced by Mental Health Intensive Care Units (MHICU). ASBD is defined as behaviour that places the patient or others at imminent risk of injury or death. It includes extreme distress, aggression, and serious self-harm, in the context of mental illness. This Evidence Check assessed the literature on models of care and treatment strategies for these conditions, aiming to refine the model used in MHICU in NSW. It attempted to find the most effective models of care for high acuity and ASBD—and the barriers and enablers to implementing them. A total of 58 relevant papers were found, spanning 2015 to 2020. They were rated on a hierarchy of evidence designed for models of care and interventions in complex settings. Two models of care, ‘Safewards’ and ‘Improving the therapeutic milieu of the wards’, were rated as best practice. These were followed by five models of care, themes and groups of treatments at middle levels of the hierarchy, and nine themes and treatment practices at the lowest level. There were several features common to numerous papers in the review: therapeutic engagement, meaningful activities, safe spaces, and welcoming spaces. Barriers and enablers to implementation were generally not addressed specifically. However, themes emerging from the papers showed several enabling factors: training, buy-in from stakeholders at all levels of the organisation, and assessment of progress. Barriers to implementation included lack of support from management and lack of engagement from frontline staff. Complex, multilevel practice change interventions appear necessary for effective implementation.

Fletcher J, Oostermeijer S, Hamilton B, Brophy L, Minshall C, Harvey C, Migliorini C, Whittles N, Jacques M, Muir-Cochrane E, Zirnsak T, Morrisroe E. Models of care and practice for the inpatient management of highly acute mental illness and acute severe behavioural disturbance: an Evidence Check rapid review brokered by the Sax Institute (www.saxinstitute.org.au) for NSW Ministry of Health, October 2020. doi: 10.57022/lppe2712