TREATMENT GUIDELINE FOR BIPOLAR MOOD DISORDER (BMD)

MINIMUM STANDARDS FOR PSYCHIATRIC HOSPITALS SET BY THE PSYCHIATRIC FOCUS FORUM (PFF)

Apr-05

Contents

Introduction

Laws and regulations

Therapeutic Milieu

3.1

Physical Dimension

3.2

Cognitive Dimension

3.3

Social Dimension

3.4

Emotional Dimension

3.5

Spiritual Dimension

Therapeutic Programme

4.1

General

4.2

Contents

Multidisciplinary team

5.1

The team members

5.2

Responsibilities

5.3

Continued Professional Development

Services

Documentation

General

1. Introduction

It is essential for psychiatric hospitals to set standards for services rendered.

Mental health care users (hereafter referred to as clients) are vulnerable and are often not aware of treatment modalities available, and which modality/modalities would be most beneficial to them.

Internationally the use of a therapeutic milieu under the control of a multidisciplinary team, using the least restrictive environment, has shown the best results in treatment.

The minimum requirements take these issues into consideration, and attempt to provide guidelines on which most effective services may be based.

2. Laws and regulations

Psychiatric hospitals must comply with all applicable laws and regulations as well as standards provided for, both by the State and the Psychiatric Focus Forum (PFF) from time to time.

In-service training to be provided to staff relating to relevant legislation.

3. Therapeutic Milieu

Therapeutic milieu refers to the general setting where treatment occurs.

The therapeutic environment must be designed in such a way that it facilitates and contributes to the recovery of the client.

The environment consists of a physical dimension as well as intellectual-, social-, emotional-, and spiritual enhancing dimensions.

3.1. Physical Dimension

The physical dimension must include all concrete features in the external environment.

The facility must be designed in such a way that client interaction and active participation is encouraged:

A communal dining room, with tables and chairs, where the clients can be seated for all their meal- and teatimes.

Designated lounge and recreation facilities (if multi-purpose then provide adequate space), as well as adequate garden-space where clients can socialize, visit and do constructive leisure-time after hours.

Sufficient and adequately sized therapy rooms for group therapy.

Smoking area which adheres to legal requirements.

Sufficient space for physical / exercise activities.

v Provision must be made for privacy:

Ø Consulting rooms where patients can meet with therapists in private.

Ø A Nurses station, office or area where confidential discussions may be held.

Ø Bedrooms and ablution facilities according to relevant regulations.

Ø Special consideration should be given to the needs of minors.

v Facilities, not necessarily on the premises, must be available for procedures such as:

Ø Electro Convulsive Treatment:

q An E.C.T. Theatre, recovery room, staff and procedures must be according to regulation R158/R187 or subsequent legislation.

Ø Other:

q A Treatment room must be available for medical procedures and other neurological- or physical assessments.

v All areas must be:

Ø clean, quiet, home-like and in tranquil surroundings;

Ø equipped with domestic furniture, except in specific designated treatment areas such as Treatment room, ECT rooms and Highcare;

Ø Safe;

q According to relevant laws and their concurrent regulations.

q Emergency equipment. The following shall be available and not accessible to clients:

· At least one portable oxygen cylinder with a flow meter

· At least one portable suction unit

· At least one battery charged defibrillator and E.C.G. monitor

· Portable first-aid equipment

· CPR board

· Ambubag, standard drugs and facilities suitable for the resuscitation of clients in the following emergency situations:

o Cardiac arrest

o Respiratory arrest

o Convulsions

o States of shock

q Policy in terms of transferring clients to another appropriate treatment facility should his / her condition warrant it.

q Fire prevention and fire-fighting equipment and disaster planning, according to applicable Acts and their concurrent Regulations.

q Psychiatric risks must be taken into consideration with specific reference to the following:

· Safety glass and slip resistant floors must be used in all relevant areas.

· Clients must not be able to lock themselves into any room or cupboard.

· Hot water taps and heaters must be thermostatically controlled.

· Windows and open spaces in a multi-storey building must be so constructed as to prevent suicide.

· Main entrance to Facility shall be security controlled.

· Clothes hooks in accommodation and ablution areas must have a breaking strain of not more than 5kg

· All cupboards and wardrobes must be fixed to the walls (excluding bedside cabinets)

· A policy for control of firearms and substances must be in place and adhered to.

3.2. Cognitive Dimension

The cognitive dimension must include aspects like:

v colour, light, sound, texture and temperature of the surroundings;

Ø Arrangements must be made to ensure that the colour scheme induces tranquillity, and that the temperature and sound levels are within comfortable levels.

v orientation and perceptual clarity of the clients:

Ø Maps of the area, directions, name boards on doors and wall clocks should contribute to the recovery of the clients.

3.3. Social Dimension

The social dimension in the therapeutic milieu must include open, positive, constructive interaction that takes place between clients and fellow clients, clients and their visitors (family and friends) and clients and the professional team members, where:

v clients are out of bed during the day (except otherwise on prescription) and dressed in appropriate day clothes;

v clients can openly express themselves and share their diversity, whilst respecting others, thus learning from each other;

v development of insight into behaviour and of social and emotional skills through feedback received from staff members and other clients;

v visiting times and access to means of communication are available in such a way that it does not interfere with therapeutic programme;

v sufficient information is shared with clients and families to make informed decisions about the treatment, taking the applicable Acts into consideration;

v special consideration should be given to the needs of minors.

3.4. Emotional Dimension

The emotional dimension in the therapeutic milieu must include a climate where

v spontaneous and appropriate expression of feelings is encouraged, while limits are set to ensure that patients feel safe and secure;

v a sense of harmony, co-operation and group cohesiveness is encouraged;

v support, involvement and spontaneity is encouraged to ensure therapeutic outcomes;

v special consideration should be given to the need of minors.

3.5. Spiritual Dimension

The spiritual dimension must make provision for controlled private places where clients can spend quiet time:

v To reflect on the day’s events.

v To plan for the future.

v To attend to spiritual and religious needs.

4. Therapeutic Programme

The therapeutic programme must be of a holistic approach in order to assist in the recovery and healing, to facilitate insight and to promote the mental health of clients.

4.1. General

The following general guidelines must be in place:

v Each client, or the responsible person for the client, should

Ø be informed of alternative methods of treatment if appropriate;

Ø be consulted throughout the care process.

v A Structured assessment and individual treatment programme, according to the clients mental and physical health needs, should be discussed with the client and agreed upon to be a compulsory treatment tool in the healing process.

v Clients must have access to a therapeutic programme of 5 - 7 hours per day during the week and 4 hours over a weekend.

v Programmes must be based on accepted theoretic models.

v A Mental Health Care Practitioner should be responsible for the presentation of the therapeutic programme.

4.2. Contents

The programme should make provision for group therapy and individual therapy including the following:

v Self-care activities

v Life skills training

v Arts / crafts / occupational therapy activities

v Physical activities

v Insight development

v Relapse prevention

v Relaxation therapy

5. Multidisciplinary Team

A Team of Mental Health Care Practitioners, as defined in the Mental Health Care Act, with a Medical Practitioner as head of the team, will be responsible for the treatment and care of the clients.

5.1. The multi-disciplinary team must consist of:

v Psychiatrist.

v Occupational Therapist.

v Psychiatric Nurses:

Ø At least one Registered Psychiatric Nurse with at least 3 years experience in psychiatry, available 24 hours per day.

Ø 2 - 5 Direct nursing care hours per client per day, according to the acuity levels of the clients and the nursing skill mix.

v Psychologist, Social Worker, Physiotherapist:

Ø Access to the above.

5.2. The multidisciplinary team is responsible for:

v The diagnosis of the client.

v The assessment of the client.

v The formulation of a treatment plan in cooperation with the client.

v The co-ordination of the treatment plan.

v The implementation of the treatment plan.

v Psychotherapy.

v Individual therapy.

v Crisis interventions.

v Assisting the client to deal with social, emotional, psychological and spiritual issues.

v Remedial learning activities.

v The development of social and recreational skills.

v The alleviation of symptoms through activities and support.

v The continuous physical, emotional, social and spiritual observation, treatment and care.

v Maintaining the therapeutic milieu.

v Program development.

v The facilitation of group therapy on different levels.

v Supervision of the treatment plan; therapy and care.

5.3. Continued Professional Development

v A continuous psychiatric training and development programme must be in place for Mental Health Care Practitioners being in the employ of the Facility.

6. Services

Pharmaceutical, Catering, Laundry, Maintenance, Cleaning and all other services rendered must be according to the applicable laws and regulations.

Pathology, Neurology, Radiology and Dietary Services should be accessible.

7. Documentation

All management processes must be legally documented.

Policies and procedures regarding:

Ø human resources;

Ø therapeutic process;

q Clinical guidelines to guide care.

q Written guidelines to guide admissions, informed consent, confidentiality, assessments, treatment interventions, reassessments, referrals, transfers and discharges.

q Comprehensive appropriate referral systems.

The following documentation for each individual client shall be in place:

Ø Nursing process:

q Psychiatric Nursing Assessment.

q Psychiatric Nursing Care Plan.

q Psychiatric Nursing Intervention.

q Psychiatric Nursing Evaluation.

q Recording.

Ø Twice-daily nursing report of each client.

Ø Participation in activities.

Ø Discharge evaluation and providing of discharge information (according to relevant legislation).

Ø Reports by all other relevant Mental Health Care Practitioners.

§ A Nursing Audit program must be in place.

§ Clients must be informed of their rights as detailed in the Mental Healthcare Act No.17 of 2002.

8. General

§ This document will be open and transparent and subjected to continuous review and update to maintain its relevance.

§ Any complaints arising out of or from these standards should be directed to the Chairperson of the PFF or the CEO of HASA.