Acute Ward INPATIENT SERVICES

33 Psychiatric And Mental Health Services Operational Policy dementia or the intellectually challenged and those under inluence or alcohol or drugs are at risk of violence towards others. Those patients who are severely depressed or having ongoing crisis are at risk of self harm or suicidal behavior. The prediction of violence is best ascertained by a history of violence either to self or to others with the return of psycho pathology associated with the previous history of violence. Reference Nancy C. Anderson and Donald W. Black in Introductory Text Book of Psychiatry, 3 edition 2001, American Psychiatric Publishing, Inc . Hence, mental health care workers in various levels of service are expected to be well versed not only to anticipate impending violent behavior but also be trained to manage such patient appropriate to the level of dangerousness. Factors helpful in assessing dangerousness to others or self based on history, mental status examination and cognitive assessment. Laboratory investigations such as presence of drug or alcohol, increased thyroxine levels, EEG evidence of seizure are necessary for assessment purposes. In the Malaysian psychiatric care setting, new or follow-up patients are invariably brought for treatment after an episode of violent behavior despite usually ongoing abnormal behavior for which the care givers may have resorted to traditional methods of management. Even for those patients who have been depressed, in many instances resort to psychiatric services may only occur after an episode of deliberate self harm. Thus, many of such patients may invariably be detained in the psychiatry ward after being seen in the emergency setting or the psychiatric clinic. 6.2.4.2 Medications For Chemical Means Of Restraint Chemical methods of restrain either by oral or parenteral means, either short acting anti psychotic medications e.g. haloperidol, ziprasidone, chlorpromazine , short acting benzodiazepines e.g. midazolam, lorazepam , or medium acting antipsychotics drugs e.g. clopixol acuphase should be available immediately in either emergency, psychiatric clinic or impatient settings. Anti dote medications to any unexpected reaction to these classes of medications should also be available in oral or parenteral formulations e.g. lumezenil, procyclidine, orphenadrine, 34 Psychiatric And Mental Health Services Operational Policy benzhexol. Mental health care workers should be familiar with the various formulations, strengths and be trained as to the necessity and indications of which ever medication that is indicated. 6.2.4.3 Training For Physical Method Of Restraint Every emergency unit and staff of psychiatric clinics and inpatient units should have regular training sessions to update the frontline staff on the techniques of physical restrain methods. The violent patient should be counsel in a calm and reassuring voice by the team leader of a team of at least 4 – 5 staff to accept treatment with the medications so that he may be less agitated, or violent towards others or self. However if these methods fail and risk of impending violence persists it is necessary for the team to either lead the patient to the seclusion room if available, or restrained and then be treated by chemical methods of restrain as well. Reference Nancy C. Anderson and Donald W. Black in Introductory Text Book of Psychiatry, 3 edition 2001, American Psychiatric Publishing, Inc . 6.2.4.4 Mental Health Regulation 2010 For The Following May Be Referred. a Indication for procedure for seclusion and restrain b Restraint area c Restraint equipment d Application of physical means of restraint e Seclusion room f Indication for chemical means of restraints g Procedures for chemical means of restraints h Indication for physical means of restraints i Procedure of physical means of restraints j Indication for seclusion k Procedure for seclusion l Information to be included in the Physical Restraint Record m Information to be included in the Seclusion Record