During admission

Personality disorder integrated care pathway
NHS Highland

If it is considered that admission to hospital is unavoidable:

  • The phase of treatment should be identified and indicated to everyone involved. Hospital admission is likely to be of benefit in safety and containment (Phase 1a and 1b) but is likely to be detrimental to the development of self-regulation and control (Phase 1c). This may help to explain why meaningful stabilisation is uncommon during extended hospital admission.
  • Admission should be kept as short as possible, with the timescale agreed and documented at the point of admission. Most acute behavioural dysregulation recedes within 24-72 hours. This provides a timeframe for discharge to community treatment and a clear rationale should be documented for admissions which exceed this duration given that it seems very likely that the risk of harm increases with the length of admission.
  • Clear objectives and purpose for the admission should be agreed and documented at the outset. At the time of admission the aims of admission should be agreed with the patient and documented along with the reasons why other options where considered and rejected.
  • Roles and responsibilities of staff and patients should be clearly explained and agreed, with contingencies of treatment frame explicitly explained. For example, it may be explained to the patient that non-engagement with the agreed treatment plan may lead to a review of the usefulness of continuing the admission. The treatment plan may include components such as an expectation that the patient takes responsibility to problem solve any factors contributing to an acute crisis, that they undertake not to self-harm while in hospital, that an attempt is made to enhance and use self-regulatory skills.
  • An admission may be viewed as an opportunity to review care plans, crisis plans and goals, and successfully re-establish outpatient treatment.
  • An admission may be an opportunity to refer for a phase-appropriate treatment. 
    Avoid inappropriate use of medication, especially benzodiazepines and similar sedatives.
  • During admission contact should be maintained with the person’s key worker in Community Mental Health Services.
  • Crisis admissions should aim to (in line with standard crisis resolution approaches):
    • Stabilise the acute crisis rather than tackle the underlying disorder. The aim is a return to pre-crisis functioning and rapid discharge.
    • Re-establish care plan and crisis plan
    • Address changeable stressors
    • Reduce access to means of suicide
    • Identify and mobilise current supports
The Crisis Admission Document may be helpful in supporting the patient and care team to keep the admission focused and time-limited.