Medical guidelines for PICU seclusion reviews

Abstract

Evidence regarding medical practice in seclusion is limited, and far outweighed by opinion. Here, we present one approach to medical reviews of patients in seclusion rooms, aiming to drive consistent practice. We address the work of clinicians prior to their arrival in the seclusion area, information-gathering prior to entry into the seclusion room, relevant aspects of history-taking and mental state examination in the seclusion area, and the implications for clinical and risk-management. We discuss issues raised by the logistics of seclusion for the planning and undertaking of the consultation. Physical examinations of secluded patients are commonly complicated by patient-related and environment-related factors; we suggest a pragmatic approach to determining the scope of physical examination in seclusion. While risk assessments are a vital aspect of seclusion practice for psychiatrists, structured instruments for the assessment of risk within these environments do not exist. We lay out principles regarding risk assessment in this population. We comment on the role of the clinician in the debrief phase of the seclusion review, and deal with legal issues pertaining to seclusion in England. Ultimately, we are left with a number of questions relating to what constitutes best practice for psychiatrists fulfilling this role on the PICU.

What factors influence the decisions of mental health professionals to release service users from seclusion?

“…In contrast, articles by medical practitioners suggested they undertook a more holistic assessment including a mental state examination (Beck ; Bhavsar et al . ). At the point of release, there was consensus the service user should no longer be deemed an imminent risk of causing harm to self or others (Beck ).…”

“…Although cognitive impairments, language barriers, and medication were mediated for, communication was seen as a key test of functioning (Bhavsar et al . ). Diminished communication (Boumans et al .…”

“…Although no specific risk assessment tools were available to support professionals making decisions to release service users from seclusion (Bhavsar et al . ), there was a general consensus among the articles of issues which were relevant. These included historical factors of previously recorded aggression, prior use of seclusion, and staffs’ own knowledge of the service user (Hyde et al .…”

“…Their current physical health status was also considered (Beck ; Bhavsar et al . ), as were immediate risks of harm (Hyde et al . ; Mason & Whitehead ; Muir‐Cochrane ), measured by the service users’ approachability (Boumans et al .…”

“…It was accepted seclusion is an environment where control was removed from the service user (Bhavsar et al . ), with professionals initially acting as a controller, protecting others against the service user exhibiting aggression or distress:

Nurse: When they don't have a clue and are disrobing, defecating, etc. … if they are so out of control that you have to control them.

…”