Use of seclusion in a psychiatric acute inpatient unit

Abstract

Background Seclusion is an intensive intervention employed in inpatient mental health units to guarantee safety when de-escalation methods have been exhausted. High rate of seclusion are associated with higher employee injury rate, lower staff engagement and increased patient length of stay. Objectives Our aim is to reduce seclusion rates in all admitted patients in inpatient psychiatry from a baseline of 136 to less than 110 per 1000 patient days by December 2016 and sustain for 12 months. Methods A multidisciplinary team developed an Aim and Key Driver Diagram focused on reducing seclusions. Evidence based interventions included milieu management techniques, proactive patient engagement and staff training on trauma informed approaches, physical deflection, and reinforcement principles. Other successful Plan-Do-Study-Act's (PDSA's) include small patient groups and skill-appropriate programming to reduce opportunities for escalating behaviours and increase patient success. Results By 1st quarter 2017, seclusion rates were reduced from 136 to 60 seclusions per 1000 patient days (56% reduction) and sustained for 12 months. In addition to seclusion rates, we achieved a 40% reduction in duration of seclusions, a 55% reduction in mechanical restraints and a 72% reduction in employee injuries. Conclusions Seclusion in children and adolescent mental health units can be significantly reduced through systematic application of quality improvement methodology to revise unit programming and address training and awareness issues. We implemented several effective and less-disruptive interventions while we established a new unit and trained inexperienced staff. These strategies may help impact care of patients in other child and adolescent mental health units.

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“…This renders comparisons impossible. The data from other studies is related only to single units [17] (UK), [18] (Australia), [19] (USA) and can therefore not be compared with our data, either. Except for one study from Finland [6] there seems to be no comparable data.…”

Nursing Staff Factors Contributing to Seclusion in Acute Mental Health Care – An Explorative Cohort Study

“…On the other hand, Bowers et al (2010) reported that seclusion was significantly associated with more male nurses on duty (IRR = 1.30, p <.05). Furthermore, lower patient/staff ratios were significantly associated with seclusion (Morrison & Lehane, 1995;Tunde-Ayinmode & Little, 2004), but not all authors found this association (e.g. Vollema et al (2012) and Husum, Bjorngaard, Finset, and Ruud (2010)).…”

“…Previous studies on this matter collected data retrospectively (Janssen et al, 2007;Nijman et al, 1994;Vollema et al, 2012), used a cross-sectional design (Bowers et al, 2010) or primarily addressed patient-staff ratios (Morrison & Lehane, 1995;Tunde-Ayinmode & Little, 2004). One of the strengths of our study is that we used a rigorous, census-based, prospective design to collect data.…”

Achieving Equilibrium within a Culture of Stability—Cultural Knowing in Nursing Care on Psychiatric Intensive Care Units

“…One specific issue to consider in PICUs is the dimension of violence, which is the most common reason for admission (Dolan & Lawson, 2001;Pereira et al, 2005), and patients should be considered as high risk (Wynaden et al, 2001). Earlier research focuses in large part on managing violent behavior using pharmacological intervention (Pilowsky et al, 1992), seclusion rooms (El-Badri & Mellsop, 2002;Tunde-Ayinmode & Little, 2004), and mechanical restraints (Kaltiala-Heino et al, 2003). Nelstrop et al (2006) emphasize that there is a lack of evidence to support the use of seclusion and restraints as safe and effective measures, and that these should be used only as a last resort.…”