Emergency Detention Research Articles

The Use of Intraosseous Infusion in the Early Resuscitation of Patients With Extremely Severe Burns.

According to research, shock, the most common complication of extremely severe burns, is also the leading cause of mortality among patients with such burns. The case fatality rate reaches 83.45% when the total burn area exceeds 90%. The American Heart Association in 2020 recommended the intraosseous (IO) access after the peripheral access and prior to the central venous access when venous cannulation is either difficult or delayed. The use and experience with intraosseous infusion in extremely severe burns are still limited. We report efficacy and safety results from 19 burn patients treated with IO infusion between June 2020 and December 2022. In these patients, the mean injury time of burns was 1.55 ± 1.10 hours, the mean burn surface area was 86.24% ± 11.33%, the mean catheterization time was 49.68 ± 10.11 seconds, and the mean emergency retention time was 2.75 ± 1.74 hours, the mean actual fluid supplement amount was 5,533.68 ± 3,077.19 mL, the mean hourly urine volume of the patient was 93.31 ± 60.94 mL, the mean emergency detention time was 4.16 ± 2.97 hours, and the mean duration of hospitalization was 34.50 ± 25.38 days. The results demonstrated a clinically meaningful improvement and higher response rate vs peripheral venous cannulation and an acceptable safety profile in those patients.

Evaluation of a Police-Mental Health Co-response Team Relative to Traditional Police Response in Indianapolis.

Criminal justice and emergency medical service (EMS) outcomes were compared for individuals experiencing a behavioral health crisis who received a response from a co-response team (CRT) or a usual response from the police after a 911 call. A prospective, quasi-experimental design was used to examine outcomes of a CRT pilot tested in Indianapolis (August-December 2017). Weighted multivariable models examined effects of study condition (CRT group, N=313; usual-response group, N=315) on immediate booking, emergency detention, and subsequent jail bookings and EMS encounters. Sensitivity of outcomes to follow-up by a behavioral health unit (BHU) was also examined. Individuals in the CRT group were less likely than those in the usual-police-response group to be arrested immediately following the 911 incident (odds ratio [OR]=0.48, 95% confidence interval [CI]=0.25-0.92) and were more likely to experience any EMS encounter at 6- and 12-month follow-up (OR range=1.71-1.85, p≤0.015 for all). Response type was not associated with jail bookings at 6 or 12 months. Follow-up BHU services did not reduce bookings or EMS encounters. CRT recipients with BHU follow-up were more likely than those without BHU follow-up to have a subsequent EMS contact (OR range=2.35-3.12, p≤0.001 for all). These findings differed by racial group. CRT responses may reduce short-term incarceration risk but not long-term EMS demand or risk of justice involvement. Future research should consider the extent to which CRT and follow-up services improve engagement with stabilizing treatment services, which may reduce the likelihood of future crises.

Improving accessebility to psychiatry in NHS Tayside

AimsOur aim is to improve the accessibility of Psychiatry to other specialties when being contacted for review and advice, both in hours and out of hours.BackgroundFrom clinical contact and informal conversations, other specialties sometimes have difficulties contacting psychiatry for advice/review. The aim of this is quality improvement project is to determine how accessible we are to other specialties and work on improving how we communicate with the general hospital.MethodWe created a questionnaire for colleagues from other specialties to fill in from 26/9/19 for 6 weeks. We gathered information regarding their grade, work site, previous contact with psychiatry, whether they knew where to find our contact information and if they could identify the correct method to ask for advice from general adult psychiatry (GAP), Psychiatry of old age (POA) , and out of hours psychiatry (OOH). We also asked colleagues to put in free text comments regarding their experience in contacting psychiatry. We also asked if our colleagues were aware of how to perform an Emergency Detention Certificate as this is advice we sometimes give which does not always need our input immediately.ResultThere was a total of 39 responses, 29 from Ninewells Hospital (NW) and 10 from Perth Royal Infirmary (PRI). There was a mixture of staff grades from Foundation Doctors to Consultants. 23/39 colleagues knew where to find contact information for Psychiatry, 14/39 colleagues correctly answered how to contact GAP (Phone), 15/39 colleagues correctly answered how to contact POA (Email), 15/39 colleagues correctly identified who to contact OOH, and 16/34 colleagues who could do emergency detentions (FY2+) knew how to do one. Free text comments often referred back to the difficulty of finding the right grade of staff first try, Feedback from PRI where there was no dedicated Liaison Service and relies on a duty doctor system was less positive, with terms ‘tricky’, ‘difficulty’, ‘awkward’ used in majority of responses.ConclusionFrom our results we can conclude that contacting Psychiatry in NHS Tayside can be confusing for other specialties. Taking this forward, we will utilize the ‘referral finder’ system in NHS Tayside and review the existing information available, and to update the contact information for our subspecialties to make contact ourselves more streamlined and accessible. We will also review appropriate clinical protocols that we can link to our page on referral finder to help save time for our colleagues as well.

Do Junior Doctors feel confident using Emergency Detention Certificates?

AimsTo assess junior doctors understanding of the law surrounding the use of The Mental Health (Care and Treatment) (Scotland) Act 2003 (MHA) with a focus on assessing confidence and knowledge of the use of the emergency detention certificate (EDC). A secondary aim was to use these findings to develop a variety of educational tools to subsequently improve junior doctors understanding in using the MHA.MethodWe created and distributed a comprehensive electronic survey to 152 Foundation Year Two Doctors working in NHS Lothian, Fife and Borders in December 2020. We subsequently interviewed 20 respondents to enquire about additional resources needed to improve knowledge of the MHA. Following on, we completed worked EDC exemplars, created an easily accessible guide with step-by-step instructions on implementing an EDC and devised a checklist pro-forma that can be accessed and inserted into a patient's electronic notes to ensure all necessary steps are completed for the EDC.Result51 doctors (34%) responded to our survey, of which 10 (19%) had previously worked in psychiatry and 16 (31%) had previously completed an EDC. 27 respondents (52%) reported a lack of self-confidence and knowledge and 26 (51%) reported a lack of understanding in the legal processes as barriers faced when putting an EDC in place. 23 (45%) respondents were unaware that a Mental Health Officer (MHO) must be contacted to grant an EDC. Respondents who had experience of working in psychiatry reported greater awareness of the MHA. From the focused interviews held, colleagues requested for worked EDC examples, an easily accessible checklist with relevant contact details and an electronic pro-forma for patients notes to assist with completing the relevant legal steps when implementing an EDC.ConclusionOur study identified a lack of confidence in understanding the MHA and completing an EDC. Our educational materials will provide an invaluable source of information for junior doctors, in particular those with little experience of the MHA. Importantly, our resources will ensure the legal aspects of implementing an EDC are both complied with and documented appropriately.

The effect of changes to Australian Capital Territory mental health legislation on rates of emergency detention.

The Australian Capital Territory (ACT) changed from the Mental Health (Treatment and Care) Act 1994 (ACT) to the Mental Health Act 2015 (ACT) on 1 March 2016. The objective was to find the association between legislative changes and detention rates. A cross-sectional study of involuntary order rates in the period 3 years before the legislative change was undertaken. Chi-squared analysis was performed to compare proportions. There was a statistically significant decrease in the proportion of Psychiatric Treatment Orders (PTOs) over the two periods, which could be impacted by the change from a period of detention for 7 days to a period of detention of 11 days in Period 2. On the other hand, the total number of Emergency Actions (EAs) increased in Period 2, where ambulance officers could detain patients. The change in mental health legislation in the ACT was associated with a change in detention rates, in particular a decrease in the proportion of PTOs and an increase in EAs. Further study needs to be undertaken, given changes to frontline supports since the study period ended.

Emergency mental health calls to first responders following a natural disaster

Introduction: Hurricane Harvey which made landfall on August 25, 2017 was a devastating storm that dumped unprecedented amount of rainfall on the area including Houston, Texas, United States of America. There are limited data about emergency service mental health utilization following disaster events. The goal for this project was to examine mental health calls to emergency medical services (EMS) and to the Houston Police Department following Hurricane Harvey. An analysis looking at this utilization following a natural disaster represents an understudied area and can potentially provide information about city services and community psychiatric services in the acute period following the event. Materials and Methods: Total number of calls to the police department and mental health calls to the police department described as crisis intervention calls (Crisis Intervention Team) were obtained from August 1, 2016 to October 31, 2016 and January 1, 2017 to December 31, 2017. Emergency detention orders (EDO) per date were obtained from January 1, 2017 to December 31, 2017. Data for mental health calls based on the primary impression of mental health complaint were obtained from the Houston Fire Department for EMS from January 1, 2016 to December 31, 2017. Results: There was a statistically significant increase in the number of mental health calls to the police following Hurricane Harvey. When comparing the prestorm, active storm, and poststorm period, there was not a statistically significant difference in the number of EDOs or the number of EMS mental health calls. Conclusions: The increase in police mental health calls suggests that there may have been an increase in the acuity of the mental health calls to EMS around in evaluating calls surrounding the period of Hurricane Harvey. The following core competencies are addressed in this article: Medical Knowledge and Patient Care.

Incidences of Involuntary Psychiatric Detentions in 25 U.S. States.

Characterizing commitment as an involuntary psychiatric emergency detention that possibly extends into a longer-term detention, the authors aimed to calculate population rates of detentions and chart interstate differences since 2011 by means of publicly available state counts. Searches of state health and court websites yielded counts from 38 U.S. states. Usable counts from 25 states were classified as emergency or longer-term detentions and converted to crude rates per 100,000 people by using Census Bureau figures. All-ages rates (per 100,000 people) of emergency detentions ranged from 29 in Connecticut to 966 in Florida. In 22 states with continuous 2012-2016 data, the average rate increased from 273 to 309. In four of five states with separate counts for adults and minors, rates over time for both were nearly parallel. In eight states that provided relevant data, the mean longer-term detention rate was 42% of a state's average emergency detention rate. Only one state provided length-of-stay data, and one counted both detentions and persons detained. In 24 states-accounting for 51.9% of the U.S. population-591,402 emergency involuntary detentions were recorded in 2014, the most recent year with most states reporting, a crude rate of 357 per 100,000. Incidences of involuntary psychiatric detentions between 2011 and 2018 varied 33-fold across 25 states, and the mean state rate increased by three times the mean state population increase. Omissions in most states' counts clouded interpretation. More valid incidences obtained from standardized national data would improve analysis of the controversial yet opaque procedure of involuntary inpatient civil commitment.

Seattle Police Department and mental health crises: Arrest, emergency detention, and referral to services

PurposeThis study sought to understand how officer, individual, and incident-level characteristics influence officer decisions to arrest, detain in emergencies, and refer individuals to services relative to taking no action in encounters with persons in mental health crises. This study allowed for the analysis of informal, scarcely examined outcomes. MethodsWe examined all available crisis incidents (n = 19,648) over a three-year period from the Seattle Police Department (SPD) using a large administrative dataset. We conducted a multinomial logistic regression. ResultsWe found that arrest was the least frequent outcome followed by no action, referral to services, and emergency detention. Further, arrests occurred primarily in the context of person and property-related crimes as well as when officers perceived individuals as belligerent and disruptive. Emergency detention was significantly more likely when officers perceived a suicide risk than when they did not. ConclusionsLargely, in the absence of a criminal offense, police officers utilized less restrictive resolutions and in many cases officers attempted to connect individuals to mental health services either through immediate emergency detention or referrals to services. Majority of crisis incidents did not involve an offense and may be better resolved by mental health professionals.

Detaining patients in the general hospital - current practice and pitfalls.

Much has been written about the use of the Mental Health Act in psychiatric settings. There is, however, little written on its use to detain patients with mental disorder in general hospitals. We therefore carried out a survey of the use of the Mental Health Act in general hospital settings in Aberdeen, and also posted a questionnaire to Scottish Liaison Psychiatrists, asking about their experience of the use of the Mental Health Act in general hospitals. Over a six-month period in Aberdeen Royal Infirmary, we identified 39 detentions. Out of hours, the use of Emergency Detention Certificates was more common than use of Short Term Detention Certificates - the latter is recommended by the Mental Welfare Commission, as patients are afforded more rights. When psychiatric staff were not directly involved, procedural and administrative errors were more likely to occur. Liaison psychiatrists elsewhere in Scotland reported similar observations. General hospital clinicians are unfamiliar with the Mental Health Act and its use. Errors in its application therefore arise, and are more common when psychiatric staff is not involved. Better education, including the provision of written information and consideration of an electronic system, may improve current practice.

Characteristics of NPS use in patients admitted to acute psychiatric services in Southeast Scotland: a retrospective cross-sectional analysis following public health interventions

ObjectivesAssess the impact of selective prohibition and seizure of novel psychoactive substances (NPS) supply on NPS use prevalence within psychiatric admissions and evaluate demographic characteristics of current NPS users.DesignA 6-month...

Application of pediatric five-level triage system and resource utilization in emergency department

Objective To explore the resources utilization in emergency under the implementation of pediatric five-level triage system and give reference for large tertiary emergency department (ED) in China. Methods In March 2015, the hospital information system platform was used to screen newly patients who visited internal emergency department, collect diagnosis and treatment items, calculate the cost produced in ED. The resource utilization was compared between the levels in the triage system. Results Out of the enrolled 7 010 cases, the major complaints were fever, cough and vomiting; 5 cases in Level-1 (0.1%), 70 cases in level-2 (1.0%), 3 416 cases in level-3 (48.7%), 3 418 cases in level-4 (48.8%), 101 cases in level-5 (1.4%); the average length of stay in emergency department (1-5 level): 65.6 min, 141.2 min, 73.1 min, 58.5 min, 48.3 min; the total cost in ED was consisted of diagnostic cost and treatment cost, 38.02% and 61.98% respectively. The average costs of 75 cases in level 1 and 2 were 691.14 Yuan, the average costs of 3 416 cases in level 3 were 182.92 Yuan, the average costs of 3 418 cases in level 4 were 187.87 Yuan, the average costs of 101 cases in level 5 were 101.66 Yuan. The ED diagnostic cost and treatment resource were used according to the severity assessed by the five-level triage system. The laboratory investigation costs made the most part of the diagnostic resource utilization, 83.16% children with fever took the blood routine examination. The costs of oral medicine accounted for the most proportion of treatment resource utilization. Conclusions The five-level triage system, not only help triage nurses to screen the critically ill children, but reflect the ED resource utilization. It may indicate that the children with fever in the pediatric emergency department can take routine blood test in advance, in order to reduce the emergency detention time, make more efficient use of emergency resources. Key words: Child; Emergency triage; Resource utilization; Economic cost

Mental health emergency detentions and access to firearms.

Following the tragic shootings in Newtown (Connecticut), Aurora (Colorado), Isla Vista (California) and others, increased national attention has focused on the relationship between mental illness and gun violence. While some have called for enhanced regulation of firearm possession by persons with mental illness, others have argued that such actions would be ineffective and enhance stigma associated with mental illness while discouraging treatment seeking.

Community Treatment Orders: Implications of the drafting of the Mental Health Act 2007 for emergency detention of Community Patients

Since the introduction of Community Treatment Orders by the Mental Health Act 2007, their use has increased year on year. Clinical experience has, however, demonstrated a weakness in the drafting of the Act, particularly in respect of patients who may be admitted informally for treatment of their mental health while also on a Community Treatment Order and then require detention under the terms of the Mental Health Act 2007. This paper describes these potential problems, particularly with regard to the inability to detain a Community Patient using sections 4 or 5 of the MHA 2007. The authors explore the difficulties that may arise from this, including the need to balance the principle of using the least restrictive option, and the rights of the patient against the potential risks to both the patient and the public. The authors propose possible considerations and options in these circumstances.

Disparate patterns of hospitalisation reflect unmet needs and persistent ethnic inequalities in mental health care: the Scottish health and ethnicity linkage study

ObjectivesThe presence and extent of mental health inequalities in Scotland is unclear. We investigated ethnic variations in psychiatric hospitalisations and compulsory treatment in relation to socioeconomic indicators.DesignIn a retrospective cohort study design, using data linkage methods, we examined ethnic variations in psychiatric [any psychiatric, mood (affective), and psychotic disorders) hospitalisations and use of the Mental Health (Care and Treatment) (Scotland) Act 2003 (Emergency Detentions (ED), Short-Term Detentions (STD) and Compulsory Treatment Orders (CTO)] using age (and sex for compulsory treatment), car ownership, and housing tenure adjusted risk ratios (RR). 95% CIs for the data below exclude the reference White Scottish group value (100).ResultsCompared to the White Scottish population, Other White British men and women had lower hospitalisation from any psychiatric disorder (RR = 77.8, 95% CI: 71.0–85.2 and 85.8, 95% CI: 79.3–92.9), mood disorder (91.2, 95% CI: 86.9–95.8 and 83.6, 95% CI: 75.1–93.1), psychotic disorder (67.1, 95% CI: 59.9–75.2 and 78.5, 95% CI: 67.6–91.1), CTO (84.6, 95% CI: 72.4–98.9) and STD (88.2, 95% CI: 78.6–99.0). Any Mixed Background women had higher hospitalisation from any psychiatric disorder (137.2, 95% CI: 110.9–169.6) and men and women had a higher risk of psychotic disorder (200.6, 95% CI: 105.7–380.7 and 175.5, 95% CI: 102.3–301.2), CTO (263.0, 95% CI: 105.4–656.3), ED (245.6, 95% CI: 141.6–426.1) and STD (311.7, 95% CI: 190.2–510.7). Indian women had lower risk of any psychiatric disorder (43.2, 95% CI: 28.0–66.7). Pakistani men had lower risk of any psychiatric disorder (78.7, 95% CI: 69.3–89.3), and higher risk of mood disorders (117.5, 95% CI: 100.2–137.9). Pakistani women had similar risk of any psychiatric and mood disorder however, a twofold excess risk of psychotic disorder (227.3, 95% CI: 195.8–263.8). Risk of STD was higher in South Asians (136.9, 95% CI: 109.0–171.9). Chinese men and women had the lowest risk of hospitalisation for any psychiatric disorder (35.3, 95% CI: 23.2–53.7 and 44.5, 95% CI: 30.3–65.5) and mood disorder (51.5, 95% CI: 31.0–85.4 and 47.5, 95% CI: 23.2–97.4) but not psychotic disorders and higher risk for CTO (181.4, 95% CI: 121.0–271.0). African women had higher risk of any psychiatric disorder (139.4, 95% CI: 119.0–163.2). African men and women had the highest risk for psychotic disorders (230.8, 95% CI: 177.8–299.5 and 240.7, 95% CI: 163.8–353.9) and were also overrepresented in STD (214.3, 95% CI: 122.4–375.0) and CTO (486.6, 95% CI: 231.9–1021.1). Differences in hospitalisations were not fully attenuated when adjusted for car ownership and housing tenure and the effect of these adjustments varied by ethnic group.ConclusionOur data show disparate patterns of psychiatric hospitalisations by ethnic group in Scotland providing new observations concerning the mental health care experience of Chinese, Mixed background and White subgroups not fully explained by socioeconomic indicators. For South Asian and Chinese groups in particular, our data indicate under and late utilisation of mental health services. These data call for monitoring and review of services.

Emergency detention of persons with certain mental disorders during public health disasters: Legal and policy issues

Public health emergencies (disasters) are associated with mental health conditions ranging from mild to severe. When persons pose a danger to themselves or others, a brief emergency detention allows a mental health assessment to determine if a lengthier involuntary civil commitment is needed. Involuntary commitment requires participation of the civil justice system to provide constitutionally mandated due process protections. However, disasters may incapacitate the judicial system, forcing emergency detainees to be prematurely released if courts are unavailable. The authors review state laws regarding emergency detention of persons deemed a potential mental health-related danger. Although some states are well prepared for the dual impact of disasters on mental health and the court system, important gaps exist. The authors recommend that state laws anticipate the need for brief extensions of emergency detention periods without court participation. States should also include mental health considerations in their disaster preparedness plans for the court system.

Case Report: Are Clinicians Obligated To Medically Treat a Suicide Attempt in a Patient with a Prognosis of Weeks?

There is broad ethical and professional consensus that preventing a patient from initiating or successfully completing a suicide attempt is a core physician obligation and justifies the use of aggressive interventions such as emergency detention and mechanical ventilation. This case examines the acute medical care of an individual with a progressive brain tumor after an apparent suicide attempt. In guiding the care of this patient, we found that the patient's prognosis of days to weeks made the ethical rationale of implementing aggressive medical interventions to treat the sequelae of his suicide attempt less compelling.

Civil detentions of older adults under successive Scottish mental health legislation: a comparative analysis

Many countries have adopted new mental health legislation, with the detention of adults for treatment of mental disorders remaining an integral part of such policies. However, there are relatively few publications on the use of mental health legislation in the detention of older adults. This paper examines the civil detention of older adults in one Scottish region under successive mental health legislation. This prospective study collected data primarily by clinician-based interviews on all emergency detentions under the Mental Health (Scotland) Act 1984 of older adults in 1994 and compared these with all emergency and initial short-term detentions under the Mental Health (Care and Treatment) (Scotland) Act 2003 of older adults during 2008 in the same Scottish region. There were a total of 124 detentions, with an initial rate of 68 increasing to 141 detentions per 100,000 of the respective over-65 year age populations, a two-fold increase. Compared to the 1994 patient cohort, the 2008 cohort had higher rates of over 85-year-olds (18.4% v 5.4%) and organic mental disorders (74.7% v 56.8%) and were significantly more likely to be detained by consultant psychiatrists (73.6% v 18.9%) during working hours (87.4% v 48.6%) and proceed to six-month detention orders (31% v 10.8%). The observed higher rates and longer periods of detention in the 2008 cohort may reflect changes in clinical attitudes and legal requirements from a previous reliance on the common law doctrine of necessity to the requirements of a more legalistic framework, and may signal future clinical requirements, given the aging population, pointing towards the need for earlier recognition and management of clinical issues in an attempt to minimize the "necessity" of clinico-legal intervention.

P02-116 - Impact of the smoking ban on the incidence of adverse events in adult psychiatry wards on the Wirral

ObjectivesTo investigate whether the smoking ban has led to an increase in adverse events in adult psychiatry wards on the Wirral.MethodsWe compared the number of violent incidents reported on the adult psychiatry wards in the 6 months before and after the smoking ban. We also compared the number of emergency detentions (section 5.2 and 5.4 of the mental health act) implemented in the 6 months before and after the smoking ban.ResultsThere was a 36% reduction in violent incidents in the 6 months after the smoking ban compared to the 6 months before the ban (70 in the 6 months before the ban and 45 in the 6 months after the ban). There was a 64% reduction in emergency detentions in the 6 months after the smoking ban compared to the 6 months before the ban (25 in the 6 months before the ban and 9 in the 6 months after the ban).The number of admissions during each 6 month period that we looked at were very similar (288 admissions in the 6 months before the ban and 299 in the 6 months after the ban).ConclusionsPrior to the smoking ban there were concerns that it would lead to an increase in the number of violent events and patients who required emergency detention (under Section 5.2 or Section 5.4 of the Mental Health Act). This study shows that there was a reduction in the incidence of adverse events following the smoking ban.

Against National Security Exceptionalism

Terrorist attacks trigger novel policy responses. New policies selected by the federal executive after the 9/11 attacks strained against constitutionally permissible margins, and prompted diverse judicial responses. The resulting scholarly literature is largely normative. But the currently dominant accounts of national security jurisprudence also each include some descriptive claim about what courts in fact do. Each account further claims that courts do something distinctive in these cases. That is, in the course of making a prescriptive argument for what courts ought to do differently in national security cases, these accounts make a descriptive claim about what courts in fact do differently in this class of cases. I argue that this threshold descriptive claim – call it “national security exceptionalism” – finds no empirical support in at least one important class of post-9/11 cases concerning emergency detention policies. Instead, judicial responses to national security emergencies align closely with transubstantive trends in public law and judicial responses to non-security emergencies. Using the Supreme Court’s recent ruling in Ashcroft v Iqbal as a starting point, I examine the close and largely unexamined relationship between national security jurisprudence and the larger domain of public law doctrine and practice. Situating judicial responses to national security emergencies in a more general public law context draws attention to the role emergencies can play in catalyzing larger legal changes law, and the effect of transubstantive trends on emergency responses. It further may have a bearing on the emergent “national security” discipline in the legal academy.

Knowledge about the Scottish Mental Health Act in a General Hospital Setting

Clinical experience suggests that non-psychiatrists' knowledge of mental health legislation in relation to emergency detention is inadequate. However, most non-psychiatrists will use this legislation at some point in their career. A questionnaire about emergency detention legislation was circulated to non-psychiatric medical staff to test their knowledge of the provisions relevant to the general hospital. Two hundred and seventy four medical staff replied (a response rate of 82%). Results showed that an understanding of detention procedures and applicability were markedly deficient, irrespective of grade, specialty or experience. The results indicate a need for increased education and awareness about emergency detention legislation especially in view of the implementation of the Mental Health (Scotland) Act (2003).