Seclusion Rates Research Articles

Staff Perspectives: Why are adolescent inpatients secluded and what causes changes in rates of seclusion on a unit?

The use of seclusion in Adolescent Inpatient Psychiatric Units is being heavily scrutinised due to its forceful nature and potential to cause harm. This study aimed to understand staff perspectives on reasons for seclusion in an Adolescent Inpatient Psychiatric Unit. A mixed methods approach that included the Attitudes to Seclusion Survey followed by a semi-structured interview on the reasons for seclusion was used. We recruited 31 participants who worked on the unit of which 27 were involved in seclusion. The findings showed that the majority of staff view seclusion as undesirable and believe it should only be used out of necessity. However, there was disagreement among staff about the reasons why adolescents were secluded and whether those reasons were justified. Staff identified factors that contributed to increases in seclusion but also provided several ways in which seclusion could be reduced. These findings highlight a need for precision on what constitutes justifiable use of seclusion to reduce the potential for misuse. It also shows opportunities exist for further reduction in seclusion through teamwork and communication.

The attitudes of nurses towards seclusion: A New Zealand in-patient mental health setting.

Seclusion is a form of restraint practised in mental health services world-wide, and has been criticised as unethical and traumatising to patients. Several countries have committed to reducing or eliminating seclusion. In New Zealand, there has been a focus on reducing seclusion of the indigenous Māori population, who experience particularly high rates. Nurses typically lead decisions to place patients in seclusion and their attitudes towards seclusion likely influence this process. This study aimed to address the primary question: what are the attitudes of registered nurses towards the use of seclusion? A mixed methods pragmatic approach was used involving qualitative interviews of nurses working in a high seclusion mental health ward located in the North Island of New Zealand, and a quantitative analysis of the seclusion data from this ward. This report is adherent with COREQ and STROBE. Thirteen nurses were interviewed and four main themes were identified: seclusion is necessary; seclusion is being used unnecessarily; nurse characteristics influence the use of seclusion; nurses perceived their ward culture to be improving in the use of seclusion. However, analysis of seclusion data indicated that rates had been increasing for this ward prior to this study, and the rates for indigenous Māori patients were especially elevated. This pattern of increasing rates was congruent with the 'supportive' attitudes of nurses towards seclusion. Interestingly, during the time of this study, the seclusion rates began to decline, including for Māori patients. This decline may have been partially due to the increased awareness prompted by the study.

Space for youth mental health-coercive measure use before and after architectural innovation at a department of child and adolescent psychiatry.

Influence of architectural features in child and adolescent psychiatric wards on coercive measure use has not been investigated so far. We aimed to assess the effect of altering the physical environment of an adolescent psychiatric inpatient unit on the proportion and frequency of adolescents experiencing mechanical coercive measures. In a naturalistic observational design, coercive measures were compared before and after an architectural intervention facilitated by rebuilding a child and adolescent psychiatric department in October 2020. Age, gender, length of stay, main psychiatric diagnosis and indices of coercion in n = 782 admissions to inpatient child and adolescent psychiatry from April 2019 to April 2022 were extracted. Group comparisons were performed using chi-squared tests for categorical and Mann-Whitney U-tests for numerical variables. After structural modernization which included amplifying space and with the newly introduced availability of seclusion rooms, significantly fewer patients were affected by mechanical restraint (8.1% vs. 13.7%, p = .013). Rate of seclusion increased to 5.0% (vs. 0%, p < .001). Rate of seclusion and/or restraint decreased from 13.7% to 11.8% (p = .425). The median cumulative duration of all coercive measures per affected case decreased significantly (2.8 vs. 5.4 h, p = .005), as well as its proportion to length of stay (0.8% vs. 2.8%, p = .006). Modernisation and restructuring of buildings hosting psychiatric departments can contribute to a reduction of coercive measures in child and adolescent psychiatric units.

Seclusion within the first 24 h following admission into inpatient mental health services and associations with referral pathways, recent service contact and HoNOS ratings.

WHAT IS KNOWN ON THE SUBJECT?: Seclusion is a harmful and traumatising intervention for people accessing mental health services. People who are subject to seclusion in inpatient mental health services often first experience this within the first 24 h following admission. There is limited research examining how recent contact with services impacts the likelihood of seclusion when people are admitted to inpatient services. WHAT THE PAPER ADDS TO EXISTING KNOWLEDGE?: Males, Māori and Pasifika experience higher rates of seclusion within the first 24 h following inpatient admission. People perceived by clinicians as overactive, aggressive, disruptive or agitated are seven times more likely to be secluded within the first 24 h. People referred from police or justice services are three times more likely to be secluded within the first 24 h. People who had frequent contact with community mental health services prior to inpatient admission were less likely to be secluded. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: The first 24 h of inpatient admission is a critical focus for eliminating the use of seclusion. Initial interactions with people recently admitted should focus on nurturing relationships and reducing distress. Mental health staff should consider the person's cultural needs, referral pathway, recent service contact and baseline ratings on the Health of the Nation Outcomes Scales (HoNOS) when working proactively to prevent the use of seclusion in the first 24 h following admission. Strengthening the focus on nurturing relationships, cultural understanding and non-coercive de-escalation approaches requires leadership support and strategic workforce development. ABSTRACT: Introduction People who experience seclusion in inpatient mental health services often do so within the first 24 h following admission. There is limited research examining the potential contributing factors, particularly recent contact with services. Aim/Question To identify factors associated with seclusion within the first 24 h following admission into acute inpatient mental health services. Method A retrospective analysis was undertaken using routinely collected data from Aotearoa New Zealand mental health services. Results A higher likelihood of seclusion within the first 24 h following admission was associated with: males, Māori, Pasifika, referrals from police/justice services, inpatient transfers, recent contact with crisis assessment teams and clinician perceptions of aggression, problematic substance use, cognitive problems and hallucinations or delusions. Recent contact with community mental health services was associated with a lower likelihood. Discussion People's cultural needs, referral pathway, recent service contact and HoNOS scores should be considered when working to prevent the use of seclusion in the first 24 h following admission. Implications for Practice The first 24 h following inpatient admission is a critical period for preventing the use of seclusion. Nurturing relationships, cultural understanding and use of non-coercive de-escalation approaches can support better outcomes for people recently admitted.

Closing the equity gap as we move to the elimination of seclusion: Early results from a national quality improvement project.

Use of seclusion within mental health inpatient facilities is harmful for consumers and staff, but it is still used in many Aotearoa New Zealand and Australian facilities, at higher, inequitable rates for the indigenous populations of both countries. We report early results from a national programme to eliminate seclusion in mental health services in Aotearoa New Zealand, using a bicultural approach to reduce inequity for Māori. The 'Zero Seclusion: Safety and dignity for all' programme, with programme teams nationwide, developed a co-designed bicultural change package combining Māori cultural and Western clinical interventions, incorporating quality improvement methodologies. Outcome measures included seclusion rates, duration, and average number of episodes per person admitted, by ethnicity, with a focus on equity. Nationally, rates of seclusion for Māori reduced from the 12-month (to August 2019) baseline mean monthly rate of 7.5% to 6.8%, sustained from late 2020 to September 2022. The duration of seclusion for Māori reduced by 33% (4.5h at baseline to 3.0). A focus on inequity for Māori in use of seclusion, and a bicultural approach with cultural and clinical interventions, has been associated with a national reduction in rates and duration of seclusion for Māori.

The Characteristics of Patients Admitted to a Forensic Psychiatric Intensive Care Unit in Australia

Background: Psychiatric intensive care units (PICUs) house some of the highest acuity patients within the mental health system. Little is known about patient characteristics and adverse events occurring in these settings and this study aimed to examine clinical, demographic and offending characteristics and correlates of problem behaviours for patients admitted to the first forensic PICU in Australia. Aims: To identify common characteristics held by patients admitted to one high secure forensic PICU in Australia. Method: Retrospective file review occurred for patients admitted between March 2019 and May 2020, during which 96 male patients were admitted. Results: Mean (range) age was 37.3 (21–76) years, and when admitted most patients were: single (n = 80; 83.3%), homeless (n = 52; 54.2%), had not completed high-school education (n = 60; 62.5%), had histories of trauma (n = 38; 39.6%) and antisocial behaviour (n = 40; 41.7%) in adolescence and presented with personality disorder (n = 23; 24.0%) and substance abuse (n = 93; 96.9%). Frequent problem behaviours, particularly aggression (n = 65; 67.7%), were encountered and rates of seclusion (n = 62; 64.6%) were high. Segregation in prison prior to admission and co-morbid personality disorder were associated with increased likelihood of aggression or self-harm respectively occurring. Conclusion: With high mental illness acuity and significant behavioural risk complicated by multi-vulnerability, forensic PICUs need specialist environments, models of care and high level relational and de-escalation staff expertise to maintain safety and promote recovery.

The Use of Alternative Rooms in Forensic and Regular Psychiatric Units: A Scoping Review.

(1) Background: Emotional regulation, distress and relational conflicts often occur during hospitalization and rehabilitation on psychiatric units, especially in patients suffering from severe and persistent mental disorders. While widely used in children and geriatric patients, little literature exists on the use and outcomes of alternative rooms in the context of forensic and regular psychiatric units for adult patients. Considering the scarcity of the literature on alternative use, this study is motivated by the following research question: what are the main uses and outcomes of alternative rooms in the context of forensic and regular psychiatric units? The main objective of this study is to conduct a scoping review of the use and outcomes of alternative rooms for the context of psychiatric inpatients. (2) Methods: A systematic search was performed in the electronic databases of MedLine, Web of Science, PsycNet (PsycINFO) and Google Scholar from their inception dates until 2022. (3) Results: A total of nine studies were analyzed. Sensory, multisensory rooms, Snoezelen, and comfort rooms are the types of alternative rooms discussed in these studies. Distress and anxiety reduction, increase in self-esteem, impact on seclusion rates, patient-staff communication and alliances, heart and respiration rate reduction, and improvement of alexithymia were identified among the main uses and outcomes of these rooms. (4) Conclusions: The scarcity of literature available to draw information from for this review and possible impact on improving patient outcomes and quality of treatment in psychiatric units opens the door to future studies to better understand the efficacy of such rooms. Research into the ideal implementation tactics of such rooms, long-term outcomes, and the influence on diverse patient demographics could be areas of improvement in the use of alternative rooms.

A scoping review of trauma informed approaches in acute, crisis, emergency, and residential mental health care

Experiences of trauma in childhood and adulthood are highly prevalent among service users accessing acute, crisis, emergency, and residential mental health services. These settings, and restraint and seclusion practices used, can be extremely traumatic, leading to a growing awareness for the need for trauma informed care (TIC). The aim of TIC is to acknowledge the prevalence and impact of trauma and create a safe environment to prevent re-traumatisation. This scoping review maps the TIC approaches delivered in these settings and reports related service user and staff experiences and attitudes, staff wellbeing, and service use outcomes.We searched seven databases (EMBASE; PsycINFO; MEDLINE; Web of Science; Social Policy and Practice; Maternity and Infant Care Database; Cochrane Library Trials Register) between 24/02/2022-10/03/2022, used backwards and forwards citation tracking, and consulted academic and lived experience experts, identifying 4244 potentially relevant studies. Thirty-one studies were included.Most studies (n = 23) were conducted in the USA and were based in acute mental health services (n = 16). We identified few trials, limiting inferences that can be drawn from the findings. The Six Core Strategies (n = 7) and the Sanctuary Model (n = 6) were the most commonly reported approaches. Rates of restraint and seclusion reportedly decreased. Some service users reported feeling trusted and cared for, while staff reported feeling empathy for service users and having a greater understanding of trauma. Staff reported needing training to deliver TIC effectively.TIC principles should be at the core of all mental health service delivery. Implementing TIC approaches may integrate best practice into mental health care, although significant time and financial resources are required to implement organisational change at scale. Most evidence is preliminary in nature, and confined to acute and residential services, with little evidence on community crisis or emergency services. Clinical and research developments should prioritise lived experience expertise in addressing these gaps.

Complaints, Restraint, and Seclusion in Massachusetts Inpatient Psychiatric Facilities, 2008-2018.

There has been limited research on the quality of inpatient psychiatry, yet policies to expand access have increased, such as the use of Medicaid Section 1115 waivers for treatment in "Institutions for Mental Disease" (IMD). Using data from public records requests, we evaluated complaints, restraint, and seclusion from inpatient psychiatric facilities in Massachusetts occurring from 2008 to 2018, and compared differences in the rates of these events by IMD status. There were 17,962 total complaints, with 48.9% related to safety and 19.9% related to abuse (sexual, physical, verbal), and 92,670 episodes of restraint and seclusion. On average, for every 30 census days in a given facility, restraint, and seclusion occurred 7.47 and 1.81 times, respectively, and a complaint was filed 0.94 times. IMDs had 47.8%, 68.3%, 276.9%, 284.8%, 183.6%, and 236.1% greater rates of restraint, seclusion, overall complaints, substantiated complaints, safety-related complaints, and abuse-related complaints, respectively, compared to non-IMDs. This is the first known study to describe complaints from United States inpatient psychiatric facilities. Policies should strengthen the implementation of patients' rights and patient-centeredness, as well as external critical-incident-reporting systems.

A systematic review of in-patient psychiatric care for people with intellectual disabilities and/or autism: effectiveness, patient safety and experience.

An increasing number of children, adolescents and adults with intellectual disabilities and/or autism are being admitted to general psychiatric wards and cared for by general psychiatrists. The aim of this systematic review was to consider the likely effectiveness of in-patient treatment for this population, and compare and contrast differing models of in-patient care. A systematic search was completed to identify papers where authors had reported data about the effectiveness of in-patient admissions with reference to one of three domains: treatment effect (e.g. length of stay, clinical outcome, readmission), patient safety (e.g. restrictive practices) and patient experience (e.g. patient or family satisfaction). Where possible, outcomes associated with admission were considered further within the context of differing models of in-patient care (e.g. specialist in-patient services versus general mental health in-patient services). A total of 106 studies were included and there was evidence that improvements in mental health, social functioning, behaviour and forensic risk were associated with in-patient admission. There were two main models of in-patient psychiatric care described within the literature: admission to a specialist intellectual disability or general mental health in-patient service. Patients admitted to specialist intellectual disability in-patient services had greater complexity, but there were additional benefits, including fewer out-of-area discharges and lower seclusion rates. There was evidence that admission to in-patient services was associated with improvements in mental health for this population. There was some evidence indicating better outcomes for those admitted to specialist services.

Nursing staff composition and its influence on seclusion in an adult forensic mental health inpatient setting: The truth about numbers

IntroductionResearch on the influence of nursing staff composition and use of seclusion in the forensic mental health inpatient settings is sparse. Nursing staff composition refers to staffing levels, roles, gender ratio and skill mix of the ward teams. Internationally, the rates of seclusion in some forensic mental health inpatient settings have increased over the past 10 years despite global efforts to reduce and eliminate its use. AimTo examine whether the use of seclusion in a forensic mental health inpatient setting can be attributed to staffing composition or to contextual factors such as day of the week, month or other clinical factors. MethodRetrospective data collection was conducted using seclusion data, daily ward reports and staff rosters. Data were collected for all shifts in the hospital over a six-month period. ResultsThree staffing variables were identified as having an influence on the use of seclusion: the number of registered nurses on duty, the presence of the shift coordinator and having a lead nurse on shift. DiscussionSenior nurse oversight and guidance are important factors in assisting staff to identify clinical deterioration and intervene early which may assist services reduce the use of seclusion. Implications for practiceAs staffing levels and composition are modifiable, the results of this study may assist nurse leaders to consider workforce improvements to reduce seclusion use.

An Evidence-Based Educational Intervention for Reducing Coercive Measures in Psychiatric Hospitals

Investing in health care staffs' education can change the scope of action and improve care. The effectiveness of staff education remains inconclusive. To examine whether an evidence-based educational intervention for nurses decreases the use of seclusion rooms in psychiatric hospitals compared with usual practice. In this pragmatic, 2-arm parallel, stratified cluster randomized clinical trial, 28 wards in 15 psychiatric hospitals in Finland were screened for eligibility and randomly allocated (1:1). Nurses joined on either intervention (n = 13) or usual practice (n = 15) wards. The intervention was performed from May 1, 2016, to October 31, 2017. The follow-up data for January 1 to December 31, 2017, were collected from hospital registers in 2018. Data analysis was performed October 27, 2021. Evidence-based education delivered during 18 months, including 8 months of active education, followed by a 10-month maintenance period. The primary outcome was the occurrence of patient seclusion (events per total number of patients). Of 28 psychiatric hospital wards screened (437 beds and 648 nurses), 27 wards completed the study. A total of 8349 patients were receiving care in the study wards, with 53% male patients and a mean (SD) age of 40.6 (5.7) years. The overall number of seclusions was 1209 (14.5%) in 2015 and 1349 (16.5%) in 2017. In the intervention group, the occurrence rate of seclusion at the ward level decreased by 5.3% from 629 seclusions among 4163 patients (15.1%) to 585 seclusions among 4089 patients (14.3%) compared with a 34.7% increase from 580 seclusions among 4186 patients (13.9%) to 764 seclusions among 4092 patients (18.7%) in the usual practice group. The adjusted rate ratio was 0.86 (95% CI, 0.40-1.82) in 2015 and 0.66 (95% CI, 0.31-1.41) in 2017 (P = .003). However, the number of forced injections increased in the intervention group from 317 events among 4163 patients (7.6%) in 2015 to 486 events among 4089 patients (11.9%) in 2017 compared with an increase in the usual practice group from 414 events among 4186 patients (9.9%) in 2015 to 481 events among 4092 patients (11.8%) in 2017. Seven adverse events were reported. In this randomized clinical trial, the educational intervention had a limited effect on the change of occurrence rate of patient seclusion, whereas the use of forced injections increased. More studies are needed to better understand the reasons for these findings. ClinicalTrials.gov Identifier: NCT02724748.

Use of a Novel Standardized Administration Protocol Reduces Agitation Pro Re Nata (PRN) Medication Requirements: The Birmingham Agitation Management (BAM) Initiative.

Agitation management is a principal challenge on inpatient psychiatric units. Overreliance on common prescribing strategies of pro re nata (PRN) medication administration is problematic, given the tendencies to have overlapping or unclear indications. Piloted project to determine whether a standardized protocol for agitation intervention may reduce PRN medication administration. The Birmingham Agitation Management (BAM) interdisciplinary team uniquely connected the Brøset Violence Checklist (BVC) for assessment of agitation severity to a standardized PRN medication order set. Nurses on the piloted unit were trained on how to score the BVC and administer medications. Patients were assessed by the BVC every 4 hours and, based on their score, would receive no medication, low-dose benzodiazepine, high-dose benzodiazepine, or high-dose benzodiazepine plus antipsychotic. The primary end point compared the number of PRNs administered after novel protocol implementation with a retrospective cohort. Secondary measures included analysis of medication-related effects, seclusion, and physical restraint rates. 377 patients were included in the final analyses (184 pre-BAM, 193 BAM intervention group). No significant differences were seen in patient characteristics between groups. The total number of PRNs administered decreased by 42.5%, with both the mean and median number of administrations decreasing significantly (95% confidence interval [CI] = [1.68-5.75]; P < 0.001). A trend was noted between the number of PRNs administered and seclusion rates, but did not reach statistical significance (95% CI = [-7.28 to 60.31]; P = 0.124). In seemingly the first initiative of its kind, we found that a standardized agitation management protocol can help decrease the total number of PRN administrations for agitation without worsening of restraint rates and may possibly reduce the risk of adverse effects. These results require validation in specific, larger populations.

Seclusion as a coercive measure in suicidality – daily routine or exception?

BackgroundCoercive measures continue to be an important topic in psychiatry. However, there is no proof of the effectiveness of the use of coercive measures, especially with suicidal people. For many years, attempts have been made to replace such measures with alternative noncoercive intervention options. This paper aims to clarify the situation of coercive measures, more precisely seclusions, in a general psychiatric hospital in Switzerland. It focuses on compulsory measures in patients with suicidal tendencies.MethodIn this single-centre retrospective cohort study, we used routinely collected medical data and performed qualitative analyses of medical histories to examine whether alternative measures to seclusion had been offered and/or provided to patients who had been secluded solely because of suicidality. Patients were aged 18–65 years and had received inpatient treatment at one of five adult acute care units at a general psychiatric hospital in Switzerland between September 2016 and December 2019.ResultsThere were 5,935 inpatient treatment cases during the study period. Suicidality was rated as “acute” or “very high” at least once during the hospitalization in 219 (3.7%) cases. Of these, 60 were excluded from further analyses as they involved seclusion, but suicidality was not the exclusive indication for this measure. Coercive seclusion was imposed exclusively due to suicidality in 53 (33.3%) of the remaining 159 cases, whereas 106 (66.7%) cases were not secluded. The rates of seclusion among suicidal patients varied considerably between the hospital wards (13.0% to 55.3%). Suicidal patients with non-Swiss residence status and/or lacking language skills were particularly prone to be secluded. Additionally, alternative interventions were offered and provided significantly more frequently in the nonsecluded patients.ConclusionsTo avoid seclusion due to suicidal tendencies, it is necessary to have a general attitude of avoiding coercive measures at all costs. It is also important for qualified staff to be able to deal with challenging sociodemographic characteristics of patients such as foreign-language, which may require translators and intercultural interpreters.

Reducing seclusion use in an Australian child and adolescent psychiatric inpatient unit

BackgroundIn inpatient psychiatric units, seclusion (isolation in a locked room) is recommended only as a last resort for serious aggression or agitation. In response to an increase in seclusion during 2015, an 8-bed child and adolescent inpatient unit implemented a suite of multidisciplinary interventions. This study examines changes in seclusion rates following intervention implementation and assesses whether specific patient factors were associated with seclusion rates before and after interventions. MethodMulti-modal interventions, comprised of patient treatment plans, intake and handover meetings, staff supervision and debriefing sessions, were implemented from January 2016. We compared quarterly seclusion rates (episodes per 1000 patient days) across a thirteen-year period, from July 2008 to June 2021. Change in seclusion rates following intervention was evaluated using a segmented regression analysis. We examined whether patient factors were associated with seclusion rates, and whether the duration of seclusion episodes differed before and after interventions. ResultsThere was a 100% reduction in seclusion rates in the 6 months following intervention implementation, from 28.4 episodes per 1000 patient days in July–September 2015, to 4.7 episodes in January–March 2016, reaching 0.0 episodes by April–June 2016. This reduction was maintained until April–June 2021. Most patients with seclusion events before and after intervention implementation had a neurodevelopmental disorder diagnosis and a minority of patients accounted for most seclusion events. There was a 65% reduction in the average duration of seclusion episodes following interventions, however this was not statistically significant. LimitationsDue to a crisis in staff morale, interventions were implemented simultaneously, preventing an understanding of whether a single intervention accounted for change. While not addressed in the current study, assessing perceptions of staff, children and parents following intervention implementation may have elucidated barriers and facilitators to change. ConclusionsMultidisciplinary, patient-centered interventions may be effective for long-term reduction of seclusion rates in inpatient psychiatric units. These findings highlight patient factors associated with seclusion reduction which should be considered when implementing interventions.

Seclusion Reduction on an Adult Inpatient Psychiatric Unit: A Quality Improvement Project.

Seclusion practices have traditionally been used in psychiatry to maintain patient and staff safety. Despite negative emotional consequences for all involved parties and the movement toward patient-centered care, these practices continue in in-patient psychiatric units across the United States. The purpose of the current quality improvement project was to decrease the rate of seclusion events on an adult inpatient psychiatric unit through the implementation of a standard debriefing process based on the National Association of State Mental Health Program Directors' Six Core Strategies for Reducing Seclusion and Restraint Use. In 2020, the seclusion rates at the project site were above state and national benchmarks. Post-intervention, the seclusion hours per 1,000 patient care hours increased by 16% (0.38 to 0.44); however, the mean duration of each seclusion episode decreased by 10% (158 minutes to 142 minutes). Intervention compliance was low, including interprofessional participation. These findings demonstrate the need to address seclusion practices with an evidence-based solution, such as debriefing, coupled with adequate support from interprofessional leadership. [Journal of Psychosocial Nursing and Mental Health Services, 60(6), 27-32.].

Elevated Rates of Restraint and Seclusion in Child and Adolescent Psychiatric Inpatients in China and Their Associated Factors.

To investigate the rate of restraint and seclusion (R&S) use in child and adolescent psychiatric inpatients in China and to examine factors associated with use of these interventions. As part of an official national survey, 41 provincial tertiary psychiatric hospitals in China were selected. Data from 196 youth inpatients discharged from these hospitals from March 19 to 31, 2019 were retrieved and analyzed. (1) The overall rate of R&S was 29.1% (N = 57) and the rate of restraint was 28.6% (N = 56), and seclusion was 11.7% (N = 23) respectively. (2) Compared to patients who did not require R&S, those who required R&S were more likely to have been hospitalized on an involuntary basis, more likely to present with either manic symptoms or aggressive behavior as primary reason for admission, had more frequent aggressive behaviors during hospitalization, and had a significantly longer length of stay. (3) A logistic regression showed that aggressive behaviors during hospitalization was significantly associated with the use of R&S (OR = 21.277, p < 0.001), along with three other factors: manic symptoms as a reason for admission, involuntary admission and a lower GAF score at admission (all p < 0.01). The rate of R&S is dramatically higher in child and adolescent psychiatric hospitalizations in China compared to other regions. Targeted training of staff, development of precise operational guidelines for appropriate use of R&S, and strict oversight are urgently needed to minimize the inappropriate use of R&S in child and adolescent patients.

Does high and intensive care reduce coercion? Association of HIC model fidelity to seclusion use in the Netherlands

BackgroundA new inpatient care model has been developed in the Netherlands: High and Intensive Care (HIC). The purpose of HIC is to improve quality of inpatient mental healthcare and to reduce coercion.MethodsIn 2014, audits were held at 32 closed acute admission wards for adult patients throughout the Netherlands. The audits were done by trained auditors, who were professionals of the participating institutes, using the HIC monitor, a model fidelity scale to assess implementation of the HIC model. The HIC model fidelity scale (67 items) encompasses 11 domains including for example team structure, team processes, diagnostics and treatment, and building environment. Data on seclusion and forced medication was collected using the Argus rating scale. The association between HIC monitor scores and the use of seclusion and forced medication was analyzed, corrected for patient characteristics.ResultsResults showed that wards having a relatively high HIC monitor total score, indicating a high level of implementation of the model as compared to wards scoring lower on the monitor, had lower seclusion hours per admission hours (2.58 versus 4.20) and less forced medication events per admission days (0.0162 versus 0.0207). The HIC model fidelity scores explained 27% of the variance in seclusion rates (p < 0.001). Adding patient characteristics to HIC items in the regression model showed an increase of the explained variance to 40%.ConclusionsThis study showed that higher HIC model fidelity was associated with less seclusion and less forced medication at acute closed psychiatric wards in the Netherlands.

Benchmarking to reduce restrictive practices in forensic mental health services: a Delphi study

Forensic mental health services (FMHS) have higher rates, duration and frequency of restrictive practices (seclusion, physical restraint and mechanical restraint). Data generated by services can be used to set targets (benchmarks) with like services to reduce or eliminate restrictive practices. The aim of this study was to develop restrictive practice benchmarks for Australian and New Zealand FMHS. A participatory action research methodology was used by conducting a Delphi study. FMHS experts provided de-identified service-specific restrictive practice data, which was used to stimulate reflection towards the development of restrictive practice benchmarks. Consensus decision-making was reached on benchmarks for the rate, duration and frequency of seclusion and physical restraint. Mechanical restraint was found to be a rare event, requiring event specific review in each service. Benchmarking with FMHS may assist in working to reduce restrictive practices and encourage the scrutiny of service practice. Establishment of a FMHS network might assist to embed the proposed benchmarks.

Variability in Psychiatric Facility Seclusion and Restraint Rates as Reported on Hospital Compare Site.

This study examined variability among U.S. hospitals in rates of seclusion and physical restraint, including the effects of hospital type and ownership, as reported on Hospital Compare. Broader aims were to highlight the wide variability in use of these measures, the need for improved data reporting, and the data source itself, which deserves further development and more attention from regulatory agencies, researchers, and others. Facility-level data from Hospital Compare for 2013-2017 were analyzed. Rates of seclusion and restraint were computed by aggregating across study years and compared by hospital type and ownership. Rates were also examined by year. Data cleaning revealed hundreds of errors. The final sample comprised 7,416 seclusion rates and 7,398 restraint rates from 1,642 hospitals. For both acute care and psychiatric hospitals, marked differences were noted in seclusion and restraint rates above the median, with for-profit hospitals reporting markedly lower rates compared with government and nonprofit hospitals. Rates above the median declined substantially during the study period. Although 67% of hospitals reported comparably low rates of seclusion (≤0.09 hours per 1,000 patient-hours) and restraint (≤0.15 hours per 1,000 patient-hours), 10% of hospitals reported rates at least five to 10 times higher. Despite some progress, many hospitals continue to report very high rates of seclusion and restraint. It is unlikely that this variability can be fully accounted for by patient-level factors. Centers for Medicare and Medicaid Services data reporting should be expanded to include frequency of seclusion and restraint use and duration of episodes.