Transcript Slide 1

The use of seclusion in forensic
mental health services:
an exploration of practice and
culture
Fiona Davidson, Queensland Mental
Health Benchmarking Unit
Karlyn Chettleburgh, Forensicare
National Mental Health
Benchmarking Project
27 November 2008
National Mental Health Benchmarking Project
27 November 2008
A joint Australian, State and
Territory Government Initiative
ACHS Seclusion Indicators
Detailed Seclusion Audit
Seclusion + Medication Audit
In 2007 an audit process was undertaken in each of the
participating Forensic Services for a one month period:
•All episodes of seclusion were recorded
•All medications administered were recorded
•A comparison of seclusion and time out policies and practices was
conducted
•An environmental audit was undertaken (how many seclusion
rooms, time out facility, ICU/HDU)
Audit Information:
Consumer Factors:
Seclusion Metrics:
Gender
ALOS (during audit)
Legal Status
Diagnosis
Offence Category
Age
Cultural background
% consumers secluded
Total hours of seclusion
Avg hours/episode seclusion
Medication Administered:
Chlorpromazine equivalent daily dose
Benzodiazepine equivalent daily dose
PRN medication use
Comparison with RANZCP guidelines
Other Issues considered:
Use of 1:1 Observations
Use of ‘Time Out’
HoNOS
Seclusion Utilisation – Number of Episodes
18
16
14
12
10
8
6
4
NB Service also
uses segregation
– unable to report
2
0
Total Number of Episodes
Socceroos
1
Wallabies
8
Matildas
12
Opals
17
Seclusion Utilisation - % consumers secluded
25
20
15
10
NB Service also
uses segregation
– unable to report
5
0
Socceroos
Wallabies
% of Consumers Secluded
2.72
13.95
Matildas
22.5
Opals
10.7
Seclusion Utilisation – Average hours/Episode
400
350
300
250
200
150
100
NB Service also
uses segregation
– unable to report
50
0
Socceroos
Wallabies
Average Hours/Episode
22
3
Matildas
171
Opals
375
Chlorpromazine Equivalencies – seclusion
comparison
1000
900
800
700
600
500
400
300
200
100
0
All Pts
Cons Secluded
Socceroos
504
475
Wallabies
569
925
Matildas
659
781
Opals
505
208
Diazepam Equivalency for Pts
experiencing Seclusion
40
30
20
10
0
All Pts
Secluded
Socceroos
3
0
Wallabies
16
34
Matildas
14
22
Opals
4
8
Findings:
•Seclusion is a complex area!
•Service culture, legislation and environment need to be considered
•Medication prescribing patterns varied considerably between
services
•Continued review of medication prescribing patterns is of interest
•Open discussion in relation to seclusion practices were of great
benefit
VIFMH - Forensicare
National Mental Health Benchmarking Project
27 November 2008
Thomas Embling Hospital
National Mental Health Benchmarking Project
27 November 2008
Thomas Embling Hospital
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Commissioned in April 2000
118 bed secure hospital (expanded in May 2007)
7 inpatient units
 Argyle and Atherton: 15 bed male acute units
 Barossa: 10 bed female acute unit
 Bass: 20 bed mixed gender sub acute unit
 Canning: 20 bed male supported living unit
 Daintree: 20 bed mixed gender rehabilitation unit
 Jardine: 18 bed mixed gender community reintegration unit
Total of 15 seclusion rooms within 5 seclusion suites
National Mental Health Benchmarking Project
27 November 2008
Patient Characteristics
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60% Forensic Patients; 10% Involuntary patients; 24%
Security Patients (remanded and sentenced prisoners),
6% Other (HSO and RITO).
92% Schizophrenia; 1% Affective Disorders; 2%
Personality Disorder; 5% Other.
87% male and 13% female
47% murder/attempted murder; 30% other violent
offences
74% past psychiatric history; 68% substance abuse;
18% from non-english speaking backgrounds
National Mental Health Benchmarking Project
27 November 2008
Benchmarking - Seclusion
Inscope pts secluded
90
80
70
60
50
40
30
20
10
0
Duration >4hrs
77
55
40
47
34
19
2004/05
2005/06
National Mental Health Benchmarking Project
27 November 2008
2006/07
Benchmarking - Seclusion
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Time of Day
Index Offence
Legal status
Age
Duration
Substance Abuse
Use of specials (1 to 1 nursing)
National Mental Health Benchmarking Project
27 November 2008
NMHRSP – Study Tour
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Leadership
Cultural change
No quick or ‘formula’ based solution
Workforce development- induction, training, retention
Physical environment is not an impediment
Using data and statistics
Financial costs
Qualified vs unqualified staff
Patient programs
Consumer empowerment
Selling it to staff
National Mental Health Benchmarking Project
27 November 2008
NMHRSP – Key Principles
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Leadership guiding and supporting
organisational change
Continuous workforce development
Genuine consumer involvement
Enhancing therapeutic practice
Use of data to support practice
National Mental Health Benchmarking Project
27 November 2008
NMHRSP - Outcomes
Seclusion events 2007/08
60
50
40
30
20
10
Ju
ly
Au
g
Se
pt
O
ct
No
v
De
c
Ja
n
Fe
b
M
ar
Ap
ri l
M
ay
Ju
ne
Ju
ly
Au
g
Se
pt
0
National Mental Health Benchmarking Project
27 November 2008
NMHRSP - Outcomes
Total hours of seclusion 2007/08
1200
1000
800
600
400
200
0
ly ug ept
u
A S
J
c t ov ec
O N
D
l
y ne
n eb
ly ug ept
ar pri
a
a
u
J
A S
F
M A
J
M Ju
National Mental Health Benchmarking Project
27 November 2008
NMHRSP - Outcomes
Number of total patients secluded
80
60
Number 40
20
0
May 2002/April 2003
May 2007/April 2008
Period
National Mental Health Benchmarking Project
27 November 2008
NMHRSP - Outcomes
Total hours of seclusion
4500
4400
4300
Hours 4200
4100
4000
3900
May 2002/ May 2003 May 2007/ May 2008
Period
National Mental Health Benchmarking Project
27 November 2008
The Structured Day
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Implementation plan developed
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3 month pilot on 1x acute and 1x continuing care units
Pre and Post measures identified
Communication strategy developed
Consultation with key stakeholders
Evaluation of pilot
Official launch
Hospital wide roll out July 21st 2008
Motivational Interviewing training for staff
Amendment to visiting hours
Work program remuneration for security patients
National Mental Health Benchmarking Project
27 November 2008
Pilot Evaluation
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The overall level of patient activity within each of the pilot sites
increased by a significant magnitude; with activity levels
increasing from an average of 1.5 activities per patient per day to
over 3 activities per day.
Patients reported an increased sense that their treating teams
had a better understanding of their current difficulties and
treatment needs.
Patients also reported a decreased sense of loneliness, which
reflected staff reports of increased social interaction amongst
patients.
While no significant decreases were observed in the overall level
of acuity or day-to-day functioning amongst patients; clinician
ratings of patients’ functioning indicated specific areas of positive
change. This was particularly salient with regard to interpersonal
warmth, ability to maintain friendships amongst patients, and the
ability of patients to engage in meaningful occupations.
National Mental Health Benchmarking Project
27 November 2008
Calming Rooms/Safe Places
National Mental Health Benchmarking Project
27 November 2008