Transcript walking the tight rope

WALKING THE TIGHT
ROPE
“balance and decision –
should seclusion ever be an
option?”
The Austinmer Adolescent Unit (AAU) is a high secure 6 bedded ward
within a 135 bed adult oriented Forensic Hospital in Sydney.
The AAU provides care for male and female adolescent patients (1321yrs old) with a mental illness who have come in contact with the
criminal justice system or who are deemed to be too high risk to be
safely managed in the community.
Part of our admission criteria is that a patient must;
“manifest a significant risk of harm to self and to others…”
Austinmer Timetable - Commencing 11.5.15
Time/ day
Monday
Tuesday
Wednesday
Thursday
Pool -or- rec hall
Pool- orRec Hall
9-10am
1100
Pool- orRec Hall
10am
9-
1300
Pool, rec hall or
Bikes
Optional Study
time
Community
Meeting
Study time
Individual
Sessions (Welfare /Nursing
also available)
Study time
Brain Gym
with Linda
Josh Psychology
Rec Hall
Kiosk
Pool -orRec Hall
9-10am
Rec Hall only
1-2pm
Pool -or- Rec Hall
1-2pm
Rec-hall only
3-4pm
Pool -orRec Hall
3-4pm
Study time
Think group
with Esther/John/
Annie
Individual
Sessions:
Individual
sessions:
OT cooking:
? William
Nursing
Medical
Will - Psychology
Kiosk
Esther -psychology
Pool -orRec Hall
1-2pm
Art Therapy
with Oleen
DVD group
wi th l i s a
Spirituality group
with Brian
1500
Individual
sessions or Rest
time
Pool -orRec Hall
1-2pm
Afternoon Tea
Individual
sessions:
Art therapy
Nursing
Medical
1530
Pool - Rec hall
4-5pm
Rec-Hall
4-5pm
1700
1800
Rec Hall only
9-10am
LUNCH
14:00
14:15
1600
Pool,
Rec- Hall, or
running
Showers - personal hygieneShowers
1145
1215
Sunday
Mornng Meeting/Morning Tea
1000
1015
Saturday
Breakfast
800
900
9:45
Friday
Dinner
Wind down time
Kiosk
Daniel - Psychology
Pool -orRec Hall
1-2pm
SnapChat
Linda and Sarah
Adolescent Statistics since 2009 to date
 Total admissions: 88
 Total discharges: 82
 Gender: 85 male / 3 female
 Primary Diagnosis: Schizophrenia, mood disorder, conduct disorder
most with the co morbidity of drug and alcohol use and trauma
experiences.
 Patients are mainly admitted from Juvenile Justice Centres or
Correctional Centre
 90% Had a history of drug and alcohol misuse
MDT model
 Consultant Forensic Psychiatrist
 Psychiatry Registrar
 Clinical forensic psychologist
 Occupational therapist
 Welfare officer
 Art therapist
 Education officer
 Nursing Unit Manager
 Clinical Nurse Consultant
 Nursing team x 18
 MHCW x 1
7
SECLUSION SEPT TO SEPT
6
5
4
3
2
1
0
Case study Sally*
 13 year old girl
 Witnessed to domestic violence

 Complex PTSD
History of trauma
 Family and community service
involvement
 Fostered in several foster homes
 Numerous suicide / self-harm
attempts
 Challenging behaviour
*pseudonym
 ADHD
 Attachment disorder
 Unstable emotional regulation
 High risk taking behaviour
 Conduct disorder
Sally- Family History
Mother -
Father –
 Smoked cannabis, excess alcohol
 Diagnosis of schizophrenia and
substance use disorder
 On methadone programme
 Diagnosis of depression and
borderline personality disorder
 Substance induced psychosis
 Cognitive impairment
 Brain cyst removed
 Admission at age 12 for selfharming behaviours
 Reported to have had gambling
“problems”
Early childhood history – Sally
 Mother and baby bonding classes
 Speech delay and social skills problems
 Neglect – in dirty clothes and soiled nappies, observed by neighbours to be in
the streets with a drug paraphernalia age 2yrs, reported sexual abuse by
mother, witness to domestic violence
 Removed from mums care at age 5
 Behaviour difficult to manage in care
 Oppositional defiant
 Nightmares and head banging whilst in foster care
 Suspended from school due to challenging behaviour
Index Offence and reasons for admission
 Assault to care workers
 Is the offence(s) that are presented before the criminal court
proceedings
 Unmanageable behavior in custody
 HIGH risk of harm to self and others
 Period of assessment and observation for diagnostic
clarification and containment
Sally triggers and protective factors
Triggers
Protective factors
 Boredom
 Consistency, firm boundaries and
positive therapeutic relationships.

Staff changeover
 Getting too many instructions
 Inability to receive positive
feedback
 Family matters
 Reading and playing card games
and math's
 Stickers
 Good sleep pattern
 Privacy – self care ADL’s
 Art – very creative, makes cards
for staff and origami
 Phone calls to her case manager
at FACS
 Good relationships with care
workers from NGO
Summary of incidents
 2 verbally de-escalated
 3 restrained without seclusion
 34 restraints with seclusion
 39 incidents during admission period of 42 days
 29 aggressive incidents – physical and verbal
 8 human behaviour – self harm acts where harm to self
was extremely high risk
Incidents by method of management
40
35
30
No. of incidents
25
20
15
10
5
0
restraint with seclsuion
restraint without seclustion
methods used
De-escalation
All Incidents by time band
Unknown time
22:00 to 22:59
20:00 to 20:59
18:00 to 18:59
Time Band
16:00 to 16:59
14:00 to 14:59
12:00 to 12:59
10:00 to 10:59
08:00 to 08:59
06:00 to 06:59
04:00 to 04:59
02:00 to 02:59
00:00 to 00:59
0
1
2
3
No. of incidents
4
5
6
7
The incident timeline - Bedroom
 14:10 Agitated
 14:20 PRN
 14:45 Bed frame
 14:47 Emergency response team summoned
 14:55 Two timber batons - police called
 15:02 Police arrived
The incident timeline
 15:02 Police briefed
 15:04 Compliance and handcuffed
 15:05 Escorted to seclusion
 15:10 Medication administered
 15:18 Safety gown
 15:22 Police departed
 15:25 Seclusion commenced
 15:30 Staff and patients debrief
Reducing Sally seclusion trauma
 Use of PMVA where appropriate to maintain a safe
environment
 Consistent approach
 Seclusion to be used as a last resort
 Can remain in clothes initially if secluded
 Continual engagement and positive reinforcement
 Policies and procedures guided practice along with use
collected data
Review
 Treatment and management plan reviewed on a daily
basis
 Involvement with Sally on her choices and needs
 Difficulty in cooperation
 Staffing concerns raised
Significant change
 Observation level 2:1 constant observations to 5 minute
visual observations
 Two nurses were still allocated to her care for support
 Therapeutic relationships with staff improved
 Able to seek staff
 Reduction in self harm
 7 days no seclusion
 Assaulted staff day before discharge
 Discharge and follow up
Conclusion
 Secluding an adolescent patient is a traumatic event
for all involved and yet it can still be difficult to find
less restrictive and less traumatic options to safely
manage patients in circumstances of extreme
violence…
 The impact of this patient’s admission was significant
to her and to the Austinmer team (Nursing, Medical
and Allied Health) and to many other staff involved
But…
What might the outcome
have been if seclusion
was not an option?
[email protected]
[email protected]