A joint Australian, State and Territory Government Initiative National Mental Health Benchmarking Project 27 November 2008 The use of seclusion in forensic

A joint Australian, State and Territory Government Initiative

National Mental Health Benchmarking Project 27 November 2008

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

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:

GenderALOS (during audit)

Legal StatusDiagnosis

Offence CategoryAge

Cultural background

Seclusion Metrics:

% consumers secludedTotal hours of seclusion

Avg hours/episode seclusion

Medication Administered:

Chlorpromazine equivalent daily doseBenzodiazepine equivalent daily dose

PRN medication useComparison with RANZCP guidelines

Other Issues considered:

Use of 1:1 ObservationsUse of ‘Time Out’

HoNOS

0

2

4

6

8

10

12

14

16

18

Socceroos 1

Wallabies 8

Matildas 12

Opals 17

Total Number of Episodes

Seclusion Utilisation – Number of Episodes

NB Service alsouses segregation – unable to report

0

5

10

15

20

25

Socceroos 2.72

Wallabies 13.95

Matildas 22.5

Opals 10.7

% of Consumers Secluded

Seclusion Utilisation - % consumers secluded


0

50

100

150

200

250

300

350

400

Socceroos 22

Wallabies 3

Matildas 171

Opals 375

Average Hours/Episode

Seclusion Utilisation – Average hours/Episode


Chlorpromazine Equivalencies – seclusion comparison

0

100

200

300

400

500

600

700

800

900

1000

Socceroos 504 475

Wallabies 569 925

Matildas 659 781

Opals 505 208

All Pts Cons Secluded

Diazepam Equivalency for Pts experiencing Seclusion

0

10

20

30

40

Socceroos 3 0

Wallabies 16 34

Matildas 14 22

Opals 4 8

All Pts Secluded

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



Thomas Embling Hospital



Thomas Embling Hospital 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



Patient Characteristics

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



Benchmarking - Seclusion

4034

55

77

19

47

010

203040

506070

8090

2004/05 2005/06 2006/07

Inscope pts secluded Duration >4hrs



Benchmarking - Seclusion

Time of Day Index Offence Legal status Age Duration Substance Abuse Use of specials (1 to 1 nursing)



NMHRSP – Study Tour 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



NMHRSP – Key Principles

Leadership guiding and supporting organisational change

Continuous workforce development Genuine consumer involvement Enhancing therapeutic practice Use of data to support practice



NMHRSP - Outcomes


Seclusion events 2007/08

0

10

20

30

40

50

60

July

AugSep

tO

ctNov

DecJa

nFeb M

arApr

ilM

ayJu

ne July

AugSep

t


NMHRSP - Outcomes


Total hours of seclusion 2007/08

0

200

400

600

800

1000

1200


NMHRSP - Outcomes


0

20

40

60

80

Number

May 2002/April 2003 May 2007/April 2008

Period

Number of total patients secluded


NMHRSP - Outcomes


3900

4000

4100

4200

4300

4400

4500

Hours

May 2002/ May 2003 May 2007/ May 2008

Period

Total hours of seclusion


The Structured Day Implementation plan developed

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



Pilot Evaluation 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.



Calming Rooms/Safe Places


Documents

A joint Australian, State and Territory Government Initiative National Mental Health Benchmarking Project 27 November 2008 The use of seclusion in forensic