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Reducing Seclusion Use in the Child and Adolescent Psychiatric Inpatient Unit

The Children's Hospital at Westmead
Project Added:
26 September 2016
Last updated:
10 October 2016

Reducing Seclusion Use in the Child and Adolescent Psychiatric Inpatient Unit

Summary

This project identified and examined the systemic issues leading to the use of seclusion at The Children’s Hospital at Westmead (CHW). It implemented preventative strategies to reduce the use of seclusion, including Multidisciplinary Team (MDT) care plans, staff education, daily intake and handover meetings, as well as supervision sessions for nursing and allied health staff.

Aim

To reduce the use of seclusion in the Child and Adolescent Psychiatric Inpatient Unit at CHW, by 75% by June 2016.

Benefits

  • Provides less restrictive care for patients.
  • Reduces patient distress and aggression.
  • Reduces risks to patients and staff.
  • Improves the ability of staff to prevent and manage violence.
  • Improves communication between staff, particularly during handover.

Background

Seclusion is the separation of a patient away from other people in a locked area. It may be a seclusion room that is a safe environment specifically designed for this purpose, or another area of the ward, such as a courtyard. Seclusion is used when a patient is highly distressed, agitated or at risk of hurting themselves or others. It’s seen as a last option for providing a safe, contained environment when other techniques for calming a patient have been ineffective. Seclusion can be traumatising for patients.

All psychiatric inpatient units report to the Ministry of Health as to how often seclusion is used. The target rate is 6.8 episodes per 1000 bed days. Regular monitoring showed that the use of seclusion had increased at CHW from 7.5 episodes per 1000 bed days between January and June 2015, to 28.4 episodes between July and September 2015. It was 17.3 episodes between October and December 2015.

Prior to the project, there were multiple episodes of aggression on the ward, leading to an increased use of seclusion. Reasons for this increase include the admission of high numbers of patients with aggressive behaviour, as well as an increase in the use of casual nursing staff, resulting in poorly coordinated care. As a result, there was low staff morale demonstrated by staff distress, increased rates of sick leave and some staff reducing their usual working hours. High rates of patient aggression also presented a risk for patient and staff safety.

It was determined that reducing the rate of seclusion use at CHW would provide less restrictive care for patients, reduce patient distress and reduce risks to patients and staff.

Implementation

  • The project team identified the systemic issues leading to the use of seclusion, which included patient mix, lack of available senior medical staff and lack of involvement by young people and their parents or carers when developing care plans.
  • MDT patient care plans were implemented, with input from patients and their parents or carers.
  • A daily intake meeting was implemented, to identify the goals of admission and proactively manage risk for new referrals or emergency admissions to the unit.
  • A daily MDT handover meeting was initiated, to identify specific risks and management strategies for each patient.
  • The availability of the inpatient unit psychiatrist was increased.
  • Weekly supervision sessions for nursing and allied health staff were implemented.
  • Staff training in violence prevention and management was implemented and included in new staff orientation processes.

Project status

Sustained - the initiative has been implemented and is sustained in standard business.

Key dates

November 2015 – June 2016

Implementation site

The Child and Adolescent Psychiatric Inpatient Unit, The Children’s Hospital at Westmead, Sydney Children’s Hospital Network

Partnerships

Clinical Excellence Commission. Clinical Leadership Program

Results

  • Seclusion rates dropped from 17.3 episodes per 1000 bed days between October and December 2015, to 4.7 episodes between January and March 2016, to 0.0 episodes in April and May 2016.
  • Solutions implemented have been welcomed by staff, with morale much improved.
  • Weekly supervision sessions have been well received by nursing and allied health staff.

From Jan-Mar 2016 seclusion rates dropped below targets

Lessons learnt

There were communication challenges between the project team and staff members in the unit. In retrospect, it would have helped if the project team had examined possible barriers to change throughout the project, so they could be addressed. A crisis of staff morale led to the urgent need for several changes to be implemented at once, which prevented Plan-Do-Study-Act cycles from being implemented systematically. It is therefore not possible to specify which particular measure resulted in the changes observed.

Further reading

Contact

Dr Michael Bowden
Child and Adolescent Psychiatrist and Head Department of Psychological Medicine
The Children’s Hospital at Westmead
Sydney Children’s Hospital Network
Phone: 02 9845 2005
Michael.bowden@health.nsw.gov.au

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