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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.

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the use of seclusion in forensic mental health services an exploration of practice and culture

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

slide3

ACHS Seclusion Indicators

Detailed Seclusion Audit

Seclusion + Medication Audit

slide4

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)
slide5

Consumer Factors:

Gender

ALOS (during audit)

Legal Status

Diagnosis

Offence Category

Age

Cultural background

Seclusion Metrics:

% consumers secluded

Total hours of seclusion

Avg hours/episode seclusion

Other Issues considered:

Use of 1:1 Observations

Use of ‘Time Out’

HoNOS

Medication Administered:

Chlorpromazine equivalent daily dose

Benzodiazepine equivalent daily dose

PRN medication use

Comparison with RANZCP guidelines

Audit Information:

seclusion utilisation number of episodes
Seclusion Utilisation – Number of Episodes

NB Service alsouses segregation – unable to report

seclusion utilisation consumers secluded
Seclusion Utilisation - % consumers secluded

NB Service alsouses segregation – unable to report

seclusion utilisation average hours episode
Seclusion Utilisation – Average hours/Episode

NB Service alsouses segregation – unable to report

slide13

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
VIFMH - Forensicare

National Mental Health Benchmarking Project 27 November 2008

National Mental Health Benchmarking Project 27 November 2008

thomas embling hospital
Thomas Embling Hospital

National Mental Health Benchmarking Project 27 November 2008

National Mental Health Benchmarking Project 27 November 2008

thomas embling hospital16
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

National Mental Health Benchmarking Project 27 November 2008

National Mental Health Benchmarking Project 27 November 2008

patient characteristics
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

National Mental Health Benchmarking Project 27 November 2008

National Mental Health Benchmarking Project 27 November 2008

benchmarking seclusion
Benchmarking - Seclusion

National Mental Health Benchmarking Project 27 November 2008

National Mental Health Benchmarking Project 27 November 2008

benchmarking seclusion19
Benchmarking - Seclusion
  • 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

National Mental Health Benchmarking Project 27 November 2008

nmhrsp study tour
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

National Mental Health Benchmarking Project 27 November 2008

National Mental Health Benchmarking Project 27 November 2008

nmhrsp key principles
NMHRSP – Key Principles
  • 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

National Mental Health Benchmarking Project 27 November 2008

nmhrsp outcomes
NMHRSP - Outcomes

National Mental Health Benchmarking Project 27 November 2008

National Mental Health Benchmarking Project 27 November 2008

nmhrsp outcomes23
NMHRSP - Outcomes

National Mental Health Benchmarking Project 27 November 2008

National Mental Health Benchmarking Project 27 November 2008

nmhrsp outcomes24
NMHRSP - Outcomes

National Mental Health Benchmarking Project 27 November 2008

National Mental Health Benchmarking Project 27 November 2008

nmhrsp outcomes25
NMHRSP - Outcomes

National Mental Health Benchmarking Project 27 November 2008

National Mental Health Benchmarking Project 27 November 2008

the structured day
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

National Mental Health Benchmarking Project 27 November 2008

National Mental Health Benchmarking Project 27 November 2008

pilot evaluation
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.

National Mental Health Benchmarking Project 27 November 2008

National Mental Health Benchmarking Project 27 November 2008

calming rooms safe places
Calming Rooms/Safe Places

National Mental Health Benchmarking Project 27 November 2008

National Mental Health Benchmarking Project 27 November 2008

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