Look, Listen, Feel: Reducing Seclusion and Restraint

Seclusion and restraint are increasingly common interventions used within emergency departments. Reducing the use of these practices is vital to improving the quality of mental health care patients and their families receive when presenting to emergency departments, as well as for the longevity and wellbeing of clinical staff.

View a poster from the Centre for Healthcare Redesign graduation, April 2022.

Aim

Improve the experience of people presenting in the five declared mental health facility emergency departments (DMHF-EDs) for mental ill-health in Southern NSW Local Health District (SNSWLHD), by reducing the use of seclusion and restraint by 20% by June 2023, thereby improving health outcomes and reducing operational costs.

Benefits

• Improved clinical decision-making by emergency department staff through a clearer care pathway
• Improved skills, confidence and knowledge for frontline clinical staff of caring for someone with escalating behaviour
• Improved quality of mental health care for those presenting to emergency departments with mental ill-health
• Reduction in use of restrictive practices to align with state and organisational goals
• Increased resources for staff when caring for someone in mental health distress

Background

The use of seclusion and restraint is not a therapeutic intervention, and these practices are not supported by relevant current literature.¹ Evidence highlights the use of seclusion and restraint can lead to trauma and re-traumatisation of people presenting to a DMHF-ED and these experiences can lead to a reluctance to engage with health services when in crisis.²

These experiences are also psychologically and physically damaging to staff involved, who often experience vicarious trauma and/or physical injury as a result.² Recent InfoMH (NSW Ministry of Health) data from September 2021, indicates that the use of restrictive practices (seclusion and restraint) in the five DMHF-EDs in SNSWLHD continues to fluctuate without any sustained change.

The rate restrictive practice use has increased and this increase has been consistent over the past two quarters. This trend is out of step with the state and organisational goal to reduce, and where possible eliminate, the use of restrictive practices from all emergency departments.¹

Staff working within the DMHF-EDs are not currently supported by a mental health clinical pathway, which leads to fragmented and inconsistent care provision. To date, no work around the use of restrictive practices in the DMHF-EDs in SNSWLHD has been completed.

Feedback from both consumers and their families and carers highlights that experiences of seclusion and restraint leave the consumer feeling violated, unheard and traumatised. The Mental Health Alcohol and Other Drugs (MHAOD) sector recognises the need to support and assist colleagues working within the DMHF-EDs in caring for mental health consumers who present to the ED in acute behaviour distress.

There have been few mental health education opportunities offered to staff working within the DMHF-EDs, leaving many of the staff feeling unsupported and unsafe as well as lacking in confidence when caring for mental health patients.

The literature informs that the use of seclusion and restraint is resource intensive. This impacts on length of stay, representation to services, and work health and safety issues such as burnout, vicarious trauma, staff turnover and physical injuries contributing to increased operational costs and poorer health outcomes.²

Implementation

Numerous site visits were made to each of the five DMHF-EDs. These visits were to run focus groups, collect data, undertake staff and consumer interviews, look at the ED spaces and meet with various key stakeholders and executive to gain support and assistance with the project. This provided the opportunity for the team to establish relationships with the staff across all sites and was beneficial in gaining a greater understanding of the challenges and key issues faced by each of the ED’s. The team collated the information and data gathered. Root cause analysis and various other solution testing techniques were undertaken to assist in ensuring solutions covered all key issue areas.

Five solutions were developed covering all key issue areas. The implementation was impacted by the strain the COVID-19 pandemic placed on the health system and timelines had to be adjusted.

Solutions

Establish a group of emergency department mental health champions

Clinical champions will be used to motivate staff to implement evidence-based mental health care. These champions will support team engagement in the reduction and prevention of seclusion and restraint practices.

Provide resources to assist with sensory modulation and diversion

These resources will allow opportunities for patients to self-soothe and develop coping strategies that can also be used outside the hospital space. The use of sensory modulation and diversion is currently considered to be an essential element within best practice seclusion and restraint reduction. This solution is in line with strategy four of the Six Core Strategies for Seclusion and Restraint Reduction.²

Develop education resources for ED staff

This solution will address the significant education deficit identified by ED staff. Staff overwhelmingly reported feeling their levels of knowledge and confidence when caring for someone in an acute behaviourally distressed state were inadequate. Work will be done within the ED space to tailor education to fit the environment and the associated complexities.

Implement a monitoring tool to recognise deterioration or escalation of mental distress

The monitoring tool developed by South West Sydney LHD safety culture coordinators will be implemented. This tool will assist clinicians to recognise early deterioration or escalation of mental distress or disturbance, as well as support them with guidance and pathways for escalating clinical concerns. With this tool, clinicians will be better equipped to deploy early intervention techniques so that the person’s behaviour does not escalate and they feel safe and cared for.

Establish a designated acute care worker in the ED

This solution will build on an existing role within the MHAOD directorate. Each Community MHAOD team across SNSWLHD will have a designated acute care worker within business hours Monday to Saturday. The acute care worker will now be based in the ED during their rostered shift to provide timely mental health assessments for patients and support and education to ED staff. This solution will now fall under the restructure of the Mental Health Triage and Emergency Care support (TECs) team. It will no longer fall as a solution in this project.

Status

Implementation – The project is ready for implementation or is currently being implemented, piloted or tested.

Dates

This project started in January 2021.

The last set of deliverables was submitted to the ACI and University of Tasmania in December 2021 and a high distinction grading. Work now begins on continuing the implementation of the solutions which has no clear end date as we hope that these can be something that are incorporated into daily practice and procedure for DMHF-ED staff.

Evaluation for this project will be a constant process as we begin to implement solutions.

Implementation sites

This project has been implemented across all five DMHF-ED sites in SNSWLHD Goulburn, Queanbeyan, Cooma, South East Regional (Bega) and Bateman’s Bay.

Partnerships

The team have worked with quality safety partners from South Western Sydney LHD around one of the solutions.

The consumer participation group has also provided consultation and input at all phases of the project to ensure that the consumer voice and experience is central to the work that the project team is undertaking.

InfoMH for assistance with data and benchmarking information.

Evaluation

Objectives

• Reduce the use of seclusion and restraint by 20% by June 2023 to align with the state and organisational strategic direction.
• Improve skills and knowledge surrounding documentation of seclusion and restraint events in the DMHF-ED from 50% to 100% by June 2023 (this is measured by the “rate your knowledge of the following topics” staff survey.
• Increase compliance of staff having undertaken the My Health Learning training modules in de-escalation and personal safety from 50% to 80% by June 2023.

Quality check measures

• Percentage of presentations that are offered sensory modulation and/or the diversion box.
• Reduction in the use of “Code Black” team responses at one site by 20% - currently only one site with this response (measured monthly).

Operational level key performance indicators

• Staff attendance to Acute Behaviour Assessment and Observation Form education.
• Seclusion and restraint documentation completed correctly on all occasions.
• ED staff attendance to solution working group meetings.

Lessons learnt

• Have all the team on board from the start of the project. We found ourselves playing catch up as not all members of the team started the project work at the same time.
• Seclusion and restraint can be an unpopular subject that people don’t want to talk about (or don’t think it’s a problem).
• Following some sort of implementation structure helps to guide the work you do and how you do it.
• COVID-19 makes implementing projects REALLY tricky.
• Be flexible, patient and adaptive and be willing to fight hard at times.
• It’s ok to feel like you’re drowning and it will never end. It does end and you won’t drown.

References

1. NSW Ministry of Health. Review of seclusion, restraint and observation of consumers with a mental illness in NSW Health facilities. Sydney: NSW Ministry of Health; 2017 [cited 21 Mar 2022].
2. Australian College of Mental Health Nurses Inc. Safe in Care, Safe at Work: ensuring safety in care and safety for staff in Australian mental health services. Canberra: ACMHN; 2019 [cited 22 Mar 2022].

Further reading

• USA National Association of State Mental Health Program Directors. Six Core Strategies to Reduce Seclusion and Restraint Use. Alexandria, USA: National Association of State Mental Health Program Directors; 2008.
• State of Victoria (Dept of Health). Safewards Victoria [internet]. Melbourne; State of Victoria (Dept of Health); 23 Oct 2021.

Contacts

Rose Roberts
A/ Director Inpatient and Access Mental Health Alcohol and Other Drugs
Southern NSW Local Health District
0477 348 943
Rose.Roberts@health.nsw.gov.au