Setting

This audit may be particularly relevant in adult and forensic in-patient units, where a small but significant number of patients may be subject to restraint and seclusion.

Background

The aim of seclusion is to contain severely disturbed behaviour that is likely to cause harm to others. It is defined in the Mental Health Act Code of Practice. The use of seclusion varies widely across institutions.

Standards

Standards were obtained from the Mental Health Act Code of Practice (Department of Health, 2008). Of particular relevance were the following:

ᐅ The decision to use seclusion is made by the doctor or nurse in charge, and a psychiatrist should attend as soon as possible.

ᐅ A documented report should be made every 15 minutes in the seclusion record.

ᐅ The patient should be under continuous observation.

ᐅ The need to continue seclusion should be regularly reviewed.

ᐅ Contemporaneous records of the seclusion period should be kept in the patient's case notes. These should document the rationale, use of restraint and medication (given as required, or p.r.n.) and subsequent outcome.

The target is that these standards are met for all episodes of seclusion.

Method

Data collection

A list of patients who had undergone seclusion was obtained from the medical records department. It is the duty of hospital managers to keep these records. The medical notes of these patients were examined to find the entries documenting the following:

ᐅ the reason for seclusion;

ᐅ use of restraint procedures and medication

ᐅ subsequent outcome

ᐅ gender, age, ethnicity, status as defined by the Mental Health Act and primary diagnosis of the patient.

The seclusion record for each episode was identified and examined for the following:

ᐅ documentation of the start and end time of seclusion, and the duration of seclusion

ᐅ whether a psychiatrist was informed, and attended, at the start of seclusion

ᐅ whether the patient was under continuous observation

ᐅ whether the need to continue seclusion was reviewed every 2 hours by two nurses and every 4 hours by a doctor and a nurse

ᐅ where the seclusion was for more than 8 hours continuously, whether the patient was seen by a consultant psychiatrist.