National safety priorities in mental health: a national plan for reducing harm

Reducing use of, and where possible eliminating, restraint and seclusion

Page last updated: October 2005

Rationale

The United Nation's Principles for the protection of people with mental illness and the improvement of mental health care states that:

'Physical restraint or involuntary seclusion of a patient shall not be employed except in accordance with the officially approved procedures of the mental health facility and only when it is the only means available to prevent immediate or imminent harm to the patient or others. It shall not be prolonged beyond the period which is strictly necessary for this purpose. All instances of physical restraint or involuntary seclusion, the reasons for them and their nature and extent shall be recorded in the patient's medical record. A patient who is restrained or secluded shall be kept under humane conditions and be under the care and close and regular supervision of qualified members of the staff. A personal representative, if any and if relevant, shall be given prompt notice of any physical restraint or involuntary seclusion of the patient.' 17
This Plan endorses the United Nation Principle and supports the enactment of the Principle in domestic legislation.

There is considerable variation in the clinical standards governing the use of restraint and seclusion in mental health services and guiding the appropriate use of the interventions or the use of alternative strategies. The goal of the Plan is to reduce the use of these interventions, and the adverse events that accompany them. However, it is acknowledged that there are situations where it is appropriate to use interventions such as restraint and/or seclusion but only as a safety measure of last resort. It is clear that restraint and seclusion are not a substitute for inadequate resources and are not to be used as a method of punishment, and if used in either of these ways is a serious contravention of consumer rights.

A systems oriented approach to reducing restraint, seclusion and associated adverse events is needed, along with a non-punitive culture that rewards incident reporting and supports its use in continuous quality improvement.

There is a close relationship between the use of restraint and seclusion and serious adverse events. The known adverse events associated with use of restraint and seclusion include dehydration, choking, circulatory and skin problems, loss of muscle strength and mobility, pressure sores, incontinence and injury from associated physical/ mechanical restraint, injury from other patients, increased psychological distress and, in rare circumstances, death. It is essential that restraint and seclusion be used in a manner consistent with defined protocols for safe management of the consumer.

Rapid sedation, where it is used in mental health emergency situations as an alternative to mechanical/ physical restraint, is considered restraint by consumers, carers and others, and carries its own risk of adverse events. However, at this time there is no definitive agreed definition of restraint that includes rapid sedation. Incidents and adverse medication events related to sedation, however, are considered
adverse drug events.

Currently States and Territories and mental health services have a range of documented policies and/or protocols for use of these interventions. State and Territory mental health legislation includes specific requirements related to use of these interventions. The Model Mental Health Legislation funded under the National Mental Health Strategy for use by States and Territories when reviewing their mental health legislation, included model clauses on seclusion and restraint.

The consultation (refer appendix 4) indicated that the safety of consumers, staff and others in situations related to restraint use was a high safety priority across sectors.
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Table 2: Reducing use of, and where possible eliminating, restraint and seclusion

Objectives

  • Reduced use of, and where possible elimination of, restraint in mental health emergency situations.
  • Reduced use of, and where possible elimination of, restraint in mental health services.
  • Reduced use of, and where possible elimination of, seclusion in mental health services.
  • Reduced adverse events associated with use of restraint.
  • Reduced adverse events associated with use of seclusion.
  • Clear protocols guiding the use of restraint are in use in mental health services and other health services.
  • Clear protocols guiding the use of seclusion are in use in mental health services and other health services.

Priority settings

  • Mental health services (particularly inpatient settings).
  • Acute care services outside mental health services, particularly emergency departments.
  • Any setting in which restraint and seclusion of consumers is practised based on a view that they are suffering from a mental health problem.Top of page

Known problem areas

  • Lack of identified good practice/agreed clinical standards for the use of restraint. No national standards on appropriate use of restraint currently exist.
  • Lack of identified good practice/ agreed clinical standards for the use of seclusion. No national standards on appropriate use of seclusion currently exist.
  • Inappropriate use of interventions and variation in practice, for example using threat of restraint or seclusion to coerce particular behaviour.
  • Known adverse events associated with use of restraint and seclusion.
  • Lack of staff knowledge or skills to prevent use and identify and use alternative interventions or to safely use restraint and seclusion interventions in emergency situations.
  • Lack of staff knowledge or skills regarding appropriate triaging of mental health presentations, particularly in emergency departments.
  • Despite restraint being commonly practised in emergency departments, there is a lack of training about restraint practices and a lack of documentation and clinical audit of restraint practices.
  • Aggressive and violent behaviours are common triggers for the use of restraint and seclusion. Lack of staff training and knowledge about early warning signs of agitation and aggression and effective interventions to prevent the use of seclusion and restraint.Top of page

Strategies

  • Implement and use incident monitoring and management systems for quality improvement by monitoring and managing:
    • instances where restraint is used
    • instances where seclusion is used
    • adverse events that occur whilst a consumer is restrained (whether the injury is to consumer or other) and
    • adverse events that occur whilst a consumer is secluded (whether injury to consumer or other).
  • Investigate adverse events proximal to restraint and seclusion using known tools/ methodologies such as Root Cause Analysis. Ensure that outcomes of such analysis are fed into quality impovement processes.
  • Propose that the Australian Council for Safety and Quality in Health Care support the inclusion of all deaths in acute health care that are proximal to use of restraint and seclusion in the national set of core sentinel events.
  • Develop national standards for the use of restraint. Identify good practices in the prevention, reduction and, where possible, elimination of restraint that are applicable across jurisdictions and settings.
  • Develop standards for the monitoring and reporting of restraint and identifying alternatives to the use of restraint that are applicable across settings and jurisdictions.
  • Develop national standards for the use of seclusion. Identify good practices in the prevention, reduction and, where possible, elimination of seclusion that are applicable across jurisdictions and settings.
  • Develop standards for the monitoring and reporting of seclusion and identifying alternatives to the use of seclusion that are applicable across settings and jurisdictions.
  • Develop an education and training strategy for management of aggression including techniques for prevention and de-escalation as an alternative to using restraint and seclusion. Consumer and carer experiences and participation are integrated into education and training strategies, products and activities.
  • Implementation and staff education about the national triage guidelines for emergency departments and the Mental Health Triage Scale.
  • Ensure mental health services and related health services (especially emergency departments and other acute care services) have in place policies and procedures for use of restraint and seclusion and consider clinical audits of restraint and seclusion as part of quality improvement processes.
  • Evaluate changes in practice and outcomes.Top of page

Complementary/linked strategies/activities

  • Existing State/Territory initiatives (such as mandatory reporting of use of mechanical restraint in some States, existing legislation, protocols and policies).
  • Australian Council on Healthcare Standards (ACHS) Clinical Indicators for Mental Health include seclusion indicators.

Footnotes

17 UN principles for the protection of people with a mental illness, Principle 11, paragraph 11.