Mental health servicesin Australia
Seclusion is defined as the confinement of a patient at any time of the day or night alone in a room or area from which free exit is prevented. The purpose, duration, structure of the area and awareness of the patient are not relevant in determining what is or is not seclusion.
Seclusion also applies if the patient agrees to or requests confinement and cannot leave of their own accord. However, if voluntary isolation or 'quiet time' alone is requested and the patient is free to leave at any time then this social isolation or 'time out' is not considered seclusion.
While seclusion can be used to provide safety and containment at a time when this is considered necessary to protect patients, staff and others, it can also be a source of distress not only for the patient but for support persons, representatives, other patients, staff and visitors. Wherever possible, alternative, less restrictive ways of managing a patient's behaviour should be used, and the use of seclusion minimised.
In 2005, Health Ministers endorsed the National safety priorities in mental health: a national plan for reducing harm, Australia's first national statement about safety improvement in mental health. This plan identified four priority areas for national action including 'reducing use of, and where possible eliminating, restraint and seclusion. Seclusion may be used across the range of mental health services; however, it is most commonly used in the acute specialised mental health hospital service setting. Subsequently, this service setting has been the focus of quality improvement initiatives.
In line with the 2005 plan, there have been a number of initiatives aimed at reducing seclusion and restraint in public mental health facilities, including a number of ad hoc seclusion data collections. More recently, the Australian Health Ministers Advisory Council's (AHMAC) Safety and Quality Partnership Standing Committee (SQPSC), in partnership with the relevant state and territory authorities, has formalised a routine, national seclusion data collection and reporting framework. The recent implementation of the Mental Health Seclusion and Restraint National Best Endeavours Dataset Specification will standardise the national collection of both seclusion and restraint data (and provide a more detailed data set) from the 2015–16 collection period.
Nationally, there were 8.1 seclusion events per 1,000 bed days in 2015–16; a decrease from 10.6 in 2011–12 (Figure AD.8). This represents an average annual reduction of 6.7% over the 5–year period. (Table AD.18).
Source: State and territory governments, unpublished.Source data: Admitted patient mental health-related care Table AD.18 (1.05MB XLS).
In 2015–16, the Northern Territory had the highest rate of seclusion with 23.9 seclusion events per 1,000 bed days and the Australian Capital Territory had the lowest (1.6). Seclusion rates have fallen for 5 of the 8 states and territories between 2011–12 and 2015–16 (Figure AD.9). (Table AD.18).
Data for smaller jurisdictions should be interpreted with caution as small changes in the number of seclusion events can have a marked impact on the overall seclusion rate.
Note: The increase in the state-wide Tasmanian seclusion rate for 2012–13 and 2013–14 data is due to a small number of clients having an above average number of seclusion events. Victoria has fewer beds per capita than other jurisdictions, and as such, it may be useful to view the rate of seclusion events in a broader population context (rates per capita). Due to the low ratio of beds per person in the NT compared with other jurisdictions, the apparent rate of seclusion is inflated when reporting seclusion per bed day compared with reporting on a population basis. Also, high rates of seclusion for a few individuals have a disproportional effect on the rate of seclusion reported.
Frequency and duration of seclusion events were collected for the first time in 2013–14.
One in 20 (5.0%) episodes of care provided by Australian public sector specialised acute hospital services involved a seclusion event in 2015–16, a slight decrease from 2013–14 (5.4%). The Northern Territory had the highest proportion of episodes with a seclusion event (10.8%), while South Australia had the lowest (2.7%). The average number of seclusion events for patients who were secluded was 2.0 events per admitted care episode in 2015–16 which remains unchanged compared to 2013–14 (2.0). The Australian Capital Territory was unable to provide the number of admitted patient care episodes and as such is excluded from the national proportion of seclusion events per episode. (Table AD.18).
The average duration of a seclusion event excluding Forensic services was 5.3 hours in 2015–16, down from 6.0 hours in 2013–14. Forensic services provide services primarily for people whose health condition has led them to commit, or be suspected of, a criminal offence or make it likely that they will reoffend without adequate treatment or containment. Forensic service data has been excluded as forensic seclusion events are typically of longer duration, and substantially skew the overall duration average. Data for South Australia is also excluded from the national average duration due to its use of a 4 hour block recording methodology.
Victoria reported the longest average seclusion duration with an average of 8.3 hours per seclusion event. The Australian Capital Territory had the shortest, of 1.9 hours (Figure AD.10). (Table AD.18).
Note: Due to longer duration times in Forensic settings, these events have been excluded from this analysis. South Australia report seclusion duration in 4 hour blocks which precludes average seclusion duration calculations. Queensland and the Northern Territory do not report any acute Forensic services, however forensic patients can and do access acute care through General units.
Seclusion data can also be presented by the target population of the acute specialised mental health hospital service where the seclusion event occurred. Around three quarters (78.7%) of in-scope care (total number of bed days) was provided in General services. Older person services accounted for 13.5% followed by Forensic (4.2%) and Child and adolescent (3.6%) services (Table AD.19).
However, data should be interpreted with caution as this methodology uses the target population of the service unit, that is, the age group that the service is intended to serve, not the age of each individual patient. Also, in 2013–14, improvements were made to the reporting of target population categories. The mixed category was removed as an option for reporting. Data for the Mixed category was most commonly a mix of General, Child and adolescent and/or Older person services. Time series data by target population should therefore be approached with caution.
The highest rate of seclusion was for Child and adolescent services with 10.3 seclusion events per 1,000 bed days, followed by General services (9.2), Forensic services (9.2) and Older person services (0.5). Although a reduction in seclusion rates for the 5 years to 2015–16 was observed for all target population categories, some variability is apparent from year to year (Figure AD.11). (Table AD.19).
Note: Queensland and the Northern Territory do not report any acute Forensic services, however forensic patients can and do access acute care through General units.
Source: State and territory governments, unpublished.Source data Admitted patient mental health-related care Table AD.19 (1.05MB XLS).
Forensic services reported the highest proportion of episodes of care involving seclusion events, with 22.2% of all mental health-related episodes involving seclusion. This was followed by General (5.1%), Child and adolescent (3.9%), and Older person (0.8%) services, with all rates relatively stable when compared with 2013–14. (Table AD.19).
Forensic services had the highest frequency of seclusion, with 3.0 seclusion events per episode when seclusion was used at least once during an episode of care. Seclusion events that occurred in Forensic services also had the longest average duration; 87.9 hours per seclusion event, which is much greater than all other target population categories (1.9 to 5.5 hours). This may also be partly due to the way seclusion is recorded in Forensic services. General services reported an average time of 5.5 hours per seclusion event, followed by Older person (2.9 hours) and Child and adolescent (1.9 hours) services. The average time of the seclusion event decreased for General services and Older person services, and increased for Child and adolescent services and Forensic services between 2013-14 and 2015-16 (Figure AD.12). (Table AD.19).
Note: Data for South Australia is excluded from the national average duration due to its use of a 4 hour block recording methodology. Queensland and the Northern Territory do not report any acute Forensic services, however forensic patients can and do access acute care through General units.
Source: State and territory governments, unpublished.Source data: Admitted patient mental health-related care Table AD.19 (1.05MB XLS)
Due to the small number of hospitals located in Outer Regional and Remote areas, for the purpose of remoteness analysis these categories have been combined. There were no hospitals in the seclusion dataset located in Very Remote areas.
In 2015–16, hospitals located in Major Cities had a seclusion rate of 7.9 events per 1,000 bed days. This rate was higher than that for Inner Regional facilities (7.7), and lower than that for Outer Regional and Remote area facilities combined (11.2). The proportion of mental health-related admitted care episodes with a seclusion event was similar across facilities in all areas (around 5%).
On average, seclusion events in facilities in Inner Regional areas were longer in duration (6.4 hours) than those in Major Cities (5.1) and Outer Regional and Remote areas (4.9). (Table AD.20).
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