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  • Background

    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'. The plan recognised that seclusion and restraint are a serious infringement of an individual’s rights, and can cause psychological trauma and physical injury to consumers and to health-care staff.

    In response, there have been a number of initiatives aimed at reducing seclusion and restraint in public mental health facilities. The Australian Health Ministers Advisory Council's (AHMAC) Safety and Quality Partnership Standing Committee (SQPSC) and Mental Health Information Strategy Standing Committee (MHISSC), in partnership with state and territory authorities, developed a national seclusion data collection and reporting framework and implemented a Mental Health Seclusion and Restraint National Best Endeavours Dataset Specification from the 2015–16 collection period. Most seclusion and restraint occurs in acute specialised mental health hospital service setting, therefore quality improvement initiatives and data collection and reporting have focused on that setting.

    Seclusion

    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.

    Seclusion and restraint may be used across the range of mental health services; however, the focus of the data collections has been limited to the acute specialised mental health hospital service setting, since this service setting has been the focus of many of the quality improvement initiatives.

    Overview

    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).


    Figure AD.8: Rate of seclusion events, public sector acute mental health hospital services, 2011-12 to 2015-16

    Vertical bar chart showing the rate of seclusion events per 1,000 bed days in public sector acute mental health hospital services from 2011-12 to 2015-16. The rate has broadly decrease over the 5 year period. In 2011-12 the rate was 10.6, in 2012-13 (9.8), 2013-14 (8.2), 2014-15 (7.9) and 2015-16 (8.1). Refer to table AD.18

    Source: State and territory governments, unpublished.
    Source data: Admitted patient mental health-related care Table AD.18 (1.20MB XLS).


    States and territories

    Over time

    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.


    Figure AD.9: Rate of seclusion events, public sector acute mental health hospital services, states and territories, 2011-12 to 2015-16

    Clustered bar chart showing the seclusion rate per 1,000 bed days for all jurisdictions over the 5 years from 2011–12 to 2015–16. The majority of jurisdictions show a decreasing rate of seclusion events from 2011–12 to 2015–16; NSW (9.9 to 8.7), Vic (13.3 to 8.6), Qld (13.3 to 9.4), SA (10.1 to 5.0), Tas (11.9 to 13.1), and NT (26.2 to 23.9). ACT and WA show an increase in the rate of seclusion events per 1,000 bed days, 1.3 to 1.6 for the ACT and 4.7 to 4.8 for WA. Total 10.6 to 8.1. Refer to Table AD.18.

    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. Due to increased use of community-based treatment, Victoria has fewer beds per capita than other jurisdictions resulting in higher acuity thresholds for admissions. As such, it may be useful to view the rate of seclusion events in a broader population context (rates per capita). Similarly 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.

    Source: State and territory governments, unpublished.
    Source data: Admitted patient mental health-related care Table AD.18 (1.20MB XLS).


    Frequency and duration

    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).


    Figure AD.10: Average number of hours in seclusion per seclusion event, public sector acute mental health hospital services (excluding Forensic events), states and territories, 2014–15 to 2015–16

    Vertical bar chart showing the average number of hours spent in seclusion per seclusion event, 2013–14 to 2015-16.  Vic was the highest for all years (9.5, 8.0, & 8.3). All jurisdictions show a decreasing rate of seclusion events from 2013–14 to 2015–16; NSW (6.0 to 5.3), Qld (3.8 to 3.3), WA (2.4 to 2.3), Tas (4.1 to 2.4), ACT (2.1 to 1.9), and NT (6.4 to 4.9). Total 6.0 to 5.3. The average seclusion duration could not be calculated for SA due to differences in reporting methodology. Refer to 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. Due to increased use of community-based treatment, Victoria has fewer beds per capita than other jurisdictions resulting in higher acuity thresholds for admissions. Higher acuity on admission may be reflected in an inflated average duration for seclusion events compared to other jurisdictions. 

    Source: State and territory governments, unpublished.
    Source data: Admitted patient mental health-related care Table AD.18 (1.20MB XLS).


    Target population

    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.

    Over time

    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).


    Figure AD.11: Rate of seclusion events, public sector acute mental health hospital services, by target population, 2011–12 to 2015–16

    Clustered bar chart showing the rate of seclusion events per 1,000 bed days for all target populations over the 5 years from 2011–12 to 2015–16. All of the target populations show a decreasing rate of seclusion events from 2011–12 to 2015–16; General (11.6 to 9.2), Child and adolescent (18.1 to 10.3), Older person (0.7 to 0.5), Forensic (10.7 to 9.2) & mixed (12.3 to 10.0; data up to 2012-13 only). The mixed category was not reported from 2013–14. Refer to 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 (1.20MB XLS).


    Frequency and duration

    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).


    Figure AD.12: Average number of hours in seclusion per seclusion event, public sector acute mental health hospital services, by target population, 2014–15 to 2015–16

    Vertical bar chart showing the average number of hours in seclusion per seclusion event by target population from 2013-14 to 2015-16. Forensic services had the highest average number of hours in seclusion per seclusion event 64.7 in 2013-14 and 87.9 in 2015-16. General (6.3 to 5.5), Child and adolescent (1.3 to 1.9), and Older person (3.5 to 2.9). Refer to 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 (1.20MB XLS)


    Remoteness

    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).

    Restraint

    Restraint is defined as the restriction of an individual’s freedom of movement by physical or mechanical means.

    Data on restraint is being presented for the first time in 2017. Caution is needed in interpreting this data and comparing results; see the data source section for further information. States and territories have different policy and legislative requirements regarding restraint and have therefore had different processes and systems for collecting data, different definitions of restraint and differences in the types of restraint which are reported. States and territories have worked together to begin to align their collections through the development of a national data collection, the Mental Health Seclusion and Restraint National Best Endeavours Data Set (SECREST NBEDS).

    Data for two forms of restraint are specified by the SECREST NBEDS: mechanical restraint (for example, using devices such as belts, or straps); and, physical restraint (for example, the application by health care staff of hands-on immobilisation techniques). Unspecified restraint, that is, the type of restraint is unknown, was a very small component in 2015–16. Data improvement initiatives are expected to remove the need for an unspecified restraint category from 2016–17 onwards.

    Nationally, there were 9.2 physical restraint events per 1,000 beds days; mechanical restraint was less common (1.7 events per 1,000 bed days) (Figure AD.13). Data on mechanical restraint was not reported by NT, and data on physical events restraint was not reported by Queensland. Of states with data, Victoria had the highest rate of mechanical and physical restraint events (5.8 and 23.2 events per 1,000 bed days, respectively). This is likely to be the result of higher acuity admission thresholds due to lower per capita bed numbers inflating the results on a per bed day basis.


    Figure AD.13: Rate of restraint events, public sector acute mental health hospital services, states and territories, 2015–16

    Bar chart showing the rate of mechanical, physical and unspecified restraint events in public sector acute mental health hospital services in each state and territory for 2015-16. NSW 0.6 mechanical & 8.8 physical, Vic 5.8 & 23.2, Qld 0.2 & 0, WA 0, 3.5 & 0.6 unspecified, SA 1.4 & 1.7, Tas 1.0, 11.1 & 1.0, ACT 0 & 2.0, NT 0 & 12.4. Refer to Table AD.21

    Source: State and territory governments, unpublished.

    Note: Victoria has fewer beds per capita than other jurisdictions resulting in higher acuity thresholds for admissions. Higher acuity on admission is likely to be reflected in an apparent higher rate of restraint per bed day compared with reporting on a population basis.

    Source data: Admitted patient mental health-related care Table AD. 21 (1.20MB XLS)


    Target population

    Restraint data can also be presented by the target population of the acute specialised mental health hospital service where the restraint event occurred. In 2015–16, the use of restraint (both physical and mechanical) was more common in Forensic services than other service types (Figure AD.14). The physical restraint rate for Forensic services (110.2 events per 1,000 beds days) was over 10 times the rate for Child and adolescent services (10.9) and 20 times the rate for General services (5.0). The rate of mechanical restraint was also highest in Forensic services.


    Figure AD.14: Rate of restraint events, public sector acute mental health hospital services, by target population, 2015–16

    Bar chart showing the rate of mehanical, physical and unspecified restraint events in public sector acute mental helath hospital services by target population in 2015-16. General mechanical 0.4, physical 5.0 & unspecified 0.1, Child & adolescent 0.2 & 10.9, Older person 1.9, 2.3 & 0.1, Forensic 26.2, 110.2. Refer to Table AD.22

    Source: State and territory governments, unpublished.

    Source data: Admitted patient mental health-related care Table AD.22 (1.20MB XLS)


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