Seclusion on Psychiatric Intensive Care Unit – Is the Trust Medical Review Policy Being Followed?

Abstract

Aims

Seclusion is a restrictive intervention used in inpatient settings for the safe management of patients who present with severe behavioural disturbance which is likely to cause harm to others. Clinical notes were used to establish if the trust policy of medical reviews for patients in seclusion was being followed on the Psychiatric Intensive Care Unit (PICU).

Methods

Patients admitted to male PICU at Springfield Hospital, Southwest London, over a 4 month period (February 2022 to May 2022) were included in this audit. Patients who were secluded outside this time period or prior to admission to PICU were excluded from this audit.

The clinical notes computer system (Rio) was searched using the term “seclusion”. The timing of initiation and termination of seclusion were noted as well as the timing and grade of medical professionals present for documented reviews.

Results

Over this period, 12 discrete episodes of seclusion were identified. The length of seclusion varied from 8 hours 45 minutes to over 5 days, with a mean length of almost 3 days (2 days, 20 hours, 25 minutes).

As the length of seclusion differed so did the required medical reviews in line with trust policy. This involves Senior House Officer (SHO) review at 30 minutes, Registrar review at 8 hours, Consultant review at 24 hours followed by 2 senior reviews (one Registrar and one Consultant) over each subsequent 24 hour period of continuous seclusion.

10 episodes of seclusion lasted over 24 hours in this audit. Of these 40% had the required medical reviews documented in the clinical notes appropriately for the full period of seclusion. 50% of cases had at least 1 missed or not documented Registrar review. There were 2 incidents of missed Consultant medical reviews for a 24 hour period of continuous seclusion.

Conclusion

From these results medical reviews were not being correctly carried out, or were not documented correctly, in the majority (60%) of cases of seclusion over 24 hours. This suggests missed opportunities for patient review to terminate seclusion at the earliest safe opportunity in line with national and trust guidance. These results have informed the update of trust guidelines on seclusion to bring it in line with national guidance with a view to improve patient care and will be re-audited.