1. A joint Australian, State and Territory Government Initiative National Mental Health Benchmarking Project 27 November 2008 The use of seclusion in forensic mental health services: an exploration of practice and culture Fiona Davidson, Queensland Mental Health Benchmarking Unit Karlyn Chettleburgh, Forensicare National Mental Health Benchmarking Project 27 November 2008

3. ACHS Seclusion Indicators Detailed Seclusion Audit Seclusion + Medication Audit

4. In 2007 an audit process was undertaken in each of the participating Forensic Services for a one month period: All episodes of seclusion were recorded All medications administered were recorded A comparison of seclusion and time out policies and practices was conducted An environmental audit was undertaken (how many seclusion rooms, time out facility, ICU/HDU)

5. Audit Information: Consumer Factors : Gender ALOS (during audit) Legal Status Diagnosis Offence Category Age Cultural background Seclusion Metrics: % consumers secluded Total hours of seclusion Avg hours/episode seclusion Medication Administered : Chlorpromazine equivalent daily dose Benzodiazepine equivalent daily dose PRN medication use Comparison with RANZCP guidelines Other Issues considered: Use of 1:1 Observations Use of ‘Time Out’ HoNOS

6. Seclusion Utilisation – Number of Episodes NB Service also uses segregation – unable to report

7. Seclusion Utilisation - % consumers secluded NB Service also uses segregation – unable to report

8. Seclusion Utilisation – Average hours/Episode NB Service also uses segregation – unable to report

9. Chlorpromazine Equivalencies – seclusion comparison

10. Diazepam Equivalency for Pts experiencing Seclusion

13. Findings: Seclusion is a complex area! Service culture, legislation and environment need to be considered Medication prescribing patterns varied considerably between services Continued review of medication prescribing patterns is of interest Open discussion in relation to seclusion practices were of great benefit

14. National Mental Health Benchmarking Project 27 November 2008 VIFMH - Forensicare National Mental Health Benchmarking Project 27 November 2008

15. Thomas Embling Hospital National Mental Health Benchmarking Project 27 November 2008

16. Thomas Embling Hospital Commissioned in April 2000 118 bed secure hospital (expanded in May 2007) 7 inpatient units Argyle and Atherton: 15 bed male acute units Barossa: 10 bed female acute unit Bass: 20 bed mixed gender sub acute unit Canning: 20 bed male supported living unit Daintree: 20 bed mixed gender rehabilitation unit Jardine: 18 bed mixed gender community reintegration unit Total of 15 seclusion rooms within 5 seclusion suites National Mental Health Benchmarking Project 27 November 2008

17. Patient Characteristics 60% Forensic Patients; 10% Involuntary patients; 24% Security Patients (remanded and sentenced prisoners), 6% Other (HSO and RITO). 92% Schizophrenia; 1% Affective Disorders; 2% Personality Disorder; 5% Other. 87% male and 13% female 47% murder/attempted murder; 30% other violent offences 74% past psychiatric history; 68% substance abuse; 18% from non-english speaking backgrounds National Mental Health Benchmarking Project 27 November 2008

18. Benchmarking - Seclusion National Mental Health Benchmarking Project 27 November 2008

19. Benchmarking - Seclusion Time of Day Index Offence Legal status Age Duration Substance Abuse Use of specials (1 to 1 nursing) National Mental Health Benchmarking Project 27 November 2008

20. NMHRSP – Study Tour Leadership Cultural change No quick or ‘formula’ based solution Workforce development- induction, training, retention Physical environment is not an impediment Using data and statistics Financial costs Qualified vs unqualified staff Patient programs Consumer empowerment Selling it to staff National Mental Health Benchmarking Project 27 November 2008

21. NMHRSP – Key Principles Leadership guiding and supporting organisational change Continuous workforce development Genuine consumer involvement Enhancing therapeutic practice Use of data to support practice National Mental Health Benchmarking Project 27 November 2008

22. NMHRSP - Outcomes National Mental Health Benchmarking Project 27 November 2008

23. NMHRSP - Outcomes National Mental Health Benchmarking Project 27 November 2008

24. NMHRSP - Outcomes National Mental Health Benchmarking Project 27 November 2008

25. NMHRSP - Outcomes National Mental Health Benchmarking Project 27 November 2008

26. The Structured Day Implementation plan developed 3 month pilot on 1x acute and 1x continuing care units Pre and Post measures identified Communication strategy developed Consultation with key stakeholders Evaluation of pilot Official launch Hospital wide roll out July 21st 2008 Motivational Interviewing training for staff Amendment to visiting hours Work program remuneration for security patients National Mental Health Benchmarking Project 27 November 2008

27. Pilot Evaluation The overall level of patient activity within each of the pilot sites increased by a significant magnitude; with activity levels increasing from an average of 1.5 activities per patient per day to over 3 activities per day. Patients reported an increased sense that their treating teams had a better understanding of their current difficulties and treatment needs. Patients also reported a decreased sense of loneliness, which reflected staff reports of increased social interaction amongst patients. While no significant decreases were observed in the overall level of acuity or day-to-day functioning amongst patients; clinician ratings of patients’ functioning indicated specific areas of positive change. This was particularly salient with regard to interpersonal warmth, ability to maintain friendships amongst patients, and the ability of patients to engage in meaningful occupations. National Mental Health Benchmarking Project 27 November 2008

28. Calming Rooms/Safe Places National Mental Health Benchmarking Project 27 November 2008