Seclusion Pathway Review Audit
Authors: Alkasser Mustafa , Riadh Mariam , Elsankary Mohammed , Merteen Maja 
Published: July 2023

Aims

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Ensure compliance with seclusion trust policy and guidelines by the mental health team (goal of 100 percent).

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Confirm that proper documentation of commencement, periodic reviews, and termination is always maintained (goal: 100 percent).

Methods

Retrospective collection of data from one adult male Psychiatric Intensive Care unit and one adult female mental health ward.

Our sample consisted of patients who were secluded between the time period of September 2021 and June 2022. 33 seclusion episodes met this inclusion criteria. Data were collected from OpenRio progress notes and OpenRio seclusion section.

We developed a tool for monitoring of seclusion reviews included different data about patients demographics and other variables in seclusion reviews.

Results

We found out the following:

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In regard to patients demographics, the predominant age groups are between 20 and 40 years old, although there is also an increase in the number of people between 50 and 70 years old and the predominant ethnicity was white British.

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The rationale for seclusion start and continuity was documented in 100% of the cases in our sample of 33 episodes.

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The initial medical review was completed in the first hour was completed in 81.82% (27) , In 18.18% (6) of cases, it was not completed within the hour window.

In 4 cases, the doctor was not contacted in time to meet the one-hour limit.

In 2 episodes, the reasons for being late were not documented.

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2 hourly nursing review completed in 93.94% (31).

There were 6.06 % (2 episodes) were the 2 hourly reviews were not completed. No specific reason found in the documentation for the missed episodes.

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The 4 hourly medical review (before MDT / consultant reviews) were completed within time in 24 episodes.

There were 9 episodes when the reviews were not completed within the time window of 4 hourly.

In 5 of the episodes the patient was sleeping, so the nursing team didn't contact the doctor.

There was 4 episodes with no documentation for the reason of the delay. However, the review was completed within extra 1-2 hours duration of time.

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The 8 hour MDT reviews with consultant were completed in 26 episodes (78.79%).

There was 7 episodes were it was not completed within the 8 hours window.

The primary reason was that the seclusion episode started on a weekend afternoon or early evening after normal working day and the consultant review was conducted on next day.

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Two medical reviews daily – at least one by responsible clinician (following initial MDT review) completed : In 3 of the episodes (9.09%), one of the two reviews was missed without specific reason or documentation.

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Rational to continue/ end seclusion documented at each review completed:

In 32 of the episodes the Rational to continue or end seclusion was documented.

There is one episode where seclusion was ended without documentation from the nursing team or doctors.

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Physical health observations record :100% compliance with physical health observations record.

Conclusion

Recommendations:

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Increase awareness of the importance of completing the initial reviews on time by conducting teaching sessions in the local academic program and informal teaching sessions with nursing staff.

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Adding the seclusion review guidelines to the junior doctors handbook and discuss the guidelines during induction meetings.

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Allocate different flyers and posters with information about seclusion reviews in the nursing stations and doctors office.

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Completing the re-audit cycle after that to gauge the scope of change.