Seclusion
This care bundle describes seven actions to ensure the best clinical outcome for patients who have been Secluded. Care must be delivered in a safe and positive manner to ensure safe decision making, administration and monitoring of seclusion used for managing behaviourally disturbed patients and ensuring its use for the shortest time necessary. Each described intervention will be required to be delivered, however these do not need to be completely sequentially.
Aim:
Support the Patient and staff in developing coping strategies before the use of seclusion.
What to do:
Ask patient and carer(s) regarding managing distress with preferred choices and primary, secondary and tertiary strategies; consider capacity.
Pre-plan care using supporting documentation such as person centred care guides, Safety plans, Positive Behavioural Support plans, risk assessments and SAFEWARDS etc., to guide use of sensory equipment in seclusion.
Consider influence/impact of
- Length of time in restraint
- Position during restraint
- Privacy and Dignity
- Physical Health conditions
Consider actions that can be proactively taken to cease seclusion, taking into account safety, Human Rights, patient choice, capacity and dignity.
Review and update risk assessment.
Aim:
Ensure timely and accurate record keeping. Develop robust systems for the implementation of seclusion and aftercare.
What to do:
Ensure all staff who are involved in seclusion have completed mandatory training, specifically life support training and Trust approved intervention training and support available from L&D training staff.
Ensure all staff observing are aware to observe any changes in patients’ mood, behaviour and presentation and able to complete direct observations and record in PARIS and input into review process.
Ensure all staff involved in the management of challenging behaviour have access to supervision and any learning needs are addressed.
Clear documentation on PARIS for decision to use seclusion and considered alternatives including reference to the primary, secondary and tertiary strategies highlighted in the care plan.
DATIX to be completed for all incidents.
Review and update risk assessment.
Aim:
Ensure timely review of decision making that prioritises use of seclusion for the shortest possible time.
What to do:
Communication is paramount during seclusion episodes:
- Between staff and patients.
- Between team members for effective decision making.
Ensure correct PPE used.
Accurately define rationale for decision/risks.
Begin defining threshold for ceasing seclusion.
Inform MDT/Duty Doctor/Bleep holder/senior Manager within 1 hour of commencement if not involved in decision.
Plan review sequence and timing. Inform expected participants to ensure prompt attendance and adherence to CoP schedule.
Facilitate review schedule, correlate timings to commencing seclusion.
Each review discussion should:
consider current presentation in seclusion, expected outcome, contingencies, what are staff roles within the intervention, what factors indicate that risk has reduced, proactive steps to be taken before next formal review, is this still the least restrictive necessary?
Aim:
Develop a robust system that ensures that the patient’s physical health is monitored.
What to do:
Monitor and complete physical observations in line with policy using NEWS2
Consider any pre-existing physical health problems and monitoring of this.
During Seclusion physical health monitoring, as possible (Oxehealth monitoring system).
Post Seclusion physical health monitoring every 15 minutes for the first hour, then hourly for 3 hours. If results are normal, routine monitoring as per policy.
All monitoring to be completed on the NEWS2 form and then embed within the electronic system.
If patient refuses or physical health monitoring, visual observation chart should be completed and uploaded.
Assess effectiveness of current care plan – consider onward referral.
Ongoing review of physical health management and routine treatment and any possible interactions.
Aim:
Develop a robust system that ensures that the patient’s psychological and emotion wellbeing is monitored.
What to do:
Communication is paramount between staff and patients during seclusion episodes to aid effective decision making.
MD Team to include in next (and subsequent) MDT reviews, active measures to assess and promote
- Psychological and emotional wellbeing
- Protection of Family and private life (article 8)
Formulate active plans for maintaining current level of activity and programme of care as well as private and family life.
Consider level of support required by staff/patient following any incident for psychological and emotional impact, taking into account individual vulnerability’s and previous trauma experiences.
Consider level of support required by staff/patient following a change in plan of care, such as increased observations, detention under the act, transfer/referral, as result of this incident.
Aim:
Foster a multi-disciplinary approach to care planning for managing challenging behaviour.
What to do:
Clinical review within 72 hours, including Nursing staff and medical staff to review care plan and future plan including person centred care plans, Positive Behavioural Support plans, Safety plans, SAFEWARDS and risk assessments, alongside information gained from this incident to aid formulation of behaviour, to ensure restrictive practices are not the first approach for managing challenging behaviour.
Feedback from clinical review to be included in care plan and risk assessment.
Discuss the incident in next MDT ward round/Clinical team review for the patient.
Assess effectiveness of current care plan – consider diagnosis.
Ongoing review of current care plan and routine treatment and any possible onward referral.
Consider referral to complex case panel.
Consider independent review of care/2nd Opinion.
Aim:
Support the patient, carer(s), staff and other witness following seclusion.
What to do:
Staff to carry out immediate post-incident debrief as described in P&PS Training.
Review incident that led to seclusion being used, with the patient, carer and/or advocate and signpost to additional support.
Review the positive behavioural support plan, advanced directives and other clinical documentation.
Ensure witnesses are given the opportunity to reflect on their experience of the incident.
Feedback from debriefs to be included in care plan and risk assessment.
Ensure all staff involved have access to supervision.
Identify training needs.
Be aware of individual responses.
Consider when, who, why, where and potential to revisit initial response.