Seclusion Reviews: Audit of Medical Documentation in a Psychiatric Intensive Care Unit

Abstract

Aims

Seclusion is a restrictive intervention used when a patient presents with risks that cannot be safely managed in their current environment. The Mental Health Act 1983 Code of Practice (MHA CoP) provides clear recommendations for both frequency and content of medical seclusion reviews, with compliance previously audited within Cheshire and Wirral Partnership NHS Foundation Trust (CWP). Following the initial findings however, change was not implemented. A new audit has therefore been commenced to reassess baseline practice and identify areas requiring improvement.

Methods

The MHA CoP audit tool outlines the following timeframes for assessment: initial medical review within 1 hour, 4-hourly medical reviews until first internal multidisciplinary review, twice daily medical seclusion reviews with at least 1 by the Responsible Clinician. Documentation should evaluate: physical and mental health, medication adverse effects, observation level, prescribed medication, risk to others and self, need for ongoing seclusion. Data were collected retrospectively for all episodes of seclusion occurring in a CWP Psychiatric Intensive Care Unit during August 2022.

Results

5 seclusion episodes related to 4 patients, ranging from 1 night to 15 days in duration. Regarding medical review frequency, 20% were seen face-to-face within 1 hour of seclusion commencing and 75% were seen 4-hourly until their internal multidisciplinary review. Mental health was more consistently commented on than physical health (97% vs 61% respectively), whilst medication was reviewed in 69% of assessments. Rationale for continuing seclusion was provided in 72%, referring to risk to others in 54%. Adverse medication effects and observation level were the least documented parameters (2%), followed by risk to self (7%).

Conclusion

Assessment time was often not explicitly stated and was substituted with time of documentation, meaning reviews may have occurred earlier than accounted for. The on-call doctor does cover multiple sites overnight, potentially contributing to delays in attending unforeseen time-sensitive tasks. Trust policy dictates constant visual observation must be maintained throughout seclusion and this is therefore not routinely subject to review or adjustment. Overall interpretation of the qualitative information was fairly subjective in a low number of seclusion episodes, however there was a notable lack of recording adverse medication effects and risk to self. Findings will be presented at junior doctor induction whilst a quick reference sheet is designed prior to reaudit. CWP's seclusion policy specifies medical review frequency, but does not outline expected content of documentation. There is scope to extend local policy and align with the MHA CoP.