AppendixA:(Designations(underBC’s( Mental’ HealthAct · Page | Secure Rooms and Seclusion...

Page | Secure Rooms and Seclusion Standards & Guidelines – A Literature & Evidence Review

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Appendix A: Designations under BC’s Mental Health Act1 [s 3(1), (2)]

Made by Ministerial Order M 116/2005 unless otherwise stated. A. Facilities Designated as Provincial Mental Health Facilities under section 3(1)

(Schedule A of M 116/2005) The Alder Unit, Vancouver (M 089/2011) March 31, 2011 Burnaby Centre for Mental Health and Addiction (M 157/2008) June 25, 2008 Cara Centre, Kelowna (M 224/2011) August 10, 2011 Connolly Lodge Coquitlam (M 228/2006) October 2, 2006 Cottonwood Lodge, Coquitlam (M 228/2006) June 2, 2006 Designations under the Mental Health Act Cowichan Lodge, Duncan (M 272/2012) November 30, 2012 Cypress Lodge, Coquitlam (M 158/2008) June 25, 2009 Forensic Psychiatric Institute, Port Coquitlam Harbour House, Trail (M 224/2011) August 10, 2011 Hillside Centre, Kamloops (M 224/2011) August 10, 2011 Iris House, Prince George Jack Ledger House, Victoria Maples Adolescent Treatment Centre, Burnaby Provincial Assessment Centre for Community Living Services, Burnaby Riverview Hospital, Port Coquitlam Seven Oaks Tertiary Mental Health Facility, Victoria Seven Sisters Residence, Terrace South Hills Centre, Kamloops (M 224/2011) August 10, 2011 Sumac Place, Gibsons (M 273/2012) November 30, 2012 Tamarack Cottage, Cranbrook (M 224/2011) August 10, 2011 Timber Creek, Surrey (M052/2012) February 20, 2012 Willow Pavilion, Vancouver (M273/2012) November 30, 2012 Youth Forensic Psychiatric Services Inpatient Assessment Unit, Burnaby C. Hospitals Designated as Psychiatric Units under section 3(2)

(Schedule C of M 116/2005) Abbotsford Regional Hospital and Cancer Centre, Abbotsford (M 179/2008) August 24, 2008 British Columbia’s Children’s Hospital, Vancouver British Columbia’s Women’s Hospital and Health Centre, Vancouver Burnaby Hospital, Burnaby Chilliwack General Hospital, Chilliwack Cowichan District Hospital, Duncan 1 Source: http://www.health.gov.bc.ca/mhd/pdf/MH_Act_Guide_Designated_Facilities.pdf, accessed May 2, 2012.


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Dawson Creek and District Hospital, Dawson Creek East Kootenay Regional Hospital, Cranbrook Fort St. John General Hospital, Fort St. John G.F. Strong Centre, Vancouver Kelowna General Hospital, Kelowna Kootenay Boundary Regional Hospital, Trail Langley Memorial Hospital, Langley Lions Gate Hospital, North Vancouver Mills Memorial Hospital, Terrace Mount Saint Joseph Hospital, Vancouver Nanaimo Regional General Hospital, Nanaimo Peace Arch District Hospital, White Rock Penticton Regional Hospital, Penticton Powell River General Hospital, Powell River Prince Rupert Regional Hospital, Prince Rupert Regional Treatment Centre (Pacific), Abbotsford Ridge Meadows Hospital and Health Care Centre, Maple Ridge Royal Columbian Hospital, New Westminster Royal Inland Hospital, Kamloops Royal Jubilee Hospital, Victoria St. Joseph’s General Hospital, Comox St. Mary's Hospital, Sechelt St. Paul’s Hospital, Vancouver Surrey Memorial Hospital, Surrey The Richmond Hospital, Richmond The Gorge Road Hospital, Victoria U.B.C. Health Sciences Centre Hospital, Vancouver The University Hospital of Northern British Columbia, Prince George Vancouver General Hospital, Vancouver Vernon Jubilee Hospital, Vernon Victoria General Hospital, Victoria West Coast General Hospital, Port Alberni D. Hospitals Designated as Observation Units under section 3(2)

(Schedule D of M 116/2005) Boundary Hospital, Grand Forks Bulkley Valley District Hospital, Smithers Fort Nelson General Hospital G.R. Baker Memorial Hospital (M 104/2007) May 14, 2007 Kootenay Lake Hospital Lady Minto Gulf Islands Hospital Port McNeill and District Hospital Wrinch Memorial Hospital


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Updated: December 18, 2012

Appendix B: Expert consultations performed for this review

All consultations led by Alisa Harrison.

Name Title Location Date and method of consultation

Maggie Bennington-‐Davis

chief medical and operating officer, Cascadia BHC Portland, OR, USA

January 9, 2012, telephone

Paolo del Vecchio

SAMHSA, acting director, Center for Mental Health Services USA January 26, 2012, telephone

Bob Glover executive director, National Association of State Mental Health Program Directors

USA January 17, 2012, telephone

Kevin Ann Huckshorn

director, Substance Abuse and Mental Health, State of Delaware. past director, Office of Technical Assistance at the National Association for State Mental Health Program Directors, and the National Coordinating Center for Seclusion and Restraint Reduction

USA January 6, 2012, telephone

Paul Links chair/chief, Department of Psychiatry, University of Western Ontario

London, ON, Canada


Mary O’Hagan mental health commissioner New Zealand December 19, 2011, Skype

Glenna Raymond

CEO (CHE), Ontario Shores Mental Health Centre for Mental Health Sciences

Whitby, ON, Canada


Sharon Simons manager, Mood Disorders Program and MH Medical Surgical/Dental Services co-‐lead, Seclusion/Restraint Reduction, St. Joseph’s Hospital

Hamilton, ON, Canada


St. Joseph’s Hospital

teleconference with Seclusion/Restraint Reduction initiative team leads

Hamilton, ON, Canada

March 14, 2012, telephone

Arne Vaaler

psychiatrist, Ostmarka Psychiatric Department, St. Olavs Hospital

Norway December 23, 2011, Skype

Phil Woods professor, associate dean, Research, Innovation and Global Initiatives, College of Nursing, University of Saskatchewan

Saskatchewan, Canada

January 4, 2012, Skype

Leslie Zun

Department of Emergency Medicine, Finch University Chicago, IL, USA December 21, 2011, telephone

Page | 58 Secure Rooms and Seclusion Standards & Guidelines – A Literature & Evidence Review

Appendix C: Comparative summary -‐ cross-‐jurisdictional scan of seclusion and secure room standards and guidelines

COMPARISON OF CROSS-JURISDICTIONAL STANDARDS/GUIDELINES FOR SECURE ROOMS - DESIGN Italics indicate guidelines (advisory), whereas a regular font indicates standards (mandatory).

Sources and acronyms: Canada United Kingdom United States Australia/New Zealand

Canadian Standards Association

CSA Health Building Organization Note 35 Part 1 – the Acute Unit, p. 30, 4.111-‐4.115

UK HBN

US Department of Veterans Affairs. Office of Construction and Facilities Management (December 2010). Design Guide: Mental Health Facilities

VA New Zealand, Health and Disability Services (Core) Standards: Continuum of Service Delivery (2008)

NZ

2000 Observation Rooms, British Columbia

BC Royal College of Psychiatrists Centre for Quality Improvement, Accreditation for Inpatient Mental Health Services (AIMS): Standards for Inpatient Wards—Working-‐Age Adults (2010)

RCP Design Guide for the Built Environment of Behavioral Health Facilities – David Sine and James Hunt, National Association of Psychiatric Health Systems

US Design Guide

Australia, Chief Psychiatrist’s Standards for Authorization of Hospitals Under the Mental Health Act 1996

ACPS

Newfoundland and Labrador, Mental Health Care and Treatment Act: Provincial Policy and Procedure Manual (2009)

NFL Note that only one entry in the UK HBN column is from a different source (RCP); the others are all UK HBN

Design standards/guidelines comparison: Canada ANZ UK HBN VA US Design Guide

SECURE ROOM Type of room NFL

There shall be a seclusion room in all facilities that have psychiatric units.

NZ Seclusion only occurs in an approved and dedicated seclusion room.

RCP 3.25 If seclusion is used, there is a designated seclusion facility available, which is


Canada ANZ UK HBN VA US Design Guide SECURE ROOM

ACPS Designated seclusion rooms are sufficient in number, located close to the nurses’ station, and fitted with features that ensure safety and security for both staff and clients.

designed to minimize risk of injury when a patient is continually monitored (S)

Bedroom size CSA 13.0 sm Additional bed area if 4-sided access is required for acute patients, 3.0 sm BC 13.9 sm

Min. 7 feet wide, max. 11 feet long. (7.15 sm)

Anteroom size CSA 5.5 sm

Self-‐harm risks CSA No vertical projections or corners, no horizontal projections that could allow climbing

5.5 No furniture.

Bed CSA Full-‐size, secured to the floor BC 6.1 Hospital bed and mattress to be used for patient comfort and care. Bed may be removed as required to maintain patient safety. The bed must be inspected to ensure there are no parts that could be detached by the patient. An electrical bed is not to be used. A thick floor mat may be used where a mattress is deemed inappropriate.



6.2 Strong sheets (6-‐7 layers sewn together) to be used for patient comfort. Do not use sheets with less layers to prevent suicide attempts.

Door CSA Multi-‐point lock with “slam-‐lock” function. BC 2.2.1 The door width is to be 42” (3’6”). The door is to be flush painted 12 gauge galvanized steel, insulated, 45 mm (1 ¾”) thick, all-‐welded construction with painted 12 gauge all-‐welded frames having a strike bucket that will accept a 25 mm (1”) throw deadbolt. The area of the strike bucket is to be wedged in to prevent spreading. Steel frames are to be fully grouted if installed in concrete block or clay tile walls. As doors are subject to tampering or body impact, special care shall be taken to permanently and securely fasten frames to wall if installed in stud walls. The door must swing outward. 2.2.3 Electro-‐magnetic lock, keying, latch, hinges and concealed closer shall be Folger-‐Adam (alternate lock: Adtec). Locks are to be operated remotely from the nurses’ station, with manual key override. 2.2.4 The door is to be painted ‘beige’ in colour.

Robust door opening outwards.

5.5 From corridor, 3’10” x 7’ From anteroom: 3’6” x 7’ Wood or metal with security grade hollow frames. SR to anteroom, 3’6” x 7’, wood or metal.

Commercial-‐grade steel doors min. 3’ 8” wide, frames hinged to open out. No exposed hardware except for a flush pull on door. Anteroom side should have 3 surface bolts which may be individual or included in one piece of hardware with a single lever to open all three.

Floors CSA Washable finish, repairable in the field

5.5 Finished in sheet vinyl, linoleum or rubber. Base:

Continuous sheet vinyl with foam backing and



BC 2.3.1 Install slip-‐resistant solvent-‐free epoxy polymer coating with quartz granules conforming to CGSB 81-‐GP-‐4M or CGSB 81-‐GP-‐5M and CAN4-‐S102.2 for the hire hazard classification, installed in accordance with manufacturers’ instructions. Alternatively, if epoxy coating is precluded, install non-‐skid, glue-‐down sheet vinyl to conform to CSA 126.3 (latest edition) Type II Grade 1 minimum gauge 2.15 mm (.085”). All joints are to be heat welded. Linoleum-‐type products are not acceptable. Resilient flooring shall be laid with an adhesive approved by the resilient flooring manufacturer for the substance to which it is to be applied. When acceptable to the manufacturer, adhesive is to be acrylic based, low TVOC, 0 TVOC (calculated) and approved by the Environmental Choice Program or equivalent. No base is required if the walls are concrete block. If the walls are gypsum board, the flooring is to have a flash cove base. In both cases, apply a continuous bead of hardening security caulking at the joint between the flooring material and the wall. 2.3.2 If a floor level change is required by retrofitting an under-‐floor heating system and lightweight concrete topping, locate at the door from the corridor or ramp up outside the room and mark with a highly visible

rubber (upgraded rubber base with molding profile recommended).

heat-‐welded seams. No baseboards.



warning strip and wall-‐mounted warning sign.

Walls CSA Washable finish, scratch and graffiti resistant, repairable in the field BC 2.1.1 Interior walls in a new facility are to be concrete block, with every core reinforced and filled with grout. Joints are to be flush. 2.1.2 In existing facilities where floor loading limitations preclude concrete block, walls are to be comprised of heavy-‐duty steel studs at 406 mm (16”) on centre with batt insulation, 13 mm (1/2”) plywood and 16 mm (5/8”) abuse-‐resistant gypsum board. Existing plastered clay tile walls are acceptable if they are in good condition. 2.1.3 Walls are to be finished with solvent-‐free epoxy polymer coating conforming to CGSB 1-‐GP-‐153M or CSGB 1-‐GP-‐186, installed in accordance with manufacturers’ instructions. Alternatively, if epoxy coating is precluded, walls are to be painted with three coats of acrylic semi-‐gloss. Painting must be in accordance with the recommendations of the CPCA/MPDA Architectural Specification Manual of the Master Painters and Decorators Association of BC. Paint must be approved by the Environmental Choice Program (e.g. Ecologo). Walls are to be painted ‘faded rose

4.3.4 Resistant gypsum board assemblies to minimize repairs.

Impact resistant gypsum board over ¾” plywood on 20 gauge metal studs at 16” center with Deco Coat finish. If no padding: plywood or 25 gauge sheet metal fastened to studs before installing gypsum board.



pink’ in color. CSA

Impact cushioning materials 5.5 Padded to prevent self-‐

harm. If padding: Kevlar-‐faced product or heavy vinyl material with a 1 ½” thick foam backing.

Wall fixtures and fittings

BC Provide a secure hinged, lockable metal cover over existing wall-‐mounted medical services outlets, such as oxygen and suction valves. Any exposed screws are to have Robertson type head. All joints between different materials, surfaces and fixtures are to be filled with hardening security caulking. No electrical receptacles; cover existing with secure blank stainless plates. (4.2)

No outlets, switches, thermostats, blank cover plates or similar.

Exterior window BC 1.1 New exterior windows are to be obscure glass block, reinforced at mortar joints to prevent their collapse on repeated impacts. Wall opening edges are to be rounded. 1.1.2 Interior of existing windows must be protected by a steel-‐framed security window composed of a layer of 3mm (1/8”) polycarbonate (Lexan) laminated between 2 layers of 6mm (1/4”) heat strengthened glass, with intermediate mullions as required for opening size and strength. Security windows shop drawings are to be signed and sealed by the design engineer. 1.1.3 For privacy, install reflective or ‘frosted’ film on existing exterior windows if room is easily observable

Allow pleasant outside views; low sill so patient can see when sitting on floor.

5.5 Small and fixed with glazing meeting impact resistance requirements. Blinds between interior and exterior glazing with no exposed hardware. Set the sill high enough to prevent kicking.

All glazing exposed to patients should be polycarbonate, strong enough to withstand impact to the centre. If glazing can’t be replaced with polycarbonate, either use security laminate or apply polycarbonate to cover the glass. Window covering: no covering or hardware accessible to patient. Could have electronically controlled blinds or shades behind polycarbonate; controls should be by electric switches outside the room.



from outside. 1.1.4 Window frames are to be painted ‘beige’ in color.

Observation window CSA Sized and positioned to allow direct view from communications station; can use audio-‐video system. Drapes in the SR to conceal the observation window when required Observation window with one-‐way vision glass of appropriate size and position to allow standing or sitting observation for up to 4 people. BC 2.2.2 The door [to the SR] must have an observation window 406 x 610 mm (16” x 2’0”), comprised of 3 mm (1/8”) smoked polycarbonate laminated between two layers of 6 mm (1/4”) heat strengthened glass. The windowsill is to be 1219 mm (4’) above the floor. The observation window in the door must be fitted on the staff side with sturdy adjustable louvres (horizontal mini blinds are not acceptable) to provide visual privacy. If the plywood/abuse-‐resistant gypsum board wall option is used, note that a non-‐standard frame ‘throat’ dimension is required.

5.5 One-‐way mirror laminate glazing between anteroom and secure room. Security grade hollow metal and glass stops on anteroom side. Provide laminate glass observation window in the door only large enough to see into room adequately.

In door, polycarbonate, no more than 100 inches square.

Washroom/Plumbing CSA Toilet and sink in lockable space Outside of bed area: 2-piece, 4.6 sm; 3-piece, 5.6 sm. Depending on design, may add vestibule, 4.0 sm.

4.8 Toilets: porcelain coated stainless steel. 5.5 2” x 2” ceramic tile; shower pan may be

Toilets as level 4B (?) or prison-‐type stainless steel combining toilet and lavatory—can get in powder-‐coated colored



BC Provide a floor mounted (wall-‐mounted if required by existing conditions) stainless steel combined sink/toilet fixture with rounded corners. The sink is to have a single push-‐button water supply complete with a mixing valve for hot and cold water, adjusted to 40 degrees C (105 F). Provide a secure water shut-‐off valve located outside the SR. Locate the floor drain with a self priming tap inside the SR. Round nickel bronze strainer with square openings to be secured with tamper-‐proof screws. (3.4)

ceramic tile or premanufactured solid surface basin. Base: rubber base. Wall finish: epoxy painted gypsum board, solid surface panels securely applied in shower areas. Ceiling height: 10’8” new construction, 9’ minimum. Slab depression: 3” depression for sloping ceramic tile door. Doors: 3’ x 7’ wood or metal door frame. No windows, one source of emergency lighting.

finish.

Location of secure room

CSA Do not locate in close proximity to an elevator, stairs, exits or common patient areas. BC Access priorities: nurses’ station and emergency room; locate away from elevator, stairs, exits or common patient areas

Separate from other patient areas.

5.5 Easily accessed from nursing station but out of view of other patients.

Close enough to nurse’s station for staff availability. Door opens directly into an anteroom, which should include access to patient toilet.

Ceiling BC 2.4.1 A minimum ceiling height of 3 m (10’) is preferred in new facilities. The ceiling is to be either concrete, cement plaster or abuse-‐resistant gypsum board. If the ceiling is suspended, cement plaster is to be on diamond lath, backed with 19 mm (3/4”) plywood or 16 mm (5/8”) abuse-‐resistant gypsum board on 13 mm (1/2”) plywood, suspended on heavy-‐duty steel studs at 406 mm

4.3.4 Gypsum board or another inaccessible and abuse resistant ceiling system. 5.5 Painted finish. 10’8: new construction, 9’ minimum.

Min. 9’, impact resistant gypsum board, painted.



(16”) on center. 2.4.2 The ceiling is to be painted three coats semi-‐gloss enamel that is off-‐white in colour.

Heating BC 3.1 Remove existing floor or wall-‐mounted convectors. Provide separately zoned hydronic or electric under-‐floor radiant heating. If under-‐floor radiant heating is precluded, electric radiant heating in plaster ceiling is an acceptable alternative. Electronic sensor is to be in a secure recessed enclosure located in the room. Temperature reset control is to be provided at the nurses’ station.

5.5 internal temperature control required.

HVAC grilles fully recessed vandal resistant with S-‐shaped air passageways; thermostats digital-‐type, mounted on wall in anteroom with sensors in return air ducts serving the room.

Ventilation BC 3.2 Ventilate secure room at a minimum rate of six air changes per hour. Exhaust the SR to the exterior. Security type ventilation grilles are to have 12 gauge faceplate with 3 mm (1/8”) diameter holes at 5 mm (3/16”) staggered centres. Locate the smoke/heat detectors in return air ducts. Alternatively provide surface mounted security-‐type detectors which cannot be used for suicide attempts or typical detectors protected by a ULC (Underwriter’s Laboratories of Canada) guard. HVAC system is to limit equipment vibration and noise propagation such that background noise from these systems do not exceed 35 NC (dB).

Fire precautions BC 3.3 If the secure room is sprinklered, provide security type sprinkler head

Tamper-‐proof smoke detector

4.3.4 Sprinklers, smoke detectors and any other ceiling mounted devices

Institutional sprinklers.



to prevent suicide attempts. should be vandal resistant and attached with tamper resistant screws. All should be recessed where possible.

Lighting BC 4.1 provide a two-‐level lighting (normal and night low level) maximum security corner mounted luminaire with polycarbonate lens. Lamp: 2F32T8 lamps. Night light: Tivoli style linear light rope, running the entire length of the luminaire. Ballast: hybrid electronic cathode cut-‐out type. Install two single-‐pole light switches to control night-‐light and normal light, located immediately outside the room. Switching: provide externally controlled light switches. Switch luminaire such that either night-‐light is on OR the fluorescent lamps are on. Both light sources shall not be on at the same time.

3 light fittings: main, night light, overbed light

4.3.4 Vandal resistant and attached with tamper resistant screws; recessed where possible. 5.5 Provide one emergency light, low level lighting at night for wayfinding; ceiling mounted light at entrance, controlled at exterior entrance. One power source.

Fixtures: fully recessed, moisture resistant, vandal resistant in ceiling.

Communications CSA Can use audio-‐visual system for staff observation. BC 5.1 Provide a stand-‐alone, two-‐way intercom system between the SR and the nurses’ station. The system is to allow continuous sound monitoring of the patient and to allow the patient to signal and speak to, and hear from the nurses’ station. Console in the SR to be flush mounted, impact and tamper resistant security



type with voice-‐activated, hands-‐free feature. Controls at the nurses’ station are to allow for adjustment of volume, capability to disable the patient’s call button and allow speaking to the patient. 5.2 Closed circuit television (CCTV) system 5.2.1 Provide a complete stand-‐alone CCTV system. All cable and equipment supplied, and installation methods used, to be as specified by the equipment manufacturer. Any hardware or software required to make programming changes to the system(s) shall be included with the system. On completion of the installation, the installer is to provide a complete set of ‘as built’ drawings, hardware and software manuals, staff instruction on the use and programming of the system(s). 5.2.2 The SR camera shall be based on the following specs: compact size; high resolution, b/w; 180 degree wide angle; pan tilt and rotation controller; auto-‐electronic iris and lens providing quality imaging in all lighting conditions (particularly at night/low level); ceiling mounted (as flush as possible), hard-‐coated optically correct, water-‐resistant polycarbonate dome housing. [recommends periodic application of a silicone-‐based rain shield on the dome.] 5.2.3 The monitor at the nurses’ station shall be based on the following



specs: 9”-‐15” high res b/w or color monitor recessed in millwork in a manner to prevent viewing by passerby. [if more than one room is monitored, provide monitor for each camera, unless 4 monitored rooms, where a 20” quad split screen would work.]

Noise 5.5 Noise (STC Rating): 45 STC

Mirrors Observation mirrors in SRs: convex, min. ¼” thick polycarbonate, filled with high-‐density foam, heavy metal frame that fits tightly to wall and ceiling. Alternative: convex mirrors made of steel; seal perimeter with pick-‐resistant caulking. Install in upper corner of room and opposite SR door. Make sure it’s visible when viewing from window in the door. Staff should have a 350-‐degree view of the rom before opening the door. Secure attachment.

STAFF VIEWING AREA Size CSA

5.5 sm (add 1.4 ms for each additional occupant over 4)

Furnishings CSA Surfaces for writing and recording equipment; task chairs or stools.

Location CSA May be associated with another room, i.e. interview/consult, therapeutic playroom, group room.


Comparison including CSA general standards (i.e., applicable but not specific to secure rooms), section 8.4. CSA 2000 Observation Rooms General Design shall accord with written safety and risk mitigation guidelines.

Specifies building elements (materials and finishes, mechanical and electrical systems) that need to accord with 8.4.3.1.1.

Personal safety A staff alert system shall be provided in all rooms if a personal alarm system is not provided.

All consult /examination rooms shall have two exit doors and a staff emergency assistance alarm station.

Windows For exterior windows, an impact test standard — such as BS 6206 (UK), 100 kg. sandbag, 1220 mm drop — shall be specified for the interior glazing light and a full scale mock-‐up test of the proposed glazing system shall be carried out. Exterior windows should have a restricted opening of no more than 125 mm. Secure exterior glazing and frames shall be provided in all rooms where

mental health and addictions patients receive care and treatment or could be unsupervised. Exterior and interior glazing and frames shall be constructed and secured to withstand high impact.

Specs in (1). Unclear how they compare.

Ceilings Solid (monolithic) ceilings shall be provided in bedrooms, washrooms, and other areas where mental health and addictions patients receive care and treatment or could be unsupervised.

Ceiling heights shall be as specified in Clause 12. [WHAT IS CLAUSE 12?]

3 m (10’) minimum height in new facilities. Specs: 2.4

Washrooms/plumbing Double acting doors shall be provided for washrooms, tub rooms, and shower rooms. Doors shall open outward by releasing a retractable stop or by other means. (An exterior lock shall also be provided to secure the room when it is out of use.)

Water sources—sink, toilet, shower, etc.—should have individual controls such as a tamperproof shutoff at valves, valves located behind lockable panels, or remotely controlled shutoff to control hydrophilia behaviour.

2.2 Doors must swing outward. 3.4: The sink is to have a single push-‐button water supply complete with a mixing valve for hot and cold water, adjusted to 40 degrees C (105 F). Provide a secure water shut-‐off valve located outside the SR.

Risk management Ligature attachment points shall be avoided. Materials and components that could become weapons shall be avoided. Trim strips between assemblies shall be avoided or securely attached. Sharp edges shall be avoided. Fasteners shall be safe and non-‐removable. Sealants/caulk shall be non-‐removable. Durable, washable finishes shall be provided. Impact-‐cushioning or impact-‐resistant finishes shall be provided. Mental health and addictions inpatient units of HCFs should be designed to

provide storage space for sharps disposal and patient waste disposal. Eye wash stations shall be provided in the unit.

No contradictions of CSA standards; intent is captures in a variety of specific standards. No discussion of sharps/waste storage/disposal or eye wash stations. 3.4 specifies rounded corners in washroom fixtures. 1.1 specifies rounded edges at wall openings in windows. 2.3.1 and 2.5 specify use of security caulking


CSA 2000 Observation Rooms Location The unit should be on the ground floor of the HCF. Where this cannot be

achieved, unauthorised access to external spaces such as balconies or roof shall be prevented.


COMPARISON OF CROSS-JURISDICTIONAL STANDARDS/GUIDELINES FOR SECURE ROOMS - PROGRAM

Sources and acronyms: Canada United Kingdom United States Australia/New Zealand Other (Europe, Africa)

Accreditation Canada, Qmentum Program: Standards for Mental Health Services (2008)

AC NHS, NICE, February 2005, Guidance on short-‐term management of disturbed/violent behavior in psychiatric inpatient settings and emergency departments. Recommendations.

NICE Draft Standards Specific for Seclusion (Masters et al., 2008)

JCAHO1 Australia, Chief Psychiatrist’s Guideline, 2006. Guideline supplements the minimum statutory requirements for seclusion, detailed in the Mental Health Act 1986, section 82.

ACPG Council of Europe’s Committee for the Prevention of Torture and Inhuman or Degrading Treatment or Punishment (Kumble & McSherry, 2010)

Europe

2000 Observation Rooms, British Columbia

BC NHS Executive, Safety, Privacy, and Dignity in Mental Health Units: Guidance on Mixed Sex Accommodation for Mental Health Services

NHS Restraint and Seclusion Standards, Jan. 1, 2001 (http://ohanet.org/csr/resource/restraintseclusion.pdf)

JCAHO2 Australia, Chief Psychiatrist’s Standards for the Authorization of Hospitals Under the Mental Health Act 1996 (2007)

ACPS South Africa, Standards in the domain or rights and protection (Muller & Flisher, 2005)

SA

Newfoundland and Labrador, Mental Health Care and Treatment Act: Provincial Policy and Procedure Manual (2009)

NFL Dept. of Health, Code of Practice for Mental Health Act 1983 (2007 Update) (2008)

DH Standards on Restraint and Seclusion (CPI Nonviolent Crisis Intervention Program, 2009)

JCAHO3 New Zealand, Seclusion under the Mental Health Act 1992—adapted from Procedural Guidelines for the Use of Seclusion, Revised Edition, MoH, 1995

NZ1

Royal College of Psychiatrists, Standards for Medium Secure Units: Quality Network for Medium

RCP American Psychiatric Nurses’ Association, 2007. Seclusion and Restraint Standards of Practice.

APNA Health and Disability Services (Restraint and Minimization and Safe Practices) Standards (2008)

NZ2


Canada United Kingdom United States Australia/New Zealand Other (Europe, Africa) Secure Units, 2007.

Lincolnshire Partnership NHS Foundation Trust, Seclusion Policy and Practice Guidelines (2009)

LP Emergency Department Treatment of the Psychiatric Patient: Policy Issues and Legal Requirements-‐-‐Seclusion, Standards for Emergency Department Treatment of Individuals with Psychiatric Disabilities, Emergency Department Project, Centre for Public Representation (Stefan et al., 2005)

ED

Royal College of Psychiatrists’ Centre for Quality Improvement, Accreditation for Acute Inpatient Mental Health Services (AIMS): Standards for Acute Inpatient Wards—Older People (2009)

RCP1

Royal College of Psychiatrists’ Centre for Quality Improvement, Accreditation for Acute Inpatient Mental Health Services (AIMS): Standards for Acute Inpatient Wards—Working-‐Age Adults(2009)

RCP2


Program standards/guidelines comparison: Canada Other US UK ANZ Medical assessment (prior to seclusion)

BC: 1.1 Policies and procedures are in place for the identification and treatment of underlying medical causes for the behavioural disturbance.

Psychiatric assessment (prior to seclusion)

BC: 1.2.1-‐1.2.3 Policies and procedures are in place for assessment of the patient exhibiting psychiatric symptoms; at risk for suicide; at risk for aggression. 1.2.4 Policies and procedures are in place to ensure effective triaging to enable the patient exhibiting psychiatric symptoms to be treated in the observation unit or referred to the nearest psychiatric unit or provincial tertiary mental health facility.

JCAHO2: TX.7.1.3 The initial assessment of each individual at the time of admission or intake assists in obtaining information about the individual that could help minimize the use of restraint or seclusion. APNA: The nursing response to persons during evolving behavioral emergencies is non-‐physical and based on a comprehensive initial and ongoing assessment of the person. The assessment includes behavioral and affective presentation as well as understanding of situations that trigger escalation.

LP: 5.1.1 A risk assessment of the situation has been carried out and the opinion is that immediate and serious risk of harm to others could occur.


Canada Other US UK ANZ Indication for seclusion

Europe: Standard 49: seclusion “should be the subject of a detailed policy spelling out…the types of cases in which it may be used; the objectives sought; its duration and the need for regular review; the existence of appropriate human contract; [and] the need for staff to be especially attentive.” Standards “recommend that seclusion and restraint only be used pursuant to a policy implemented to reduce the risk of harm” (p. 557). SA: 1.1.20 Seclusion: The seclusion of users is non-‐abusive and occurs within clear treatment parameters and guidelines. a. Seclusion may only be used when prescribed by a medical practitioner. b. Seclusion is prescribed in the best

JCAHO2: TX.7.1.4.1 Restraint or seclusion use is limited to emergencies in which there is an imminent risk of an individual physically harming himself or herself, staff, or others, and non-‐physical interventions would not be effective. JCAHO3: PC.03.05.01: The [organization] uses restraint or seclusion only when it can be clinically justified or when warranted by patient behaviour that threatens the physical safety of the patient, staff or others.

NICE: Rapid tranquilization, physical restraint and seclusion should only be considered once de-‐escalation and other strategies have failed to calm the service user. The intervention selected must be a reasonable and proportionate response to the risk posed by the service user. LP: 5.1.2 The patient’s behavior is likely to result in injuring others imminently. 5.1.3 All other feasible interventions and ways of managing the situation have been explored to manage the patient’s behavior. 5.1.4 On no account should seclusion ever be used as a punishment or threat. 5.1.5 Seclusion should never be part of a planned treatment programme, although it is recognized in well known clients that it may be anticipated. 5.1.6 Seclusion should not be used or continued because of a shortage in staffing resources. 5.1.7 Seclusion should not be used where it will exacerbate the risk of suicide or as a method of controlling behavior. LP:(Practice Guideline) 2. Crisis intervention: Seclusion is a crisis intervention measure of last resort, only used when


Canada Other US UK ANZ interest of the user, and not as a disciplinary measure. d. Seclusion may only be prescribed when other treatment measures fail (e.g. medication and interpersonal means). f. Seclusion occurs in a sensitive manner, without unnecessary force, or any injury or degradation to the user. Europe: Seclusion should never be used as a punishment.

behavior is likely to harm others, not when only indication of self-‐harm. Seclusion should never be incorporated as part of any planned program of care. DH: Interventions such as physical restraints, rapid tranquilization, seclusion and observation should only be used when de-‐escalation is insufficient, and should always be used in conjunction with further efforts to de-‐escalate. They must never be used as punishment.

Use of restraints BC: 1.3.1 A range of behavioural control options, including mechanical, pharmacological and environmental restraints, are available and are applied in the least restrictive manner consistent with patient and staff safety. 1.3.2 Policies and procedures are in place for the assessment of the patient requiring restraint, appropriate application of restraints and the care of the patient in restraints.

Avoiding physical interventions

JCAHO2: TX.7.1.4 Non-‐physical techniques are the preferred intervention in

DH: Regardless of terminology, any supervised confinement of a patient in a room, which may be

NZ2: Services demonstrate that all use of seclusion is for safety reasons


Canada Other US UK ANZ the management of behaviour. TX.7.1.16 Organization policy(ies) and procedure(s) address the prevention of the use of restraint and seclusion and, when employed, guide their use. APNA: Psychiatric-‐mental health nurses provide leadership to create a culture that minimizes the use of seclusion or restraint while promoting a safe environment for persons served as well as staff. Organizational leaders working toward realizing the vision of seclusion and restraint free environments must assure sufficient resources as well as effective administrative and clinical structures and processes to prevent behavioral emergencies and to support the implementation of alternatives.

locked, and is intended to contain severely disturbed behaviour should be treated as seclusion. Facilities should minimize the culture of containment.

only.

Initiating seclusion

BC: 1.4.1 At least one secure room that meets the provincial technical standards is available in the hospital. 1.4.2 Policies and procedures are in place for assessment of

SA: 1.1.20. c. A team reviews seclusion prescriptions as soon as possible.

JCAHO2: TX.7.1.5 A licensed independent practitioner orders the use of restraint or seclusion. JCAHO3:

LP: 5.2.1 The decision to use seclusion can be made in the first instance by a medical officer or the nurse in charge. Where the decision is taken by someone other than a medical officer, the

NZ2: Seclusion only occurs in an approved and dedicated seclusion room. ACPS


Canada Other US UK ANZ the patient requiring seclusion, appropriate steps to be undertaken in initiating seclusion of the patient and the care of the patient in seclusion. NFL There shall be a seclusion room in all facilities that have psychiatric units.

PC.03.05.05: The [organization] initiates restraint or seclusion based on an individual order. APNA: Seclusion or restraint is initiated only when less restrictive measures have proven ineffective and the behavioral emergency poses serious and imminent danger to the person, staff or others and staff involved have been adequately trained and deemed competent to initiate these measures. Persons are never restrained and left alone in a locked room. Seclusion and restraint should not be used as a means of coercion or punishment, for the convenience of staff, or when less restrictive measures to manage behaviors are available. When deciding which intervention to use, the risks and benefits considered must include an individualized assessment of the person’s known history of physical or sexual abuse as well as current physiological and psychological status. In

Responsible Medical Officer or duty doctor should be notified at once and should attend within 30 minutes if rapid tranquilization or seclusion are implemented. The service user should be made aware that reviews will take place at least every 2 hours. LP Practice Guideline: 3. Duration: short as possible. 15. Authorization of seclusion: first by senior nurse on duty, medical officer or senior manager. If someone else, RMO or deputy should be notified and attend immediately where possible unless seclusion less than 5 min. DH: The decision to use seclusion can be made by a doctor, a suitably qualified approved clinician or, at the hospital’s discretion, a professional in charge of the ward. RCP Designated seclusion rooms are sufficient in number, located close to the nurses’ station, and fitted with features that ensure safety and security for both staff and clients.

Designated seclusion rooms are sufficient in number, located close to the nurses’ station, and fitted with features that ensure safety and security for both staff and clients.


Canada Other US UK ANZ addition, the factors that contribute to the sustained behavioral emergency must be examined and person preference must be considered. When an individual is physically restrained, immediate action is required to mitigate positional risks: prone restraint requires monitoring for the risk of positional asphyxiation; supine restrained requires monitoring for the risk of airway obstruction. Seclusion or restraint is initiated by qualified staff authorized by the organization to initiate seclusion or restraint in a behavioral emergency and must be followed by an order for a physician or Licensed Independent Practitioner (LIP).

Continuing seclusion

JCAHO2: TX.7.1.7 Written or verbal orders for initial and continuing use of restraint and seclusion are time-‐limited. TX.7.1.9 Clinical leadership is informed of instances in which individuals experience extended, or multiple episodes, of restraint or seclusion

LP Practice Guideline: If seclusion lasts more than 1 hour, a care plan needs to be developed for the seclusion period. DH: Periods of seclusion should end as quickly as possible. The need for seclusion should be reviewed regularly throughout the duration of the event.

NZ1: 5. Prolonged seclusion. 5.1 If cumulative hours in one admission over 24 in 4 weeks, need to reassess. 5.2 If prolonged seclusion is necessary, consult with Clinical Director or other senior clinician.


Canada Other US UK ANZ Ending seclusion

JCAHO2: TX.7.1.12 Restraint and seclusion use are discontinued when the individual meets the behaviour criteria for their discontinuation. APNA: Seclusion or restraint is discontinued based on the assessment that the behavioral criteria for release are met.

LP Practice Guideline: 16. Cancelling seclusion: senior nurse on duty, attending MO or review team can end. If team can’t decide, contact senior manager. 17. Sleeping patients: no more than 2 entries in notes of patient sleeping, and specific entry of why seclusion continued. If seclusion ends while asleep, open door to room; continue observations to help patient avoid disorientation on waking. 18. Never cancel without a clear plan for how to nurse patient, and level of observation.

NZ1: 6. Reintegration for patients undergoing seclusion 6.1 planned and gradual process 6.2 start by opening door, and integrate at times of least stress/disruption 6.3 assess reintegration attempts when deciding whether or not to continue seclusion. 7. Ending seclusion 7.1 2 clinicians in agreement with responsible clinician can end. 7.2 ended when patient leaves conditions of seclusion without expectation of return, or for more than one hour.

Post-‐seclusion debriefing

JCAHO2: TX.7.1.13 The individual and staff participate in a debriefing about the restraint or seclusion episode. APNA: As soon as possible, following the release from seclusion or restraint, the nurse, the person and others as appropriate


Canada Other US UK ANZ should participate in a debriefing.

Care planning BC: 1.5.1 Policies and procedures are in place to ensure that a written care plan, including follow-‐up after care, is initiated on admission of the patient to the hospital. 1.5.2 Policies and procedures are in place to ensure that the patient and family are involved in the care plan.

APNA: During the individual’s admission, the psychiatric-‐mental health nurse collaborates with him/her and caregivers to formulate strategies that may minimize the potential for a behavioral emergency and the subsequent use of seclusion or restraint.

ACPG: 2.2 Each person has a documented seclusion management plan covering the primary diagnosis, assessment of clinical needs, anticipated outcomes, risk assessment, and strategies to manage those risks.

Gender and cultural competence

BC: 1.6 Policies and procedures are in place to assist staff in the provision of gender and culturally sensitive care.

DH: Patients in seclusion should always be clothed.

NZ1 4.2 Aim for staff of same gender and culture as patient.

After-‐care/discharge planning

BC: 1.7 Policies and procedures are in place to ensure that the patient and the family receive a copy of the written after-‐care plan upon discharge of the patient from the hospital.

Professional consultation

BC: 2. Policies and procedures are in place to assist physicians and other health care team members involved in the assessment and care of people presenting to the hospital with psychiatric emergencies to access psychiatric consultation in a timely manner.

Patient legal rights

BC: 3.1 Mental Health Act 3.1.1 Policies and procedures are in place to inform patients

RCP: 3.23 The unit operates within the appropriate legal framework in relation to the use of physical


Canada Other US UK ANZ and family members of their rights under the MHA. 3.1.2 Policies and procedures are in place to support patients in accessing legal counsel and in exercising their rights under the MHA. 3.2 Freedom of Information and Protection of Privacy Act (FOIPPA) 3.2.1 In accordance with FOIPPA, policies and procedures are in place to share information among health care team members and third parties.

restraint (S) LP Practice Guideline: 14. Patient’s rights in seclusion are guaranteed, have the right to have them explained verbally and in writing: • Respect and dignity • Explanation for seclusion • Told when it will end • Are of time of day with clock

in view or answer to question

• Told how to get staff while in SR

• Get adequate food and fluid • Appropriate access to toilet

and washing facilities • Appropriate clothing • Visits, opportunities to

speak to senior staff regularly

• Record that patient has been made aware of rights.

Notifying family JCAHO1: The patient’s family must be notified promptly of the initiation of seclusion or restraint. JCAHO2: TX.7.1.5.1 The individual’s family is notified promptly of the initiation of restraint or seclusion.

LP Practice Guideline: 7.6 Notify nearest relative of decision to use seclusion 9. Carers and relatives: inform relatives with regard to patient’s wishes and confidentiality. Consider visitors as appropriate.

Documentation BC: 4.1 Policies and procedures are in place for documenting assessment and care of the patient and family members.

Europe: Must document causes, methods, duration, effects in patient record and

JCAHO2: TX.7.1.14 Medical records document that the use of restraint or seclusion is consistent with

RCP: 3.24 The circumstances and justification for using physical restraint are recorded immediately… (S)

ACPG: 2) An accurate account of each episode of seclusion is recorded in the clinical record,


Canada Other US UK ANZ 4.2 Policies and procedures are in place for documenting and reporting of critical incidents, including the evaluation conducted and follow-‐up steps initiated. 4.3 Policies and procedures are in place for documenting assessment and treatment recommendations in a form that can be promptly transmitted to community agencies.

also a database for ward.

organization policy. JCAHO3: PC.03.05.15: The [organization] documents the use of restraint or seclusion. APNA: All aspects of the seclusion and restraint episode, including the behaviors and events leading up to it, the less restrictive interventions employed, the care provided during the episode and the release from seclusion or restraint are recorded in the clinical record.

LP: 5.2.4 A designated staff member will make a written observation of the patient and what they are doing every fifteen minutes. LP Practice Guideline: 7.9 Ensure attempts made to record physical observation (temp, pulse, respiration, BP). 18. Records and documentation: important, nurses are key. Detailed notes in patient’s record, cross referenced to a separate seclusion book or forms. Step-‐by-‐step account. Record food, drink, meds, record of physical observation and elimination. DH: Seclusion should be carefully supervised and documented at least every 15 minutes.

which demonstrates the delivery of effective, humane, efficient and evaluated treatment. Indicators: 2.1 Clinical record documentation of an episode of seclusion contains the requirements of relevant policies and procedures. 2.3 The rationale for the decision to seclude the person is recorded. 2.4 All medical and psychiatric examinations, clinical reviews and treatments are recorded. 2.5 The person’s response to treatments and interventions is recorded. 2.6 The rationale for any change to the treatment plan is recorded. 2.7 Details of second opinions and/or case reviews are recorded. 2.8 Reasons for variation of the four hourly reviews is recorded and are consistent with this guideline. NZ1:


Canada Other US UK ANZ 9.1 specific form must be used, along with clinical notes; also forms to record 10-‐minute and 2-‐hourly observations 9.2 start recording on initiation 9.3 seclusion records: one in patient notes, one in central seclusion register 9.4 Information provides basis for internal quality assurance and review and audit.

AC: Staff should receive training required for performing the specific tasks associated with their job (i.e. assessment and care planning, self-‐harm and suicide awareness and prevention, dementia awareness, seclusion and restraint, etc.).

RCP1 and 2, DH: Staff should receive training required for performing the specific tasks associated with their job (i.e. assessment and care planning, self-‐harm and suicide awareness and prevention, dementia awareness, seclusion and restraint, etc.).

BC: 5.1 Policies and procedures are in place for staff to receive education and training related to assessment and diagnosis of a variety of psychiatric conditions across the age-‐range, including the care of acutely ill psychiatric patients.

Staff education & training

BC: 5.2 Policies and procedures are in place for staff to receive education and training related

ACPG: 1.2 Clinical staff are able to articulate a sound knowledge of


Canada Other US UK ANZ to relevant legislation including the Hospital Act, MHA, FOIPPA and other relevant legislation.

the key principles, legal requirements, guidelines and local policies and procedures relating to seclusion.

BC: 5.3 Policies and procedures are in place for staff to receive education and training to develop skills in the assessment of suicide risk and in the prevention and management of suicidal crisis.

BC: 5.4 Policies and procedures are in place for staff to receive education and training to develop skills in the assessment of potential for aggression/violence and in the prevention and management of disturbed behaviour and aggression/violence.

APNA: Any staff providing care to persons at risk for harming themselves or others and who participate in seclusion and restraint shall have received training and demonstrate current competency in all aspects of dealing with behavioral emergencies.

BC: 5.5 Use of restraints 5.5.1 Policies and procedures are in place for staff to receive education and training related to the appropriate use of restraints. 5.5.2 Policies and procedures are in place for staff to receive education and training related to the care of the patient in restraints, including seclusion.

JCAHO2: TX.7.1.2 Staff are trained and competent to minimize the use of restraint and seclusion, and in their safe use. JCAHO3: PC.03.05.17: The [organization] trains staff to safely implement the use of restraint or seclusion.

NICE: Staff who may need to employ physical intervention (such as restraint) or seclusion and those involved in administering rapid tranquilization must be trained to an appropriate level in life support techniques (such as the use of defibrillators). LP Practice Guideline: 19. Training: staff must be trained appropriately.

BC:


Canada Other US UK ANZ 5.6 Critical incidents 5.6.1 Policies and procedures are in place for staff to receive education and training related to the reporting and analysis of critical incidents. 5.6.2 Policies and procedures are in place for staff to receive support following a critical incident. BC: 5.7 Policies and procedures are in place for staff to receive education and training related to gender and culturally sensitive issues and care.

Staffing levels JCAHO2: TX.7.1.1 Staffing levels and assignments are set to minimize circumstances that give rise to restraint or seclusion use and to maximize safety when restraint and seclusion are used.

Care and safety during seclusion

SA: 1.1.20. Seclusion: The seclusion of users is non-‐abusive and occurs within clear treatment parameters and guidelines. f. Seclusion occurs in a sensitive manner, without unnecessary force, or any injury or degradation to the user.

JCAHO2: TX.7.1.10 Individuals in restraint or seclusion are assessed and assisted. JCAHO3: PC.03.05.03: The [organization] uses restraint or seclusion safely.

LP Practice Guideline: 5. Searching the SR: must check for dangerous items before using, and maintain for safety at all times. 6. Patients’ clothing: Patients should wear own clothing, but remove dangerous accessories (i.e. belts, shoes). Under no circumstances must a patient be left without clothing. Allow to keep personal items including those of religious or cultural significance as long as no safety risk.


Canada Other US UK ANZ 7. Professional responsibilities of senior nurse. Responsible for all aspects of health and safety during seclusion; monitor patient’s health and any deterioration 7.2 Ensure that the door is unlocked on per instructions of nurse in charge. 7.4 Ensure visits to patient are planned, and others’ health and safety protected. 7.10 Ensure nursing staff is aware of signs/symptoms of side effects/adverse reactions to meds administered 10. Visits by members of clinical team: plan all visits with senior nurse on duty. 11. visits by the Mental Health Act Commission 12. Visits by medical officers and approved social workers should be allowed. RCP: 3.25 If seclusion is used, there is a designated seclusion facility available, which is designed to minimize risk of injury when a patient is continually monitored (S) DH: Restraint, rapid tranquilization, seclusion and observation should be used in a way that minimizes risk to the patient’s health and safety and interference with their privacy and dignity.


Canada Other US UK ANZ Observation and evaluation of patient in seclusion

SA: 1.1.20. e. Users within seclusion are subject to regular review and observation on an hourly basis.

JCAHO1: Patients must be monitored continuously and in person for the first hour and then either in person or via audio and video equipment with staff in the seclusion room or looking in the window of the room from the outside, or video camera monitoring if this is consistent with the patient’s condition or wishes. Medicare-‐funded hospitals require that a physician or licensed independent practitioner conduct a face-‐to-‐face evaluation of a patient within 1 hour of the initiation of a restraint or seclusion. Non-‐Medicare participating hospitals that are JCAHO-‐approved require that a patient 17 years and younger be evaluated within 2 hours, and patients 18 or older be evaluated within 4 hours. • Re-‐evaluation must occur in-‐person every 2 hours for patients 17 and younger and every 4 hours for patients 18 and older. A qualified registered nurse or a qualified trained individual may perform the re-‐evaluation, but the

LP: 5.2.2 A nurse should be readily available within sight and sound of the seclusion room at all times throughout the period of the patient’s seclusion, and remain within eyesight at all times with a patient who has received rapid tranquilization medication. The patient should receive physical care in line with the Trust rapid tranquilization policy. 5.2.4 A designated staff member will make a written observation of the patient and what they are doing every fifteen minutes. 5.3.1 The need to continue seclusion must be reviewed: Primary review (30 min. after instigation), must include either the Responsible Medical Officer or attending medical officer deputy. Two hourly review – 2 nurses, one not involved in decision to instigate Four hourly review by a Medical Officer, to be repeated every 4 hours for the duration of seclusion. 8 or 12 hourly review – by the MDT An 8-‐hour review should be carried out when seclusion has been consecutive and the 12 hourly review when seclusion has been intermittent over a period of 48 hours. Must include the Responsible Medical Officer or attending medical officer for the

NZ1: 2. Continuous observation. 2.1 No more than 10 min. between observations. 2.2 At minimum, observe condition, colour, breathing, position, activity, behavior 3. Two-‐hourly assessments. 3.1 Qualified clinician at least every 2 hours to assess physical wellbeing. 3.2 Same for mental state. 3.3 Safety precautions when entering room. 3.4 Each entry to SR is opportunity to assess patient’s readiness to leave SR. 4. Eight-‐hourly assessments and care 4.1 Care and assessment is recorded in each shift, by registered nurse. 4.3 Qualified clinician must assess patient psychiatrically at least once every 8 hours, and document. 4.4 Before 8 hours, if seclusion is to extend,


Canada Other US UK ANZ licensed independent practitioner must perform follow-‐up in-‐person re-‐evaluations of the patient every 4 hours for individuals aged 17 and younger and every 8 hours for patients aged 18 and older. • If the individual is no longer in seclusion or restraint when the original verbal order expires, then the licensed independent practitioner must conduct an in-‐person evaluation of the individual within 24 hours of the initiation of the seclusion or restraint. • All patients in seclusion or restraint must be monitored continuously. All restrained patients should have their pulse, blood pressure, and the range of motion in their extremities checked every 15 minutes. The need for nutrition, hydration, and elimination and the physical and psychological status and comfort of the patient should be monitored and responded to once these needs are identified. JCAHO2: TX.7.1.6 A licensed independent practitioner

patient if they are unavailable. Nursing staff and other professionals not involved in the decision to instigate seclusion should also be part of this review. LP Practice Guideline: 7.1 Delegate a member of the clinical team to stay outside SR door at all times. The person should have no other duties. 7.3 Ensure supervision of meals and drinks during seclusion. 7.7 Ensure staff monitors signs/symptoms of breathing difficulties 8. Observations: clinical staff outside SR at all times to continuously monitor physical and psychological well-‐being. Continually have patient in line of vision. Make attempts to communicate in clear, simple language. Assess behavior/presentation to identify when to end seclusion. Document every 15 min. DH: Seclusion should be carefully supervised and documented at least every 15 minutes.

need confirmation by initiating and supporting clinicians or other qualified clinicians if original not available. Notify responsible clinician when possible.


Canada Other US UK ANZ sees and evaluates the individual in-‐person. TX.7.1.8 Individuals who are in restraint or seclusion are regularly re-‐evaluated. TX.7.1.11 Individuals in restraint or seclusion are monitored. JCAHO3: PC.03.05.07: The [organization] monitors patients who are restrained or secluded. PC.03.05.11: The [organization] evaluates and re-‐evaluates the patient who is restrained or secluded. PC.03.05.13: The [organization] continually monitors patients who are simultaneously restrained and secluded. APNA: Within one hour of initiation of seclusion or restraint, the person must be seen and evaluated by a physician, LIP, or a trained and competent registered nurse (RN) or physician assistant (PA) who collaboratively with the treatment staff ascertains


Canada Other US UK ANZ the person’s response and determines if seclusion or restraint is to continue. The attending physician or other LIP responsible for the care of the person must be consulted as soon as possible when the one-‐hour evaluation is conducted by a trained and competent RN or PA. Persons in restraint are monitored by continuous one-‐to-‐one supervision. Persons aged 12 and under must be monitored continuously by face to face observation or direct observation through the seclusion room window. Persons in seclusion are monitored continuously through the seclusion room window for the first hour and then at least every fifteen minutes thereafter, by face-‐to-‐face observation or direct observation through the seclusion room window. Persons are monitored by staff who are trained and competent to recognize and report untoward physical and psychological reactions as well as to facilitate release from seclusion or restraint. Persons are assessed by a


Canada Other US UK ANZ registered nurse at the time the seclusion or restraint is initiated and at least hourly thereafter. The registered nurse may delegate monitoring through one-‐to-‐one supervision of persons in restraint or fifteen-‐minute direct observation of persons in seclusion to qualified staff as appropriate.

Children JCAHO1: For children who are medically unstable and for whom seclusion would present a medical risk (in this case, clinical guidelines would suggest that 1:1 supervision of the patient would be a preferred intervention). Verbal and written orders for seclusion or restraint are limited to: 1 hour for children younger than age 9; 2 hours for children and adolescents aged 9 to 17; 4 hours for individuals aged 18 and older. Once the child or adolescent has settled and regained self-‐control, the seclusion or restraint should be terminated. Staff should support and encourage patients in


Canada Other US UK ANZ calming down and regaining control of their own behaviour.

Seniors RCP1: There are policies on the use of de-‐escalation, restraint, rapid tranquilization, physical intervention and seclusion with older people.

Emergency department

NFL: There shall be a safe space available in the emergency department of the health facility in which the psychiatric assessment is conducted. This policy applies to all facilities that have psychiatric units and other facilities designated as safe spaces in the region. In facilities that have psychiatric inpatient beds this space will be a safe space only. In facilities that have no psychiatric inpatient beds this space shall double as a safe space/seclusion room.

ED: 1. Under federal regulations, locked assessment rooms constitute seclusion, and patients may not be prevented from leaving rooms in which they are alone unless the conditions for seclusion have been met. 2. The use of seclusion to prevent a voluntary patient from leaving the hospital prior to assessment is not justified and should not be permitted. The use of seclusion for a brief period of time to permit a medical evaluation for the purpose of determining if the individual has a life-‐threatening condition or is competent is permissible if the period of time is as short as possible under the circumstances, and in no case over one hour. 3. The reduction of seclusion and restraint in emergency departments


Canada Other US UK ANZ should be a core indicator of performance for purposes of quality assurance and risk assessment. 4. The use of seclusion should be as humane and non-‐traumatizing as possible under the circumstances.

Patient involvement

JCAHO1: Patient evaluation of the procedure is highly recommended.

Oversight AC: 8.11 The team establishes and adheres to policy and procedures for the use of seclusion and restraints. Guidelines: The policy includes criteria and procedures for the use of seclusion and restraints to control or modify behaviour. The policy is developed and implemented in accordance with recognized guidelines or protocols.

JCAHO1: Clinical leadership must be informed of any individual who has two or more episodes of seclusion or restraint in a 12-‐hour period. The clinical leadership must be notified every 24 hours if either of these conditions continues. JCAHO2: TX.7.1 The leaders establish and communicate the organization’s philosophy on the use of restraint and seclusion to all staff who have direct care responsibility. JCAHO3: PC.03.05.09: The [organization] has written policies and procedures that guide the use of restraint and seclusion.

LP Practice Guideline: 7.5 Inform RMO and mangers of decision to use seclusion. 7.8 Ensure that injury to patient is reported immediately to med officer, who should then examine patient and document appropriately NHS, DH, RCP: There is a policy on the use of seclusion, which takes into account patients’ dignity. DH: Facilities should have clear written policies on the use of restraint and physical interventions; all relevant staff should be aware of the policies; and policies should include provisions for post-‐incident reviews.

ACPG: 1.1 There is a written policy and procedure for seclusion, which is informed by the clinical guideline issued by the Chief Psychiatrist. 3) Statutory reporting requirements are achieved. ACPS: There is a policy on the use of seclusion, which takes into account patients’ dignity.


Canada Other US UK ANZ Monitoring and performance improvement

BC: 4.2 Policies and procedures are in place for documenting and reporting of critical incidents, including the evaluation conducted and follow-‐up steps initiated.

JCAHO2: TX.7.1.15 The organization collects data on the use of restraint and seclusion in order to monitor and improve its performance of processes that involve risks or may result in sentinel events. JCAHO3: PC.03.05.19: The [organization] reports deaths associated with the use of restraint and seclusion. APNA: Data are systematically collected on all incidents of seclusion and restraint to both monitor performance and guide improvement initiatives.

LP Practice Guideline: 18. Ward team reviews use of seclusion weekly.

Additional relevant AC standards, not specific to seclusion: Source Qmentum Program 2010 -‐ Standards Mental Health Services 15.6

REQUIRED ORGANIZATIONAL PRACTICE: The team implements verification processes and other checking systems for high-‐risk activities. Guidelines: Mental health teams follow established verification processes to reduce the risk of harm. Verification processes for high-‐risk activities, such as working with clients with dietary restrictions, including severe allergies in settings where patients may not be in touch with reality or suicidal, the use of seclusion or restraints, ordering and receiving results of critical tests, administering surgical or other invasive procedures, diagnostic testing, and administering medication are an effective method of protecting client safety. Tests for compliance: 15.6.1 The team has implemented verification processes for high-‐risk activities.

Patient safety area 4: worklife/workforce

Goal: Create a worklife and physical environment that supports the safe delivery of care/service. ROP: Develop and implement a client safety plan, and implement improvements to client safety as required. Tests for compliance: The organization assesses client safety issues. There is a plan and process in place to address identified client safety issues.

Patient safety area 4: Goal: Create a worklife and physical environment that supports the safe delivery of care/service.


Source Qmentum Program 2010 -‐ Standards worklife/workforce

ROP: Deliver client safety training and education at least annually to senior leaders, staff, service providers, and volunteers including education targeted to specific client safety focus areas. Test for compliance: There is annual client safety training, tailored to staff needs and the organization’s focus areas.

For mental health services only. Patient safety area 7: risk assessment

New goal: The organization identifies safety risks inherent in its client population. New ROP: The organization assesses and monitors client for risk of suicide. Tests for compliance: The organization assesses each client for risk of suicide at regular intervals, or as needs change. The organization identifies clients at risk of suicide. The organization addresses the clients immediate safety needs. The organization identifies treatment and monitoring strategies to ensure client safety. The organization documents the treatment and monitoring strategies in the client’s health record.


Appendix D: Six Core Strategies to Reduce the Use of Seclusion and Restraint in Inpatient Facilities©

Published in 2002 by the American National Association of State Mental Health Program Directors (NASMHPD), the six core strategies were developed via a thorough evidence review and consultation with national experts. The strategies are based on a public health disease prevention and health promotion approach to trauma-informed care, and focused on identifying risk factors for conflict and violence before they occur, along with any intervention strategies to immediately respond to conflict so that violence and the use of restraint and seclusion can be prevented (Haimowitz et al., 2006). Subsequent research suggests that the strategies are effective in reducing physical interventions (Azeem et al., 2011).

1. Leadership Toward Organizational Change. Reduction efforts require the commitment of senior leaders, and development of a specific plan spearheaded by leaders and involving consumers, family members, advocates, and staff. The plan should be based upon trauma-informed principles.

2. Use of Data to Inform Practice. Effective reduction efforts use facility data in a transparent, non-punitive manner to encourage change. Data on seclusion and restraint should be collected by unit, shift, day, and by staff member involved, then graphed and posted in all areas of the facility so that it is clearly visible for staff and patients.

3. Workforce Development. Efforts to reduce restraint and seclusion are most successful in facilities where policy, procedures, and practices are based on the principles of recovery and the characteristics of trauma-informed systems of care. The core strategies require that staff receive training to this effect and to resolve conflict. They also require facility leaders to develop policies that avoid the rigidity that can cause conflict on the unit, and empower staff to make in the moment decisions.

4. Use of Prevention Tools. Staff use clinical and other tools to prevent restraint and seclusion, including: assessments to identify patient’s risk for violence;


assessments to identify medical risk factors for death and injury; assessments to identify psychological risk factors and history of trauma; development with patients of de-escalation or safety plans; changes to physical environment; daily implementation of engaging treatment activities.

5. Supporting Consumer and Advocate Roles in Inpatient Settings. Include these stakeholders to send the message that recovery is real, that recovery happens. Administrators take steps to integrate mental health consumers and advocates into the inpatient environment.

6. Debriefing Tools. Debriefing serves two purposes: it provides information to inform policy and reduce future use of seclusion and restraint; and it addresses the adverse effects of these interventions on patients and staff. Debriefing follows a two-step process and includes the patient as an active participant.


Appendix E: Engagement Model Building patients’ sense of personal empowerment, control and accountability to the therapeutic community on the unit may prevent the types of emergencies that require seclusion, and help to foster patients’ coping skills when they sense their own behaviour escalating (Huckshorn, 2006; Visalli & McNasser, 2000; Johnson, 2010; Haimowitz et al., 2006; Mann-Poll et al., 2011; Mayers et al., 2010).

One means of doing this could be the engagement model. The model, which has been articulated as a method of reducing or eliminating restrictive interventions, is a multi-pronged, patient-centred, non-coercive framework that promotes patients’ accountability to the therapeutic community and ability to solve problems and reduce distress, and ensures that staff treat patients with respect, enable them to maintain their dignity, account for individual experiences of trauma, and emphasize each person’s potential for recovery (Azeem et al., 2011; Delaney, 2006; Borckhardt et al., 2007; Murphy & Bennington-Davis 2005).


Appendix F: Diagram of a seclusion suite


(Source: Curran et al., 2005)

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