Journal of Psychiatric Intensive Care

Journal of Psychiatric Intensive Care Vol.00 No.0:111 doi:10.1017/S1742646413000198 c NAPICU 2013 J

Review Article

Medical guidelines for PICU seclusion reviews

Vishal Bhavsar1, Faisil Sethi2, Bradley Hillier3
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ST4, South London and Maudsley NHS Foundation Trust; 2Consultant Psychiatrist, South London and Maudsley NHS Foundation Trust; 3Locum ST4-6, South London and Maudsley NHS Foundation Trust

Abstract
Evidence regarding medical practice in seclusion is limited, and far outweighed by opinion. Here, we present one approach to medical reviews of patients in seclusion rooms, aiming to drive consistent practice. We address the work of clinicians prior to their arrival in the seclusion area, information-gathering prior to entry into the seclusion room, relevant aspects of history-taking and mental state examination in the seclusion area, and the implications for clinical and risk-management. We discuss issues raised by the logistics of seclusion for the planning and undertaking of the consultation. Physical examinations of secluded patients are commonly complicated by patient-related and environment-related factors; we suggest a pragmatic approach to determining the scope of physical examination in seclusion. While risk assessments are a vital aspect of seclusion practice for psychiatrists, structured instruments for the assessment of risk within these environments do not exist. We lay out principles regarding risk assessment in this population. We comment on the role of the clinician in the debrief phase of the seclusion review, and deal with legal issues pertaining to seclusion in England. Ultimately, we are left with a number of questions relating to what constitutes best practice for psychiatrists fullling this role on the PICU.

Keywords
Seclusion; management; risk

INTRODUCTION The management of psychiatric patients in seclusion is common (Mason, 1994; Beer et al. 1997). Seclusion has been used throughout much of recorded human history to contain those suffering with mental disorder (Wells, 1972). Evidence of the coverage of seclusion arrangements is greater in the West than in the rest of the world, where data on the use of seclusion is more patchy (Beer et al. 2008). Literature on seclusion broadly breaks down
Correspondence to: Dr Vishal Bhavsar, Pyschosis Clinical Academic Group, Maudsley Hospital, London SE5 8AZ. E-mail: vishal.bhavsar@slam.nhs.uk

into investigations of the legal and ethical implications of the practice, the examination of the effects of seclusion on levels of violence in the inpatient setting, and the demographic proles of patient populations. In the UK, seclusion rooms are not located in every unit, However, all wards will have the capacity to transfer patients to seclusion rooms in situtations where violence is uncontainable on the ward. While local, trust-based protocols are available, national guidance on clinical management of secluded patients is sparse. NICE guidance on the management of violence notes that evidence on the effectiveness of physical interventions, including seclusion, is limited (National Institute for Health and Clinical Excellence, 2005).
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Guidance on what medical practitioners should be doing during seclusion reviews is absent. Most advice on the medical management of violence relates to prescribing in acute behavioural disturbance, a concept known as rapid tranquillisation (RT). The other aspect of the management of severely violent behaviour is the use of seclusion, which will be our concern in this article. No treatment of seclusion in any context can avoid discussion on whether seclusion can ever be justied. The pervasiveness of seclusion environments in psychiatric care indicates that this question should be approached carefully. The use of seclusion can be argued for in terms of consequentialist ethics (better consequences arise from conning a violent patient compared to not doing so), or evidence (the presence of a seclusion area within a service reduces violence or other negative outcomes). The lawfulness of seclusion, and in particular the departure of seclusion policy from the MHA Code of Practice, has been the subject of a number of legal cases heard by the Court of Appeal. Debates around the moral and ethical justiability of seclusion are long, winding and parallel those that surround psychiatry itself. So, while seclusion raises ethical and legal questions, in this article we will deal specically with the role of clinicians in the care of secluded patients. DEFINITIONS Denitions of seclusion have two components: the act of containment, and its purpose. Seclusion is usually dened as the restriction of a person alone in a locked room for the protection of others from signicant harm (Beer et al. 2008). The Code of Practice for the Mental Health Act (Code of Practice: Mental Health Act 1983) forms the most authoritative source of guidance on the use of seclusion. The Munjaz case (Munjaz v UK, 2012) established that departure from the Code was not lawful in the absence of cogent reasons; in this case, the treating hospital was held to have acted unlawfully in deviating from the Code in its seclusion policy. The Code dened seclusion as the supervised connement
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of a service user in a room, which may be locked. Its sole aim is to contain severely disturbed behaviour which is likely to cause harm to others. While the ruling related to a case in a high-secure setting, it emphasised the principle of not deviating from the Code of Practice without cogent reason, and that in appropriate circumstances the use of seclusion can be justied. The Code calls for the ready availability of a nurse at all times, including the need for the physical presence of a nurse with a patient who has been sedated. The Code also refers to other treatment models, such as therapeutic isolation and open supervised connement, under the banner of seclusion, indicating that these terms should never be used to deprive patients of the safeguards established for seclusion (Department of Health, 2008, para. 15.44). Seclusion can be regarded as a group of interventions designed to contain acutely disturbed behaviour that exposes other patients and staff to risk of serious harm. In this article, we focus on the review of patients being nursed in seclusion rooms; we will not consider other interventions for the management of acutely disturbed behaviour such as time-out, zoning, nursing in the extra care area (ECA), therapeutic isolation, and open supervised connement. Seclusion reviews tend to share a number of features. They usually follow violent incidents, and are accompanied by ongoing processes of risk assessment and incident management. Many seclusion reviews take place out-of-hours, and clinicians called to attend reviews usually do so as part of out-of-hours work. The seclusion review is among the rst experiences many trainee psychiatrists have of multi-disciplinary management of acutely unwell patients. They are one of the few patient engagements in the psychiatric hospital that are always undertaken by a multi-disciplinary care team, rather than by one or two individuals. The seclusion review will be focussed on the assessment of behaviour and mental state, and on an interview recalling a violent risk incident. We divide the process into the information gathering phase, the examination of mental state, the assessment of physical status, the assessment of risk and the debrief. We conclude by making
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Figure 1. (Colour online) The seclusion review process

some points about the psychiatrists role in team decision-making. Our approach is laid out in Figure 1. A WORD ON LOGISTICS A multi-disciplinary team (MDT) is dened as a group of health workers, from varied professional backgrounds, brought together to plan and deliver coordinated health care interventions for patients with complex medical conditions. The seclusion review team consists of a team leader, usually an experienced psychiatric nurse, together with a reviewing clinician, a number of other nurses, and occasionally health care assistants trained in control and restraint techniques. Given the limited evidence on seclusion, the practice of the MDT around seclusion seems to vary greatly between, and possibly within, centres. Most policies describe a timetable for scheduling regular reviews of secluded patients, aiming to review the patients clinical state, and whether criteria for seclusion continue to be met. An example of a review schedule is shown in Figure 2; this presents a framework for the scheduling of senior reviews at regular intervals. The escalation of clinical reviews to clinical leads or managers is not uncommon, particularly in cases where seclusion continues for more than 24 hours. In high secure forensic settings for example, longer term seclusion is necessary for a small group of patients. Staff on the review team should be appropriately trained and refreshed in
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the practice of up-to-date physical interventions for the management of disturbed behaviour, and in emergency resuscitation techniques. Seclusion reviews usually involve, in a stepwise fashion: an explanation to the patient of what is about to happen; the entry into the seclusion room of the review team; the securing of the patient in holds; an explanation of what will happen next; the measurement of vital signs; the medical interview; the administration of medication; the provision of food and drink to the patient; a further explanation of what will happen next; and nally the exit of the review team from the room. There will then follow a discussion amongst the members of the review team about the appropriate course of action, a debrief, and a recording of events. There are some points to be made about planning and preparation. The team of professionals identied to conduct the seclusion review, or the review team, would not usually be resident on the ward; arrangements should be made to bring this team together in a timely fashion (Department of Health, 2008, para. 15.50). Levels of training in physical restraint techniques are likely to vary within the team and will inuence discussions of who does what, when. Gathering information from the staff in a calm environment, away from the clinical area, usually proves benecial. The individual roles of the members of the review team should be clearly assigned in advance. If a face-to-face review is
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30 minutes

Initiation

Hour 10

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Nursing Review Junior Medical Review Senior Medical Review Consultant Review

Figure 2. Seclusion review pathway

taking place, who will actually enter the room, and who will be responsible for securing the patient in the relevant holds? Will a nurse conduct an initial conversation with the patient, followed by the clinician, or will the clinician begin the discussion? When is the physical examination to take place? Is the physical examination likely to require assistance from another professional? Usually, the senior nurse will be responsible for these decisions. The reviewing clinician will need to ensure that the patient has a clear grasp of these matters before the review happens.

The reviewing clinician should note the interventions that have failed and resulted in transfer to seclusion. Changes in the frequency of periodic assessment of behaviour mental state and risk by nursing staff (nursing observations) could reect changes in the patients condition over time. Typical management responses to behavioural disturbance would be an increased frequency of nursing observations, or the commencement of continuous face-to-face observations, or one-to-one. Increased observations can involve unacceptable risks of harm to staff, with whom relationships with the patient may have broken down. Changing a violent persons status to continuous observaINFORMATION GATHERING tions by a single staff member requires an Professionals conducting seclusion reviews have appropriate risk assessment contingent on the a number of information-gathering skills at their nature and extent of violent behaviour, as well as disposal. Identifying the reason for the patient the characteristics of the ward and of the being in seclusion should be high amongst the putative observer. Gathering background inforconcerns: why have other approaches failed? mation on the patient and the reasons for Patients may have advance statements recorded seclusion should be done in a timely manner, in their clinical notes indicating a wish to be and guided by evidence of risk to others, given nursed in a particular way, with respect to that this is likely to be the main area for medication and restraint. Decisions will need to assessment. be made after taking into account factors The reviewing clinician should evaluate the relating to the patients general health. For example, pregnancy or haemodynamic compro- ward staff s emotional response to the patient, mise will have great implications for behavioural and to prepare themselves for what follows. management, and the balance between physical Psychiatric intensive care units are emotionally and pharmacological management of agitated charged, highly active units where antagonism behaviour. Other patient-related factors include and aggression may be frequent, aspects which communication impairments or language differ- compound uncertainties regarding stafng and ences, which can present barriers to effective resource limitations. The social and affective milieu around the patient needs to be assessed de-escalation techniques.
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through discussions with the medical and nursing team, who are likely to display feelings of anger, hopelessness, perhaps against a background of declining morale. No health professional reacts in the same way to a given scenario, and the responses of the care team to the patient will depend on the professionals previous experiences, gender, training and other factors. Team members often react in starkly different ways to a patient, leading to different views on what to do. On occasion, a team appears divided, along disciplinary or other lines, and this needs to be pointed out. The reviewing clinician should take stock of these responses and the impact these are having on patient care, in order to adopt an approach that is as patient-centred as possible. The relationship between the care team and the patient will be shaped by the patients personality; patients with borderline features may engender splits within the team, for example on the basis of gender or ethnicity. Team members can begin to feel themselves responsible for a patients situation; it is not uncommon for clinicians to interpret these feelings as a reection of underlying projective mechanisms emanating from the patient. MENTAL STATE REVIEW In this section we cover aspects of the mental state which are of particular signicance during seclusion reviews. The priority is to try to have some sort of therapeutic engagement with the patient. In dealing with the role of the mental state examination framework in reviewing secluded patients, we are guided by four main provisions. Firstly, it is unlikely that the mental state examination one carries out will be full in any real respect. Experience suggests that most, if not all, mental state examinations are driven by a need to do the maximum that the patient will tolerate, or the maximum which is safe for the multi-disciplinary team, without losing therapeutic engagement. A certain amount of exibility is necessary. Second comes the question of how representative the mental state assessment will be of the underlying mental illness (seclusions can cause high levels of distress
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in and of themselves) mental state assessments undertaken in seclusion should be contextualised in this regard. Thus, much of the evidence for a mental state review should derive from observations of behaviour and mental status outside the period of review itself. Thirdly, it is impossible to disentangle the assessment of mental signs and symptoms from the impact that those have on the risk of violence. As such, we will refer frequently to the risk implications of certain mental phenomena. Such discussions are a matter for conjecture to some degree, and there are no hard rules, or even, in many cases, good evidence. Finally, while the approach of a mental state examination should be to investigate the reasons for a patients distress, this ought to be done from an empathic base, as an attempt to understand the patients experience; in particular, care should be taken to avoid focussing entirely on the incident, which will interfere with any useful gathering of information on affect. Indeed, the clinician will have to negotiate a signicant feeling of injustice coming from the patient. Appearance & behaviour States of undress, or inappropriate dress, can reect the patients mental state and should have a bearing on care planning. Signs of physical injury and ripped clothing related to previous violence should be recorded. A good assessment of a patients appearance and behaviour should incorporate an evaluation of aspects related to the patients dignity, given the limitations to their freedom. Physical build should be noted, so as to guide the assessment and management of violence; physically strong patients can warrant different procedures by the review team. Restlessness and physical arousal ought to be recorded; a patient who cannot keep still is likely to pace around the ward, make repeated demands and intrude into other patients affairs. Behaviour should be assessed longitudinally as well; a patient moving straight to the door to prevent the team from entering the room could be extremely fearful, or present risks to himself.
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Excretions in the seclusion room are not uncommon, and their intention and physical context (constipation, infection and diet) should be assessed; deliberate defecation in the seclusion room might be conceptualised as exertion of control in an environment where all control has been removed from the patient. Mood and affect The assessment of mood and affect in seclusion can be straightforward; a threatening attitude, anger and hostility are common among secluded patients. A key objective of the medical review should be to identify how these phenomena are related to the violence that precipitated the transfer into seclusion. Hostile, angry, externalising engagement over recent events on the ward might be more comforting for a reviewing clinician than a withdrawn patient with whom it is difcult to have a conversation, although such impressions should be formed in the context of the patients known risk factors. The role of anger in inuencing violent behaviour should be distinguished from other elements of the mental state. On its own, anger is not necessarily pathological, and serves psychological functions, for example in motivating corrective behaviours, facilitating persistence at relevant tasks, and aiding the expression of negative sentiments. In epidemiological studies, anger is predictive of violence before, during and after psychiatric admissions (Otto, 2000; Douglas et al. 1999). As part of the mental state assessment of a patient at risk of being violent, the role of anger should be carefully claried. Anger in psychotic disorder for example, emerges secondary to paranoid delusions about others. Command hallucinations to harm others have been associated with violence in some studies (Rogers et al. 1990; Junginger, 1990); threat/control override symptoms, where a patient experiences a level of threat that overrides internal proscriptions to violence, also raise the risk of violence during psychosis. In this regard, the reviewing clinician should assess the level of threat the patient experiences on the ward, and how this changed during the incident.
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In assessing the relationship between mental state, anger and violence, the assessment of personality traits is valuable. Personality features from the cluster B group of personality disorders (antisocial, borderline and narcissistic types) are particularly relevant. Violence emanating from anger as part of borderline personality organisations requires consistent, highly structured management and careful attention to previous management plans (National Institute for Health and Clinical Excellence, 2009). Attempts should be made to identify the effect of seclusion on mood disturbance; is the patient low in mood because of their connement? Affective instability and the presence of a fearful affect point towards the possibility of further violence. Speech A patients speech should be assessed for features that relate not only to the mental state (classical formal thought disorder, or loud rapid speech that maintains variations in tone and pitch), but also to the risk of violence. Experience suggests that some patients choose to express anger in the form of loud, abusive rudeness. Slurred speech may indicate an overmedicated patient. Communication which is impaired by formal thought disorder or by the side- effects of medication may render the patient vulnerable to further altercations with other unwell patients. Perception A patient who is distracted by disturbances in perception, with whom it is impossible to converse, is more difcult to review. Behaviour consistent with auditory hallucinations indicates a need for a review of the diagnosis and management plan. In particular the effects of such psychopathology on behaviour should be assessed: does the patient look behind them from time to time, as if looking for the source of his experiences, or is he able to maintain his focus throughout the interview? Whilst data on the link between command hallucinations and violence is equivocal (McNiel et al. 2000; Rogers et al. 2002), such phenomena ought to
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Medical guidelines for PICU seclusion reviews

be noted. Active psychosis, quite apart from command hallucinations, displays an association with violence (Mullen, 2006). Thought content Delusional beliefs are a key feature of the mental state to be clearly ascertained. Screening for delusional beliefs will be carried out during history-taking from the patient about the incident(s) which led to the seclusion. However, an assessment of delusional belief should go beyond identifying a falsely-held paranoid belief; assessment should be made of the extension of the belief into the patients life, including other, non-violent effects of the belief on the patients behaviour; for example, the avoidance of food and water. Delusions involving other individuals, such as the patients family, peers on the ward, or the ward staff have a bearing on risk assessment and management planning. Thought content assessment should also involve evaluation of obsessional beliefs, over-valued ideas and beliefs relating to the events which resulted in the initiation of seclusion.

Insight The assessment of insight in seclusion can be approached in two ways. On the one hand, elaborating the patients insight into the events preceding seclusion should reveal aspects relating the patients views of their condition, treatment and their relationships on the ward. Alternatively, an approach which contextualises the trigger incident in wider issues, such as the patients longer term state of mind, engagement with treatment, and behaviour, could stand a greater chance of maintaining engagement with the patient. What is the patients understanding of the reasons for his admission, and for his transfer to the seclusion? Having gathered the patients account of the incident(s) that led to the seclusion, does he share the teams views on what happened? Does the patient have alternative suggestions for action, and how realistic are these?

The reviewing clinician should monitor the impact of these discussions on the patients mental state; a patient who calmly gives his account and even shows some appreciation of other possible points of view, plainly displays healthier insight that one who begins the interview calmly but who becomes angry and agitated on discussion of Orientation the trigger incident. The patients view of events The assessment of orientation in time, place and should be recorded, as should his thoughts on person, as well as providing signicant evidence how treatment planning should proceed in the for the assessment of the patients mental state future. The ability to successfully undertake a and response to medications, offers the oppor- two-way dialogue in the seclusion room, however tunity for straightforward non-confrontational articial it appears, is one of the few tests of social exchanges with the patient, in contrast to functioning that is conducted with a patient in questions about paranoid ideas or bizarre this environment. psychotic phenomena. Cognitive functioning has a bearing on the aetiology of violence and risks of further violent behaviour. For example, PHYSICAL EXAMINATION the misidentication of staff in the context of delirium should point towards a careful assess- The key question in driving the physical ment of their physical status, and urgent examination should be: what is relevant and safe treatment of the organic cause. In any case, the to do within the space, time and risk constraints differential diagnosis of an organic confusional offered by the seclusion review? Clearly none of state should be noted and considered together what follows can replace the exercise of clinical with the patients physical status. As in other judgement based on experience. However, it is settings, the assessment of orientation should be possible to suggest pointers for the exercise of approached with care; direct, closed questioning physical assessments in seclusion. Firstly, at no of a secluded patient with do you know where stage should the physical safety of any member of you are? may elicit an unintended and unhelpful the review team be compromised by the process response. of carrying out a physical; if a patient requires
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an abdominal examination urgently, then is seclusion the right place for them to be? The inevitable limitation to the physical examination must lead to increased focus on ancillary assessments of physical status. Prior to entry into the seclusion area, notes and charts recording food and uid intake and excretions should be reviewed alongside the nursing notes describing the patients mental state and behaviour. A secluded patient will usually have had a series of vital signs taken at 2-hourly intervals, which should be reviewed. A record of medicines administered in the previous 72 hours will contextualise the assessment. It will be necessary to note results of any recent physical investigations; for example, ECGs, blood tests, urine drug screens and the results of the most recent physical examination. Knowledge of co-existing medical conditions, both arising from the violent incident and existing independently, will help to guide care planning. Alertness should be assessed alongside a careful review of medicines administered both regularly and as necessary, in order to assess both the need for greater levels of anxiolysis to manage violence, and the need for tapering medicines because of unwanted sedation. Sleep pattern should be assessed with this background, as should changes in libido. Given that secluded patients are frequently the most medicated patients in the psychiatric hospital, serious adverse effects, both long and short term need to be looked for carefully, alongside the treatment chart. It is possible to carry out an assessment for most dystonias and respiratory depression without touching the patient directly, if necessary. At the same time, managing a patient in seclusion should not stand in the way of undertaking the physical health screening that is routine for psychiatric in patients. The rst step for patients who refuse all contact with the reviewing clinician, should be to encourage them to allow recording of their physical observations. The level of cooperation with physical examination and investigations is an excellent indicator of the patients engagement; a patient who readily cooperates with a complete physical and an ECG, for example, is
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unlikely to warrant seclusion for much longer. As with any area of medicine, a more complete physical assessment involving history, examination and investigations will reduce the index of suspicion around the patients condition. Situations where a secluded patient becomes acutely and seriously medically unwell are not uncommon, but understandably occasion great anxiety among reviewing clinicians. Decisions regarding behavioural management, prescribing and consent become even more challenging on these occasions. In general, three scenarios present themselves. Where a patient is not fully compliant with the physical review, and where there are no urgent concerns, the patient should be reviewed regularly by the review as per local protocols. Urgent review should be arranged where new concerns about a patients physical condition arise. Where a patient is fully compliant with the physical assessment, but there remains an indication for ongoing seclusion, then regular reviews should proceed as normal, unless new urgent physical concerns emerge, which should bring about an urgent review. Finally, any patient who requires immediate attention in an acute medical setting, including the emergency department or ICU, should be transferred as soon as possible, after an assessment of their capacity to consent to the management plan. Finally, entering into some sort of conversation about the future with the patient, usually towards the end of the review, is inevitable. These interchanges should be tackled dispassionately; the patients views should be noted alongside those of the team in order to formulate the management plan. RISK ASSESSMENT As with any risk assessment in psychiatry, assessing risk in seclusion rests on certain assumptions. For example, it is assumed that it is possible to predict future behaviour on the basis of known facts about the case and the consistency of an individuals behaviour over time. Risk assessment tools like the HCR-20 emphasise historical risk items. However, it would be wise to remember that a persons
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behavioural strategies change over time, and a persons response to circumstances ten years ago may not necessarily be the same as in the present, particularly in light of therapeutic interventions. Structured methods for the assessment of risk in seclusion do not exist to our knowledge. However, structured risk assessment instruments for inpatient units usually score previous violence in terms of severity, include violence towards property as well as to the person, and generate an overall score at the end. We recommend that a sensible risk assessment in seclusion should proceed in a similar fashion to other situations in the intensive care unit; in other words, taking account historical and current risks, and static together with dynamic factors. Recent incidents of violence should be recorded and understood in terms of precipitants, triggers, contexts, alleviating and exacerbating factors, and so on. Violent incidents precipitating seclusion may be analysed using an ABC technique, by noting antecedents to violence, the behaviour itself and the consequences for the patient, in order to assess whether possible antecedents remain, and therefore evaluate the potential for further violence. It is likely that a secluded patient has been violent already. Given this, acute management in seclusion will probably not result in the elimination of all risk. In particular, the patient may display behaviours which present real risks to himself, for example head banging (in the context of psychosis, a disorder of personality, or a protest at his containment). Risky behaviour can persist despite the best efforts of the care team and the environmental safety interventions. Despite the increased procedural, physical, and relational security offered by the seclusion room, there remains the potential for ligatures and sharp blades to be concealed and brought into the room and used to inict self-harm, damage to the seclusion room itself and cause harm to others. In situations where substance misuse has been identied as a trigger for an escalation of aggressive behaviour, the seclusion review often affords the rst opportunity for assessment for intoxication and withdrawal. The seclusion review can also be useful as an arena for the
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assessment for the side-effects of increasing doses of psychotropic medication. Further, removing the patient from the open ward could allow a safer investigation into the procedures and policy that led to the incidents, where relevant. It will be necessary to review how the patient has coped and behaved in the context of institutional containment and seclusion and connement in the past. Formulating risk in terms of nature (risk of what), extent (how big is the risk), direction (risk to whom or what), alleviating and exacerbating factors, and contingencies for the risk being realised, is useful. The scheduling of regular seclusion reviews should form an active part of the management of risk, offering an opportunity for regular review of treatment, and of concordance with treatment plans. The seclusion review cycle should also provide a structure for seeking the opinions of colleagues. Given the key role of information quality in forming a good impression of risks, assessing the patients engagement with interview is especially relevant; the accessibility of the patients internal world must be commented upon, to give an idea of how reliable the risk assessment might be. Potential victims of violence should also be considered. If there was a victim involved in previous aggressive behaviour, is that person at risk currently and how might this risk be reduced, for example by outward transfer to another ward? Patients with cognitive impairment, challenging behaviour, or limited social skills should be regarded as especially vulnerable. THE DEBRIEF The above sections (information gathering, mental state assessment, physical assessment, risk assessment) will not be addressed purely in sequence; in practice these will occur in parallel. At the conclusion of the seclusion review, a discussion, or debrief, should take place among the multi-disciplinary team. In our experience, it is most helpful to separate the emotional, transference-oriented debrief part of the discussion from the decision making part to avoid frank mixture of the emotional responses and the decision making process itself. The clinician
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Date and Time of Medical review with MDT: Name of patient (DOB): PICU admission date: Date and time of initiation of seclusion: Indications for initiation of seclusion: Nursing Report pre-review: Mental State Examination: Physical status: Risk assessment: MDT discussion: Diagnosis and current concerns: Need for ongoing seclusion: Impression of clinical and risk management: PLAN 1. Decision and termination 2. Step-down planning 3. Medication changes 4. Physical monitoring/care 5. Risk monitoring 6. Liaison (family, nursing team, police/legal, social worker, second opinions, collateral sources) 7. Note time frame for the next review

Figure 3. An example format for the documentation of seclusion reviews

should feel able to comment on countertransference processes occurring within the review team. Jagarlamudi et al. (2012) pointed out that such responses are common on intensive care units. The care teams experiences of intense feelings of inadequacy, frustration, and anger around a secluded patients care should be commented upon, where relevant. For the clinicians themselves, discussing their emotional responses to the patient under review will also be benecial; the clinician should be able to comment on transference/counter-transference explanations for the responses of the review team to the patient, and the patients behaviour. Of course, it is also possible that members of nursing staff may have experience of commenting on interpersonal dynamics and transference issues, but this should not be assumed. The diagnosis and effects of treatment should be reviewed in this setting. THE TERMINATION OF SECLUSION Discussions during the review will tend to revolve around whether seclusion should be terminated or not. Where a decision is made by
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the review team that the patient no longer meets criteria for being cared for in seclusion, the decision to end may be relayed to the patient via any member of the review team. It is often appropriate to instigate a step-down management plan, which could constitute a period of intermittent observations, a segregation plan to a particular section of the ward, or a behavioural contract. Making a decision to end seclusion must be done as a team, and appropriate space must be given to contrary views, and to those of professionals who may have particular experience of that patient, or of the particular factors involved. No decision should be made without taking into account background factors that may not be patient-related; for example: has the nursing staff composition changed to a more favourable one; are there more staff available now, so that step-down to 2:1 observations is possible and safe; has the patient population changed, so that further altercations are much less likely? Finally, it is often wise to trial the termination of seclusion, where appropriate processes have been followed, where re-initiation of seclusion is easily available. The serial failure of seclusion and other measures to reduce violence should lead to consideration of onward referral to low secure or forensic services.
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Medical guidelines for PICU seclusion reviews

DOCUMENTING THE SECLUSION REVIEW Clear, consistent and thorough documentation of the encounter is pivotal in a setting where risk issues predominate, where the multidisciplinary team changes frequently with shift patterns, and where complex decisions need to be made. In Figure 3 we lay out one example of how a seclusion review might be documented. Such a framework could also be used in the form of an electronic document. CONCLUSIONS In reality, on-call clinicians will arrive in the seclusion area with a number of competing considerations to do with patient care, resources, staff safety, and the management of their own anxiety, fear and workload. The circumstances, no matter how much structured knowledge they enter the situation with, will be dynamic and require considerable exibility. Factors will be in play that the on-call clinician will know nothing about, not being part of the regular clinical team. How to behave clinically in this scenario, particularly when more junior, may be a subject of some worry for core trainees. It is hoped that the framework presented here provides a starting point for approaching these scenarios in a structured, safe, and patientcentred way. We are reminded that the evidence on which we base our practice in this area is lacking on a number of levels; from the utility of seclusion in general, to the appropriateness of seclusion in given patient scenarios, to comprehensive risk assessments, to the paucity of data on the right way to do things in seclusion, and remains a central area for future research in psychiatric intensive care units. Instruments for the formal assessment of risk to others in seclusion have not been tested, and current seclusion policies appear to rely on common sense rather than empirical evidence. For the trainee, discussion of seclusion reviews in clinical supervision and Balint groups should guide the development of clinical experience in this area of mental health inpatient work.

References
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