Associate Professor Jonathan Knott1,2, Associate Professor Marie Gerdtz1,2, Mrs Sheriden Dobson1,2, Dr Catherine Daniel1,2, Professor Andis Gaundis3, Professor Biswadev Mitra4, Associate Professor Bruce Bartley5, Dr Pauline Chapman6
1The Royal Melbourne Hospital, Melbourne, Australia, 2University of Melbourne, Parkville, Australia, 3Dandenong Hospital, Dandenong, Australia, 4The Alfred Hospital, Melbourne, Australia, 5Geelong Hospital, Geelong, Australia, 6Ballarat Hospital, Ballarat, Australia
Aim: To describe the restrictive interventions that occur in Emergency Departments (EDs) in Victoria, Australia.
Methods: A multicentre retrospective study involving five EDs collated data on all patients who attended in 2016 including the rate of security calls for threats to self, patients or staff, and any restrictive interventions used. This included physical, mechanical restraint, and chemical sedation. From each site, 100 patients who had a restrictive intervention were randomly identified and data extracted from the medical record.
The primary aim was to determine rates of restrictive interventions. Secondary aims were to ascertain rates of security codes, whether patients were being contained under the Mental Health Act or under a Duty of Care, and to examine patient outcomes.
Results: In 2016, of the 327 454 patients presented to the five EDs, 3 871 had at least one security code (1.5%). Within the population that had a security code, 942 had at least one restrictive intervention (22.7%). Details were extracted on 494 patients. The majority (62.8%) were restrained under a Duty of Care and not the Mental Health Act. Physical restraint was used for 165 (33.4%) patients, 296 were mechanically restrained (59.9%, median length of restraint 180 minutes IQR: 75-360), and 388 chemically restrained (78.5%).
Approximately half the patients were discharged home or to an ED observation ward, only 81 (16.4%) were admitted to a mental health facility.
Conclusion: Restrictive interventions in the ED are largely occurring under a Duty of Care and only a minority of patients will be admitted to a mental health ward. Care for patients managed under legislation that covers assessment and treatment of mental illness has a strong clinical governance framework, however this will not be the case for the majority of patients who experience restraint in Victorian EDs.
Key Words: Duty of Care (DOC), Victorian Mental Health Act 2014, Restraint
Dr Cathy Daniel has both a clinical and academic role. She is a Consultation Liaison Psychiatry at The Royal Melbourne Hospital and works casually on PACER. She has completed a Masters Research Degree in minimising mechanical restraint in acute health in 2010. In 2015 she completed a PhD at The University of Melbourne that explored how the how the risk of violence can be accurately identified at ED triage. Cathy is also a Mental Health lecturer and the Coordinator of Post Graduate Mental Health Nursing at The University of Melbourne.