The report is a product of the VA/HSR&D Evidence Synthesis Program.
Protocols to Reduce Seclusion in Inpatient Mental Health Units
Takeaway: Despite great interest from policymakers, staff, and patients for effective alternatives to seclusion for individuals with mental illness, there are limited data on the benefits of protocols designed to reduce seclusion in adult inpatient mental health wards. However, reducing the use of seclusion has the potential to align care that respects patients' rights and autonomy, as long as it does not increase the use of restraints.
In psychiatric inpatient settings, conflict behaviors such as patient aggression, agitation, and self-harm require immediate intervention to prevent physical and emotional injury to the patient, other patients, and staff. Seclusion is commonly used to manage conflict behaviors that place patients and staff at risk of immediate harm. Seclusion generally consists of involuntarily confining a patient alone in a restricted area until the patient’s conflict behaviors subside. A 2017 report commissioned by the Joint Commission found that VA hospitals use more seclusion than non-VA hospitals. In response to the report, VA’s Office of Mental Health and Suicide Prevention (OMHSP) developed a seclusion and restraint reduction toolkit, which was credited with a voluntary reduction in seclusion practices within the VA healthcare system.
The VA Evidence Synthesis Program (ESP) was asked by VA’s OMHSP for an evidence review on protocols to reduce seclusion practices for adults hospitalized in inpatient mental health units. VA’s ESP Center located at the VA Providence Healthcare System conducted this review. Investigators searched for peer-reviewed articles in Medline (via PubMed), Embase, the Cochrane Register of Clinical Trials, PsycINFO, CINAHL, cairn.info, and ClinicalTrials.gov from date of inception to September 6, 2022. Additional citations were identified from hand-searching reference lists of relevant systematic reviews and consultation with clinical experts.
Summary of Findings
From nearly 11,000 articles, investigators identified 37 protocols to reduce the practice of seclusion in psychiatric inpatient settings that were evaluated in a comparative design – and 6 protocols described without empirical data. Overall, the evidence base was limited, allowing at best low confidence conclusions.
Based on their analysis of protocols using a scheme of 9 intervention functions (education, persuasion, incentivization, pressure, training, restriction, environmental restructuring, modelling, and enablement), investigators categorized protocols into 5 groups, including:
- Hospital unit/restructuring
- Protocols involved implementing architecturally positive elements and restructuring the environment (i.e., in some cases, implementing an open-door policy).
- May reduce seclusion events and duration, restraint duration, and forced medication use (all with low confidence). The impact on restraint events was mixed across studies, and there was insufficient or no evidence regarding effects on composite measures of seclusion and restraint events, patient outcomes (e.g., aggressive incidents, injuries), or staff outcomes (e.g., injuries, satisfaction).
- Staff education/training
- Education/training interventions provided staff with de-escalation techniques and alternative strategies to seclusion. Common intervention functions across the described protocols were persuasion, education, training, or modelling.
- Staff education/training may reduce forced medication use and staff injuries (both low confidence). The impacts on seclusion events, restraint events, and a composite measure of seclusion and restraint were mixed across studies, and there was insufficient or no evidence regarding effects on seclusion duration, restraint duration, and patient outcomes.
- Sensory modulation
- Sensory modulation rooms involved creating a dedicated space in the unit to meet the multisensory needs of patients (i.e., intervention function environmental restructuring). Protocols describing sensory rooms also included elements of education, persuasion, enablement, and restrictions. Primary resource needs included space and equipment.
- Sensory modulation rooms may reduce seclusion events and forced medication use (low confidence) but may not reduce seclusion duration (low confidence). The impacts on restraint events, a composite measure of seclusion, restraint and forced medication, patient outcomes, and staff outcomes were mixed across studies, and there is insufficient or no evidence regarding effects on restraint events and restraint duration.
- Risk assessment and management protocols
- These protocols involved using a structured tool to help staff identify potentially aggressive patients to direct clinical efforts (e.g., de-escalation techniques). Protocols included intervention functions of environmental restructuring, education, and
- The Brøset Violence Checklist used as a risk assessment measure may reduce seclusion events and a composite measure of seclusion, restraint and forced medication – and may improve patient outcomes (low confidence). However, the checklist may not reduce restraint events and may increase restraint duration (both low confidence). The impact on seclusion duration was mixed across studies, and there was no evidence regarding forced medication use and staff outcomes.
- Investigator-developed risk assessment measures may reduce restraint events and restraint duration (low confidence) but may not reduce seclusion duration or staff outcomes (both low confidence). Their impact on seclusion events and patient outcomes was mixed across studies, and there was no evidence regarding composite measures of seclusion, restraint and forced medication use.
- Comprehensive mixed protocols
- Included intervention functions of education and Protocols often included elements of persuasion to reinforce staff education and environmental restructuring to change the physical or social context of the wards.
Reducing the use of seclusion has the potential to align care that respects patients’ rights and autonomy, as long as it does not increase the use of restraints and forced medication. However, at best, there was low confidence in the conclusions due to methodological limitations of the studies and sparseness of studies addressing most interventions. Thus, it is likely that future research may change some conclusions, and it remains unclear what specific interventions may be most effective. Nevertheless, these findings may generalize to VA, which is already implementing several strategies demonstrating reductions in seclusion.
A major limitation of the evidence was that all the studies relied on self-reported outcome data: staff were either the target or implementers of interventions – and were also the outcome observers. Further, in protocols with patient-directed interventions, they also implemented the intervention. Given that most interventions and quality improvement initiatives were explicit in their aims to reduce seclusion, it is feasible that staff could have either changed their behavior or measured their behavior differently to meet hospital or researcher expectations. Another important limitation of the evidence base was the sparse reporting of outcomes of interest to stakeholders; namely outcomes of patient aggression, patient and staff injuries, and patient and staff satisfaction. Another limitation of available evidence is inconsistent outcome reporting: some studies reported rates of seclusion per number of admissions, others reported raw counts of events, and others did not clearly specify units of time for duration-related outcomes.
Implications for VA
As VA continues to implement protocols to reduce the practice of seclusion, there are opportunities for system-level approaches to evaluate efforts. VA-wide improvement efforts have already been implemented towards standardized documentation in the electronic health record, such as the Violence Risk Assessment; further opportunities exist for reporting on seclusion events and the use of least restrictive means prior to seclusion. Once data are uniformly reported, frontline staff and leadership can evaluate trends and identify units with above/below average process and outcome measures. With standardizing measures, it is also possible for VA to conduct secondary database analyses to develop interventions to identify Veterans at high risk for seclusion or who exhibit conflict behaviors.
Most studies were observational and used data from the electronic medical records, but they did not account for potential confounding between groups. Future observational studies could account for confounders in their analyses by, at a minimum, conducting regression adjustment that includes patient characteristics that are also routinely captured in the electronic medical record. Studies should also make efforts to study effect modification based on demographics, diagnoses, or acuity.
For hospitals that are part of large systems, there are also opportunities to use electronic medical record data and quasi-experimental methods to compare units that do and do not implement interventions. Such larger studies should use more sophisticated methods to account for potential confounders (such as propensity score matching or inverse probability weighting). Reporting seclusion, restraint, and medication separately rather than as a combined outcome would allow decision-makers to understand the trade-offs between reducing seclusion and other interventions. Finally, studies should use standardized reporting guidelines to clearly document intervention elements.
Konnyu K, Quinn M, Primack J, et al. Evidence Brief: Protocols to Reduce Seclusion in Inpatient Mental Health Units: A Systematic Review. Washington, DC: Evidence Synthesis Program, Health Services Research and Development Service, Office of Research and Development, Department of Veterans Affairs. VA ESP Project #22-116; 2023.
To view the full report, go to: vaww.hsrd.research.va.gov/publications/esp/seclusion-mh.cfm (Intranet only)
ESP is currently soliciting review topics from the broader VA community. Nominations will be accepted electronically using the online Topic Submission Form. If your topic is selected for a synthesis, you will be contacted by an ESP Center to refine the questions and determine a timeline for the report.
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