Restrictive Interventions in Victorian Emergency Departments: What is really going on?

Associate Professor  Jonathan  Knott1,2, Associate Professor Marie Gerdtz1,2, Mrs Sheriden Dobson1,2, Dr Catherine Daniel1,2, Professor Andis Graundis3, Professor Biswadev Mitra4, Associate Professor Bruce Bartely5, Dr Pauline Chapman6
1The Royal Melbourne Hospital Emergency Department, Melbourne, Australia, 22 The University of Melbourne, Department of Medicine and Health Science , Melbourne, Australia, 3Dandenong Hospital, Emergency Department , Dandenong, Australia, 4The Alfred Hospital, Emergency & Trauma Centre , Melbourne, Australia, 5Geelong Hospital, Emergency Department, Geelong, Australia, 6Ballarat Hospital, Emergency Department, 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.

Sheriden Dobson is a Clinical Nurse Specialist at the Royal Melbourne Hospital specialising in Emergency.  She is enthusiastic and passionate about emergency medicine, trauma care, emergency preparedness and research.  Within the 7 years of nursing experience she has completed a graduate certificate in Emergency, and is currently completing her Masters of Advance Nursing Practice with the career ambition of becoming a Nurse Practitioner. Last year she was provided an opportunity to take on the role as a project officer for a research project, headed by the DHHS which is the topic of the Minor Thesis she is currently completing as well as the project being presented to ICEN.