Hawke’s Bay District Health Board leads the way towards zero seclusion

Hawke’s Bay District Health Board (DHB) is making great progress working toward eliminating seclusion.

In March 2018, district health boards (DHBs) were invited to take part in a national project from the Health Quality & Safety Commission (the Commission) and Te Pou o Te Whakaaro Nui (Te Pou) toward eliminating seclusion in mental health and addiction (MHA) care by 2020. The project is one of the five priority areas of the Commission’s national five-year MHA quality improvement programme.

At the time of the project launch, Dr Clive Bensemann, clinical lead of the MHA quality improvement programme, said seclusion was an aspect of mental health care practices that needed to change.

‘As well as causing trauma in itself, for some people seclusion can actually trigger the re-experience of past trauma and abuse,’

‘People deserve care that is without harm and without seclusion. We are confident the new approach will support providers to develop alternative pathways of care that are safe and effective for both consumers and staff.’

DHBs sought input from clinicians, consumers, whānau and families when reviewing current models of care and ways they could change. Monthly meetings were held between DHB mental health teams to share information and help work through challenges.

Hawke’s Bay DHB mental health nurse director and project sponsor Peta Rowden said, when initially presented with the project, the team got to work and made the decision early on to set a specific goal based around its most vulnerable consumers – Māori.

‘A large number of our consumers are Māori and reducing inequities is the key driver in what we’re doing, so we chose to narrow the focus to one that was achievable and realistic: Reducing seclusion on admission for Māori by 50 percent,’ says Peta.

‘If we were to make inroads toward reducing seclusion, we needed to review what we were doing, how we were doing it and why we were doing it. Speaking with Māori consumers who had been, or were still in our care, was absolutely key to making sense of this because we couldn’t begin to make changes to our models of care if we didn’t know what it was that we needed to change.’

The project was led by kaitakawaenga for mental health intensive services, Robbie Walker and police liaison clinical nurse specialist, Nikki Prendeville, who were instrumental in the research and review of the project.

Staff safety, de-escalation training and linking closely with stakeholders, such as police, was also key to building a picture of the current model and what needed to change.

‘Robbie and Cecily Miller-Heperi, consumer advisor (previously Whatever It Takes Trust, now with Hawke’s Bay DHB) met with eight Māori consumers who had been in our system and put into seclusion. They put in an incredible effort and the insight they received was key to the success of changing our model of care,’ says Peta.

‘Consumer stories painted a confronting picture for our team. They made us question our models of care and review the reasons we put people into seclusion in the first place.’

Between January 2017 and May 2018, Hawke’s Bay DHB secluded 109 patients in the inpatient unit. Seclusions on admission accounted for 40 patients (36 percent) of the total seclusions. Māori represented 27 (67 percent) of the seclusions on admission with 20 (50 percent) reported as being secluded due to an overactive, aggressive, disruptive or agitated behaviour with 18 also requiring police intervention or assistance.

‘Our seclusion statistics were among the highest shared by our DHB peers, so we delved into the data and started identifying how we could change practice.’

The project team worked with ward staff to create care plans without seclusion, that could be consistently implemented into normal practice.

To date, 98 percent of inpatient nursing and allied health staff have completed Safe Practice, Effective Communication (SPEC) training which focuses on de-escalation techniques and less restrictive practice. The project and its success so far can be attributed to ongoing SPEC training and application, and the support of nursing leadership on the ward. There has been a clear downward trend in seclusion events, the number of staff assaults and the use of restraint.

A police liaison role was also identified as a crucial component to better managing admissions or presentations when consumers arrived into DHB care via police.

Peta says the process has been liberating for many involved.

‘Identifying trigger points and ways to manage these prior to admission was also key to this work.’

Project leaders, and the Commission, paired up project teams from other DHBs to meet regularly and report on progress and/or discuss barriers or ways forward.

‘Being able to network when you’re working on something like this was hugely beneficial and allowed us to see the bigger picture of achieving a national target,’ says Peta.

What the team has achieved:

• 2019 was the lowest number of seclusion hours in 8 years for Hawke’s Bay DHB (1798 hours). This was a reduction from 2018 (2026 hours).
• Seclusion hours for Māori from 2016–19 reduced by over 900 hours.
• Seclusion hours for Pacific people reduced from 333 hours in 2016 to zero in 2019.

‘These outstanding achievements have correlated with a reduction in inpatient assaults on staff, but more importantly a reduction in harm related to assaults on staff,’ says David Warrington, MHA service director, Hawke’s Bay DHB.

‘This was achieved during what was a challenging year around capacity and demand, and new leadership. Our new target is 804 hours for this year which equates to 67 hours per month. This is a 50 percent reduction from 2019 and is a big challenge.’

The team will continue to:

• find ways for inpatient and community teams and police to work together more effectively to reduce the number of seclusions on admission for Māori
• regularly review whaiora (consumers) who are secluded on admission with a view to identifying improvements in their quality of care in the community
• regularly review care plans of whaiora with high rates of admissions to the inpatient unit
• work with community teams to reduce non-adherence with self-medicating whaiora.