Chief Psychiatrist Standard:
Compliance is mandatory
Restraint and Seclusion Recording and Reporting Chief
Psychiatrist Standard
Objective file number: 2013-01674
Document classification: PUBLIC: I1-A1
Document developed by: Office of the Chief Psychiatrist
Approved by the Minister for Mental Health and Substance Abuse: 30 July 2015
Next review due: 30 July 2017

Compliance with this Chief Psychiatrist Standard is mandated under section 90 of the
Mental Health Act 2009.

Version control and change history
Version Date from Date to Amendment
1.0 30/07/15 current Original version

Summary The Restraint and Seclusion Recording and Reporting Chief
Psychiatrist Standard outlines the requirements of health
services to record information and make notifications to the
Office of the Chief Psychiatrist, to enable the monitoring of
the use of restraint and seclusion.

Keywords Restraint, Seclusion, Reporting, Recording, Notification, Chief
Psychiatrist Standard, Incident, SLS, EPAS, Physical Restraint,
Chemical Restraint

Policy history Is this a new policy? Y
Does this policy amend or update an existing policy? N
Does this policy replace an existing policy? N
If so, which policies?

Applies to All Health Networks

Staff impacted All Clinical, Medical, Nursing, Allied Health, Emergency, Dental,
Mental Health, Pathology

EPAS compatible Yes

Registered with Divisional Policy
Contact Officer

Policy doc reference no. S0003

Restraint and Seclusion
Recording and Reporting

Chief Psychiatrist Standard

Document control information

Document owner Chief Psychiatrist, Office of the Chief Psychiatrist

Contributors Chief Psychiatrist, Office of the Chief Psychiatrist

Document Classification PUBLIC: I1-A1

Document location
SA Health internet policies page , mental health policies

SA Health intranet policies page

Reference

Valid from 30/07/2015 Approval by Minister

Anticipated Date of Review 30/07/2017

Document history

Date Version Who approved New/Revised Version Reason for Change

30/07/2015 V.1 Minister for Mental Health and Substance Abuse Minister Approved Version

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Contents Page

1. Objective .............................................................................................................................. 4
2. Scope ................................................................................................................................... 4
3. Principles .............................................................................................................................. 4
4. Detail .................................................................................................................................... 4
5. Roles and Responsibilities ................................................................................................... 5

5.1 Health services staff .................................................................................................. 5
5.2 Service Managers ...................................................................................................... 5
5.3 Office of the Chief Psychiatrist staff ........................................................................... 5

6. Reporting .............................................................................................................................. 5
7. EPAS .................................................................................................................................... 6
8. Exemption ............................................................................................................................ 6
9. National Safety and Quality Health Service Standards ....................................................... 6
10. Risk Management ................................................................................................................ 6
11. Evaluation ............................................................................................................................ 6
12. Definitions ............................................................................................................................ 7
13. Associated Policy Directives / Policy Guidelines ................................................................. 7
14. References, Resources and Related Documents................................................................ 8

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Restraint and Seclusion Recording and
Reporting Chief Psychiatrist Standard

1. Objective

Sections 90(1)(b) and 98(2)(c) of the Mental Health Act 2009 (the Act) require the Chief
Psychiatrist to monitor the use of mechanical body restraints and seclusion in relation to
voluntary and involuntary patients and for health services to keep records of the use of
mechanical body restraints and seclusion.

The purpose of this Standard is to outline the requirements of health services to record
information and make notifications to the Office of the Chief Psychiatrist and Mental
Health Policy (OCPP), to enable the monitoring of the use of restraint and seclusion.

2. Scope

This Standard applies to all SA Health, Mental Health Service settings and is relevant to
all SA Health staff providing services to people with an experience of mental illness and
their support person/s across the age spectrum.

3. Principles

The Act contains a set of Guiding Principles which are designed to provide guidance to
everyone involved in the administration of the Act. These principles should assist health
professionals in decision-making and undertaking actions.

The observation of consumers being restrained or secluded is guided by sections 7(1)(b),
(h) and (g) of the Act which require that services should be provided on a voluntary basis
as far as possible and in the least restrictive way and environment; mechanical body
restraints and seclusion must only be used as a last resort; and medication should not be
used as punishment or for the convenience of others.

4. Detail

All incidents of restraint or seclusion are to be entered on the Safety Learning System and
any other relevant electronic database system.

Incidents of restraint and seclusion considered a critical incident (see Part 12
Definitions), these incidents will be automatically notified to the OCP via the SLS system.
An additional report is required by the OCP within one business day and is located on
the OCP website as part of the Restraint and Seclusion Policy Guidelines Toolkit entitled
Restraint and Seclusion Reporting on Page 8.

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5. Roles and Responsibilities

5.1 Health services staff

It is the responsibility of health service staff involved in the care of people with a mental
illness to:

&gt; Comply with the requirements of this Standard.
&gt; Reduce and where possible eliminate the use of restraint and seclusion.
&gt; Ensure a record of restraint and seclusion incidents, including the name, age,

gender, ethnicity, diagnosis, type of restraint used, time applied and removed,
attempted preventative interventions, medical review, direct visual observations,
post incident follow up and all relevant documentation is completed.

&gt; Enter incidents of restraint and seclusion on the Safety Learning System, ensuring
less than 1 hour is a SAC 4 event, less than or equal to 4 hours is a SAC 3, more
than 4 hours, is a SAC 2 and an incident over 8 hours or resulting in harm to any
person, is a SAC 1 event.

&gt; Critical Incidents are any incident of restraint or seclusion where the consumer or
staff were injured, the incident lasted more than 12 hours or intubation was utilised
in the process of sedation for the management of challenging behaviours.

5.2 Service Managers

It is the responsibility of Service Managers to:

&gt; Ensure procedures outline what staff can do to prevent or minimise the use of
restraint and seclusion, ensuring it is used only as an option of last resort.

&gt; Establish local review processes to monitor and review incidents with a focus on
reduction and elimination of restraint and seclusion.

&gt; Ensure staff have access to required systems to report incidents.
&gt; Ensure local procedures include how to escalate the reporting process.
&gt; Ensure compliance with this standard across the LHN.

5.3 Office of the Chief Psychiatrist staff

It is the responsibility of the OCPP to:

&gt; Report quarterly to the Local Health Networks and private hospitals on the use of
restraint and seclusion across all networks.

&gt; Include data on the use of restraint and seclusion in the annual report to the
Minister for Health and Aging for tabling in Parliament.

&gt; Provide information annually to the Estimates Committee Hearing.
&gt; Nominate a system for state-wide data collection.
&gt; Provide data for national reporting requirements.

6. Reporting

See Part 4.

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7. EPAS

Restraint and Seclusion is recorded as part of the electronic record which is built in to
EPAS.

Any incidents of Restraint or Seclusion are also entered in to the Safety Learning System
as a matter of process.

8. Exemption

No exemption allowed for this policy directive.

9. National Safety and Quality Health Service
Standards

The Australian Commission on Safety and Quality in Health Care has developed 10
National Safety and Quality Health Service Standards (the Standards).

The Standards provide a nationally consistent and uniform set of measures of safety and
quality for application across a wide variety of health care services. They propose
evidence-based improvement strategies to deal with gaps between current and best
practice outcomes that affect a large number of patients.

This policy guideline contributes to the standards in the following way:

National
Standard 1

Governance

for Safety
and Quality

in Health
Care

National
Standard 2

Partnering

with
Consumers

National
Standard 3

Preventing

&amp;
Controlling
Healthcare
associated
infections

National
Standard 4

Medication

Safety

National
Standard 5

Patient

Identification
&amp; Procedure

Matching

National
Standard 6

Clinical

Handover

National
Standard 7

Blood and

Blood
Products

National
Standard 8

Preventing

&amp;
Managing
Pressure
Injuries

National
Standard 9

Recognising &amp;
Responding to

Clinical
Deterioration

National
Standard 10

Preventing

Falls &amp;
Harm from

Falls

? ? ? ? ? ? ? ? ? ?

10. Risk Management

Risks to SA Health staff and patients are protected by the following documents:

Restraint and Seclusion in Mental Health Services Policy Guideline,
Chief Psychiatrist Standard - Restraint and Seclusion Recording and Reporting
Chief Psychiatrist Standard - Restraint and Seclusion Application and

Observation

11. Evaluation

Restraint and seclusion is monitored, evaluated and reported on by the Chief Psychiatrist
and the five Local Health Networks (LHNs) as required by sections 90(1)(b) and 98(2)(c)
of the Mental Health Act 2009 (the Act). Data from the OCPP and LHNs is separately
reported nationally to the Safety Quality Partnership Standing Committee.

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All three documents mentioned in Part 10 will be evaluated through the above
mechanisms.

12. Definitions

In the context of this document:

chemical restraint means: no agreed definition available.

critical incident means any incident of restraint or seclusion where the consumer
or staff were injured, the incident lasted more than 8 hours or intubation was
utilised in the process of sedation for the management of challenging behaviours.

least restrictive means: the concept of allowing the consumer to be cared for in
an environment which places the least amount of restriction on freedom of
movement while maintaining their safety and the safety of others.

mechanical restraint means: The application of devices (including belts,
harnesses, manacles, sheets and straps) on a person s body to restrict his or her
movement. This is to prevent the person from harming him/herself or endangering
others or to ensure the provision of essential medical treatment. It does not
include the use of furniture (including beds with cot sides and chairs with tables
fitted on their arms) that restricts the person s capacity to get off the furniture
except where the devices are used solely for the purpose of restraining a person s
freedom of movement. The use of a medical or surgical appliance for the proper
treatment of physical disorder or injury is not considered mechanical restraint.

physical restraint means: The application by health care staff of hands-on
immobilisation or the physical restriction of a person to prevent the person from
harming him/herself or endangering others or to ensure the provision of essential
medical treatment.

restraint means: The restriction of an individual s freedom of movement by
physical or mechanical means. This applies to person s receiving specialist mental
health care.

seclusion means: - Defined as the confinement of a person, alone in a room or
area from which free exit is prevented. (National Documentation, MHSRP, 2009)

13. Associated Policy Directives / Policy Guidelines

Office of the Chief Psychiatrist and Mental Health Policy Seclusion and Restraint
Standard Application and Observation Requirements

Restraint and Seclusion in Mental Health Services Policy Guideline

National Practice Standards for Mental Health Workforce, 2002, Commonwealth of
Australia

National Standards for Mental health Services, 2010, Commonwealth of Australia

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14. References, Resources and Related Documents

Australian Commission on Safety and Quality in Health Care (ACSQHC) (September
2011), National Safety and Quality Health Service Standards ACSQHC, Sydney

Work Health Safety Policy Guideline Prevention and Responding to Workplace
Challenging Behaviour, Violence and Aggression (WHS GD 043)

Work Health Safety Policy Guideline Hazard identification and risk assessment tool
(WHS FOR020)

Work Health Safety Policy Guideline Factsheet worker support (WHS FS022)

SA Health Policy Directive Prevention and Responding to Challenging Behaviour

SA Health Policy Directive - Prevention and Responding to Challenging Behaviour
Challenging behaviour toolkit

SA Health Policy Directive Minimising the use of Restrictive Practices

SA Health Policy Directive Minimising the use of Restrictive Practices Restrictive
practices toolkit.

Mental Health Policy Guideline Restraint and Seclusion in Mental Health Services

Chief Psychiatrist Standard Restraint and Seclusion Application and Observation

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Restraint and Seclusion Recording and Reporting_Cover_July2015
Restraint and Seclusion Recording and Reporting_policy_July2015

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