Restrictive interventions in Victorian emergency departments: what is really going on?

Abstract

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.