Generally implemented as a last resort treatment ( 10), at times alone, more often in combination with other, mainly pharmacological approaches ( 11, 12), seclusion use is criticized as an unjustifiable and potentially traumatic practice for patients ( 13– 17). The use of seclusion is controversial ( 8, 9). Although rates of seclusion have fallen worldwide ( 4, 5), rates of violence on psychiatric wards have not substantially changed with evidence denoting an upward trend ( 6, 7), arguably indicating that seclusion is a therapeutic option increasingly reserved to contain more extreme cases of violence. Reducing restrictive practice via the reduction of seclusion has become one of the top priorities of many health authorities ( 1– 3). The ELMB is a sensitive and specific instrument that can be used to guide the decision-making process when implementing seclusion. ROC analyses indicated that ELMB was significantly more accurate that BVC, with higher sensitivity, specificity, and positive likelihood ratio. Predictors of seclusion were: physical violence toward staff/patients OR = 24.2 non-compliance with PRN (pro re nata) medications OR = 9.8 and damage to hospital property OR = 2.9. Data analyses were carried out using multivariate regression and Receiver Operating Characteristic (ROC) curves. ELMB, an 8-item modified version of the 6-item BVC, was retrospectively employed to evaluate the seclusion decision-making process on two Psychiatric Intensive Care Units (patients n = 201 incidents n = 2,187). Our aim was to test the predictive and discriminatory characteristics of the East London Modified-Broset (ELMB), to delineate its decision-making profile for seclusion of adult psychiatric patients, and second to benchmark it against the psychometric properties of the Broset Violence Checklist (BVC).
There is no current objective and practical decision-making instrument for seclusion use on psychiatric wards. Seclusion is a last resort intervention for management of aggressive behavior in psychiatric settings.
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