The use of seclusion in psychiatry is highly problematic. Effects on reducing stimuli and creating a context for calming the patient, which are often mentioned as a reason for secluding an agitated patient, have not been demonstrated [1–4]. On the other hand, negative experiences and traumatizing effects have been shown [5, 6]. In acute adult psychiatry in the Netherlands, seclusion use has been an issue of debate over the past twenty years. The Dutch Government invested heavily in seclusion reduction between 2006 and 2012 [7, 8, 9]. A national program was started, aiming at reduction of seclusion by 10% a year, without substitution by other coercive measures, including forced medication. This aim was underlined by the Dutch ministry of Health, Welfare and Sport in a letter to the House of Representatives in 2012 [10]. Hospitals were provided with funding to improve involuntary care and to reduce seclusion. As part of this program, several interventions have been developed and implemented [11, 12]. The effects of some of these initiatives have been studied [8, 9]. The overall result was a reduction of the number and duration of seclusion of 41% and 30% respectively between 2008 and 2013 [8, 13]. Yet, not all institutions were successful, and some even showed an increase of seclusion rates [8]. Moreover, results from the national seclusion reduction programs showed a relative increase of forced medication by 81% between 2011 and 2013 suggesting substitution of seclusion by forced medication [8]. Long term follow-up data confirmed this impression [14, 15] .
From several studies over the last decade we know comprehensive approaches in the reduction of seclusion and restraint to be substantially more effective than less comprehensive approaches [14, 16–20]. In order to further reduce seclusion and improve quality of care, from 2012 onwards a new comprehensive care model was developed for acute inpatient mental healthcare: High and Intensive Care (HIC) [21]. The HIC model combines new organization of care with a new care approach. The HIC model integrates the medical model and the recovery model and focuses on contact and crisis prevention and continuity of care between outpatient treatment and acute admission wards. The model is widely adopted in Dutch mental healthcare; a large majority of healthcare institutions have reorganized acute care and built new HIC wards. On these wards, patients are admitted for a maximum of 3 weeks, when outpatient treatment is no longer sufficient and admission to a closed setting is necessary. The HIC model aims at a reduction of coercive measures by improving healthcare practice using evidence- and practice-based approaches [21].
The HIC model focuses on hospitality at admission, care planning and risk assessment. Within the HIC ward a distinction is made between a “high-care function” and an “intensive-care function”. Initially, patients are admitted to the High Care (HC) section, consisting of single patient rooms, living areas and a comfort room. One-to-one care is given either at the HC section, or, depending on the severity and nature of the crisis, at the Intensive Care (IC) section. The IC section consists of several Intensive Care-Units (ICUs) with an individual bedroom and living area and High Security Rooms (HSRs). The purpose of the ICU is to provide one-to-one care in a separate area, without contact with other patients on the HC, while avoiding seclusion in a HSR for as long as possible.
The HIC model implies a set of quality criteria, described in the HIC monitor [21]. The monitor contains various domains, including team structure, team processes, diagnostics and treatment, and building environment. We hypothesized that a higher fidelity to the HIC model, as expressed in higher total scores on the monitor, to be associated with less coercion use (seclusion and forced medication).
This article presents the associations between HIC model fidelity and seclusion rates in acute psychiatric wards in the Netherlands. We aim to answer three research questions.
1. Is HIC model fidelity associated with seclusion rates?
2. Is HIC model fidelity associated to substitution of seclusion by forced medication?
3. How much variance of seclusion rates is explained by the HIC monitor scores taking patient characteristics into account?