Seclusion is a protocol used in hospital settings when a patient is displaying unsafe behaviors. Many organizations, including U.S. health care accrediting body the Joint Commission, say that it should be used as a “last resort,” but at Harry S. Truman Memorial Veterans Hospital in Columbia, rates of patient seclusion are among the highest in the nation.
KBIA analyzed nine years of data ranging from 2015 to 2023 for seclusion measures within VA facilities.
In four of those nine years, Truman Veterans’ Hospital in Columbia reported the highest rate of seclusion in the nation.
Seclusion is defined by the Joint Commission as “the involuntary confinement of a patient alone in a room or an area where the patient is physically prevented from leaving.” Jennifer Primack is a research psychologist at the Providence VA Health Care system in Rhode Island. She and a team of researchers at Providence’s evidence synthesis program were asked to write a report that analyzed the most effective methods for reducing seclusion in inpatient psychiatric units.
“There's a variety of different definitions for what seclusion is, but generally it's recognized as involuntarily confining a patient alone in a locked room or restricted area until their conflict behaviors are decreased,” Primack said.
Primack said that how seclusion is implemented can vary widely depending on each facility, but overall it should only be used in times when staff and patient safety may be at risk.
“It's intended to be a process to handle potential patient aggression, agitation, self harm or other potentially dangerous behaviors that would require immediate intervention. So seclusion is one of the types of strategies or interventions that's used to manage these kinds of conflict behaviors that put both patients and staff at risk,” Primack said.
Jon Retzer is the deputy national legislator for health at Disabled American Veterans. Retzer served in the U.S. Army and then with the Minnesota National Guard before being medically discharged. He says when he was hospitalized in active duty, he was confused after waking up from sedation for surgery and became combative.
“When I was hospitalized with DOD, they did restrain me and they did seclude me from others, but I was not alone. So I still had the nurses coming in, doing their thing until I was fully aware of the situation,” Retzer said.
Modern seclusion protocols require seclusion to be used only under certain circumstances for certain lengths of time, and require hospital staff to monitor patients.
“It's not something that is intended to happen frequently,” Primack said. “Therapeutic alliance is difficult to build if you have to seclude a patient, so it falls under that category of what we call kind of coercive practices, because someone's not giving their consent.”
Data shows high rates of seclusion at Truman Veterans’ Hospital
It’s required for any facility that accepts money from the Centers for Medicare and Medicaid Services to report certain quality measures for their psychiatric services — including how many hours seclusion and restraint were used in the hospital. The measures are set by the Joint Commission, which accredits all VA medical centers, and all Department of Veterans Affairs hospitals are required to report the measures.
The measures are known as a Hospital-Based Inpatient Psychiatry Measures, which are meant to measure the quality of inpatient psychiatric care for facilities that accept CMS funding. For seclusion, the measure is hours of seclusion per 1,000 patient hours .
Because of these requirements, the Centers for Medicare and Medicaid Services keeps a database of all of these reports on its website. One of those reports is specific to the psychiatric facilities within hospitals run by the United States Department of Veterans Affairs .
Currently, the department is required to keep data archives up to eight years, ranging back to 2016. KBIA began reporting this story before the most recent data was published and was able to analyze nine years of data ranging from 2015 to 2023 for seclusion measures within VA facilities. The years 2017 and 2018 are considered outlier years because of a nationwide lack of reported data.
In four of those nine years, Harry S. Truman Memorial Veterans Hospital in Columbia reported the highest rate of seclusion in the nation.
In 2022, Truman VA reported a rate roughly 15 times the national average for VA facilities. In 2019, Truman VA secluded patients at more than 20 times the national mean.
Terrence Hayes is the former press secretary for Veterans Affairs - he provided comment for this story in late 2024 and has since left the position. The Veterans Health Administration did not respond to a request for additional comment from current VHA officials. In a statement sent via email in December of 2024, Hayes said the behavior of three patients drove the Columbia facility’s rate higher in 2022. But he also said interpreting the data over time was key:
“Use of seclusion at Truman VA for the third quarter of calendar year 2022 was an outlier in comparison to other time periods, which largely contributed to the overall elevation in seclusion. Subsequent releases of Care Compare for calendar year 2023 indicated that Truman VA’s use of seclusion was more consistent with national averages on this measure. The increase in seclusion events seen during the third quarter of 2022 was predominantly the result of care needs for three patients who demonstrated exceptionally high-risk behaviors to themselves and others at the time. Interpretation of measure results on a trended basis, rather than a single data point, is a more accurate and useful method for evaluating quality,” Hayes said in the statement.
However, an analysis of trends over 9 years showed that Truman Memorial Hospital consistently reported some of the highest rates of seclusion in the country, except for in a two year period where there was a nationwide lack of reported data for this measure.
Hayes said that data is still being analyzed for calendar year 2024, but that early indicators suggest Truman VA's seclusion rate may have dropped further in 2024. Hayes said officials at Truman VA were aware of the increase:
“In 2022, the facility [Truman] identified an increased frequency and duration of seclusion events and identified opportunities for improvement, including providing additional training to staff regarding the need to discontinue seclusion at the earliest safe opportunity and reviewing less restrictive interventions that would effectively manage risk to the patient and others. In 2023, Truman VA demonstrated a 30% reduction in the average number of seclusion hours compared to 2022. Data from 2024 are incomplete but suggest there is further significant reduction in seclusion hours,” Hayes said in the statement.
Setting the standard
So, when does a reported rate become concerning? In other words - how much is too much seclusion? Well, it depends whom you ask.
The Inpatient Psychiatric Facility Quality Reporting (IPFQR) Program is the program under CMS that is responsible for reporting and analyzing all Inpatient Psychiatric Quality measures, such as HBIPS-3.
During a 2022 IPFQR annual data review for the 2023 Fiscal Year, IPFQR program lead Evette Robinson stated that: “a rate equal to or greater than 5 hours per 1,000 patient hours of care was considered a questionable rate that would require re-evaluation for the HBIPS-3 measure.”
Hayes said that VA facilities adhere to seclusion standards set forth by the Joint Commission. But, he said there aren't clear thresholds for specific rates:
“Metrics are developed and defined by the Joint Commission, which is responsible for evaluating each individual measure. There are no specific benchmarks on this metric; however, the Truman VA strives to use seclusion as infrequently as clinically appropriate,” Hayes said in a statement.
In its seclusion standards, the Joint Commission does not specify a rate threshold for seclusion measures - that is, they don’t specifically say what number per 1000 patient hours is too high. However, the standards do specify the maximum amount of hours certain types of patients should be secluded in a singular event:
- Four hours for adults ages 18 and older
- Two hours for children and youth ages 9 to 17
- One hour for children under age 9
According to the Centers for Medicare and Medicaid Services Code of Patient’s Rights: “seclusion may only be used when less restrictive interventions have been determined to be ineffective to protect the patient a staff member or others from harm.”
A study published in 2020 in the journal Psychiatric Services looked at rates of seclusion reported through the Centers for Medicare and Medicaid Services Hospital Compare website for psychiatric facilities in the US in the years 2013 - 2017. The study found that around 67% of the facilities reported a “comparably low” rate of seclusion, which is defined in the study as less than 0.09 hours per 1000 patient hours. The study also found that for-profit hospitals were more likely to have lower rates of seclusion than government and nonprofit hospitals.
At Disabled American Veterans, Jon Retzer said all VA healthcare facilities have their own quality standards that they must abide by. Retzer said his experiences at VA Medical Centers in Minnesota, Arizona, and Baltimore were all very positive - but he said every VA facility is ultimately different.
“When you look at physical infrastructures, they're not all going to be the same,” Retzer said. “And I think that's the realistic perspective that we understand. But the thing is, our goal is that we hope that they have the same standards, of high quality standards, and that they have safety in mind.”
Reducing seclusion becomes a priority
Seclusion has a long history of being used in hospital settings, particularly in psychiatric hospitals - formerly known as “asylums”. Seclusion protocols for patients were often similar to solitary confinement for prisoners, and were often paired with physical restraints like shackles, harnesses and collars.
Seclusion and restraint are still used today, but protocols are vastly different than those followed in historical asylums. Seclusion takes place in regular patient rooms and involves continuous monitoring by staff, and modern restraints are made of soft fabric and allow the patient to stay in a bed. But in recent years, practitioners and health organizations have advocated for the reduction of seclusion and restraint in care settings.
In 2000, the American Psychiatric Nurses Association stated one of their goals as the reduction of seclusion and restraint in psychiatric facilities. 2002, the Substance Abuse and Mental Health Services Administration identified the same goal for mental health and substance use treatment as a top priority. Both organizations stated that elimination of seclusion and restraint was the eventual goal, and both organizations have stuck by their statements.
In the year 2025, seclusion and restraint are still being used in psychiatric and substance use facilities nationwide - and reduction of these protocols is still a priority. But research on seclusion rates is a mixed bag.
At Providence VA Medical Center, Jennifer Primack and the team’s report examined the effectiveness of different protocols in reducing seclusion. She said staff training and education, risk assessment and management, and structural redesign can help - but the confidence intervals associated with many of the strategies the team examined were still fairly low.
“There is some evidence showing that these protocols might decrease these seclusion events. But overall, the quality of the research that has been done to look at these things is not sufficient for us to be able to make a strong determination either way,” Primack said.
Advocates say fewer barriers can lead to higher engagement within VA mental health system
Jon Retzer with Disabled American Veterans, or DAV, says that vets shouldn’t be afraid to engage with psychiatric care through the VA - he says in his experience, they’re truly there to help. But he also believes seclusion should be used only when absolutely necessary.
“You know, we want to make sure that it doesn't further cause more psychological damage or harm. I mean, they're in there for a purpose. They're asking for help, and secluding is not providing help,” Retzer said.
Retzer said he thinks it’s important to focus on continuing to improve the mental healthcare system and keep building trust among veterans. He said numbers showing high levels of trust in the VA health system among veterans and high performance rates for VA hospitals are promising. But, Retzer said many veterans are still scared to engage with the mental health side of things - and he believes more stories of hope are needed.
“The single horror story gets amplified so badly, and someone who needs help may read that message the wrong way and just never get the help that they want,” Retzer said.
Retzer said one of the most beneficial resources can often be the veteran community itself - and wants veterans to know that they don’t have to go through the process of seeking mental health treatment alone. Retzer said that DAV and other veterans organizations can help connect vets to advocacy and support services, and said that patient advocates can often be a helpful resource in speaking up for patients.
“At the VA medical centers, they have patient advocates. And it's good to know. And one of the things that we're [DAV] encouraging Congress to do is increase the patient advocate ratio to our veteran population,” Retzer said.
