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SERIES ON BEHAVIORAL EMERGENCIES

Elements of Successful Restraint and Seclusion Reduction Programs and Their Application in a Large, Urban, State Psychiatric Hospital

FISHER, WILLIAM A., MD

Author Information
Journal of Psychiatric Practice®: January 2003 - Volume 9 - Issue 1 - p 7-15

Abstract

In recent years, there has been a strong desire in inpatient psychiatric programs to reduce the use of seclusion and mechanical restraint. This wish has been driven by a number of interrelated forces, including media coverage of recipient deaths while in seclusion and restraint, 1 new regulations and accreditation standards, 2,3 intense opposition to the use of restraint and seclusion from the consumer empowerment movement, 4–7 and a growing acceptance by mental health providers of the profoundly deleterious “side effects” of these procedures for both recipients of mental health services (referred to in this article as “recipients”) and staff. 4,5,8–11 Efforts to reduce the use of restraint and seclusion have also been underway in the nursing home industry since the passage of the Omnibus Budget Reconciliation Act of 1987. In this article, I will briefly review the literature on reduction of restraint and seclusion rates and describe successful efforts to reduce rates of restraint and seclusion use at a large, urban, state psychiatric hospital, in the hopes of highlighting a number of general principles that will be applicable to other psychiatric inpatient programs engaged in the same endeavor.

LITERATURE REVIEW

Six elements have been emphasized in the literature on programs that have successfully reduced the use of restraints and seclusion. These are high level administrative endorsement, recipient participation, culture change, training, data analysis, and individualized treatment.

Administrative Endorsement

A number of authors have cited enthusiastic administrative endorsement for restraint reduction as a key element in reducing restraint and seclusion rates. Visalli and McNasser 12 describe “organizational leadership” (along with individualized interdisciplinary treatment) as the key element in a program at a rural, state-operated psychiatric hospital that has produced a robust and stable reduction in restraint and seclusion rates. Jensen et al. 13 describe the importance of administrative endorsement in reducing use of restraints on medical units, as do Dunbar et al. 14 in the nursing home setting. Davidson et al. 15 found a reduction in restraint use in a developmentally disabled population when administrative endorsement was the only intervention made. The National Association of State Mental Health Program Directors (NASMHPD) has advocated that state mental health authorities should take a leadership role in reducing restraint and seclusion use. 16,17

Recipient Participation

Recipient participation can add enormously to the effectiveness of efforts to reshape policy and procedure in any mental health organization. Fisher et al. describe the importance of recipient participation in New York State’s efforts to reshape its restraint and seclusion policies between 1992 and 1994. 18 NASMHPD also strongly endorses recipient participation in efforts to reduce restraint and seclusion. 16,17 Visalli and McNasser note that many of their successful initiatives to reduce the use of restraint and maintain those reductions “…stem from a working relationship with recipients on how to improve customer service.”12

Culture Change

Based on a review of the literature on restraint and seclusion in 1994, I concluded that “local, nonclinical factors, such as cultural biases, staff role perceptions and the attitudes of hospital administration have a greater influence on rates of restraint or seclusion [than do demographic or clinical factors].”8 Minnick et al. noted the importance of similar local factors in comparing the use of restraint in three medical hospitals, 19 as did Flannery et al. among emergency services providers. 20 In order to reduce restraint and seclusion use, NASMHPD recommends that state mental health agencies develop statewide strategies to “create positive environments and cultures that would reduce the development of situations that may lead to seclusion and restraint.”16 Palmer et al. reported a successful public awareness campaign, “Restraints Have Risks,” conducted by the Colorado Department of Health to catalyze restraint reduction in nursing homes. 21 Raja et al. described a culture of treatment in an Italian psychiatric intensive care unit that rules out the use of restraint or seclusion. 22 The impact of training programs on reduction in restraint use in nursing homes appeared to result in part from their influence on the value placed on these procedures by staff, 13,14,23–27 which includes dispelling the myth that the use of restraint reduces staff injury. 28

Training

Staff training appears to be a common element in programs that have reduced the use of restraint and seclusion in psychiatric settings, 12,15,29–32 and reduced the use of restraint in nursing home 27,33–35 and medical settings. 13,36,37 Such training has included sensitization to the impact of seclusion and restraint on recipients, sensitization to inadvertent precipitants of violence (arbitrary rules, power struggles, lack of respect), early detection of impending violence, noncoercive techniques for defusing potentially violent situations, and nonviolent self-defense training to reduce staff fear and consequent over-reliance on restrictive measures. Several authors have demonstrated the necessity for hands-on training and consultation as opposed to purely didactic courses in order to produce reductions in rates of restraint and seclusion. 32,33

Data Analysis

Information management is a sine qua non for any attempt to change behavior and is therefore an integral part of restraint and seclusion reduction programs; it is used in two ways. First, information management is used to identify outliers (hospitals, units, practitioners) as a target for intensive analysis and intervention; second, it is used to evaluate the outcome of interventions and provide feedback to those towards whom the interventions are directed as well as to those conducting the interventions. 12–14,25,36 The data consist not only of rates of restraint and seclusion analyzed by setting, shift, and practitioner, but also include changes in staff knowledge, evaluation of training programs, and information about staff and recipient attitudes and actions used to conduct behavioral analyses of restraint and seclusion episodes. 16,17

Individualized Treatment

An emphasis on individualized treatment is an important part of many successful restraint reduction programs. Treatments that may reduce the aggressive and self-injurious behavior that can trigger restraint or seclusion can have a major impact on restraint and seclusion rates, whether the emphasis is on individualized behavioral interventions 12,38–41 or the use of atypical antipsychotics such as risperidone 42 and particularly clozapine. 43–49 This can be especially evident when an effective treatment is found for a recipient who has been involved in frequent, repetitive episodes of restraint or seclusion.

SETTING

Creedmoor Psychiatric Center is a state-operated psychiatric hospital located in Queens County, a borough of New York City. Queens has a population of approximately 2.2 million and is considered one of the nation’s most culturally diverse counties. 50 Creedmoor’s inpatient division provides intermediate and extended psychiatric hospitalization to mentally ill individuals over 18 years of age who remain dangerous to others or actively or passively dangerous to self despite acute treatment (averaging 3–6 weeks in duration) in the psychiatric units of local general hospitals. Creedmoor also admits mentally ill individuals from the New York City jail system whose misdemeanor charges are dismissed after they have been found incompetent to stand trial, individuals from the prison mental health system who upon reaching their mandatory parole date meet civil involuntary commitment criteria, and insanity acquitees who no longer require a forensic hospital setting. Creedmoor admits approximately 50 recipients per month. 50% of these are discharged within 30 days while 15% “age in “ to lengths of stay greater than 1 year. The hospital operates 19 wards with a typical census of 26 recipients per ward (fewer on its Secure Care ward). Typical treatment teams consist of a full-time psychiatrist, a one-third time non-psychiatric physician, a half-time psychologist, a full-time social worker, a full-time staff member from one of the rehabilitation disciplines, and a full-time nurse and three full-time paraprofessional aides on each shift. Psychiatric and social work staffing is enriched on Creedmoor’s two admission wards.

PROGRAM ELEMENTS

In late 1999, Creedmoor began a project to reduce restraint and seclusion rates. The project had the wholehearted endorsement of the hospital’s Executive Director and support for it was enlisted at every major hospital meeting. A multidisciplinary performance improvement workgroup (chaired by the author) with recipient representation was convened, and the hospital’s information management resources were put at its disposal. These steps are examples of the need for enthusiastic administrative support at the highest levels in order to identify restraint and seclusion reduction as a hospital priority and the need for recipient representation on groups that influence policies that affect recipients.

Survey of Staff and Recipients

In early 2000, the performance improvement workgroup administered an identical survey (see Appendix, p. 14) to both staff and recipients to get a better sense of the culture and practices surrounding aggressive behavior and the use of seclusion and restraint in the hospital: 148 recipients responded (about 25% of the census at the time), 54% of whom had been restrained or secluded at some time; 112 staff responded (about 15% of the inpatient clinical staff at the time), 47% of whom were paraprofessionals. These relatively low response rates probably reflect the method of survey distribution and return (by hand-out and hand-in rather than individual mailing), which did not allow for tracking and follow-up of non-responders. The responses were used to guide training and policy in terms of what to eliminate, what to retain, and what to modify. As noted above, the impact of institutional culture on the use of restraint and seclusion has been emphasized by a number of authors and is felt by some to be the major determinant (as opposed to factors such as recipient demographics, clinical variables, and staffing) of inter- and intra-hospital variation in restraint and seclusion rates.

Among the actions that substantial numbers (> 35%) of both staff and recipients felt would have a positive impact were increased staff politeness, more explanations of staff actions, fewer rules, more individualized expectations for participation in treatment activities, and the availability of more concrete de-escalation strategies (e.g., taking a shower or a walk) as opposed to verbal interventions and medication. Both staff and recipients (> 90%) endorsed the value of post-restraint debriefings in preventing repeat occurrences. A large majority of both staff and recipients (> 85%) endorsed the value of having staff, as part of their training, hear presentations from recipients who had a history of being restrained. In addition, about half of staff and recipients endorsed the value of staff experiencing restraint or seclusion as part of their training.

New York State Training Curriculum

At about the same time that the Performance Improvement Project began, the New York State Office of Mental Health issued a new staff training curriculum entitled Preventing and Managing Crisis Situations (PMCS) 51 for use in its state-operated psychiatric centers. As opposed to previous programs that tended to emphasize the mechanics of safely applying restraint or seclusion, this curriculum put greater emphasis on increasing staff sensitivity to situations which may lead to violence and training staff in noncoercive measures of de-escalating potentially violent situations. Training with this curriculum was already underway when the results of the survey described above became available, and the results were used to modify the curriculum, placing even greater emphasis on staff sensitivity and noncoercive de-escalation for the remaining treatment teams being trained.

Focus on Interpersonal Respect

Even with the revised PMCS training, it became clear that basic interpersonal respect remained an area in which there was much room for improvement. The hospital therefore undertook three initiatives to address this issue. Joel Slack, a recipient of mental health services and the former Director of Consumer Affairs for the Alabama Department of Mental Health, was invited to speak to staff on all shifts on the topic of respect. Mr. Slack, who has spoken throughout the United States and internationally, gave a moving talk in which he presented many first-hand anecdotes which served as an introduction to staff on the critical nature of interpersonal respect in creating a safe and therapeutic environment. The hospital then applied for and received a training grant for an 8-hour curriculum entitled “Creating A Respectful Environment,” which expanded on these issues. To date, 50% of staff have received this training. In order to emphasize the importance of this issue, the hospital issued a policy on respect, making basic respectful behavior a performance requirement for all jobs.

Policy Changes and Debriefing

Concurrent with these efforts at the hospital level, the New York State Office of Mental Health was in the process of revising its policy on the use of restraint and seclusion for all of its state-operated psychiatric centers. The author served on the statewide work group charged with revising the policy, and this allowed for considerable cross-pollination between efforts at the hospital level and those at the state level. For example, an innovation adopted at both levels was the use of two types of post-event discussions. The first is a “post-event analysis,” which takes place immediately after the application of restraint or seclusion and involves the staff members who participated in the intervention along with supervisory staff (on off-shifts, this may be the doctor on call or the nursing supervisor) who review the concrete handling of the situation while it is still fresh in their minds, look at what might have been done differently to avoid restraint or seclusion, and make a short-term plan to avoid a repetition of the intervention. The second discussion is a “debriefing” that includes the recipient and his or her regular treatment team and involves a more detailed behavior analysis, from both the recipient’s and the team’s points of view, of the events leading up to the intervention and more long-range planning to avoid a repetition of the restraint or seclusion. This requirement for a dual discussion goes beyond any regulatory requirement but both work groups felt that no single discussion could fulfill both the need for immediacy and the need for thoughtful input from the recipient.

Information Management and Data Analysis

As discussed earlier, a number of authors have emphasized the use of information management as a means of analyzing opportunities for reducing restraint and seclusion rates and providing ongoing feedback on the success or failure of efforts to do so. Creedmoor’s restraint and seclusion reduction effort used information on many levels, from systemwide to the ward and practitioner levels. At the systems level, for a number of years prior to the initiation of this project, the New York State Office of Mental Health had distributed restraint and seclusion data through its Quarterly Management Indicator Report, allowing state-operated psychiatric hospitals to benchmark against each other. Creedmoor’s rate generally ran slightly above the average for all adult psychiatric hospitals operated by the state of New York and about equal to that of the larger urban facilities within that group. At about the same time that Creedmoor’s project began, the Office of Mental Health began setting restraint reduction goals for its hospitals based on the relationship of their rates for the previous 5 years to the statewide average. OMH’s goal for Creedmoor was a 15% reduction in its restraint and seclusion rate, a goal that was greatly exceeded (see Figure 1 and discussion of “Program Results” below). More recently, OMH has selected restraint and seclusion rates as one of the JCAHO ORYX indicators for its hospitals (ORYX is a benchmarking system operated by the JCAHO, which allows hospitals around the country to compare themselves with each other in terms of specific measures of the quality of care). This allowed Creedmoor to compare itself with state-operated psychiatric hospitals outside of New York. This systems level data provided both motivation for and feedback on Creedmoor’s restraint reduction efforts.

Figure 1.
Figure 1.:
Average annual combined restraint/seclusion rates at Creedmoor Psychiatric Center and for all New York State operated adult psychiatric centers

On the institutional level, Creedmoor used comparative data to identify areas on which to focus its efforts. Not surprisingly, an analysis of restraint rates by ward showed that the Secure Care Unit accounted for a significant percentage of the hospital’s use of restraint and seclusion. This was not surprising in that, by definition, those recipients transferred to the Secure Care Unit are those with the most severe aggressive and self-injuring behaviors. However, major changes in both pharmacological and nonpharmacological therapies were in the process of being instituted through strong local clinical leadership. Monthly posting of restraint and seclusion rates and monthly determination of restraint and seclusion reduction goals provided powerful reinforcement to both staff and recipients as new therapeutic technologies produced changes in both individual recipients’ behavior and the ward milieu.

Data at the practitioner level have proved less relevant to Creedmoor’s restraint and seclusion reduction efforts, since individual practice has tended to change along with the hospital and ward milieu. In addition, Creedmoor’s policies, which require supervisory approval for the use of restraint, tend to obviate differences in individual practice. However, these data remain available to identify individual outliers.

At the recipient level, data on those who have experienced multiple episodes of restraint or seclusion are used to identify recipients who would benefit from additional therapeutic intervention. Recipient and staff have the opportunity to provide input in debriefing sessions (including, in some cases, formal behavioral analyses). In addition, recipients who have had three or more episodes of restraint or seclusion in a month receive a formal review by a supervising psychiatrist or a consultant from outside the hospital. This is consistent with the view that restraint and seclusion are emergency safety interventions that represent failures of the treatment plan, rather than treatments per se, and that they flag opportunities to improve the treatment plan.

Treatment Interventions

Data-driven training and policy that modify institutional culture and practice can go a long way towards reducing the use of restraint and seclusion. However, the underlying illnesses that are producing the repetitive aggressive and self-destructive behaviors, especially in those individuals who experience multiple episodes of restraint or seclusion, must ultimately be addressed.

Pharmacological interventions.

In terms of pharmacological treatment, two elements were emphasized, one specific and one general. The specific element was the aggressive use of clozapine. In addition to being the only well established treatment for schizophrenia that is refractory to other antipsychotics, several authors using before and after designs to study the effects of clozapine on aggression have noted clozapine’s apparent ability to reduce aggressive behavior (perhaps independently of its antipsychotic effect). 44,45 Thus clozapine use was encouraged by ongoing discussions with psychiatrists, recipients, and families. These discussions included a review of the potential risks of clozapine treatment versus the—in our view, greater—potential risks of ongoing aggressive behavior and repeated restraint or seclusion. In a few cases in which recipients remained adamant in their refusal of clozapine and highly dangerous behavior persisted, the hospital obtained court orders to administer clozapine over objection, even administering the first doses by nasogastric tube if necessary. (In these cases, the judge made the risk-benefit decision on the recipient’s behalf). In almost all of these court-ordered cases, once the effects of clozapine became evident, recipients were willing to continue its use on a voluntary basis. The general principle was simply to avoid psychopharmacologic complacency—that is, never to say “we’ve tried everything.” Once well established treatments had been exhausted, serial trials of medication regimens based on small published series or even individual case reports were conducted with clear target symptoms and endpoints in mind. For example, significant success for several recipients was achieved with addition of topirimate to existing medication regimens or the use of the combination of mesoridazine and amantadine in recipients who were unable to tolerate or were unresponsive to clozapine. The addition of ECT to clozapine also proved helpful for several recipients.

Nonpharmacological interventions.

Creedmoor’s most powerful nonpharmacological tool for reducing the behaviors that precipitated restraint and seclusion proved to be Linehan’s Dialectic Behavior Therapy (DBT). 52 Although DBT was developed for the treatment of self-injurious behavior in individuals with borderline personality disorder, many of Creedmoor’s most behaviorally dyscontrolled recipients shared similar types of cognitive and emotional dysregulation, even after symptoms of the underlying Axis I disorder had been ameliorated through medication. The use of DBT skills training provided these recipients with the necessary skills to counteract cognitive distortions and affective storms without resorting to violent or self-destructive behavior. Equally important, DBT skills training and the inherently team-based nature of DBT treatment had a powerful impact in reducing inappropriate reactions on the part of staff, which could in turn lead to the unnecessary use of restraint or seclusion.

PROGRAM RESULTS

The results of Creedmoor’s restraint and seclusion reduction program are illustrated in Figure 1, which compares Creedmoor’s combined restraint and seclusion rate (expressed in physician orders per 1,000 recipient days) with the average rate for all adult psychiatric centers operated by New York State during 1999, 2000, and 2001. As can be seen, Creedmoor experienced a 67% decline in its rate between 1999 and 2001 and went from being 46% above the average state rate to 44% below it. Of note, in May of 1999, the maximum duration of a physician’s restraint or seclusion order was decreased from 4 hours to 2 hours, and in April of 2000 it was decreased again from 2 hours to 1 hour. Since virtually 100% of recipients were spending the full 4 hours in restraint or seclusion during 1999, the decrease in combined hours of restraint and seclusion per 1,000 recipient days between 1999 and 2001 was approximately 92%.

CONCLUSIONS

There is a consensus among those who have successfully implemented restraint and seclusion reduction programs that the essential elements of such programs are high level administrative endorsement, recipient participation, culture change, training, data analysis, and individualized treatment. This article describes in some detail the use of these elements in a successful restraint reduction program at Creedmoor Psychiatric Center as an example of how they were applied in a large, urban, state-operated psychiatric hospital. The methods of applying these essential elements will differ depending on the setting in which they are applied. However, some of the techniques described in this paper may be applicable, without major changes, to other treatment settings attempting to reduce their use of restraint and seclusion.

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Appendix

CREEDMOOR PSYCHIATRIC CENTER RESTRAINT AND SECLUSION SURVEY

We hope that your answers to this survey will help the hospital find ways to reduce the use of restraint and seclusion.

Please check the best answer. If more than one answer is true, please check all of the answers that are true.

  1. Are you a patient?
    • □ Yes
    • □ No
  2. Are you a staff member?
    • □ Yes
    • □ No
  3. If you are a staff member, are you a
    • □ MHTA/SCTA
    • □ MHTA/SCTA Assistant
    • □ Nurse
    • □ Member of the Rehab Department
    • □ Social Worker
    • □ Psychologist
    • □ Psychiatrist
    • □ Non-Psychiatric Physician
    • □ Supervisor/Administrator
  4. If you are a staff member, what shift do you usually work?
    • □ Day
    • □ Evening
    • □ Night
  5. If you are a patient, have you ever been
    • □ Put in restraint?
    • □ Put in the seclusion room with the door locked?
  6. What things about being in the hospital make patients upset?
    • □ Being locked up
    • □ Patients don’t feel safe on the ward
    • □ Not enough activities
    • □ Enough activities but not interesting or useful
    • □ Being pushed to attend activities
    • □ Too many rules
    • □ Rules don’t make sense
    • □ Not enough time to relax
    • □ Not enough time to smoke
    • □ Not enough privacy
    • □ Staff are not polite to patients
    • □ Staff don’t explain things to patients
    • □ Other (please explain)
  7. Which of the following behaviors can cause a patient to be restrained or secluded?
    • □ Pacing
    • □ Muttering
    • □ Arguing
    • □ Insulting
    • □ Yelling
    • □ Cursing
    • □ Threatening
    • □ Breaking things
    • □ Trying to hurt self
    • □ Trying to hurt others
  8. What are some things that could help patients control their behavior to keep it from getting to the point where they try to hurt themselves or someone else?
    • □ Talk to a staff member
    • □ Talk to another patient
    • □ Discuss it in a group
    • □ Take a walk
    • □ Spend time alone
    • □ Exercise
    • □ Do an activity (like drawing or writing) alone
    • □ Do an activity (like drawing or writing) in a group
    • □ Hit something soft
    • □ Take a shower
    • □ Let off steam (Yell or curse in a place where it won’t bother anyone else)
    • □ Go to bed
    • □ Medication
    • □ Other (please explain)
  9. Which of these methods areactually usedon your ward to help patients control behavior to keep it from getting to the point where patients try to hurt themselves or someone else?
    • □ Talk to a staff member
    • □ Talk to another patient
    • □ Discuss it in a group
    • □ Take a walk
    • □ Spend time alone
    • □ Eat something
    • □ Exercise
    • □ Do an activity (like drawing or writing) alone
    • □ Do an activity (like drawing or writing) in a group
    • □ Let off steam (Yell or curse in a place where it won’t bother anyone else)
    • □ Hit something soft
    • □ Take a shower
    • □ Go to bed
    • □ Medication
    • □ Other (please explain)
  10. When a patient gets restrained or secluded, does staff explain why it’s happening?
    • □ Yes
    • □ No
  11. When a patient gets restrained or secluded, are they usually kept in restraint or seclusion for
    • □ Too long
    • □ The right amount of time
    • □ Not long enough
  12. After a patient comes out of restraint or seclusion, is there a discussion between staff and patient about what happened and what could have been done differently?
    • □ Yes
    • □ No
  13. If so, are these discussions helpful?
    • □ Yes
    • □ No
  14. When a “code green” is called and extra staff rush to the ward, does it usually
    • □ Make things better
    • □ Make things worse
  15. Do staff get enough training in how to keep situations from getting to the point where somebody gets restrained or secluded?
    • □ Yes
    • □ No
  16. Should staff hear from patients who have been through restraint or seclusion as part of their training?
    • □ Yes
    • □ No
  17. Should staff be put into restraint or seclusion as part of their training?
    • □ Yes
    • □ No
  18. What changes could Creedmoor make to make it less likely that patients get restrained or secluded?
Keywords:

restraint; seclusion; culture change; training; individualized treatment

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