Patient Safety Advisory Reprinted from the PA-PSRS Patient Safety Advisory—Vol. 2, No. 1 (March 2005) Produced by ECRI & ISMP under contract to the Pennsylvania Patient Safety Authority Changing the Culture of Seclusion and Restraint T he Commonwealth of Pennsylvania demonstrated leadership in behavioral health when the state hospitals participated in an aggressive statewide pro- With the national focus on the behavioral health in- dustry, both regulatory and accrediting bodies took on the mission of changing gram to significantly reduce the use of seclusion and their standards to ad- Healthcare providers restraints. According to Steven Karp, DO, former dress the goal of reduc- have changed their Chief Psychiatric Officer of the PA Department of ing seclusion and re- philosophical model Public Welfare, seclusion hours: straint use. Healthcare providers have changed for managing the com- ”…dropped from more than 5,000 in February not just policies and pro- bative patient from 1993 to just over 4 in February 2003. During cedures but also their one of control to one this same period, the number of mechanical philosophical model for of collaboration, from restraint hours dropped from almost 11,000 to managing the combative slightly more than 90. Two state hospitals in force to facilitation. patient. This model has Pennsylvania have not used restraints, and two shifted from control to others have not used seclusion, in more than collaboration, from force to facilitation, and from domi- two years.”1 nance to empowerment. Patient injuries associated with seclusion and restraint were the catalyst for an Further, staff injuries did not increase during this pe- opportunity to explore alternatives in care delivery for riod as a result of decreased use of seclusion and this patient population. restraints.2 Regulatory and Accrediting Obligations The clinical literature on mental health treatment fre- The Centers for Medicare and Medicaid Services quently refers to this statewide success story as evi- have revised the conditions of participation such that dence that a safe environment can be attained for patients have the right to “freedom from restraint and psychiatric patients without resorting to force. Re- seclusion use to manage violent or aggressive behav- straints and seclusion became the exception rather ior unless clinically necessary.”5 OSHA has provided than the rule in response to patient’s escalating be- Guidelines for Preventing Workplace Violence for haviors. The state hospitals’ change in delivery of Health Care and Social Service Workers6 and “has care was an extraordinary accomplishment which was cited healthcare facilities under its general duty acknowledged in October 2000, when Pennsylvania’s clause for failure to prevent patient violence against Seclusion and Restraint Reduction Initiative received healthcare workers since at least 1993.”7 the prestigious Harvard University Innovations in American Government Award.”2 Accrediting bodies such as the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) As the state hospitals met the challenge of providing have stringent standards on restraint use that are ap- support rather than control over the institutionalized plied everywhere in the acute care setting where be- mentally ill, a newspaper in Connecticut was review- havioral patients are managed, including the Emer- ing deaths related to the use of seclusion and re- gency Department, medical/surgical units, and oth- straints in the nation. The investigative reporting of the Hartford Courant in October 1998 was precipi- tated by the death of a restrained 11-year-old. The This article is reprinted from the PA-PSRS Patient Safety Advisory, Vol. 2, No. article documented 142 deaths related to restraints 1—March 2005. The Advisory is a publication of the Pennsylvania Patient nationwide over a decade.3 The leading cause of Safety Authority, produced by ECRI & ISMP under contract to the Authority as part of the Pennsylvania Patient Safety Reporting System (PA-PSRS). death related to restraints was death secondary to unintentional asphyxiation that occurs during the re- Copyright 2005 by the Patient Safety Authority. This publication may be re- straining of the patient. The very act of restraining printed and distributed without restriction, provided it is printed or distributed in brings significant risk to the patient and staff, and to- its entirety and without alteration. Individual articles may be reprinted in their entirety and without alteration provided the source is clearly attributed. day restraints are recognized as an extreme use of force. According to one researcher, “high restraint To see other articles or issues of the Advisory, visit our web site at rates are now understood as evidence of treatment www.psa.state.pa.us. Click on “Advisories” in the left-hand menu bar. failure.”4 ©2005 Pennsylvania Patient Safety Authority Page 1 Reprinted from the PA-PSRS Patient Safety Advisory—Vol. 2, No. 1 (March 2005) Changing the Culture of Seclusion and Restraint (Continued) ers.8 The Proposed 2006 National Patient Safety Strong leadership with management and staff ac- Goals and Requirements and Rationale Statements countability is essential. The physician’s role as clini- for Behavioral Health Programs includes reducing cal leader is critical in moving the multidisciplinary “the risk of harm associated with emotional and be- team toward a change in response to the patient with havioral crisis.”9 These draft standards reinforce escalating behavior. Learning from Each Other: Suc- JCAHO’s commitment and focus on the issue of cess Stories and Ideas for Reducing Restraint/ forceful patient management. Seclusion in Behavioral Health12 was published col- laboratively by the American Psychiatric Association, Current Knowledge on Seclusion and Restraints the American Psychiatric Nurses Association, and the What do we know of the effectiveness and therapeu- National Association of Psychiatric Health Systems. tic value of restraints and seclusion? A 2003 litera- This online resource offers creative approaches to ture review on the use of physical restraints and se- providing an environment of caring rather than one of clusion came to the following conclusions: control. • Seclusion and restraints are used frequently, but For example: the actual rate is unknown. • Building a sensitive program by putting yourself in • Least restrictive alternatives are considered effec- the patient’s place. tive, though this has not been empirically studied. • Having patient-centered policies as the infrastruc- • Educational programs have been effective in re- ture of the program. ducing the use of seclusion and restraints. • Proactively negotiating with patients for their sug- • Legal and ethical issues will continue until re- gested alternatives to crisis management. search demonstrates the efficacy of seclusion and restraints. • Identifying alternative management strategies with your peers in collaborative workgroups. • Until empirical research supports a change, there is consensus that the least restrictive measures • Rooting out the underlying causes of aggressive are preferable. behavior.12 • Restraints could be used “less arbitrarily, less Communication is central when shifting the treatment frequently, and with less trauma” than in current model from one of force to one of support. Organiza- practice. tional and clinical leaders are encouraged to be in • Staff education is an effective tool in reducing the “constant dialogue with staff”12 and to consistently incidence of restraint and seclusion. reinforce the reframing of care such that “least restric- tive” becomes “most facilitative.” The language and • Research is critical to address the many issues labels used in the clinical setting are important. Con- related to predictive behaviors, effectiveness, al- sider proactive prevention, by shifting from a show of ternatives, legal and ethical ramifications.10 force to a show of support. In this alternative environ- ment, isolation for patient management shifts towards Organizational Responses to Minimizing Restraint an upbeat and supportive setting such as a “comfort and Seclusion Utilization room” rather than the punitive-sounding “time out How can a multidisciplinary team respond to an esca- room.”13 lating patient situation without resorting to force? Some clinical teams have changed the way they think Education is key to assure that staff at the front line about the needs of the patient and have moved to- are skilled in de-escalating techniques and are ward a more humanistic approach of supportive nego- prompt in responding to defuse potentially volatile tiation rather than control. The successful change to situations. Almost every article includes emphasis on less restrictive behavior management necessitates staff education.14,15 more than procedural changes but rather a philoso- phical and cultural change to the point where the pa- Some additional considerations: tient is encouraged and supported as a participant in their treatment plan. “Values of respect and dignity • Reading and reviewing policies according to a must permeate the system, and disrespectful behav- schedule. ior by staff must be confronted and changed.”11 • Developing a competency based education for interdisciplinary staff. Page 2 ©2005 Pennsylvania Patient Safety Authority Reprinted from the PA-PSRS Patient Safety Advisory—Vol. 2, No. 1 (March 2005) Changing the Culture of Seclusion and Restraint (Continued) • Requiring staff to demonstrate their competence for controlling measures which are reserved for on an ongoing basis. the most extreme situations.11 • Using role playing to reinforce de-escalation inter- ventions. Team Development and Deployment CPR is called by a code name in most institutions to • Delivering education conveniently around-the- provide discretion in a sensitive situation and to notify clock. the team of clinical specialists skilled at resuscitative • Holding staff accountable for their education.12 measures as to where to respond. Each member of • Educating patients on the changes occurring.15 the team has a specific responsibility. These team members do two things. First, they provide an ad- • In programs that manage children and adoles- vanced level of knowledge and skill to a life- cents, training in developmentally appropriate threatening situation. Second, they provide supple- strategies for carrying out seclusion and physical mental staff to support the needs of a patient in crisis, and chemical restraint, including hands-on prac- thus allowing the staff to attend to the needs of the tice with restraint equipment and techniques and other patients. cardiopulmonary resuscitation (CPR) training.16 • Incorporating cultural changes into the educa- Similarly, the behavioral health code involves pre- tional program requires integrating shared values identified staff responding to the request for support in of dignity and respect while minimizing the need managing a patient with challenging behavior. The behavioral team members are equally highly skilled Reports Involving Seclusion and Restraint Submitted to PA-PSRS Since its inception, PA-PSRS has received multiple reports de- and one of these cases required surgery. The demographics of scribing restraint or seclusion of behavioral health patients. Typi- the affected patients are revealing in that six of the seven pa- cally these reports do not include the particulars of the efforts to tients are male, with ages ranging from 12 to 56. manage the situation, but they do highlight what occurred when a patient’s behavior cannot be contained. Occasionally, reports One detailed report provides some insight into the extent of clini- describe staff interventions. For example: cians’ efforts to manage a challenging situation: • Escalating behavior requiring four staff to escort the pa- The patient was asked to take a time out due to tient to seclusion, administration of intramuscular medica- verbally threatening behavior during a group ses- tions and two hours later patient returned to the patient’s sion. Attempts to redirect were unsuccessful. room to sleep. While in time out, the patient began to push staff. He was placed in a manual hold and continued to • Peer to peer aggression, response team called to inter- be combative. He was placed in mechanical re- vene, time out initiated, no injuries noted. straints until calm. The next day he complained of • Patient attempting to inflict harm to self, staff intervened, right shoulder discomfort. An x-ray indicated a no harm occurred to patient. fracture of the greater tuberosity of the humerus, which was later confirmed by the orthopedist. • Crisis team and police called. Patient was holding an- other patient. Pepper spray was used to subdue the pa- This case exemplifies multiple, gradually escalating levels of tient. intervention: time out, redirection of patient behavior, and manual hold necessitating the use of force. Finally, restraints were ap- When a patient demonstrates escalating behavior the clinical plied as a last resort. team responds in an individualized, strategic, progressive man- ner. The efforts generated are to contain the situation yet remain In this case the hold used was not described beyond a “manual supportive of the patient in crisis. When de-escalating techniques hold,” but holds have been associated with injuries even fatali- fail, the risk versus benefit of restraining is considered, and ulti- ties.1,2 Certain holds (such as the chokehold or the basket hold) mately the situation may necessitate restraint to protect the pa- and positions (face down/prone) are particularly threatening to tient or others. In these frustrating and disturbing situations the the patient, and many organizations have banned their use.3 potential for injury—even death—exists. PA-PSRS has received Restrictive measures applied to the neck or near the patient’s reports of patient injuries which have occurred during restraining, airway are particularly hazardous. Compression of the chest also most of which are lacerations, abrasions, and bruises. However, carries the risk of positional asphyxiation if the chest’s normal there are seven cases in which the patient sustained a fracture, respiratory expansion cannot occur. (Continued on next page) ©2005 Pennsylvania Patient Safety Authority Page 3 Reprinted from the PA-PSRS Patient Safety Advisory—Vol. 2, No. 1 (March 2005) Changing the Culture of Seclusion and Restraint (Continued) Reports Involving Seclusion and Restraint Submitted to PA-PSRS (Continued) The JCAHO Sentinel Event Alert on Preventing Restraint • Developing structured procedures for consistent appli- Deaths4 reports that 30 percent of restraint-related deaths oc- cation of restraints. curred during a therapeutic hold. When absolutely necessary and all other less restrictive measures have failed in managing • Continuously observing any patient in restraints. a situation where the patient, other patients, and staff are • If a patient must be restrained in the supine position, threatened, restraining of an individual may be necessary. Cer- ensuring that the head is free to rotate to the side and, tain factors or patient characteristics may place the patient at when possible, elevating the head of the bed to mini- greater risk of fatality during restraint, such as: mize the risk of aspiration. • Neck holds • If a patient must be restrained in the prone position, • Obstruction of nose, mouth, or chest expansion ensuring that the airway is unobstructed at all times • Prone or hobble tying (for example, not covering or “burying” the patient’s • Hyperflexion in a seated position face). • Obesity • Heart disease • Ensuring that expansion of the patient’s lungs is not • General poor health restricted by excessive pressure on the patient’s back • Exhaustion or prolonged struggling (with special caution for children, elderly patients, and • Illicit or prescribed medications obese patients).4 • Drug intoxication1,2,5 Notes Recognizing the hazards of patient restraint, consider the fol- 1. Horsburgh D. How, and when, can I restrain a patient? Postgrad Med J lowing strategies to mitigate the risk: 2004;80:7-12 2. Paterson B, Bradley P, Stark C, et al. Deaths associated with restraint use in • Redoubling efforts to reduce the use of physical re- health and social care in the UK. The results of preliminary survey. J Psychiatr straint and therapeutic hold through the use of routine Ment Health Nurs 2003(10):3-15. risk assessment and early intervention with less re- 3. Stefan S. Legal and regulatory aspects of seclusion and restraint in mental health settings. Special edition violence and coercion in mental health settings: strictive measures. eliminating the use of seclusion and restraint. Sum/Fall 2002. 3 4. Joint Commission on Accreditation of Healthcare Organizations. Sentinel • Enhancing staff orientation/education with alternatives event alert [online]. 1998 Nov 18 [Cited 1 Mar 2005]. Available from Internet: to physical restraints and proper application of re- http://www.jcaho.org/about+us/news+letters/sentinel+event+alert/sea_8.htm straints or therapeutic holding. 5. Masters KJ, et al. Practice parameter for the prevention and management of aggressive behavior in child and adolescent psychiatric institutions, with special reference to seclusion and restraint. J Am Acad Child Adolesc Psychiatry. 2002 Feb;41(2 Suppl):4S-25S. and typically have certain physical characteristics of Debriefing or Restraint Review size and strength. More important than their size and When it is necessary to use force and restrain a pa- strength is their commitment and competence in de- tient, an opportunity for improvement exists. How livering a clinical intervention that supports the patient could this situation been handled differently? Did the in a non-threatening manner. patient provide clues to their changing needs? Were the interventions attempted sufficient? Could a com- These rapid response teams have been mentioned in promise been employed? If we had intervened ear- some PA-PSRS reports. Two widely used terms are lier, could the situation have been managed with a “Code Gray” for combative individuals and “Code Sil- less restrictive intervention? ver” if a weapon is brandished.7 Pennsylvania state hospitals use the acronym “PERT,” Psychiatric Emer- Reviewing interventions immediately after occurrence gency Response Team, according to Dr. Karp.17 in a “debriefing” format allows the clinical team to con- front the successes and shortcomings of the team Behavioral health code teams provide advanced skills response, the interventions, and alternatives at- at negotiating, verbal de-escalation techniques, and tempted. Aside from dissecting the event, considera- safe methods of containing a struggling patient. Re- tion of the attitudes and feelings of the staff, the vic- maining supportive rather than controlling is the goal, tim, and those patients who witnessed the event are but despite the best of efforts, some situations may of value. A patient-centered program is sensitive to need to be managed with force. It is important to re- the perceptions of all involved in an effort to under- member that restraining the already traumatized psy- stand individual responses. Ultimately these internal chiatric patient can have long lasting physical and reviews are intended to improve the response to fu- emotional consequences. ture events.7,12,15 Page 4 ©2005 Pennsylvania Patient Safety Authority Reprinted from the PA-PSRS Patient Safety Advisory—Vol. 2, No. 1 (March 2005) Changing the Culture of Seclusion and Restraint (Continued) While Pennsylvania has assumed a leading role in 9. JCAHO. Proposed 2006 national patient safety goals and re- quirements and rationale statements – behavioral health program reducing restraint and seclusion use, there is still [online]. [Cited 24 Jan 2005]. Available from Internet: http:// room for improvement. Additional effort is necessary www.jcaho.org/accredited+organizations/behavioral+health+ care/ to reduce the need to resort to restraint and seclusion standards/field+reviews/06_npsg_bhc_fr.htm and, when restraint becomes necessary, to minimize 10. Bower FL, McCullough C, Timmons M. A synthesis of what we the risk of patient injury. Though restraining the pa- know about the use of physical restraints and seclusion with pa- tient is recognized as “a treatment failure”4 it is ac- tients in psychiatric and acute care settings: 2003 update. Online J Knowl Synth Nurs. 2003 Apr 22;10:1. knowledged that in some situations restraints are vital 11. Karp S. Coercive Tactics Are No Longer Viable Treatment in preventing injury to patients and/or staff. Methods. Special Edition Violence and Coercion in Mental Health Settings: Eliminating the Use of Seclusion and Restraint. Sum/Fall Notes 2002:15. 1. Reducing seclusion and restraint use – what works! [online] May 12. American Psychiatric Association, American Psychiatric Nurses 2003. [Cited 11 Feb 2005] Available from Internet: http:// Association, National Association of Psychiatric Health Systems. alt.samhsa.gov/seclusion/SRMay5report7.htm Learning from each other: Success stories and ideas for reducing 2. Pennsylvania Department of Public Welfare, Office of Mental restraint/seclusion in behavioral health [online]. 2003. [Cited 2005 Health and Substance Abuse Services. Leading the way toward a Feb 21.] Available from Internet: http://www.psych.org/psych_pract/ seclusion and restraint-free environment. Pennsylvania’s seclusion treatg/pg/LearningfromEachOther.pdf and restraint reduction initiative. Harrisburg (PA): Office of Mental 13. Bluebird G. Comfort and communication help minimize con- Health and Substance Abuse Services; 2000. flicts. Special edition violence and coercion in mental health set- 3. Weiss E. A nationwide pattern of death. Hartford Courant 1998 tings: Eliminating the use of seclusion and restraint. Sum/Fall Oct 11-15. 2002;18 4. Stefan S. Legal and regulatory aspects of seclusion and restraint 14. Jorgensen BA, Geisler C. Perspectives from the field education in mental health settings. Special edition violence and coercion in is key to system-wide change. Special edition violence and coer- mental health settings: eliminating the use of seclusion and re- cion in mental health settings: Eliminating the use of seclusion and straint. Sum/Fall 2002. 3 restraint. Sum/Fall 2002;9. 5. Health Care Financing Association. Medicare and Medicaid Pro- 15. McCue RE, Urcuyo L, Lilu Y, et al. Reducing restraint use in a grams: Hospital Conditions of Participation: Clarification of the public psychiatric inpatient service. J Behav Health Serv Res. Apr/ Regulatory Flexibility Analysis for Patients’ Rights: Interim Final Jun 2004;217-24. Rule. Fed Regist 2002 Oct 2;67(191):61805-8. 16. Masters KJ, et al. Practice parameter for the prevention and 6. Occupational Safety and Health Administration. Guidelines for management of aggressive behavior in child and adolescent psy- Preventing Workplace Violence for Health Care and Social Service chiatric institutions, with special reference to seclusion and re- Workers [online]. 2004. [Cited 28 Dec 2004]. Available from Inter- straint. J Am Acad Child Adolesc Psychiatry. 2002 Feb;41(2 net: http://www.osha.gov/Publications/osha3148.pdf. Suppl):4S-25S. 7. ECRI. Patient violence healthcare risk control risk analysis, Jul 17. Karp, Steven (Rosewood Woman’s Center for Eating Disor- 2002. Healthc Risk Cont 4(2). ders, Wickenburg, AZ) E-mail to: Monica Davis 8. Joint Commission on Accreditation of Healthcare Organizations (JCAHO). Behavioral health care. Restraint and seclusion. [online] Updated: 1 Jan 2004. [Cited 24 Jan 2005]. Available from Internet: http://www.jcaho.org/accredited+organizations/ behavioral+health+care/standards/faqs/provision+of+care/ special+interventions/restraint_seclusion.htm ©2005 Pennsylvania Patient Safety Authority Page 5 Reprinted from the PA-PSRS Patient Safety Advisory—Vol. 2, No. 1 (March 2005) An Independent Agency of the Commonwealth of Pennsylvania The Patient Safety Authority is an independent state agency created by Act 13 of 2002, the Medical Care Availability and Reduction of Error (“Mcare”) Act. Consistent with Act 13, ECRI, as contractor for the PA-PSRS program, is issuing this newsletter to advise medical facilities of immediate changes that can be instituted to reduce serious events and incidents. For more information about the PA- PSRS program or the Patient Safety Authority, see the Authority’s website at www.psa.state.pa.us. ECRI is an independent, nonprofit health services research agency dedicated to improving the safety, efficacy and cost-effectiveness of healthcare. ECRI’s focus is healthcare technology, healthcare risk and quality management and healthcare environmental management. ECRI provides information services and technical assistance to more than 5,000 hospitals, healthcare organizations, ministries of health, government and planning agencies, and other organizations worldwide. The Institute for Safe Medication Practices (ISMP) is an independent, nonprofit organization dedicated solely to medication error prevention and safe medication use. ISMP provides recommendations for the safe use of medications to the healthcare community including healthcare professionals, government agencies, accrediting organizations, and consumers. ISMP's efforts are built on a non-punitive approach and systems-based solutions. Page 6 ©2005 Pennsylvania Patient Safety Authority