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States reduce
use of restraints
(June
2005 Issue)
By Pamela Berard
A number of New England states are actively engaging in restraint
reduction initiatives. Proposed regulations in Massachusetts focus
on prevention and alternative to restraints, reductions in the length
of time that restraints can be in effect and an outright prohibition
on the use of restraints for children under the age of 13, except
for emergencies.
Other New England states have also curtailed the use of restraints
in recent years.
Jim Siemianowski, LICSW, spokesman for Connecticut Department
of Mental Health and Addiction Services, says the state commissioner's
policies for seclusion and restraint were both revised in 2002.
"(We were) embarking on trying to transform the system to become
more recovery oriented," Siemianowski says, including reducing restraint
and seclusion and trying to identify alternative measures clients
felt would help them.
The state's largest inpatient facility, Connecticut Valley Hospital,
about six years ago began transforming its culture to reflect a
stronger recovery orientation and to train staff in de-escalation
techniques. "They put into place a whole system that focused on
decreasing the amount of time somebody spends in restraint and seclusion,"
Siemianowski explains. "They implemented policies, conducted training
and developed some very specific intervention strategies."
The hospital has a patient personal safety preferences form where
patients may specify their wishes in terms of crisis intervention,
"hopefully as a way to avoid seclusion or restraint," he says.
Siemianowski says data shows significant reductions in terms of
the number of patients involved in restraint and seclusion and also
the mean monthly usage within the facility of restraint and seclusion.
For example, he says in 1999, the mean monthly amount of restraint
and seclusion hours combined was about 4,500 hours in the 600-bed
facility.
"The latest data that I saw, from 1999 to 2003, it went from a
little over 4,500 to less than a 1,000, maybe about 900 (mean monthly)
in terms of restraint/seclusion," he says.
Teresa Mayo, Psy.D., director of psychology for Riverview Psychiatric
Center, one of two state hospitals in Maine, says restraint and
seclusion reduction is a topic of focus at Riverview.
A "Rights of Recipients of Mental Health Services" document outlines
the right to be free from any unnecessary seclusion and restraint
and specifies when seclusion and restraint can be used, under whose
authority, time limits and other information.
"About a year ago, we changed our intervention method to NAPPI
(Non-abusive Physical and Psychological Intervention) and began
an active education process with staff," including increased tolerance
and understanding, distress tolerance intervention skills and implementing
'Therapeutic Holds' as separate from mechanical restraints, Mayo
says.
"The total time of restraints has decreased steadily over the past
nine months," she says. "Reduction is roughly from over 3.5 hours
per event to an average of 40 minutes."
"We have an active NAPPI instructor committee that is researching
the latest in best practice and how we can continue to move in a
restraint free direction," Mayo adds.
At Eleanor Slater Hospital, the state-run hospital in R.I., Brandon
Krupp, M.D., chief of psychiatric services, says the hospital policy
is continuously updated, most recently in December 2004.
"Our policy is reviewed by our Restraint Clinical Management Team,
which is part of our hospital's performance improvement program,"
Krupp says. "It's a standing team looking at data every month. It's
something we look at and are constantly sort of tweaking."
The Restraint Clinical Management Team reports to a performance
improvement program steering committee.
Krupp says the use of restraints has been stable, "at a very low
level… Just over two percent on average of our patients each month
experience a restraint episode" at the approximately 400-bed facility.
"We try to use as few restraints as possible and by policy, we actually
must try a variety of alternatives to restraint first," Krupp says.
The total usage data is reviewed every month with other hospitals
of its type through the Joint Commission on Accreditation of Healthcare
Organizations' initiative ORYX, which integrates outcomes and other
performance measurement data into the accreditation process, he
says.
Richard Willgoose, director of performance and resource management
for New Hampshire Hospital, says the state hospitals have been very
involved in trying to reduce and ultimately eliminate the use of
restraints, through various training and intervention initiatives.
"We see them as not a therapeutic intervention but an emergency
intervention or a last resort," Willgoose says. "The reality is,
it's really a therapeutic failure when we have to use one of those
interventions."
Willgoose says the issue of restraint reduction came to the national
forefront in the late 1990s. "I don't think anybody has ever seen
this as a particularly good way to provide treatment," he says.
Willgoose adds the state hospital has a crisis intervention plan
for patients and there is a debriefing after any intervention episode.
"We had a breakthrough (maybe within the last six to seven years)
we really saw our ability to get some real reduction," he says.
"We certainly are seeing that when we do use the restraint or seclusion
intervention that we don't use it for very long. The time period
is much shorter," he adds.
According to the Vermont Department of Health, the state does not
have any regulations specifically governing restraint. Regulations
do address the use of restraints when administering non-emergency
involuntary medication, however, and provide that restraints may
only be used in emergency circumstances to protect the safety of
the patient or others. Each hospital has its own policies and procedures,
according to an official.
In Massachusetts, the final public hearing on the new regulations
was held April 11 and the state is reviewing comments and testimony
and determining the timeline for implementation.
"The restraint reduction initiative, of which our proposed restraint
regulations are just one part, are very important, not only to the
department, but also to providers and to individuals with mental
illness," said Massachusetts Department of Mental Health Commissioner
Elizabeth Childs, M.D., in a prepared statement. (See related story
on page 6).
"The goal to reduce - and even eliminate - the use of restraints
recognizes that restraint and seclusion are not therapeutic interventions,
but rather reflect a failure of treatment. So many individuals who
are in psychiatric facilities have been traumatized at some time
during their lives. The use of restraint and seclusion is re-traumatizing,
and is thus contrary to the treatment goals we espouse."
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