RISK MANAGEMENT: PART 1
SECLUSION AND RESTRAINT
From Navigating the Maze of Malpractice Risks: Let Risk Management Lead the Way,
presented by Professional Risk Management Services, Inc
Kim J. Masters, MD, Assistant Clinical Professor, College of Health Professions, Medical University of South Carolina, Charleston; Medical Director, Three Rivers Midlands Campus Residential Treatment Center, West Columbia, SC
Educational Objectives
| The goal of this program is to reduce the use of seclusion and restraint in psychiatric facilities and to improve their safety in settings where they are needed. After hearing and assimilating this program, the clinician will be better able to: |
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Examine the historical roots of seclusion and restraint procedures. |
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Describe 3 elements of coercive treatment in a psychiatric service or child and adolescent residential treatment facility. |
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Explain why institutions are never completely free of coercion, but should always strive toward collaboration. |
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Discuss patients’ views of seclusion and restraint. |
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Improve the safety of restraint by using pulse oximetry to monitor patients being restrained. |
Faculty Disclosure
In adherence to ACCME Standards for Commercial Support, Audio-Digest requires all faculty and members of the planning committee to disclose relevant financial relationships within the past 12 months that might create any personal conflicts of interest. Any identified conflicts were resolved to ensure that this educational activity promotes quality in health care and not a proprietary business or commercial interest. For this program, the faculty and planning committee reported nothing to disclose.
Acknowledgements
Dr. Masters was recorded at Navigating the Maze of Malpractice Risks: Let Risk Management Lead the Way, presented November 15, 2008, in Charlotte, NC, and sponsored by Professional Risk Management Services, Inc. The Audio-Digest Foundation thanks Dr. Masters and PRMS for their cooperation in the production of this program.
| Introduction: definitions from Center for Medicare and Medicaid Services (CMS); seclusion—involuntary confinement of a patient alone in a room or in an area where patient is physically prevented from leaving by (including but not limited to) manually or electronically locked doors, one-way doors, presence of staff proximal to room who prevent exit, or threat of consequences if patient leaves room; physical restraint—includes any manual method or mechanical device, material, or equipment attached or adjacent to patient’s body that patient cannot easily remove or that restricts patient’s freedom of movement or normal access to his or her body; chemical restraint—defined by CMS as medication used to control patient’s behavior or to restrict his or her freedom of movement, and which is not standard treatment for that patient’s condition (however, Joint Commission on Accreditation of Healthcare Organizations [JCAHO] defines chemical restraint as improper use of medication, and most psychiatrists do not consider it improper to use patient’s own medication to help decrease his or her agitation) |
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Controversies about seclusion and restraint date back to French Revolution, when Dr. Philippe Pinel proposed that mental patients in asylums deserved to experience revolutionary ideals of liberty, equality, and brotherhood; Dr. Robert Gardner-Hill in England agreed; Dr. John Gray in United States disagreed, opining that seclusion and restraint were valuable therapeutic tools; opposing viewpoints still exist |
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Attitudes about restraint depend upon: population of individuals being restrained; disorders being treated; frame of reference (eg, patient-physician relationship vs therapeutic milieu) |
| Case law: case laws used to challenge seclusion and restraint same case laws used to challenge involuntary commitment; early challenges relied on Eighth Amendment to Constitution of United States, which guarantees freedom from cruel and unusual punishment; however, courts consistently interpret this amendment to apply only to correctional settings; more recently, challenges based on 14th Amendment, which guarantees due process; in 1974 case, United States Supreme Court said that if patient confined involuntarily, facility must provide treatment (“quid pro quo doctrine”); in 1982 case, Supreme Court said that patients have right to reasonably safe conditions of confinement and freedom from unreasonable restraint; “reasonable” determined by “appropriate use of medical and professional judgment”; in cases in which patient was injured or died as result of restraint, states have not been held liable, but individuals who carried out restraint have been held liable |
| Regulation of seclusion and restraint: speaker confines remarks to CMS and JCAHO (although they are not the only regulatory agencies); in 1999, as result of report on death during restraint, both agencies announced that seclusion and restraint could be used only in emergency situations in which patient endangering self or others |
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CMS final ruling on restraint (2006): restraint must be ordered by licensed medical practitioner; licensed medical practitioner or designee (ie, nurse or physician assistant trained in seclusion and restraint) must conduct face-to- face assessment of patient within 1 hr of order; treating physician and family must be notified of restraint; debriefing of patient and staff after restraint not required; people doing restraint must be trained in seclusion and restraint, but “training” not defined |
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JCAHO: regulations usually compatible with those of CMS; seclusion and restraint must be ordered by licensed medical practitioner; in children <9 yr of age, seclusion and restraint limited to 1 hr; 9 to 17 yr of age, limited to 2 hr; >17 yr of age, limited to 4 hr; if patient still in restraint at end of allowed time, licensed medical practitioner must do face-to-face assessment at that time; if restraint discontinued before end of allowed time, face-to-face assessment must be done within 24 hr; JCAHO also has standards for reducing use of seclusion and restraint, stresses use of nonphysical techniques, promotes assessment and monitoring, collects data, and addresses other issues |
| Psychologic issues in seclusion and restraint: provide some of most compelling reasons for abolition of this practice; in Maslow’s hierarchy of needs, physiologic needs at bottom of pyramid, and next level up identified as feelings of safety and comfort; if these levels of needs not met, patient cannot engage in treatment; in state hospitals and some residential settings, needs for, eg, food, clothing shelter, might not be met or met inadequately (eg, patient may have minimal or inadequately-fitting clothing, or may be required to wear paper gown; such problems will not result in feelings of comfort, and hearing other patients’ screams related to violence or restraint will not make patient feel safe) |
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Reenactments: institution’s failure to meet patient’s physiologic and psychologic needs may remind patient of past situations in which needs not met; consequently, patient may feel helpless, fearful, violated, and controlled by institution, and will likely be unwilling to engage in treatment; use of restraint or seclusion may result in posttraumatic stress disorder (PTSD); eg, patient restrained during previous abusive situation who is now being restrained in psychiatric facility may have those memories triggered, and will be unable to respond rationally to person restraining him or her; staff members’ raised voices may cause hyperarousal in patient |
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Intramuscular (IM) medication: when used as behavioral restraint, may trigger PTSD in patient being restrained and fear in other patientswho hear about or witness it; carries risks—related to trauma and reexperiencing of abuse, and dissociation; promoted by coercive environments and by failure of institution to meet first 2 levels of Maslow’s hierarchy; patients see use of IM medication as coercive; used as immediate solution for patient’s agitation, IM medication associated with long-term sequelae, which may be “far worse than any beneficial effects that come from using medication” |
| Coercive ecology: restraints instruments of coercion; to reduce restraint use, other elements of coercive culture must also be reduced |
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Role of staff in development of coercive environment: individuals at lowest pay and with little opportunity for promotion often have same history as patients (eg, neglect, abuse, violence, PTSD); training does not override personal experiences, especially in crises; among lowest paid staff, turnover 15% to 50% per year, due to low pay and stress; in presence of agitated patient, staff member’s first reaction may be to restrain patient |
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Characteristics of coercive ecology: authoritarian; rule-bound; past-oriented (“you’ve always had conduct disorder”); all patients treated the same (“we need everybody to behave”); language of correctional facilities utilized (“that’s a verbal aggression”; “that’s an elopement”); emphasis placed on punishment and conformity to produce change; obedience favored over thinking and personal growth; success defined as “the patient getting in the institution’s boat”; most members of the environment (including staff) feel angry, depressed, and/or helpless; resistant to change; patients discouraged from reading or otherwise obtaining information; might and power at base of hierarchy; fearfulness and victimization prevalent; crisis-prone; high rates of seclusion, restraint, IM medications, and runaways |
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Coercion involves: abuse—verbal, physical, and emotional; neglect—disregard for patients’ needs from first 2 levels of Maslow’s hierarchy; patients’ concerns that are nonpsychiatric also disregarded (“that’s not my job”); patients discouraged from discussing their futures after leaving psychiatric facility; exploitation—sexual, physical, and emotional |
| Collaborative ecology: no institution completely free from coercion, but collaboration always goal |
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Characteristics of collaborative ecology: authoritative but not dictatorial; problem solving encouraged; future-oriented; everyone assessed and treated based on individual strengths and limitations; explanatory language utilized; individual and community growth favored over obedience; success defined as “the institution getting in the patient’s boat”; most members of community become hopeful and resourceful; change welcomed; patients encouraged to read and otherwise obtain information; hierarchy based on creativity and knowledge; trust and hope encouraged; most members feel empowered; crises usually anticipated and prevented; low rates of seclusion, restraint, IM medications, and runaways |
| Seclusion: longer seclusion continues, greater the risk for traumatic response; some patients with anxiety disorders have been literally scared to death; JCAHO reports 115 deaths associated with restraint and 5 associated with seclusion from 1994 to 2005; seclusion may be medically safer, but not psychologically safe; in study, patients asked to draw pictures of their experience in seclusion; drawings indicated confusion, fear, and anxiety; one drawing depicted seclusion room as gas chamber waiting for gas to be turned on; 1 yr later, patients still remembered negative aspects of seclusion |
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Snoezelen room: snoezelen Dutch word for “comfort”; seclusion room fitted with pillows, cushions, paintings, and other items of comfort; creates room to which patient voluntarily retires to calm down, which is purpose of seclusion |
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Conundrum: “how come we have rocket science for distressed cardiac patients but stone-age science for agitated mental patients?” ie, technology in other fields of medicine has moved forward dramatically, while no improvement seen in restraint and seclusion technology for >2000 yr; conflicting views of future of restraint lead to status quo and lack of innovation |
| The case for pulse oximetry: pulse oximetry one form of “rocket science” that can help improve safety for patients in restraint; used in places other than hospitals; benefits psychologic and medical |
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Another conundrum: when nonpsychiatric patient says he or she cannot breathe, he or she receives immediate medical attention; but when patient in restraints says he or she cannot breathe, why is he or she usually ignored? (“well, how do we know he’s telling the truth?”) |
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Current restraint monitoring: consists of checking patient’s pulse and respiratory rate, both of which increase when patients restrained; when pulse or respiration cease, too late to intervene |
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Pulse oximetry: majority of patients who die in restraints die of suffocation; pulse oximeter monitors oxygen saturation in blood, alerting caregiver to problem before patient suffocates; can be used anywhere; caregivers can be trained in ≈7 min; much easier to use than, eg, cardiac defibrillator; inexpensive |
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Psychologic benefits: patient sees that dangers of restraint being assessed; fosters caregiver-patient collaboration (speaker recommends introducing patient to pulse oximeter before needed, and obtaining baseline measurement of oxygen saturation); if patient rejects pulse oximeter applied to finger, toe or earlobe alternatives; pulse oximetry should be used before, during, and after restraint (note, some patients have died of postrestraint bronchospasm), and “any time anybody thinks that the patient doesn’t look right” or whenever patient complains of difficulty breathing |
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Outcomes: using pulse oximetry did not increase number of times that staff used restraint or duration of restraint; however, it did cause staff and patients to be more aware of danger of restraint and more conscientious about safety |
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American Psychiatric Association (APA): currently reviewing all practice guidelines to determine in which cases use of pulse oximetry might be indicated |
| Summary: history of methods used in seclusion and restraint centuries-old; mental health law and JCAHO accreditation standards help limit abuse of seclusion and restraint; PTSD potential outcome of this practice; in coercive ecology, restraint use increased, and in collaborative ecology, restraint use decreased; modernization of seclusion and restraint and of its monitoring lags behind other technologic gains in medicine; pulse oximetry recommended to monitor oxygenation in all patients in restraint |
Suggested Reading
AACAP News: Seclusion and restraint articles. Available at: http://www.aacap.org/cs/root/member_information/ practice_ information/aacap_news_seclusion_and_restraint_articles, 1/30/2009; Ashcraft L, Anthony W: Eliminating seclusion and restraint in recovery-oriented crisis services. Psychiatr Serv 59:1198, 2008; Bilanakis N, Peritogiannis V: Attitudes of patients and families toward restraint and seclusion. Psychiatr Serv 59:1220, 2008; Borenstein J: Teaching tool to reduce restraint and seclusion. Psychiatr Serv 59:448, 2008; Greene RW, Ablon JS: Treating Explosive Kids: The Collaborative Problem Solving Approach. New York: Guilford Press, 2006; Martin A et al: Reduction of restraint and seclusion through collaborative problem solving: a five-year prospective inpatient study. Psychiatr Serv 59:1406, 2008; Masters KJ: Pulse oximetry use during physical and mechanical restraints. J Emerg Med 33:289, 2007; Nunno M et al: For Our Own Safety: Examining the Safety of High-Risk Interventions for Children and Young People. Child Welfare League of America, 2008; available at http://www.cwla.org/pubs/pubdetails.asp?PUBID=0005 , 1/30/2009; Picoult J: Nineteen Minutes. New York, NY: Washington Square Press, 2008; van Doeselaar M et al: Professionals’ attitudes toward reducing restraint: the case of seclusion in the Netherlands. Psychiatr Q 79:97, 2008; Witte L: Reducing the use of seclusion and restraint. A Michigan provider reduced its use of seclusion and restraint by 93% in one year on its child and adolescent unit. Behav Healthc 28:54, 2008.
Programs of Related Interest
Masters K: Prevention of restraint and seclusion in adolescents. Audio-Digest Psychiatry, vol 33, issue 22; November 21, 2004; Scott C: Correctional psychiatry and right to treatment. Audio-Digest Psychiatry, vol 37, issue 19; October 7, 2008.
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