Reducing Risk Associated With Seclusion and Restraint

Seclusion and restraint (S/R) are major risk management issues for health care providers. In 2006, the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) attributed 153 deaths to S/R in the United States,¹ with asphyxiation as the primary cause of death.² There are no national statistics that fully capture the extent of physical and emotional trauma experienced both by patients and staff during and after episodes of S/R. The standards put forth by the Centers for Medicare and Medicaid Services (CMS)³ and JCAHO⁴ represent an effort to codify measures to reduce risk associated with S/R, so the standards themselves should be viewed as tools to reduce risk.

This article briefly reviews the federal standards regarding S/R and methods of reducing the risk associated with their use. CMS standards that went into effect February 6, 2007, will be emphasized; however, some of these standards vary from JCAHO standards. Where there are variances, clinicians are advised to follow the more stringent standards. Since JCAHO mandated behavioral standards for when S/R is used for behavioral reasons, behavioral health standards will be included. Clinicians are strongly encouraged to familiarize themselves with their state's standards for S/R.

Definitions

As defined by CMS,S/R may only be used for the management of self- destructive or violent behavior to ensure the immediate physical safety of the patient or others. "Seclusion" occurs when a patient is involuntarily confined in a room or area and is physically prevented from leaving.

In comparison, a "time-out" is when a patient voluntarily stays in an unlocked room. A "restraint" is any manual method or physical device that immobilizes or reduces a patient's ability to move. The term is also used to describe the administration of a medication beyond its standard dose to manage or restrict a patient's freedom of movement. This does not include the administration of medication on an as-needed basis that targets specified symptoms.

For clarity, it is important to understand that there are physical interventions that are not considered to be restraints. For example, CMS does not consider prescribed devices, surgical dressings, protective helmets, and other methods that involve physically holding the patient for the purpose of medical examinations or that allow the patient to participate in activities without risk of physical harm as restraints.

Similarly, JCAHO does not include holding a child for less than 30 minutes (the holder must have proper training and has to be observed by another trained staff person throughout the session), a time-out for less than 30 minutes, and handcuffs or devices applied by law enforcement officers as S/R.

Federal standards for S/R

The role of leadership in reducing risk associated with S/R cannot be overstated. There has to be a strong institutional commitment to create a culture that values the reduction of S/R. As such, the chief of staff and the organization's leadership must communicate a philosophy for the use of S/R to the staff. The philosophy must, at minimum, convey the importance of preventing S/R by identifying situations that can lead to S/R and that if S/R is necessary, it is used because there is imminent risk and less restrictive means have failed.

The organization's philosophy must also stress the impact of S/R on patients and emphasize the commitment to patient safety and dignity when S/R is used. The leadership is obligated to provide staffing levels that are consistent with staff qualifications and patient needs, and mechanisms must be in place to monitor staff performance and address deficiencies.

Patients' rights are also set forth in the federal standards. S/R must not be used for coercion, discipline, or for the convenience of the staff. Patients have the right to have restraints applied only for immediate safety purposes and for the shortest period. On admission, patients and/or family should be educated about S/R with an eye toward identifying ways to reduce its use.

S/R must be ordered by a licensed independent practitioner (LIP). A LIP is any individual permitted to independently order S/R that is in accordance with state law and hospital policy. For example, JCAHO would allow licensed physicians, psychiatric clinical nurse specialists, registered nurses, and licensed social workers to order S/R if permitted by state law and the organization's policy.

The orders must include the reason for the restraints, the type of restraint (eg, plastic, leather, or soft), the number of restraints applied, and a time limit for the order. Restraints can be ordered for 4 hours for adults 18 years or older, 2 hours for those 9 to 17 years of age, and 1 hour for children younger than 9 years. As-needed S/R orders are not permitted.

Nurses are able to initiate S/R. The LIP should be notified immediately if there is a change in the patient's condition. Otherwise, the nurse has 1 hour to contact the LIP to obtain an order (verbal or written) and to discuss the patient's condition. In addition, if the LIP is not the attending physician, he or she should also be notified "as soon as possible" (the time frame for this is determined by the facility and is based on the needs of the patient population).

Staff must also document the behaviors that led to the episode of S/R and the measures taken to avoid S/R. Staff should notify the family if the patient has consented; and if multiple episodes of S/R have occurred, the unit's leadership should be notified.

JCAHO requires that an LIP perform the initial assessment within 1 hour of initiating S/R. If the patient is removed from S/R before the initial evaluation, an LIP must still perform an in-person evaluation within 24 hours. Reevaluations by an LIP or a qualified, trained individual designated by the organization must be performed every 8 hours for adults, 2 hours for children aged 9 to 17 years, and 1 hour for children younger than 9. If the reevaluator is not an LIP, an LIP must still perform an in-person evaluation every 8 hours for adults and every 4 hours for those aged 17 and younger until S/R is discontinued.

JCAHO standards require face-to-face monitoring for all patients in S/R. For patients in seclusion only, audio and visual equipment can be used after the first hour.CMS standards require that patients who are placed in seclusion and restrained must be continuously monitored by trained staff, either face-to-face or with audio and visual equipment. Monitoring staff must be able to immediately respond to the patient.

JCAHO expects patients to be checked initially andevery 15 minutes to determine comfort and readiness for discontinuing S/R. In addition, JCAHO mandates that within 24 hours of an S/R episode, there must be a debriefing with the patient and his or her treatment plan reevaluated.

Protocols in medical settings are allowed for specific situations (eg, intubations). For interventions that meet the definition of a restraint, an order must be obtained and documentation made of a patient assessment indicating the symptoms and diagnosis that triggered use of the protocol.

Staff must be trained and demonstrate competency in 7 key areas:

• The ability to identify factors that may trigger an episode of S/R.
• Nonphysical intervention skills.
• The ability to choose the least restrictive intervention for any given situation.
• Knowledge of the safe application and use of S/R.
• The ability to recognize when S/R can be discontinued.
• The ability to monitor the physical and psychological well-being of the patient, including how to recognize and respond to patient distress.
• Possess current certification in cardiopulmonary resuscitation and knowledge of first aid techniques.

Individuals providing staff training must be qualified personnel. The hospital must document personnel records at the completion of training, including a record of competency testing.

The hospital must report any death that occurs while S/R is used or within 24 hours after discontinuation of S/R. The hospital must also report any death that occurs within 1 week following the use of S/R where it is reasonable to assume that restraint or seclusion contributed to the patient's death.

CMS and JCAHO have not mandated a particular position for restraining patients. Restraining patients in a prone position can lead to an increased risk of death, especially if the patient is obese, abuses drugs, presents with agitated delirium and/or underlying cardiac or respiratory conditions, and there has been a prolonged state of agitation.⁵ Patient positioning should therefore be considered as part of a risk reduction program.

Avoiding the need for S/R

A number of resources are available to assist facilities in reducing the use of S/R, including the American Psychiatric Association's Learning From Each Other⁶ and the Substance Abuse and Mental Health Services Administration's Roadmap to Seclusion and Restraint Free Mental Health Services.7

Throughout the literature, several key areas have been associated with reduction rates.^8-14 These include adherence to S/R standards, administrative reviews, consistent supportive leadership, proper staffing levels, staff training and support, environmental factors, individualized treatment plans, effective communication with patients and their families, and debriefings after episodes of S/R.

Leadership that is focused on adherence to S/R standards¹⁵ and that is committed to following new CMS regulations¹⁶ has been associated with reductions in the number and duration of S/R episodes. Leadership that performs timely administrative reviews has also been demonstrated to reduce episodes of S/R.¹⁷

Staff must buy into any S/R reduction program for it to be effective. This requires consistent, supportive leadership that nurtures a well-trained staff and values minimal use of S/R. Staff can feel overwhelmed in their efforts to manage a challenging patient. Training to identify and manage a potentially violent patient, with emphasis on verbal de-escalation skills, is vital. Staff should be encouraged to cooperate with patients rather than to control them. It is important to have a medical staff that listens to patients' concerns and works in a collaborative manner.

A welcoming and comfortable environment can have a calming effect on patients. One suggestion is to provide a safe place that patients can go to relax. This can be a room with a comfortable recliner, blankets, and soft music to create a home-like atmosphere. Another suggestion is the use of service animals to help patients unwind and improve self-esteem.

Creating a culture in which patients participate in treatment decisions will empower them to take more responsibility for their behavior. One can foster a belief that patients have control over their behavior and, with help from staff, can make more appropriate decisions. To this end, when a patient enters the program, staff and physicians should:

• Inquire about prior history of being secluded and restrained.
• Identify methods of de-escalation that have and have not been effective in the past (eg, for some patients, time-outs can be very helpful to avoid S/R, but for more attention-seeking patients, this strategy is not effective).
• Inquire about the patient's history of abuse, because patients who filter their experiences through their abusive pasts might misinterpret communication by staff and may be particularly susceptible to feeling traumatized by S/R.
• Advanced directives can be used to facilitate this process.

Creating an adaptive treatment plan can prevent a crisis. It should be updated as the patient's status changes and it should give the patient options, not merely consequences. The Wellness Recovery Action Plan, developed by Mary Ellen Copeland, PhD, empowers patients to be more involved in controlling their problematic behaviors.¹⁸ Staff help patients develop daily maintenance plans that serve to remind them of what is needed to maintain a sense of mental wellness. Triggers and early warning signs are identified, and crisis plans are developed. The crisis plans outline what patients would want done when they feel out of control. Plans are also developed for postcrisis management.

Options for de-escalating patients can include a one-on-one session with staff; a time-out in a comfort room, separate from other patients; involvement in alternative activities; medication; and privacy. Having options and paying attention to the individual needs of a patient will maximize the effectiveness of the treatment plan.

Open communication is essential for all members of the patient's treatment team. It is essential that patients and their families are active participants in the treatment-planning process. When S/R is used, the patient should be given an explanation of why it was used and the patient's family should be informed, assuming consent has been provided. Caregivers should work to minimize barriers to good listening by reducing prejudices, identifying and working through anger, and learning to appreciate differences.

Debriefing has several functions. S/R can be a traumatic event for all involved--the patient, other patients who witness the event, and the staff. Debriefing is important for several reasons: it provides the opportunity to share thoughts openly and honestly and helps reincorporate the patient into the community after an episode of S/R. The patient can begin to identify problematic behaviors and work on finding alternatives to relieve stress. The other patients can assess if/how their behavior may have contributed to the crisis and find solutions to help keep the unit safe. In addition, staff can reassess the patient and his current treatment plan, which may need to be significantly revised.

Conclusion

The use of S/R is occasionally necessary but can often be prevented. Each year, there are many S/R-related deaths and injuries. Physicians can play a key role in providing the necessary leadership to change the culture of their programs so that S/R episodes are reduced. This, in turn, will decrease patient morbidity and mortality and provide a safer and more positive environment for everyone. With some effort, risk associated with S/R can be significantly reduced and, in the process, patients can have a more therapeutic and empowering experience.

References:

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