Mental Hospital Seclusion and Restraint Reduction Commonwealth of Pennsylvania

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Mental Hospital Seclusion and Restraint
ReductionCommonwealth of Pennsylvania

• 2000 Innovation in American Government Award
  Winner
• Presented by Marsha Edgington-Bott

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Background

• In the late 1980s national attention was
  beginning to be focused on practiced use and
  risks associated with the use of seclusion and
  restraint with adults, children, and adolescents
  in mental health programs and facilities.
• Risks include accidental death, injuries and
  emotional harm to both staff and patient,
  continual disruption of the therapeutic
  relationship with the patient and families and
  exposing them to further trauma.

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Pennsylvania-A Model for Reform

• In 1997 the Pennsylvania Department of Public
  Welfare instituted an aggressive program to
  reduce and ultimately eliminate seclusion and
  restraint use in its nine state hospitals.
• They began the reform in 1990 by carefully
  tracking the use of Seclusion/Restraint (S/R) and
  then used the 1997 data as its baseline to
  measure improvements.

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Year 2000

• By 2000, Pennsylvania had reduced incidents of
  seclusion and restraint in its nine state
  hospitals by 74, and reduced the number of hours
  patients spent in seclusion and restraint by 96.
• By July of 2000, one state mental hospital had
  not used seclusion for over 20 months.
• Another had used neither seclusion or restraint
  for 8 of the last 12 months.
• Three hospitals had been S/R free for one or more
  consecutive months and others were approaching
  zero use.

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Prevalence and duration of seclusion and restraint
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Changes that Influenced S/R Reduction

• Leadership the non-restraint movement within
  the Pennsylvania state hospital system predates
  the period covered by the study. The most
  dramatic reductions occurred from 1993 to 1997.
• The greatest credit goes to the direct care
  staff, aides, nurses, doctors and program staff.

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Changes continued

• Advocacy - organized advocacy efforts led by
  parents and former patients who represented the
  National Alliance for the Mentally Ill, the
  Pennsylvania Mental Health Consumers Association,
  and the Pennsylvania Protection and Advocacy,
  Inc. were effective at addressing individual
  patient issues and challenging leadership.

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Changes continued

• State Policy changes state policy on the use of
  restrictive procedures changed three times during
  the study period.
• Defined physical restraint, mechanical restraint,
  and seclusion as extreme measures and limited
  their use to emergency situations.
• Defined Chemical restraint.
• Established guidelines for annual staff training
  and patient/staff debriefing.
• Required notification of a persons family after
  the use of restrictive measure.
• Limited orders for restraint and seclusion to no
  more than 60 minutes requiring the person be
  seen within 30 minutes of a phone order.
• Required monitoring of policies through
  performance improvement program.
• Limited the types of restraint that could be
  used.

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Changes continued

• Psychiatric emergency response teams (PERTs)
  brings together a large group of workers to the
  scene of the crisis in a short period.
• The goal is to manage a crisis using conflict
  resolution, mediation, therapeutic communication,
  and violence-prevention skills to diffuse and
  safely resolve a crisis.
• PERTs involves a core group of staff which are
  required to upgrade the quality and quantity of
  crisis management and verbal de-escalation
  techniques at least annually.

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Changes continued

• Unit size and patient-to-staff ratios having
  fewer patients on a unit allows more sensitive
  care and a safer, restraint-free hospital.
• The average number of people served on a typical
  hospital unit during the study period decreased
  from more than 36 in 1990 to 32 or less in 2000.
• In 1990-the 36 patients had one licensed nurse
  and three psychiatric aides.
• During 2000-the 32 patients had two licensed
  nurses and four psychiatric aides.

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Changes continued

• Incident management system July 1998 a new
  application was implemented statewide that
  increased the performance indicators which would
  be reported.
• The system enables measurement of physical
  hands-on restraint to the second and mechanical
  restraint use by device type.
• Tracks the PRN and STAT medications administered.
• Data is summarized each month and shared with the
  hospital system and external advocates.

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Changes continued

• Second generation antipsychotics
• Increase in the quantity and quality of treatment
  - focusing on functional programming such as
  vocational services, paid work, money management
  skills, and training in the self-administration
  of medications.
• Increases in the quantity and quality of
  therapies due to reduced unit sizes and improved
  patient-to-staff ratios.

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Most Important Changes

• Changes in the culture of the state hospitals.
• Pennsylvania required open public access to S/R
  data.
• Creating competition among the hospitals to
  reduce S/R.
• Giving awards and acknowledgments for
  improvements.

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Where are they now?

• Currently five of the nine hospitals have
  eliminated the use of seclusion.
• Danville State Hospital has gone more than two
  years without using mechanical restraint or
  seclusion.
• Since January 2005, the hospital system, which
  averages more than 60,000 days of care each
  month, has used seclusion only 19 times for a
  total of 18 hours.
• Mechanical restraint has been used 143 times for
  a total of 160 hours.
• During December 2005, in the nine hospital system
  S/R was used 8 times for a total of 8.67 hours
  and seclusion was used only 2 times for a total
  of 1.08 hours.

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Where are they going?

• In the Spring of 2005, the hospital system
  established a goal eliminating the use of
  mechanical restraint and seclusion by January 1,
  2006.
• They havent met the goal at this time, but they
  are committed to achievement.