1. 1 Restraint & Seclusion: Review and Update Leslie Morrison, MS, RN, Esq. Protection & Advocacy Inc. Supervising Attorney, Investigations Unit

2. 2 What is restraint? Restrict freedom of movement, physical activity or normal access to one’s body Physical force; manual methods Mechanical device, material or equipment Drugs (“chemical restraint”) With or without patient permission Excludes [JCAHO]: Brief interactions to redirect patient or assist w/ ADLs Holding children for < 30 minutes Customary part of medical diagnostic or treatment procedure Indicated to treat medical condition or symptoms Promote patient’s independent functioning Devices for security (forensic) or prudent safety (transport)

3. 3 Medical vs. Behavioral Restraint: How does it function for and affect the individual? Medical Voluntary mechanical support used to achieve proper body position balance or alignment [CMS] Device used during surgical diagnostic, dental or other medical procedure [ CMS] PRN in accordance with specific parameters in behavioral plan for chronic SIB [ CMS] When the primary reason for use directly supports medical healing [JCAHO] Behavioral For an unanticipated outburst of severely aggressive or destructive behavior that poses an imminent danger to patient or others [CMS] The use of r/s are primarily to protect the patient against injury to self or others b/c of an emotional/behavioral disorder [JCAHO]

4. 4 What is seclusion? Involuntary confinement of a person in a room or an area where the person is physically prevented from leaving Locked vs. unlocked [JCAHO vs. CMS] Excludes [JCAHO] : “Timeout” when person is restricted to an unlocked room/area for 30 minutes or less; is consistent with patient’s treatment plan (behavior mgmt program) Instances when restricted to unlocked room or area consistent with unit rules or hospital P&P

5. 5 What is “chemical restraint”? Medication used to control behavior or to restrict pt’s freedom of movement & is not a standard treatment for pt’s medical/psychiatric condition [CMS] Improves/reduces ability of individual to effectively/appropriately interact with world Used to treat specific clinical condition, target symptoms FDA, manufacturer, national practice standards for use Inappropriate use of a sedating psychotropic drug to manage or control behavior [JCAHO] SB 130 Bans chemical restraint Data collection for emergency involuntary medication

6. 6 Psychiatric Polypharmacy Report Plug Thorough evaluation of patient, symptoms and medication regimen, including PRNs and chemical restraints. Refrain from polypharmacy where possible; plan carefully & monitor patient response. Only prescribe that for which there is a demonstrated need. Avoid using the same class of medication to treat the same symptoms. Consider drug interactions. Be familiar with adverse drug reactions. Carefully monitor the patient for potential adverse drug reactions.

7. 7 When can R/S be used? When can R/S be used? Indications for Use: In emergency situations if needed to ensure the patient’s physical safety and less restrictive interventions have been determined to be ineffective to protect patient or others from harm. [CMS] In emergency situations when there is an imminent risk of the patient physically harming self or others, and nonphysical interventions would not be effective. [JCAHO] Exclusions: Coercion, discipline, staff convenience, retaliation by staff Solely based on prior history of r/s use or prior history of dangerous behavior

8. 8 Orders MD/LIP to order [CMS] Qualified trained staff may initiate before order obtained [JCAHO] MD/LIP to see pt.: w/in 1 hr [CMS] w/in 4 hrs (or less for kids) [JCAHO] Reevaluation & renewed order by primary treating MD/LIP [both] q 4 hr for adults q 2 hr for 9-17 yo q 1 hr for under 9 yo MD/LIP in person reevaluation every 24 hours thereafter [CMS] MD/LIP in person reevaluation thereafter [JCAHO] q 8 hr for adults q 4 hr for under 18 yo No PRNs or standing orders [both] Can “reuse” existing order if hasn’t expired [JCAHO]

9. 9 Observation & Other Requirements Monitoring: In restraint AND seclusion continually monitored face to face Or by continuous video & audio in close proximity [CMS] In restraint OR seclusion: Continually assessed, monitored and reevaluated face to face [CMS] If in seclusion > 1hr, continuous simultaneous video & audio [JCAHO] Physical holds require 2 nd staff just to observe [JCAHO] Assessment every 15 minutes [JCAHO] : readiness to d/c (behavioral criteria) comfort checks Debriefing < 24hrs [JCAHO] How things could have been handled differently

10. 10 S/R Regulations Type of FacilityOrdersObservationOther CA GACH MD order MD cosign next visit Renewed ??? Assess every 15 minutes Silent on chemical restraint SNF w/STP MD order MD cosign in 5 days Renewed every 24 hr Assess every 30 minutes No seclusion??? Chemical restraint = any drug used to control behavior and used in a manner not required to treat the patient’s medical symptoms. PHF MD/clinical psychologist Co-sign in 24 hrs except wkend/holidays Renewed every 24 hr Within line of vision Assess every 15 minutes No physical restraint w/locking device unless okay by Fire Marshall Seclusion (locked area) & exclusion time out (no lock) = physical restraint Exclusionary time out considered physical restraint

11. 11 Training All staff who have direct patient contact must have ongoing education and training in the proper and safe use of s/r application and techniques and alternative methods for handling behavior, symptoms, and situations that traditionally have been treated through the use of r/s [CMS] Staff is trained and competent to minimize the use of r/s and, when use is indicted to us r/s safely [JCAHO] Viewpoints of patients incorporated and, whenever possible, patients contribute to/participate in training [JCAHO] Technical assistance & training programs based on best practices, with input from stakeholders, to lead to avoidance of r/s: [SB 130] Intake assessment & debriefing Engage clients in assessment, avoidance, crisis mgmt. Recognize & respond to underlying reasons for escalating behavior Individual treatment planning w/risk factors & early intervention Conflict resolution, effective communication, deescalation

12. 12 Health & Safety 1180 [SB 130] Responsibility of HHS – reasoning Funding limitation (“within existing resources”) – reality Facilities covered: 3 groups State Hospitals & DCs GACH, acute psych. hospitals, PHFs, Crisis stabilization units (23 hour), CTFs, group homes, SNFs, ICFs, community care facilities, MHRCs ERs to be considered later

13. 13 Safeguards in H&S 1180 Only use for behavioral emergencies when behavior present imminent danger of serious harm to self or others Prohibited: Restraint technique that obstructs airway or impairs breathing Pressure or body weight on back or torso Pillow, blanket, other item covering face Physical/manual restraint on person w/known medical/physical condition where believed would endanger life or seriously exacerbate medical condition Prone with hands held/restrained behind back Containment as extended procedure Prone mechanical restraint with those at risk for positional asphyxiation, unless written authorization by MD Based on patient preference When other clinical risks take precedence

14. 14 Avoid prone containment 1 staff to observe for physical distress where possible, not involved in restraint Least restrictive/maximum freedom of movement – minimum number of restraints (”points”) Constant face-to-face observation when in seclusion AND restraint unless facility currently okay to use video Right to be free from use of a drug to control behavior/restrict freedom of movement & not standard treatment for condition

15. 15 Initial Assessment With input from patient and others as patient desires Advanced directive re: de-escalation & use of r/s ID early warning signs, triggers, precipitants ID techniques, methods, tools to help individual control his/her behavior Preexisting medical conditions that places individual at risk Relevant trauma history

16. 16 Debriefing Purpose: “how to avoid a similar incident in future” Discuss circumstances resulting in s/r Strategies to be used by staff to prevent future use:  ID precipitant  Suggest methods for more safely responding  Assist staff to understand precipitant  Develop alternative methods for helping individual cope/avoid Revise treatment plan with interventions to address root cause Assess if r/s necessary & done consistent with training & policies No longer than 24 hours after use Attendees

17. 17 The Great Divide State Hospitals & DCs Develop TA & training programs including Intake assessment De-escalation, avoidance, mgmt of crisis, individual treatment planning, underlying reasons Collecting data now Report to PAI all deaths or serious injuries occurring during or related to use of seclusion/restraint All others Develop TA & training programs Centralized data collection asap within existing resources

18. 18 Data Elements JCAHO [number of episodes] Shift Staff who initiated Length of episode Date & time of episode Day of week of episode Type of restraint Injuries to patient or staff Age of patient Gender of patient SB 130 Number of incidents Duration of incident Deaths of patients occurring while or proximately related to r/s Serious injuries to patient and staff Number of involuntary emergency medications Publicly available on internet

19. 19 Current Data DMH : January thru March 2004 Links: state hospital, additional links, state hospital seclusion and restraint data http://www.dmh.cahwnet.gov/Reports/Seclusion&Restraint/default. asp DDS : January thru June 2004 Links: developmental centers, restraint data for DCs and community facilities (bottom), restraint statistics (bottom) http://www.dds.cahwnet.gov/Restraint/RestraintStats.cfm