1. Reducing Behavioral Restraint & Seclusion & SB 130
Leslie Morrison, MS, RN, Esq.
Protection and Advocacy, Inc.
Investigations Unit

2. Six Core Strategies Culture Change
1. Leadership toward Organizational Change
Articulating [& living by] a mission & philosophy of reduction & elimination
Management oversight of every S/R event (“witnessing”)
Holding people accountable
Reduction action plan
Performance improvement team
2. Use of Data to Inform Practice: publicly available
# of incidents, duration, injuries, [stat involuntary med use]
By unit, shift, day, staff member
Set improvement goals from baseline
National Technical Assistance Center &
National Association of State Mental Health Program Directors

3. DMH RESTRAINT STATISTICS Frequency and Duration per 1000 Hospital Hours 2005
Facility
1st Quarter 2005
2nd Quarter 2005
Total # of Episodes
Duration per 1000 Hosp Hrs
Mean Duration in Hours
ASH
Seclusion 22
0.13
16.5 56
0.41
20.20
Restraint
253
3.02
32.55
283
2.38
23.52
Walking 75
0.22
8.0 83
0.20
6.90
MSH 46
0.04
1.2 4
1.30
830
2.40
4.3
694
2.13
4.44 90
0.60
9.9 26
0.08
4.60
NSH
279
1.45
12.4
209
0.95
11.10
444
4.49
24.2
562
6.05
26.23
185
0.83
10.7
214
0.92
10.50
PSH
341
1.11
9.4
311
0.93
9.20
821
4.26
15.0
612
2.57
12.90
793
1.82
6.6
554
1.12
6.20

4. Napa State Hospital Total Restraint or Seclusion Hours

5. 3. Workforce Development
“Culture Change” “Trauma Informed Care” “Recovery”
Training
Job Description
Performance Evaluation
Involvement of/equal partnership w/consumers, family members, advocates
4. Use S/R Reduction Tools
Risk Assessment: trauma history, risk for violence, medical risks
De-escalation plans: identifying emotional triggers; developing awareness of interpersonal & environmental stressors
Comfort Rooms
Daily Meaningful Activities
National Technical Assistance Center &
National Association of State Mental Health Program Directors

6. 5. Consumer/Family/Advocate Roles in Inpatient Settings
Full & formal inclusion in S/R reduction roles: Director of Advocacy Svc, Peer Specialist, Consumer Advocate
6. Debriefing Techniques
Immediate post-event debriefing: assure safety, interview all involved, return to ‘pre-crisis’ milieu
Treatment team review: root cause analysis
National Technical Assistance Center &
National Association of State Mental Health Program Directors

7. Center for Medicaid & Medicare Services Webcast
“Reducing the Use of Seclusion & Restraint in Psychiatric Facilities”
[aired Sept. 23rd but available for viewing]
“This broadcast was designed to provide a brief overview of the history of this initiative, emerging findings on effectiveness, a review of the core theories and literature that added support to the development of the 6 core strategies and recommendations for administrative and practice change.”

8. SB 130 / Health & Safety Code § 1180
“The use of seclusion and behavioral restraints is not treatment, and their use does not alleviate human suffering or positively change behavior.”
Treatment failure
“The commitment of managers and staff is essential to changing the culture of those facilities and reducing he use of seclusion and behavioral restraints.”
Involving clients
Good milieu programs & attention to person’s needs

9. Components Alternatives
Technical assistance & training programs with consumer involvement
Intake assessment
Proactive interventions
Safeguards
Data
Mandatory, consistent, timely, publicly accessible
Debriefing

10. Oversight Structure ultimately falls to HHS

11. 1. Alternatives Intake assessment with consumer input
Advanced directives to de-escalate, early warning signs/triggers, techniques that help person maintain/regain control, pre-existing medical conditions, trauma history,
Proactive interventions
Avoidance, crisis management, responding to reasons underlying behavior, conflict resolution, effective communication, positive early intervention
Technical assistance & training programs with consumer involvement
Alternatives (above); trauma mitigation, minimizing duration, & ensuring safety when R/S
H&S § § (b)(2) & (a)

12. 2. Safeguards Prohibited: Avoid prone containment
Restraint that obstructs airway or impairs breathing
Physical/manual restraint of person w/known medical/physical risks
Prone with hands restrained behind back
Containment as extended procedure
Prone mechanical restraint with those at risk for positional asphyxiation, unless written authorization by MD
Avoid prone containment
1 staff to observe for physical distress
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 or restrict freedom of movement & not standard treatment for condition
H&S §

13. 3. Data A mandatory, consistent, timely, publicly accessible
Number of incidents
Duration of incident
Deaths of patients occurring while or proximately related to S/R
Serious injuries to patient and staff
Number of involuntary emergency medications
Available on internet
Currently only state facilities reporting
H&S §1180.3(c)

14. Physical, Non-ambulatory Restraint per 1000 hospital hours by State Hospital

15. 4. Debriefing
ASAP [within 24 hours] with resident, involved staff & supervisor
Purpose: How to avoid a similar incident in future?
Assist resident
Identify precipitant
Suggest safe, constructive methods for responding
Assist staff
Understand precipitants
Develop alternative to help resident
Revise treatment interventions to address root cause
Assess if S/R was necessary & done consistent with training & policies
H&S §1180.5

16. What’s Happened Since SB 130?
Use, injuries & deaths reportedly & seemingly decreasing
State facilities publishing some data
Improvements recommended
Trending over time? Comparing with other facilities?
All other facilities – no data published
HHS promises to move forward with mandated reporting from all facilities
No technical assistance or training programs
State facilities revised training but w/out consumer involvement
Continued problems with culture change

17. Definitions
Behavioral Restraint – restraint used as an intervention when a person presents an immediate danger to self or to others:
mechanical – using a mechanical device, material or equipment attached/adjacent to person’s body that restricts freedom of movement
physical – use of a manual hold to restrict freedom of movement of or normal access to all/part of persons’ body and is used as a behavioral restraint
excludes medical, postural, devices to prevent injury or improve mobility
Containment – brief physical restraint to effectively gain quick control of person who is aggressive or agitated or who is a danger to self or others

18. Facilities -
General Acute Care Hospitals
Not ERs yet
Acute Psychiatric Hospitals
Psychiatric Health Facilities (PHFs)
Crisis Stabilization Units (23 hour)
Community Treatment Facilities
Group Homes
Skilled Nursing Facilities
Intermediate Care Facilities
Community Care Facilities
Mental Health Rehabilitation Centers
State Facilities
Seclusion – involuntary confinement of a person alone in a room or an area from which the person is physically prevented from leaving; Excludes timeout
Serious Injury – any significant impairment of the physical condition as determined by medical personnel, includes burns, lacerations, bone fractures, substantial hematoma, or injuries to internal organs