11

MONITORING RESTRAINT USEMONITORING RESTRAINT USE

to to IDENTIFY BEST PRACTICESIDENTIFY BEST PRACTICES

Roderick Shaner, M.D.Roderick Shaner, M.D.rshaner@dmh.lacounty.gov

Alysa Solomon, Ph.D.Alysa Solomon, Ph.D.asolomon@dmh.lacounty.gov

Los Angeles County Department of Mental Health and

The Saks Institute for Mental Health Law at University of Southern California

Policy and EthicsApril 22, 2011

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SAMHSA National Action Plan on SAMHSA National Action Plan on Seclusion and RestraintSeclusion and Restraint

Revised and Adopted May 2003Revised and Adopted May 2003 The use of seclusion and restraint on persons with The use of seclusion and restraint on persons with

mental health and/or addictive disorders has resulted in mental health and/or addictive disorders has resulted in deaths and serious physical injury and psychological deaths and serious physical injury and psychological trauma.  In 1998, the Harvard Center for Risk Analysis trauma.  In 1998, the Harvard Center for Risk Analysis estimated deaths due to such practices at 150 per estimated deaths due to such practices at 150 per annum across the nation.annum across the nation.

SAMHSA has set forth a vision to reduce and ultimately SAMHSA has set forth a vision to reduce and ultimately eliminate the use of seclusion and restraint practices for eliminate the use of seclusion and restraint practices for all age groups in behavioral health care settings both all age groups in behavioral health care settings both institutional and community-based.  The agency institutional and community-based.  The agency recognizes that these are to be used solely as safety recognizes that these are to be used solely as safety interventions designed to protect consumer and staff interventions designed to protect consumer and staff safety.  The focus is on identifying and encouraging the safety.  The focus is on identifying and encouraging the application of alternatives to prevent such use.   application of alternatives to prevent such use.  

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SAMHSA National Action Plan on Seclusion SAMHSA National Action Plan on Seclusion and Restraint: and Restraint: 5 Domains5 Domains

Data CollectionData CollectionEvidence-Based Practices and GuidelinesEvidence-Based Practices and GuidelinesTraining and Technical AssistanceTraining and Technical AssistanceLeadership and Partnership DevelopmentLeadership and Partnership DevelopmentRights ProtectionRights Protection

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April 02, 2010 - For immediate release: April 02, 2010 - For immediate release:

Massachusetts Sweeps First-Ever National Award Massachusetts Sweeps First-Ever National Award for Reducing and Eliminating Restraint and for Reducing and Eliminating Restraint and

SeclusionSeclusion BOSTONBOSTON — Massachusetts swept the first-ever — Massachusetts swept the first-ever

awards given by the U.S. Substance Abuse awards given by the U.S. Substance Abuse Mental Health Services Administration Mental Health Services Administration (SAMHSA), recognizing sustained restraint and (SAMHSA), recognizing sustained restraint and seclusion reduction and prevention work. Five of seclusion reduction and prevention work. Five of the ten awards were given to Massachusetts' the ten awards were given to Massachusetts' facilities, including Taunton State Hospital and facilities, including Taunton State Hospital and the nine child/adolescent statewide programs the nine child/adolescent statewide programs operated by the Department of Mental Health operated by the Department of Mental Health (DMH). (DMH).

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SB 130 (Chesbro) 2003SB 130 (Chesbro) 2003Legislative findingsLegislative findings

(a) The (a) The use of seclusion and behavioral restraints is not use of seclusion and behavioral restraints is not treatmenttreatment, and their use does not alleviate human , and their use does not alleviate human suffering or positively change behavior. suffering or positively change behavior.

(b) Good milieu programs, interesting activities, and (b) Good milieu programs, interesting activities, and attention to every person's need for sufficient space all attention to every person's need for sufficient space all contribute to an environment in which the contribute to an environment in which the use of use of seclusion and behavioral restraints can be minimized.seclusion and behavioral restraints can be minimized.

(g) It is (g) It is the intent of the Legislature in enacting this act to the intent of the Legislature in enacting this act to achieve a reduction in the use of seclusion and achieve a reduction in the use of seclusion and behavioral restraintsbehavioral restraints in facilities in California. in facilities in California.

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SB 130 (Chesbro) 2003SB 130 (Chesbro) 2003(became CA Health and Safety Code1180.3)(became CA Health and Safety Code1180.3)

(a) This section shall apply to psychiatric units of general acute care (a) This section shall apply to psychiatric units of general acute care hospitals, hospitals, acute psychiatric hospitalsacute psychiatric hospitals, psychiatric health facilities, crisis , psychiatric health facilities, crisis stabilization units, community treatment facilities, group homes, skilled stabilization units, community treatment facilities, group homes, skilled nursing facilities, intermediate care facilities, community care facilities, and nursing facilities, intermediate care facilities, community care facilities, and mental health rehabilitation centers.mental health rehabilitation centers.

c) (1) The secretary or his or her designee shall take steps toc) (1) The secretary or his or her designee shall take steps toestablish a system of mandatory, consistent, timely, and publiclyestablish a system of mandatory, consistent, timely, and publiclyaccessible data collection regarding the use of seclusion andaccessible data collection regarding the use of seclusion andbehavioral restraintsbehavioral restraints in all facilities described in subdivision (a) in all facilities described in subdivision (a)that utilize seclusion and behavioral restraints.that utilize seclusion and behavioral restraints.

It is the intent of the Legislature that data be compiled in a mannerIt is the intent of the Legislature that data be compiled in a mannerthat that allows for standard statistical comparisonallows for standard statistical comparison and be maintained for and be maintained foreach facility subject to reporting requirements for the use ofeach facility subject to reporting requirements for the use ofseclusion and behavioral restraints.seclusion and behavioral restraints.

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SB 130 (Chesbro) 2003SB 130 (Chesbro) 20031180.41180.4

(k) A person in a facility described in subdivision (a) of (k) A person in a facility described in subdivision (a) of Section 1180.2 and subdivision (a) of Section 1180.3 has Section 1180.2 and subdivision (a) of Section 1180.3 has the right to be free from the use of seclusion and the right to be free from the use of seclusion and behavioral restraints of any form imposed as a means of behavioral restraints of any form imposed as a means of coercion, discipline, convenience, or retaliation by staff.coercion, discipline, convenience, or retaliation by staff.

This right includes, but is not limited to, the right to be This right includes, but is not limited to, the right to be free from the use of a drug used in order to control free from the use of a drug used in order to control behavior or to restrict the person's freedom of behavior or to restrict the person's freedom of movement, if that drug is not a standard treatment for the movement, if that drug is not a standard treatment for the person's medical or psychiatric condition. person's medical or psychiatric condition.

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California Psychiatric AssociationCalifornia Psychiatric AssociationRevised position statement 2011Revised position statement 2011

Seclusion and restraints are not treatment.Seclusion and restraints are not treatment. Properly designed mental health facilities, with Properly designed mental health facilities, with

adequate staffing with trained mental health personnel, adequate staffing with trained mental health personnel, should be used to make the use of seclusions and should be used to make the use of seclusions and restraints unnecessary in almost all behavioral restraints unnecessary in almost all behavioral emergencies. emergencies.

In the absence of proper design and staffing, however, In the absence of proper design and staffing, however, preventing responsible physicians from ordering preventing responsible physicians from ordering seclusion and restraint during serious behavioral seclusion and restraint during serious behavioral emergencies is a misguided practice that exposes emergencies is a misguided practice that exposes patients, staff, and the community to grave risks.patients, staff, and the community to grave risks.

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Changing S&R use at DMHChanging S&R use at DMHThe expressed concernsThe expressed concerns

Environmental safetyEnvironmental safetyLiabilityLiabilityPatient safetyPatient safetyPersonal/moral responsibility for fellow Personal/moral responsibility for fellow

man. man. Therapeutic effectsTherapeutic effects

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Ending DMH MHC S&R (1)Ending DMH MHC S&R (1)POLICYPOLICY

2-3.1 Aggressive client behavior: Forceful actions directly expressed physically 2-3.1 Aggressive client behavior: Forceful actions directly expressed physically or verbally by a client that have caused or may indicate the potential for or verbally by a client that have caused or may indicate the potential for causing bodily injury in LAC-DMH outpatient clinics and programs should be causing bodily injury in LAC-DMH outpatient clinics and programs should be clinically managed in a manner that maximizes safety for everyone, respect clinically managed in a manner that maximizes safety for everyone, respect for the client, and recognition of the therapeutic mission of our services.for the client, and recognition of the therapeutic mission of our services.

  3.2 LAC-DMH staff may not use mechanical restraint or involuntary seclusion to 3.2 LAC-DMH staff may not use mechanical restraint or involuntary seclusion to

clinically manage aggressive client behavior.clinically manage aggressive client behavior.3.2.1 In situations in which there is immediate risk to life, staff may 3.2.1 In situations in which there is immediate risk to life, staff may

intervene as necessary in order to mitigate that risk, including calling intervene as necessary in order to mitigate that risk, including calling 911 for emergency assistance.911 for emergency assistance.

3.3 While the following procedures apply to adults, those under the age of 18 3.3 While the following procedures apply to adults, those under the age of 18 should also be managed without seclusion and restraints, but in accordance should also be managed without seclusion and restraints, but in accordance with recognized responsibilities to act in specific situations in order to with recognized responsibilities to act in specific situations in order to protect children from harm. protect children from harm. ttp://dmhhqportal1/Document%20Library/IIPP.pdfttp://dmhhqportal1/Document%20Library/IIPP.pdf

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Ending DMH MHC S&R (2)Ending DMH MHC S&R (2)

In a situation in which a client or individual In a situation in which a client or individual wishes to leave the clinic, staff shall not wishes to leave the clinic, staff shall not attempt to physically detain that person or attempt to physically detain that person or physically impede the way to the exit. physically impede the way to the exit. Rather, staff shall attempt to safely and Rather, staff shall attempt to safely and respectfully convince the client to stay, respectfully convince the client to stay, discussing the reasons for staying, discussing the reasons for staying, alternatives and possible repercussions. alternatives and possible repercussions.

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Ending DMH MHC S&R (3)Ending DMH MHC S&R (3)

In situations in which the client placed on an In situations in which the client placed on an involuntary hold wishes to leave the involuntary hold wishes to leave the clinic:clinic:

Every attempt shall be made to convince the patient to Every attempt shall be made to convince the patient to stay.stay.

In situations in which the patient is likely to leave, In situations in which the patient is likely to leave, notify the program head or designee, and request notify the program head or designee, and request assistance from law enforcement when indicated.assistance from law enforcement when indicated.

In situations in which there is immediate risk to life, In situations in which there is immediate risk to life, staff may, but shall not be required to, intervene as staff may, but shall not be required to, intervene as necessary in order to mitigate that risk, including calling necessary in order to mitigate that risk, including calling 911 for emergency assistance.911 for emergency assistance.

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The rationale for LAC DMH review The rationale for LAC DMH review of inpatient S&Rof inpatient S&R

DMH has statutory responsibility for DMH has statutory responsibility for reporting S&R in LPS designated facilitiesreporting S&R in LPS designated facilitiesCalifornia Welfare & Institutions Code (WIC): California Welfare & Institutions Code (WIC):

5326.15326.1DMH considers quality of care in LPS DMH considers quality of care in LPS

facility designation and re-designationfacility designation and re-designationDMH will monitor restraint use in LPS DMH will monitor restraint use in LPS

designated facilities to determine quality of designated facilities to determine quality of care issuescare issues

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The challenge for LAC DMH review The challenge for LAC DMH review of inpatient S&Rof inpatient S&R

Collect useful dataCollect useful dataDefine comparison methodology among Define comparison methodology among

diverse hospitalsdiverse hospitalsDetermine outliersDetermine outliersDetermine opportunities for improvementDetermine opportunities for improvementDetermine interventionsDetermine interventions

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1616

1717

1818

0

20

40

60

80

100

120

Incident Rate by LPS Hospital FY 2009

1919

LACDMH’s Progress (con’t)LACDMH’s Progress (con’t)

Revision of Denial of Rights formRevision of Denial of Rights formNew data collection/reporting processNew data collection/reporting process

Consult with National Association of State Consult with National Association of State Mental Health Program Directors Mental Health Program Directors (NASMHPD), National Research Institute, Inc (NASMHPD), National Research Institute, Inc (NRI) (NRI) www.nri-inc.org

Begin with LPS Designated settingsBegin with LPS Designated settings

2020

2121

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Formulas for Calculating Formulas for Calculating Comparison RatesComparison Rates

The choice of formulas depended on the The choice of formulas depended on the assumption of the underlying distribution and assumption of the underlying distribution and assumes that non-normal distributions are used assumes that non-normal distributions are used for fair comparison. These formulas include for fair comparison. These formulas include statistical adjustments used to approximate a statistical adjustments used to approximate a normal distribution. These formulas are taken normal distribution. These formulas are taken from Joint Commission requirements for from Joint Commission requirements for calculating comparison rates. Please email us calculating comparison rates. Please email us for a copy of the formulas. for a copy of the formulas.

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Joint Commissions Joint Commissions

Joint Commission along with NASMHPD is Joint Commission along with NASMHPD is now requiring all accredited psych now requiring all accredited psych hospitals via the ORYX system to report hospitals via the ORYX system to report hours of Seclusion and Restraint use as hours of Seclusion and Restraint use as part of their core measures: part of their core measures: http://www.jointcommission.org/accreditationprograms/hospitals/oryx/

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Roadmap to Seclusion and Roadmap to Seclusion and Restraint Reduction Restraint Reduction

SAMHSA’s Roadmap to Seclusion and Restraint SAMHSA’s Roadmap to Seclusion and Restraint Free Mental Health Services: Free Mental Health Services: http://www.samhsa.gov/samhsa_news/VolumeXIV_4/article13.htm

UK’s National Institute for Clinical Excellence UK’s National Institute for Clinical Excellence (NICE) Guidelines: (NICE) Guidelines: http://www.nice.org.uk/niceMedia/pdf/2005_003_NICE_launches_clinical_guideline_disturbed_violent_behaviour.pdf

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Health Reform NotesHealth Reform Notes Eligibility = Enrollment Eligibility = Enrollment

LAC/DMH holds responsibilities for California laws LAC/DMH holds responsibilities for California laws Health & Safety Code 1180 & 11.80.6 which address Health & Safety Code 1180 & 11.80.6 which address the imposition of behavioral restraints and the right to the imposition of behavioral restraints and the right to be free from the use of a drug used in order to control be free from the use of a drug used in order to control behavior for individuals with psychiatric conditions behavior for individuals with psychiatric conditions during enrollments.during enrollments.

Debrief Debrief

This will extend to individuals with substance abuse This will extend to individuals with substance abuse issues without psychiatric conditions. issues without psychiatric conditions.

This will be explicit on LA County’s 1115 Waiver. This will be explicit on LA County’s 1115 Waiver.

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Health Reform Notes (con’t)Health Reform Notes (con’t)

Patient will have the ability to choose their Patient will have the ability to choose their health care provider. health care provider.

Health providers will no longer cover billing Health providers will no longer cover billing for those held in mechanical restraint over for those held in mechanical restraint over 10 minutes and in psychiatric crisis; 10 minutes and in psychiatric crisis; providers will have to know how to de-providers will have to know how to de-escalate individuals who are presenting. escalate individuals who are presenting.

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Additional WebsitesAdditional Websites Center for Medicare and Medicaid Services Final Interim Rule Center for Medicare and Medicaid Services Final Interim Rule

Available: Available: http://www.cms.gov/CFCsAndCoPs/downloads/finalpatientrightsrule.pdf

Restraint and Seclusion – A Risk Management Guide: Restraint and Seclusion – A Risk Management Guide: http://www.nasmhpd.org/general_files/publications/ntac_pubs/R-S%20RISK%20MGMT%2010-10-06.pdf

Crisis Prevention Institute: Crisis Prevention Institute: http://www.crisisprevention.com/ Therapeutic Crisis Intervention: Therapeutic Crisis Intervention:

http://rccp.cornell.edu/TCIpage1.htm Hartford Courant articles Hartford Courant articles

::http://articles.courant.com/1998-10-17/news/9810170180_1_mental-retardation-psychiatric-restraints