Successful S/R Reduction Experiences

What Worked?

Creating Violence Free and Coercion Free Service Environments for the

Reduction of Seclusion and Restraint

The PennsylvaniaThe Pennsylvania Seclusion & Restraint Reduction Seclusion & Restraint Reduction

ProgramProgram

Gregory M. Smith, MSChief Executive Officer

Allentown State HospitalAllentown, Pennsylvania

Donna Ashbridge, RN, MSChief Executive OfficerDanville State HospitalDanville, Pennsylvania

The PA State Hospital System

The Pennsylvania State Hospital System isthe largest provider of inpatient psychiatriccare in the Commonwealth.

The system is comprised of:• 8 state hospitals • 3 regional forensic units at Mayview,

Norristown, & Warren State Hospitals• 1 restoration center serving older individuals

with persistent mental illness

MayviewMayview

WarrenWarrenWarrenWarren

TorranceTorrance

ClarkClark SummitSummitClarkClark SummitSummit

AllentownAllentownAllentownAllentown

NorristownNorristownNorristownNorristownWernersvilleWernersville

WernersvilleWernersville

DanvilleDanvilleDanvilleDanville

SouthSouth MountainMountain

The Pennsylvania State Hospital SystemThe Pennsylvania State Hospital System

Pennsylvania Department of Public WelfarePennsylvania Department of Public WelfareOffice of Mental Health & Substance Abuse ServicesOffice of Mental Health & Substance Abuse Services

The PA State Hospital System

• Full-time civil and forensic staff: 4,719• Typical unit (32 beds) in civil hospitals is

staffed with: 2 RNs & 3 psychiatric aides on 1st & 2nd shifts

• People served: 2,130 – Civil 1,800; Forensic 200; LTC 130.

• Gender: 64% men, 36% women, Avg. age: 42• >1,000 civil admissions & discharges/year• Provides ~ 65,000 days of care/month

Who Pennsylvania Serves

• 68% diagnosis of schizophrenia or related psychotic disorder

• 50% + co-occurring substance use diagnosis

• 10% + diagnosis of MR/DD

• 30% in civil hospitals have a criminal history

• 50% in civil hospitals have an LOR of 2+ years

PA State Hospital SystemIs Reduction Possible? Is Elimination Possible?

• Restraint use early 1990s– 140,000 hours of restraint/year– Equivalent to 16 consumers in restraint 24

hours/day, 365 days/year

• Seclusion use early 1990s– 96,000 hours of seclusion/year– Equivalent to 10 consumers in seclusion 24

hours/day, 365 days/year

PA State Hospital SystemCritical Factors in Change

State LeadershipEstablished the goal, maintained it, supported staff tomake changes, and continues to advance the effort:

- 1990s 5 Deputy Directors, 3 Medical Directors all promote change, make S/R elimination top priority

- 1996 Charles Curie declares S/R

““a treatment failure”a treatment failure”

- 1999 S/R orders limited to 1 hour, Incrementally decreased - 2005 max

order = 15 minutes

(NETI, 2006; Smith et al, 2005)

PA State Hospital SystemCritical Factors in Change

(continued)

- 2005 PA DPW initiates Office of Children, Youth & Family restraint reduction effort for

C/A residential programs- 2006 PA DPW initiates Dept-wide initiative:

Alternatives to Coercive Techniques with statewide goal of all PA serving systems to be restraint-free

(Ibid)

PA State Hospital SystemCritical Factors in Change

• Resources redeployed, changed staff/patient ratio – but no new money

• Primary Prevention:– Implemented universal risk assessment

– Created consumer-centric culture of care

• Meaningful treatment alternatives created

• Consumer choice

• Elimination of rules of convenience

• Awareness of re-traumatization

• Respectful care

PA State Hospital SystemCritical Factors in Change

• Secondary Prevention:

– Increased training in de-escalation, not S/R technique

– Psychiatric Emergency Response Teams implemented all hospitals

• Tertiary Prevention:

– Patient, staff & administrative debriefing - every incident reviewed by executive team & advocate daily

(NETI, 2006; Smith et al, 2005)

PA State Hospital SystemCritical Factors in Change

Data

Active use of data from performance measurement

system supports quality improvement process• Collect data on all episodes of S/R• Separate system for recording psych use of PRN & STAT

medication use• Reporting based on a 1-page incident report format• Dedicated section to record consumer perspective• Closure codes for recording team actions for every incident• 30+ indicators of performance measurement• Monthly summary report on prior month’s incident data

PA State Hospital SystemCritical Factors in Change

Facility CEO Leadership

Sets and keeps the standard for positive, non-offensive culture• Reviews every restraint event and follows-up.• Responds to code “orange” emergencies.• Gets directly involved in debrief process following a restraint

event with treatment team.• Identifies organizational barriers that impede efforts to

eliminate SR.• Makes non-restraint approach a basis for medical appointments. • Adopts patient centered policies/procedures.• Involves employee unions in the change.• Celebrates success.

PA State Hospital SystemSeclusion & Mechanical Restraint Use

1990 - 2004

137,924 140,045

17,183

2,852 2,241 1,440 1,097 1,235 638

14,73216,465

49,500

96,219

124,530

97,065

11892261290

93,55389,370

77,02269,020

58,245

24,692

12,378

4,715 3,660 941 5030

20,000

40,000

60,000

80,000

100,000

120,000

140,000

160,000

1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004

Act

ua

l H

ou

rs U

sed

Mechanical Restraint hours Seclusion hours

(NETI, 2006; Smith et al, 2005; Data from the PA State Hospital Risk Management System)

State Hospital Use (Civil & Forensic) of Mechanical Restraint & Seclusion

24-Month Trend 2004 - 2006

56.62

68.34

43.96

51.85

35.76

57.57

29.32

26.66

30.14

33.68

36.47

33.75

24.12

28.73

17.70

13.42

10.4110.75

5.47

11.178.92 8.20 8.98 8.08

9.48

12.75

2.670.83

5.72

2.00

7.17

14.18

1.50

10.35

2.581.12 1.08

46.11

8.66

23.70

15.25

54.82

33.11

24.54

4.082.17

14.08

8.00

0

10

20

30

40

50

60

70

80

M-04 A-04 M-04 J-04 J-04 A-04 S-04 O-04 N-04 D-04 J-05 F-05 M-05 A-05 M-05 J-05 J-05 A-05 S-05 O-05 N-05 D-05 J-06 F-06

Total

Hou

rs b

y M

onth

Mechanical Restraint Seclusion

Pennsylvania Today

• November, 2003: State hospital system (civil side) achieved first seclusion-free month in 100+ year history

• 7 / 8 state hospitals have been seclusion-free for more than one year

• June 2, 2005: Danville State Hospital becomes first hospital to go 2 years without using S/R. Now, Allentown state hospital is S/R-free, too.

(NETI, 2006; Smith et al, 2005)

Pennsylvania Today

• Psychiatric use of PRN medication orders discontinued on March 1, 2005

• Psychiatric use of STAT orders part of monthly risk management review process

• The PA Goal & Plan: All PA state hospitals will be S/R-free

by January 1, 2007

(NETI, 2006; Smith et al, 2005)

PennsylvaniaContact Information

Gregory M. Smith, M.S.Gregory M. Smith, M.S.Chief Executive OfficerChief Executive Officer

Allentown State HospitalAllentown State Hospital1600 Hanover Avenue, Bldg. #111600 Hanover Avenue, Bldg. #11

Allentown, PA 18109-2498Allentown, PA 18109-2498

717 – 772 – 7609717 – 772 – 7609grsmith@state.pa.us