use of control interventions in ontario: where are we now—where are we heading? nawaf madi...
TRANSCRIPT
1
Use of Control Interventions in Ontario: Where Are We Now—Where are We Heading?
Nawaf Madi
Canadian Institute for Health Information
2
Mental Health Services in General Hospitals
Where Are We Now?
Where are We Heading?
Control Interventions--Overview
Mental Health Services in General Hospitals
3
4
Hospital Mental Health Services in Canada
1982-1983 1993-1994 2006–2007 2007–2008 2008–2009 2009–20100%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
General Hospitals Psychiatric Hospitals
Sep
arat
ion
s
5
General Hospital Separation Rates 2009-2010
Newfo
undla
nd &
Lab
rado
r
Prince
Edw
ard
Islan
d
Nova
Scotia
New B
runs
wick
Quebe
c
Ontar
io
Man
itoba
Saska
tche
wan
Alberta
British
Colu
mbia
Yukon
North
west T
errit
ories
Nunav
ut
Canad
a0.0
200.0
400.0
600.0
800.0
1000.0
1200.0
1400.0A
ge
Sta
nd
ard
ize
d S
ep
ara
tion
Ra
te\
10
0,0
00
6
Hospital Mental Health Services in Canada 2009-2010
Org
anic
D
isor
ders
Sub
stan
ce-
Rel
ated
D
isor
ders
Sch
izop
hren
ic
and
Psy
chot
ic
Dis
orde
rs
Moo
d D
isor
ders
Anx
iety
D
isor
ders
Per
sona
lity
Dis
orde
rs
Oth
er
Dis
orde
rs
0
5
10
15
20
25
30
35
40
General Hospitals Psychiatric Hospitals
Diagnosis Category
Per
cen
tag
e o
f S
epar
atio
ns
7
General Hospital Length of Stay 2009-2010
Newfo
undland a
nd Lab
rador
Prince
Edwar
d Isla
nd
Nova S
cotia
New B
runsw
ick
Quebec
Ontario
†
Man
itoba
Saska
tchew
an
Alber
ta
Britis
h Colu
mbia
Yukon
Northwes
t Ter
ritorie
s
Nunavut
Canad
a0.0
5.0
10.0
15.0
20.0
25.0
30.0
Average
Median
Len
gth
of S
tay
(Day
s)
8
Hospital Mental Health Services in Canada 2009-2010 General Hospitals Psychiatric Hospitals
Non–Mental Illness Mental Illness Mental Illness
Male (%) 41.5 49.5 56.8Mean Age (Years) 52.9 46.3 42.0Age (%) 0–14 7.3 3.1 2.3 15–24 6.9 15.5 16.1 25–44 22.9 31.7 39.0 45–64 23.7 28.4 30.8 65+ 39.1 21.3 11.9Income Quintile (%) 1 (Low) 23.0 28.8 NA
2 20.7 21.2 NA
3 19.8 17.5 NA
4 18.6 15.2 NA
5 (High) 16.6 13.4 NA
Unknown 1.3 4.0 NAAdmitted via the Emergency Department (%) 51.8 76.9 NADeath in Hospital (%) 4.2 1.1 0.7Separations (%) 94.1 5.9 NATotal Length of Stay (%) 86.6 13.4 NAAverage Length of Stay (Days)
7.4 18.3 80.5
Median Length of Stay (Days) 3 8 22Distribution of Lengths of Stay (%) 1 Day 24.0 14.1 9.1
2–7 Days 53.7 34.4 18.6 8–30 Days 4.0 15.5 35.3 31–365 Days 18.4 35.8 33.8 366+ Days 0.0 0.1 3.2
9
A Look at the Data
Where Are We Now?
Control Interventions Defined
10
Acute Control Medication
• Psychotropic (e.g. sedative) medication given as an immediate response to prevent harm to self or others
Mechanical Restraint
• Restrained in bed and unable to ambulate• Wrists restrained but able to ambulate
Physical Restraint
• Holding the person for a brief period to restore calm
Seclusion
• A room that confines and from which the person cannot exit freely
Legislation, Guidelines, Policies & Practice
• Patient Restraint Minimization Act (2001) stipulates use should be limited to prevention of bodily harm
• CNO & RNAO Guidelines emphasize least restrictive approaches
• Interventions classified by level of restrictiveness
• Many institutional policies stipulate restraints as a measure of last resort
• It is generally agreed that restraints are to be avoided if possible
– Although stigma and negative attitudes remain
11
12
Control Interventions an Issue of Importance
• Adverse outcomes
– Physical injury to patients & staff
– Negative emotional\psychological impacts
• Retraumatization
– Not conducive to therapeutic alliance
• Time spent on CI’s is time not spent on therapeutic care
– Financial costs
• Ethical Issue
– Media interest drawn by question of human rights
13
What the Data Tell Us?
• International Estimates Vary
– Estimates vary from 0%-35% of admissions (Steinert, 2009)
– Variation in definitions and policies
• Limited Standardized & Comparable Canadian Data
– Except in Ontario
– Many gaps, much analyses focus on elderly
• …but interest is growing
14
Control Intervention Use in Ontario
FY2006 FY2007 FY2008 FY2009 FY2010 FY2011 FY2006 FY2007 FY2008 FY2009 FY2010 FY20110.0
5.0
10.0
15.0
20.0
25.0
Admission (72 Hrs) Quarterly/Change in Status Discharge Short Stay
Percent
General Hospitals Psychiatric Hospitals
15
Acute Control Medication Use in Ontario
FY2006 FY2007 FY2008 FY2009 FY2010 FY2011 FY2006 FY2007 FY2008 FY2009 FY2010 FY20110.0
2.0
4.0
6.0
8.0
10.0
12.0
14.0
Admission (72 Hrs) Quarterly/Change in Status Discharge Short Stay
Percent
General Hospitals Psychiatric Hospitals
16
Physical\Mechanical Restraint Use in Ontario
FY2006 FY2007 FY2008 FY2009 FY2010 FY2011 FY2006 FY2007 FY2008 FY2009 FY2010 FY20110.0
0.5
1.0
1.5
2.0
2.5
3.0
3.5
4.0
4.5
5.0
Admission (72 Hrs) Quarterly/Change in Status Discharge Short Stay
Percent
General Hospitals Psychiatric Hospitals
17
Seclusion Room Use in Ontario
FY2006 FY2007 FY2008 FY2009 FY2010 FY2011 FY2006 FY2007 FY2008 FY2009 FY2010 FY20110.0
0.5
1.0
1.5
2.0
2.5
3.0
3.5
4.0
4.5
Admission (72 Hrs) Quarterly/Change in Status Discharge Short Stay
Percent
General Hospitals Psychiatric Hospitals
What factors are associated with CI use?
CI Analysis Part I:
18
19
20
Purpose of Analysis in Brief
• Examining rates within Ontario hospitals
• Profile of individuals experiencing CIs
• Identifying risks factors for CIs with adjustment for socio-demographic, clinical, & other variables
• Examining differences between types of CIs interventions
21
Methods
• Used OMHRS data for 2006-2007 to 2009-20010
• Three mutually exclusive groups of control intervention
– Acute Control Medication
– Physical\Mechanical Restraint
– Seclusion
– Comparison: Psychiatric hospitalization with no control interventions
• 70 general hospital and specialty mental health facilities
22
Individuals who experienced a CI 2006-2009
15%
5%
5%
74%
Acute control medication only
Physical/mechanical restraint
Seclusion
No control intervention
Risk factors:
23
Sociodemographic
• Gender - male
• Age - younger • Education • Employment• Neighbourhood Income
Behavioural
• Danger to others• Danger to self• Inability for self-care due to MH• Police Intervention
Clinical
• Depression• Substance Use
• Organic disorders
• Bipolar disorders
• Schizophrenia or Psychosis
Treatment
• >6 lifetime MH admissions
• Medication non adherence
Cognitive/ Communication
• Cognitive impairment
• Unable to consent to treatment
• Difficulty making self understood
Life Stressor
• History of emotional, physical or sexual abuse or assaulte
24
Adjusted Odds Ratios
Domain Potential Predictor ACMMechanical/Physical Restraint
SeclusionAll Control
Interventions
DemographicAge (years)
18-24 (reference) 1 1 1 1 25-34 0.90 0.68 0.70 0.81 35-44 0.82 0.63 0.61 0.73 45-54 0.75 0.56 0.53 0.66 55-64 0.65 0.43 0.47 0.57 65-74 0.65 0.45 0.33 0.53 >=75 0.64 0.59 0.22 0.54
Male gender (vs. female) 1.18
More than high school education 1.08 1.14 0.84 Not employed (vs. employed) 1.22 1.13 1.28 1.22Highest SES (vs. lowest) 0.84
Behavioral Threat/danger to self 1.64 1.33 1.29 1.53Threat/danger to others 1.48 2.14 2.00 1.72Cannot care for self due to mental illness
1.65 1.66 1.37 1.60
Recent police intervention (vs. none) 1.35 1.62 1.64 1.51Recent violence to others (vs. none) 1.54 3.11 1.99 1.98
Cognitive/communication
Not capable of consenting 1.19 1.90 1.38 1.39Making self understood
Understood 1 1 1 1 Usually/often understood 1.71 1.78 1.41 1.68 Sometimes/rarely understood 1.60 2.92 2.36 2.09
Life stressors
History of abuse 0.84
Risk Factors for Control Interventions
25
Adjusted Odds Ratios
Domain Potential Predictor ACMMechanical/Physical Restraint
Seclusion
All Control Interventio
nsTreatment Number of lifetime psychiatric hospitalizations
0 (reference) 1 1 to 3 1.31 1.29 1.42 1.33 4 to 5 1.69 1.58 1.86 1.71 6 or more 1.98 2.00 2.21 2.03
Medication adherence Always adherent (reference) 1 80% or more 1.45 1.65 1.25 1.43 <80% and fail to buy meds 1.86 2.61 1.82 1.95 No meds prescribed 1.28 1.87 1.40 1.37
Type of facility Psychiatric/Specialty (reference) 1 General Hospital 1.68 2.61 1.45 1.76
Clinical Primary mental health diagnosis Depression/other mood disorders 1 1 1 1 Organic disorders 1.42 2.66 1.97 1.69 Substance related disorders 0.88 1.37 0.91
Schizophrenic/other psychotic disorders
1.28 1.82 1.51 1.40
Bipolar disorders 1.22 2.27 2.09 1.50 Anxiety disorders 0.43
Concurrent substance abuse/addiction Yes 1.07
Concurrent personality disorder Yes 1.13 1.09
Risk Factors for Control Interventions
Part I:Summary
26
Patients admitted to a general hospital more likely to experience restraint use
• Difficulty communicating, violent behavior greatly increase chances of patients experiencing control interventions
Highlights areas for intervention: treatment compliance, communication, training
What are the outcomes of control intervention use?
CI Analysis Part II:
27
28
0 11 22 33 44 55 66 77 88 99 1101211321431541651761871982092202312422532642752862973083193303413523633743850
5
10
15
20
25
30
35
40
First psychiatric readmission following index hospitalization by restraint type
No restraint ACM Physical/Mechanical Seclusion
Time to readmission (Days)
Pe
rce
nt
rea
dm
itte
d
5.4%
9.9%
11.9%
11.4%
22.3%
32.7%
36.0%
36.4%
29
Age*
Abuse
Homeless
Control intervention
≥6 Hospitalization (vs. 0)
General facility (vs. Psych)
Bipolar
Anxiety
Substance related
Schizophrenia
Aggressive Behaviour Scale**
Risk of self-harm†
Self-care difficulties‡
-1
-0.5
0
0.5
1
1.5
Adjusted odds ratios from the logistic model of readmission within 30 days
Odd
s Rati
o
1
0
1.5
2.0
NSNS
NS
0.5
*Age: Oldest quintile vs. youngest**Highest risk vs. none (3-12 vs. 0)†Severity of Self-Harm Scale (5-6 vs. 0)‡Self-care Index (high risk vs. none)
Part II Summary
30
Preliminary findings--those experiencing CI’s are 60% more likely to be readmitted within 30 days even when adjusted for other factors
• At 1 year, those who experienced CI’s were more likely to be readmitted
Need to understand what is it about control intervention use in previous hospitalizations that is related to readmissions
31
Where are We Heading?
The Role of Data
“People being locked in tiny rooms they cannot leave, tied
to a bed and injected with chemicals against their
will are clearly
traumatic experiences that taken in any other
context would be seen as
devastating”
A patient’s perspective – Jennifer Chambers
32
Out of the Shadows at Last
33
Larue et al. 2009
Larue et al. 2009
Leadership• Restraint reduction vision• Philosophy of care• Values and Strategies
Data• Evidence based
decisions• Est. baselines• Reduction targets• Peer comparison• Trends• Cost analysis• Resourcing• Etc.
LEGISLATION
In Ontario
• Patient Restraint Minimization Act, (2001) Government of Ontario
• Mental Health Act, (2001) Government of Ontario
• College of Nurses of Ontario Practice Standard: Restraints, (2009)
• Health Care Consent Act, 1996 (2010) Government of Ontario
• Restraint use as a patient safety issue
• Restraint use as a Quality of Care Indicator (HQO)
34
35
Comparative Reporting on CI’s
Fac Peer LHIN Prov0
10
20
30
40
50
60
70
80
90
100Prevalence of physical restraint use
Prevalence of acute control medication use
No physical restraint or acute control medication used
%
Informing Clinical PracticeMental Health Clinical Assessment Protocols (CAPs)
• CI CAP will trigger based on the following RAI-MH components:
– Recent self-injurious attempt
– Intent of any attempt was to kill self
– Violent behaviour/Extreme disturbance to others
– Recent command hallucinations
– ABS score of 6 or higher
– Recent ACM use
36
Clinical Assessment Protocol ReportsInforming Management Decisions
37
0.0
10.0
20.0
30.0
40.0
50.0
60.0
70.0
80.0
90.0
100.01. Harm to Others
2. Suicidality andPurposeful Self-Harm
3. Self Care
4. SocialRelationships
5. Support Systemsfor Discharge
6. InterpersonalConflict
7. Traumatic LifeEvents
8. Criminal Activity
9. Personal Finances10. Education and
Employment11. Control
Interventions
12. MedicationManagement and…
13. Rehospitalization
14. Smoking
15. Substance Use
16. WeightManagement
17. Exercise
18. SleepDisturbance
19. Pain
20. Falls
Facility, Peers and Province Overall Triggered CAPs Percentage
FACILITY
PEERS
PROVINCE
Informing Communities of Practice
Control Interventions Experienced 2006-2009
39
0.0
10.0
20.0
30.0
40.0
50.0
60.0
5.3
51.4
4.4
38.3
OMHRS Facilities
Percent
General Hospitals Psychiatric Hospit-als
40
Acute Control Medications 2006-2009
0.0
5.0
10.0
15.0
20.0
25.0
30.0
35.0
40.0
45.0
1.7
39.4
1.2
31.3
OMHRS Facilities
Percent
General Hospitals Psychiatric Hospit-als
41
Physical\Mechanical Restraints Experienced 2006-2009
0.0
5.0
10.0
15.0
20.0
25.0
30.0
0.2
26.3
0.0
6.8
OMHRS Facilities
Percent
General Hospitals Psychiatric Hospit-als
42
Seclusions Experienced 2006-2009
0.0
5.0
10.0
15.0
20.0
25.0
30.028.2
0.8
27.0
OMHRS Facilities
Percent
General Hospitals Psychiatric Hospit-als
0.0
Evidence Informed Decisions
43
Standardized, accurate clinical assessments provide evidence to:
• Identify risks• Guide care planning • Measure treatment effectiveness
Aggregate reporting of comparable clinical information provides evidence to:
• Evaluate quality of care• Guide decision making at all levels from unit, to facility, to
Ministry of Health• Identify areas for improvement
