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Special Section on Seclusion and Restraint Pennsylvania State Hospital System’s Seclusion and Restraint Reduction Program Gregory M. Smith, M.S. Robert H. Davis, M.D. Edward O. Bixler, Ph.D. Hung-Mo Lin, Ph.D. Aidan Altenor, Ph.D. Roberta J. Altenor, M.S.N. Bonnie D. Hardentstine, B.S. George A. Kopchick, M.S.

Objectives: This study examined the use of seclusion and mechanical re- he use of seclusion and re- straint from 1990 to 2000 and the rate of staff injuries from patient as- straint in psychiatric hospitals saults from 1998 to 2000 in a state hospital system. Methods: Records of Tto control people with dis- patients older than 18 years who were civilly committed to one of the nine turbed or violent behaviors has been state hospitals in Pennsylvania were included in the analyses. Two data- occurring for centuries. The litera- bases were used in each of the nine hospitals: one identified date, time, ture is replete with examples of how duration, and justification for each episode of seclusion or restraint and clinicians have struggled with the eth- the other identified when a patient was hospitalized and the demograph- ical issues involved with the use of ic characteristics and the diagnosis of the patient. Rate and duration of these interventions (1–4). The litera- seclusion and restraint were calculated. Reports from compensation ture has also provided the rationale claims were used to determine staff injuries from patient assaults. Results: for the continued use of physical con- The rate and duration of seclusion and mechanical restraint decreased trols in modern psychiatric settings, dramatically during this period. From 1990 to 2000, the rate of seclusion much like it did in the past for asy- decreased from 4.2 to .3 episodes per 1,000 patient-days. The average lums (4–6). More recent research has duration of seclusion decreased from 10.8 to 1.3 hours. The rate of re- questioned the need to use these straint decreased from 3.5 to 1.2 episodes per 1,000 patient-days. The av- practices and pointed to studies erage duration of restraint decreased from 11.9 to 1.9 hours. Patients showing inconsistency in the applica- from racial or ethnic minority groups had a higher rate and longer dura- tion of seclusion and restraint (6,7). tion of seclusion than whites. Seclusion tended to be less likely, but An international review of these pro- longer, during the night shift. Patients were restrained less often during cedures found the same inconsisten- the night shift, but for a longer duration. The rate of restraint was high- cies in the use of seclusion and re- er during the week than during weekends and holidays. Younger patients straint with psychiatric patients and were more likely to be secluded and restrained, but older patients re- the same struggles with the ethics of mained secluded and restrained longer. No significant changes were seen these practices (8). Seclusion and re- in rates of staff injuries from 1998 to 2000. Conclusions: Many factors straint has prevailed internationally as contributed to the success of this effort, including advocacy efforts, state the primary approach to managing vi- policy change, improved patient-staff ratios, response teams, and second- olent behaviors, although the degree generation antipsychotics. (Psychiatric Services 56:1115–1122, 2005) of use depends on the country or ge- ographical location (9–12). Since 1990 the Pennsylvania state hospital system has experienced con- Mr. Smith, Dr. Davis, Dr. Altenor, Ms. Altenor, Ms. Hardentstine, and Mr. Kopchick are affiliated with the Office of Mental Health and Substance Abuse Services of the Com- stant changes that have resulted in re- monwealth of Pennsylvania in Harrisburg. Dr. Bixler and Dr. Lin are with the Pennsyl- markable outcomes in reducing the vania State University School of Medicine in Hershey. Send correspondence to Mr. Smith use of seclusion and restraint. The at , 1600 Hanover Avenue, Allentown, Pennsylvania 18109-2498 Pennsylvania state hospital system, (e-mail, [email protected]). This article is part of a special section on the use of seclu- one of the oldest in the country, sion and restraint in psychiatric treatment settings. serves adults within a civil and foren-

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sic inpatient setting who have severe were averaged across patients who and older. Race and ethnicity were and persistent mental illnesses. Dur- had at least one event during that considered in terms of whites and all ing most of its history the hospital sys- year. racial and ethnic minority groups. tem provided direct admission servic- The Jonckheere-Terpstra test (13) The events were categorized in terms es. However, during the study period, was used to compare the ordinal dif- of hospital work shift (day shift, 7 a.m. the admission of civilly committed pa- ferences of the seclusion and restraint to 3 p.m.; evening shift, 3 p.m. to 11 tients was limited to referrals from lo- rates over time or among different p.m.; and night shift, 11 p.m. to 7 cal psychiatric acute care settings for classes. The generalized estimating a.m.) and by weekday compared with individuals who were unable to be equations (GEE) method (14) was weekend or holiday. The Jonckheere stabilized within a 30-day acute care employed to perform various hypoth- Terpstra test was used to evaluate stay. esis tests, including testing whether data derived from the annual census The purpose of this study was to the overall duration or rate of one fac- data from the hospital system. All systematically report changes in pat- tor depends on the level of the other other analyses were evaluated by us- terns of seclusion and mechanical re- factor. The GEE method is a useful ing the GEE method (14). straint over an 11-year period (1990 extension of the generalized linear Data on staff injuries from patient to 2000) that took place within Penn- models for continuous and categori- assaults were available only for 1998 sylvania’s nine state hospitals. Be- cal data that does not require the ex- to 2000. We examined the number of cause so many changes were imple- events in which employees lost time mented during this period it was not from work as a result of injuries from possible to isolate and analyze the ef- assaults and events in which first aid fects of a single variable. Changes only was needed as a result of an as- that influenced the reduction of sault. Each hospital’s compensation seclusion and restraint are discussed. claims were used for this analysis. Since 1990 The counts were not duplicated with- Methods in these measures. To determine the The data used for this study were tak- the Pennsylvania rate of change each year, these events en from two sources maintained by were calculated per 1,000 patient- each of the nine hospitals. The first state hospital system days of care. database identified date, time of day, duration, and justification for each has experienced constant Results event of seclusion or restraint. The The annual census for the hospital second database identified when a changes that have resulted system during this 11-year period de- patient was present in the hospital creased 56 percent, from about 6,300 and supplied basic demographic and in remarkable outcomes to about 2,800. During this time the diagnostic information. All data were gender ratio remained constant (53 merged and reformatted by using an in reducing the use percent men and 47 percent women), anonymous patient identifier for and representation of racial or ethnic analysis. Only adults 18 years and old- of seclusion and minority groups increased slightly er who were served on civil units of (p=.03). This change was consistent the hospitals were included in this restraint. with changes in the size of the popu- study. In addition, only the use of lation of racial or ethnic minority seclusion and mechanical restraint groups in Pennsylvania. was evaluated. As shown in Table 1, the rate of An individual annual rate was cal- seclusion decreased from a high of culated as the total number of events 7.2 episodes per 1,000 patient-days in divided by the total number of days act knowledge of variance-covariance 1991 to .3 episodes per 1,000 patient- in the hospital that year multiplied structure of the repeated outcomes. days in 2000. The average rate of by 1,000 (referred to as rate per 1000 The GEE is favored over multivariate seclusion was similar for men and patient-days). If a patient was not re- analysis of variance (MANOVA) be- women, and this rate significantly de- strained during that year’s stay in the cause our study consists of double re- creased during the study period hospital, they were assigned a rate of peated measurements from hospitals (p<.01). The rate of seclusion was zero. For the year-specific average and patients nested under hospitals greater for persons in racial or ethnic rate, the individual rates were aver- over the 11-year period. Estimation minority groups than for whites (4.3 aged across all patients in the hospi- of the covariance structure using episodes per 1,000 patient-days com- tal that year. Duration was defined as MANOVA proves to be problematic pared with 2.5 episodes per 1,000 pa- hours per event. An individual annu- sometimes. tient-days, p<.01). Over the study pe- al duration was calculated if the pa- For the purpose of analysis, the riod, the rate of seclusion decreased tient had one or more events that sample was divided into four age to a greater degree among persons year. For the year-specific average groups: 25 years and younger, 26 to from racial or ethnic minority groups duration time, the individual means 40 years, 41 to 65 years, and 66 years (p<.05). The rate of seclusion was in-

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versely associated with age—that is, Table 1 the youngest group had the highest Prevalence and duration of seclusion and mechanical restraint among adults who rate (6.0 episodes per 1,000 patient- were civilly committed to state hospitals in Pennsylvania days for the youngest age group com- pared with .3 episodes per 1,000 pa- Seclusion Mechanical restraint tient-days for the oldest age group, p<.01). The rate of seclusion was low- Duration Duration (hours) (hours) est during the night shift (1.4, 1.5, and Rate per 1,000 Rate per 1,000 .4 episodes per 1,000 patient-days, for Year patient days Mean SD patient days Mean SD the day, evening, and night shifts, re- spectively, p<.01) and higher during 1990 4.23 10.83 16.24 3.51 11.92 55.97 the week than during weekends and 1991 7.20 11.64 16.00 6.41 9.76 30.37 1992 3.55 10.14 19.03 3.82 12.12 39.04 holidays (2.5 episodes per 1,000 pa- 1993 3.61 9.91 21.44 4.70 8.98 18.33 tient-days compared with .6 episodes 1994 3.26 8.27 14.30 3.99 8.91 16.50 per 1,000 patient-days, p<.01). 1995 2.52 5.79 9.93 3.61 5.09 5.59 The average duration of seclusion 1996 2.24 3.75 3.55 2.65 3.83 4.31 decreased from a high of 11.6 hours 1997 1.73 2.68 2.05 2.01 3.19 5.14 1998 1.47 2.14 1.51 2.96 3.98 15.81 in 1991 to 1.3 hours in 2000 (Table 1). 1999 .64 1.35 .82 1.57 1.97 2.76 The duration of seclusion was longer 2000 .28 1.31 .93 1.20 1.93 3.00 for men than for women (8.7 hours compared with 7.4 hours, p<.01) and was shorter for whites than for per- sons from a racial or ethnic minority The average duration of mechani- tient-days. The overall rate of staff in- group (7.6 hours compared with 9.8 cal restraint decreased from a high of juries from assault involving first aid hours, p<.01). Older patients were se- 12.1 hours in 1992 to 1.9 hours in only was .21 episodes per 1,000 pa- cluded longer than younger patients 2000 (Table 1). The duration of me- tient-days in 1998 and .23 episodes (8.7 hours for the oldest age group chanical restraint remained similar per 1,000 patient-days in 2000. compared with 5.0 hours for youngest for women and men and for whites age group, p<.01). The duration for and persons from a racial or ethnic Changes that influenced reduction seclusion tended to be longer during minority group. Older patients tend- in seclusion and restraint the night shift (8.0, 8.4, and 10.7 ed to be in mechanical restraint Leadership. The nonrestraint move- hours, for the day, evening and night longer than younger patients (11.4 ment within the Pennsylvania state shifts, respectively, p<.01) and short- hours for the oldest age group com- hospital system predates the period er during the week than during week- pared with 5.0 hours for youngest age covered by this study. Most of the dra- ends or holidays (8.0 hours compared group, p<.01). Patients tended to be matic reductions occurred from 1993 with 9.5 hours, p<.01). in mechanical restraint for longer pe- to 1997 and are credited to direct care The rate of mechanical restraint riods during the night shift (8.0, 8.0, staff at local hospitals (aides, nurses, decreased from a high of 6.4 episodes and 15.4 hours for the day, evening, doctors, and program staff) and com- per 1,000 patient-days in 1991 to 1.2 and night shifts, respectively, p<.01). munity advocates (for example, par- episodes per 1,000 patient-days in The duration was about the same dur- ents and representatives of the Na- 2000 (Table 1). The rate of restraint ing the week and during weekends or tional Alliance for the Mentally Ill and was about the same for women and holidays (8.5 hours during the week Pennsylvania Protection and Advoca- men and for whites and persons from compared with 8.9 hours during cy, Inc.). When these groups applied a racial or ethnic minority group. The weekends or holidays). their values through individual and rate of mechanical restraint was in- Data on staff injuries from patient group leadership, they were success- versely associated with age. The assaults were available only from ful in changing the culture of restraint youngest group had the highest rate 1998 to 2000. Even though major re- that existed within the hospital system (8.2 episodes per 1,000 patient-days ductions in the use of seclusion and in the early 1990s. Staff arguments at compared with 1.2 episodes per 1,000 restraint had already occurred, it is the unit level for and against the use of patient-days for the oldest age group, valuable to consider this measure, be- restraint, sometimes during the crisis p<.01). The rate of mechanical re- cause it is common for health care itself, were common. It was common straint tended to be lowest during the workers to be concerned about staff for advocates to complain to hospital night shift (1.8, 1.5, and .5 episodes injury when the use of these proce- and state officials about the unneces- per 1,000 patient-days, for the day, dures is reduced. The rate of staff in- sary use of restraint or seclusion. Staff evening, and night shifts, respectively, juries did not change during this peri- and advocates worked with the system p<.01). The rate was higher during od. In 1998 the overall rate of staff in- internally and externally to change the the week than during weekends and juries involving lost work time from a culture of restraint in hospitals. holidays (2.7 episodes per 1,000 pa- patient assault was .1 episodes per During the study period, five dif- tient-days compared with .7 episodes 1,000 patient-days and in 2000 the ferent individuals served as the per 1,000 patient-days, p<.01). rate was .13 episodes per 1,000 pa- deputy secretary for the State Office

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of Mental Health and Substance This effort led to greater emphasis on pendence on these restrictive proce- Abuse Services (OMHSAS), and staff training in the areas of crisis dures (personal communication three different individuals served as management and nonoffensive skill Banks J, Madigan P, 2003). chief psychiatrist for OMHSAS. All of development that reinforced verbal These groups were particularly ac- them played a role in reducing seclu- deescalation techniques. tive in the southeast region of the sion and restraint. However, it was Finally, during the study period commonwealth, where they regularly Charles Curie, OMHSAS deputy sec- there were several facility closures engaged the leadership of Allentown, retary from 1996 to 2001, who chal- across the state. These closures in- Haverford, Norristown, and Philadel- lenged the status quo by establishing creased the number of new staff who phia state hospitals with complaints new standards that further limited entered the hospital system. These involving the misuse and overuse of the use of these restrictive proce- closures affected every hospital and seclusion and restraint (personal dures. In 1997 he announced that the typically involved staff from the state communication, Rehrman M, 2003). use of seclusion and restraint repre- mental retardation centers who chal- Additionally, by 1995 state govern- sented “treatment failure” and chal- lenged the long-standing treatment ment had independent advocates as- lenged the system to eliminate their concepts of the hospital system. This signed to each hospital. These facili- use and find more positive ways of group of workers, using behavioral ty-level advocates provided a needed supporting a person in crisis. Accord- support principles, helped decrease layer of protection for the patient on ing to Curie, consumers and their a day-to-day basis (personal commu- families, as well as the Pennsylvania nication, Zuber B, 2003). advocacy community, provided sup- At the state level there were con- port for this important change. He stant questions by these groups about added that the use of restraint and the hospital system’s use of seclusion seclusion conflicted with the recovery By 1995 the and restraint. Demands were made approach (15) that was being imple- for regular reports on the use of these mented statewide (personal commu- state government had procedures that led to improved data nication, Curie C, 2003). collection. They also pushed for more The importance of this announce- independent advocates effective staff training that would ment cannot be overstated. At the make the use of seclusion or restraint time, the debate over the nonre- assigned to each hospital, an intervention of last resort. straint approach was growing. Some Although these groups never joined clinicians argued that it was a psychi- who provided a needed together to pressure the state govern- atric decision if and when to use ment to decrease the use of these seclusion or mechanical restraint. layer of protection procedures, they were effective at ad- They felt that seclusion and restraint dressing individual patient issues and were important tools that were re- for patients on a challenging the leadership of OMH- quired to manage a crisis and that SAS to monitor and reduce the use of without them the hospital environ- day-to-day seclusion and restraint. Deputy Sec- ment would become more violent retary Curie’s announcement in 1997 and unsafe. Curie’s “treatment fail- basis. that the use of seclusion and restraint ure” announcement did not ban the constituted treatment failure was a use of seclusion or restraint. Howev- credit to their individual efforts. er, the announcement served as a State policy change. State policy on challenge to the system to find more the use of restrictive procedures in positive ways of supporting a person dependence on the use of restrictive the state hospitals changed three in crisis. The announcement put to procedures. Their contributions to times during the study period. After rest arguments occurring at the hos- this change, at all levels of the hospi- Curie’s “treatment failure” announce- pital level between clinicians and ad- tal system, were invaluable. ment the policy was revised to further ministrators on the restraint issue and Advocacy efforts. Organized advo- limit the circumstances in which re- established direction for further sys- cacy efforts to reduce the use of strictive procedures could be used. temwide changes. seclusion and restraint in the state This change defined physical re- Curie attributed the continued de- hospital system started long before straint, mechanical restraint, protec- crease in the use of seclusion and re- the study period. Often led by parents tive restraint, and seclusion as ex- straint to improved data collection and former patients who represented treme measures and limited their use and greater transparency in the way local and state chapters of the Nation- to emergency situations. It also de- information is shared and used to al Alliance for the Mentally Ill, the fined chemical restraint as the use of compare restraint rates between the Pennsylvania Mental Health Con- medication for the specific purpose of hospitals. He also credited statewide sumers Association, Pennsylvania controlling aggressive behavior, performance improvement projects Protection and Advocacy, Inc., and which restricts a person’s freedom of that focused on ways to reduce the others, these efforts were instrumen- movement by rendering him or her in use of these restrictive procedures. tal in challenging the system’s de- a semistupor or unable to attend to

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personal needs, and the policy pro- the day and evening shifts. Teams of staffed with one licensed nurse and hibited its use. seven, led by a captain, serve on-call three psychiatric aides during the day The policy also established guide- PERT duty about twice a week. If in- and evening shifts. During 2000, the lines for annual staff training sessions. sufficient volunteers are available, average staffing for a 32-bed unit in- The policy change included proce- nursing staff are assigned to the team creased to two licensed nurses and dures for patient and staff debriefing on a rotating basis. four psychiatric aides during the day sessions after the use of restraint or When a crisis occurs the staff and evening shifts. seclusion. It also required, with con- member at the scene announces a The smaller units were made pos- sent, the notification of a person’s “code orange” and the location of the sible through the state-funded Com- family after the use of a restrictive emergency over the pager system. munity Hospital Integration Project procedure. New physician protocols When PERT members receive the Program (CHIPP) that supports the were also part of this change, which page, they stop what they are doing discharge of people with two or limited orders for restraint and seclu- and report to the area. As team mem- more years of inpatient hospital care. sion to no more than 60 minutes and bers arrive they are met by the PERT During the study period, more than required that the person be seen captain, who determines which ap- 1,600 people were discharged within 30 minutes of a phone order. proach to take with the person in cri- through this program. CHIPP is Each hospital’s performance im- sis on the basis of personal observa- credited with expanding the capacity provement programs were required tion and treatment team input. Un- of local communities to support peo- to monitor the ongoing use of these less the person presents an immedi- ple with severe mental illnesses procedures (16). Finally, the policy ate danger to self or others, the initial while decreasing dependence on change limited to eight the number of PERT response focuses on clearing state hospital services (18). approved restraint devices that could the area. Next, the PERT members, Pennsylvania’s experience since be used: one-, two-, three-, and four- under the direction of the captain, at- 1990 reinforces the belief that having point soft Velcro restraint devices; tempt to engage the person in a ther- fewer patients on a unit allows more soft mitts; and two-, three-, and four- apeutic conversation directed at sensitive care and a safer, restraint- point leather restraint devices. identifying the underlying reasons free hospital. Psychiatric emergency response for the crisis. The focus of this meet- Incident management system. Be- teams (PERTs). The concept of pre- ing is to help the individual under- fore 1998 the state hospital system senting a large show of staff support stand what needs to occur for him or used a basic network database that at the scene of a psychiatric crisis to her to regain control (17). Once the recorded the application of any re- ensure safety has been around for crisis has been resolved, a debriefing strictive procedures used for a patient more than 200 years. In 1794 session is held with staff to critique in the hospital system. The reporting Philippe Pinel, a French psychiatrist, the response and review the out- and tracking system required a cause was one of earliest to write about the come. A separate debriefing session for each use of a restrictive procedure effectiveness of teamwork as a proce- is conducted with the patient when (19). Most of the aggregate data used dure in managing a psychiatric emer- he or she is calm. The Allentown in this study were taken from this sys- gency (1,4). model also involves a PERT assist tem. However, the complexities of PERTs bring together a large group process that is used in anticipation of this database made it difficult for hos- of workers at the scene of the crisis in a possible crisis with people who pitals to use. These difficulties meant a short period. The goal of PERTs is have a history of aggression. that staff at the unit level saw little of to manage a crisis by using conflict Data on the effectiveness of PERT the comparative information or the resolution, mediation, therapeutic in Allentown were available from history of individual patients that this communication, and violence-pre- 1998 to 2000. During this time PERT system contained. vention skills to diffuse and safely re- has successfully managed 70 percent In July 1998 a new application was solve a crisis. of its crises without resorting to the implemented statewide that increased This approach was first implement- use of a restrictive procedure. the number of performance indicators ed by Allentown State Hospital in During the study period, all hospi- on which the hospitals would report. 1993 during its peak year of seclusion tals were required to upgrade the The application was designed to en- and restraint use. PERTs are credited quality and quantity of their training able staff at the unit level to request for eliminating the use of seclusion on crisis management and verbal reports on any of the 35 performance and dramatically decreasing the use deescalation techniques, making it an indicators. Enhanced at least twice of restraint in Allentown. This annual requirement for all clinical, since its original design, the system method evolved out of a similar pro- nursing, and program staff (16). now enables measurement of physical gram that was used at the Depart- Unit size and patient-to-staff ratios. hands-on restraint to the second and ment of Veterans Affairs Medical The average number of people served mechanical restraint use by type of de- Center in Coatesville, Pennsylvania, on a typical hospital unit during the vice type. It also tracks the psychiatric but includes many enhancements. study period decreased from more use of PRN (as needed) and STAT PERTs involve a core group of than 36 in 1990 to 32 or less in 2000. (immediate) medications adminis- about 40 volunteer nursing and pro- In 1990 the typical hospital unit for tered as a result of a reportable inci- gram services staff who work during 36 civilly committed individuals was dent. These data are summarized each

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month and shared with the hospital discharge. The increase in the quanti- activity during the day and evening system and external advocates. The re- ty and quality of therapies was made hours, sleep patterns improved and port provides comparative tables, by possible by the reduced unit size and there were fewer nocturnal behaviors. type of care, on the use of restrictive improved patient-to-staff ratios. The same can be said of the variances measures. This application also pro- By 1997 there was a shift from the between the use of these procedures vides the state hospital system’s nation- practice of providing therapy for the during the week compared with week- al benchmarking data (20). “cooperative few” to providing thera- ends and holidays. Second-generation antipsychotics. py for all patients by using small and Our study did not show any racial, Another significant change that oc- large group approaches to program- ethnic, or gender differences in the curred during this period was the in- ming. Program centers were estab- use of mechanical restraint through- troduction of second-generation an- lished to move therapy away from the out this study period. The rate of tipsychotics. A central state formula- unit whenever possible. Much of this seclusion during the early years of ry for all hospitals was developed in change was driven by the need to pro- this review was higher for racial or 1993 in conjunction with the cre- vide patients with more functional ethnic groups than for whites. How- ation of a joint pharmacy, therapeu- programs and activities that rein- ever, as the rate of seclusion declined, tics, and formulary committee. To forced the skills that they would need the use of seclusion among racial and this day the committee maintains the for their recovery (personal commu- ethnic groups reduced at a faster rate. formulary and develops drug usage nication, Storm R, 2003). This difference and change may be policies and procedures (21). All sec- The impact of this change on re- attributed to increased attention to ond-generation antipsychotics were ducing the hospital’s use of seclusion the data and more sensitivity by staff added to the formulary as soon as and restraint has been difficult to toward the overall use of seclusion. they were released. Additionally, measure. However, anecdotal evi- Personal leadership by direct care there were no restrictions on their dence reinforces the belief that “the staff who applied their nonrestraint use. As of December 31, 2000, more you do with your patients, the values helped to change the culture of among people who had been given a less you have to do to them” (person- restraint within the system. The diagnosis of schizophrenia in the al communication, O’Dea RM, 1995). Pennsylvania advocacy community state hospitals, 85 percent were giv- challenged the hospital system at the en a prescription for second-genera- Discussion highest levels of state government to tion antipsychotics. The Pennsylvania movement toward reduce the use of seclusion and re- The impact of second-generation a nonrestraint approach to the care straint. Increased monitoring by staff antipsychotics on the use of seclusion and treatment of people with severe and advocates in the day-to-day use of and restraint in the state hospital sys- mental illnesses predates the period restrictive procedures, PERTs, policy tem cannot be isolated from the other covered by this study. The dramatic changes, increased quantity and qual- changes that occurred during this pe- decreases in the use of these restric- ity of patient programming, reduced riod (22). Second-generation antipsy- tive procedures by state hospital sys- unit size, and improved patient-to- chotics have been shown to reduce ag- tems were the result of many staff ratios coupled with effective gression and hostility as well as seclu- changes. It did not occur through leadership at all levels of the hospital sion and restraint (23–25). Studies litigation or a sentinel event. Nor accounted for this transformation. from in Penn- did it happen at the same rate for OMHSAS Deputy Secretary Curie’s sylvania suggest that clozapine and each hospital. The nine hospitals 1997 announcement that the use of risperidone reduced the use of these used similar approaches, although seclusion and restraint constituted procedures (26,27). However, the au- they applied them in different ways treatment failure was pivotal, because thors of these studies acknowledged and at different times. Rates of staff this announcement, when coupled that among the weaknesses of their re- injury from patient assaults from with the resulting policy change, end- search was the failure to control for 1998 to 2000 suggest that the transi- ed all debate within the hospital sys- the many other changes that occurred tion from a restraint culture did not tem about the nonrestraint approach. during this period. put staff at greater risk of assault. Curie stated, with hindsight, that if he Increase in the quantity and quali- Because this is one of the larger had it to do all over again, he would ty of treatment. Another significant studies on restrictive procedure use in have started sooner, pressed harder for change in the hospital culture during a large hospital system, our findings this important change, and given the study period was an increase in were generally consistent with the greater credit to the direct care staff the quantity and quality of active pa- data published thus far. Differences in for the tremendous job that they did. tient treatment. This change was im- the use of these restrictive measures A challenge to Pennsylvania’s plemented in 1995 and involved between the three shifts (day and seclusion and restraint reduction greater emphasis on functional pro- evening shifts compared with night program is the perceived difference gramming—such as vocational servic- shift) may be attributed to reduced between the type of patients served es, paid work, money management levels of stimuli that would cause agi- in a state hospital system and those skills, and training in the self-admin- tation and trigger aggression. Anecdo- in other psychiatric acute care set- istration of medication—that would tal evidence suggests that as patients tings. Differences such as a lack of be needed to prepare a person for became engaged in more purposeful familiarity with patients who have

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shorter lengths of stays and the fre- the early signs of aggression and man- in Government through an Innovations in American Government Award. The quency at which a patient is in crisis aging aggression result in reduced use authors thank Mary Ellen Rehrman, somehow justifies, for some staff, of seclusion and restraint and a more B.S., Charles Curie, M.S.W., Feather O. greater dependence on the use of a therapeutic milieu (33–42). Houstoun, M.B.A., Joan L. Erney, J.D., restrictive procedure. Although this It will also be important to measure and Estelle B. Richman, M.S., for their issue deserves further review, and monitor the effect that these support of this transformational initia- tive. Finally, the authors gratefully ac- PERTs and similar response team changes have on the use of STAT and knowledge the work of Richard M. programs that are designed to man- PRN medications during emergen- O’Dea, M.S., R.N. age psychiatric crises in a nonoffen- cies. Additionally, seclusion and re- sive manner have proven their effec- straint may place a demand for more References tiveness, regardless of a patient’s one-to-one patient-staff assignments. 1. Weiner DB: Phillippe Pinel’s “Memoir of length of stay. We recognize the Madness” of December 11, 1794: a funda- need to work with other psychiatric Conclusions mental text of modern psychiatry. Ameri- can Journal of Psychiatry 149:725–732, acute care settings to obtain data and In 2000 the Ford Foundation, in con- 1992 further study these differences. junction with Harvard University’s 2. Soloff PH, Gutheil TG, Wexler DB: Seclu- Other issues that hospitals need to John F. Kennedy School of Govern- sion and restraint in 1985: a review and up- consider and measure are the effects ment, recognized the Pennsylvania date. Hospital and Community Psychiatry that these changes will have on pa- state hospital system for its seclusion 36:652–657, 1985 tient-to-patient and patient-to-staff and restraint reduction program with 3. Gutheil T: Observations on the therapeutic assaults. Khadavi and colleagues (28) the Innovations in American Govern- bases for seclusion of the psychiatric inpa- tient. American Journal of Psychiatry found an increase in “other-directed ment Award. Many factors con- 135:325–328, 1978 patient violence” during a 12-month tributed to the success of this effort, 4. Tomes N: The Art of Asylum-Keeping: study of three acute inpatient psychi- including improved patient-staff ra- and the Origins of atric units when seclusion and re- tios and response teams. However, American Psychiatry. Philadelphia, Penn, straint were reduced. However, the the nonrestraint values of hospital University of Pennsylvania Press, 1994 authors acknowledge that their find- staff and community advocates with 5. American Psychiatric Association Task ings are at variance with previous re- the administrative recognition that Force Report 22: Seclusion and Restraint: The Psychiatric Uses. Washington, DC, ports. Owen and colleagues (29) seclusion and restraint are not treat- American Psychiatric Association, 1985 found that the use of seclusion led to ment modalities but treatment fail- 6. Fisher WA: Seclusion and restraint: a re- a significant number of violent inci- ures were the major reasons for the view of the literature. American Journal of dents. Some warning sign preceded changes in attitude, culture, and envi- Psychiatry, 151:1584–1591, 1994 three-quarters of the serious violent ronment within Pennsylvania’s state 7. Busch AB, Shore MF: Seclusion and re- incidents that they studied. They also hospital system. straint: a review of recent literature. Har- found that the relationship between Since the end of this study period vard Review of Psychiatry 8:261–269, 2000 staffing level and violence was not the Pennsylvania state hospital sys- 8. Mason T: Seclusion: an international com- clear. More female staff, more staff tem, civil and forensic, has continued parison. Medicine, Science, and the Law without psychiatric training or aggres- to decrease its dependence on the use 34(10):54–60, 1994 sion management training, and more of these restrictive procedure. Cur- 9. Wynn R: Medicate, restrain, or seclude? staff absenteeism had a positive rela- rently, five of the nine hospitals have Strategies for dealing with violent and threatening behavior in a Norwegian Uni- tionship with violence, whereas eliminated the use of seclusion. versity Hospital. Scandinavian Journal of younger staff and staff with high lev- Danville State Hospital has gone Caring Sciences 16:287–292, 2002 els of psychiatric experience had a more than two years without using 10. Cannon ME, Sprivulis P, McCarthy J: Re- negative relationship with violence. mechanical restraint or seclusion. straint practices in Australasian emergency A study done in Norway found that Since January 2005 the hospital sys- departments. Australian and New Zealand Journal of Psychiatry 35:464–467, 2001 most staff believed that using restraint tem, which averages more than or seclusion made patients calmer and 60,000 days of care each month, has 11. Needham I, Abderhalden C, Dassen T, et al: Coercive procedures and facilities in did not cause aggression or anxiety. used seclusion only 19 times for a to- Swiss psychiatry. Swiss Medical Weekly However, 70 percent of these same tal of 18 hours. Mechanical restraint 132:253–258, 2002 workers reported having been assault- has been used 143 times for a total of 12. Dabrowski S, Frydman L, Zakowsha- ed by patients in places where these 160 hours. This past spring the hospi- Dabrowski T: Physical restraints in Polish interventions were used (30). Deesca- tal system established a goal eliminat- psychiatric facilities. International Journal lation strategies are an essential part ing the use of mechanical restraint of Law and Psychiatry 8:369–382, 1986 of minimizing the use of seclusion and and seclusion by January 1, 2006. ♦ 13. Stokes ME, Davis CS, and Koch GG: Cate- restraint while preventing and manag- gorical Data Analysis Using the SAS Sys- tem, 2nd ed. SAS Institute, Cary, NC, 2000. ing aggressive behavior (31). Although Acknowledgments one study suggested that fewer on- 14. Heagerty P, Liang K-Y, Zeger S, et al: Analysis of Longitudinal Data, 2nd ed. Ox- duty staff resulted in decreased use of This research project was funded, in part, by an award from the Ford Foun- ford University Press, New York, 2002 seclusion (32), many studies have dation in conjunction with Harvard Uni- 15. Anthony WA: A recovery-oriented service shown that increased staff-to-patient versity’s John F. Kennedy School of Gov- system: setting some system level stan- ratios with staff trained in recognizing ernment and the Council for Excellence dards. Psychiatric Rehabilitation Journal

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24:159–168, 2000 24. Chiles JA, Davidson P, McBride D: Effects State Mental Health Program Directors, of clozapine on use of seclusion and re- Jul 1999 16. Pennsylvania Mental Health and Substance straint at a state hospital. Hospital and Abuse Bulletin on the Use of Restraints. Community Psychiatry 45:269–271, 1994 34. Schwartz T, Park T: Assaults by patients on Seclusion and Exclusion in State Mental psychiatric residents: a survey and training Hospitals and Restoration Center, Jul 1, 25. Mallya AR, Roos PD, Roebuck-Colgan K: recommendations. Psychiatric Services 2001. Harrisburg State Hospital, Harris- Restraint, seclusion, and clozapine. Journal 50:382–383, 1999 burg, Penn, 2001 of Clinical Psychiatry 53:395–397, 1992 35. Kostecka M, Zardecka M: The use of phys- 17. Allentown State Hospital Policy Memoran- 26. Chengappa KNR, Levine J, Ulrich R, et al: ical restraints in Polish psychiatric hospitals dum A-124, Psychiatric Emergency Re- Impact of risperidone on seclusion and re- in 1989 and 1996. Psychiatric Services sponse Plan, Allentown State Hospital, Al- straint at a state psychiatric hospital. Cana- 50:1637–1638, 1999 lentown, Penn, 2002 dian Journal of Psychiatry 45:827–832, 2000 36. Leiberman R: CHARPP Seclusion and Re- 18. Pennsylvania Community Hospital Integra- train Update. Corvallis, Oreg, Child and tion Projects Program. Harrisburg State 27. Chengappa KNR, Vasile J, Levine J, et al: Adolescent Residential Psychiatric Pro- Hospital, Harrisburg, Penn, 1999 Clozapine: its impact on aggressive behav- grams, 2003 ior among patients in a state psychiatric 19. Slawich S, Leitzel L, Martin R: Manual for hospital. Schizophrenia Research 53:1–6, 37. D’Orio B, Purselle D, Stevens S, et al: Re- the Exclusion, Restraint, Protection, and 2002 duction of episodes of seclusion and re- Seclusion Reporting and Tracking System, straint in a psychiatric emergency service. Office of Mental Health, Allentown State 28. Khadivi A, Patel R, Atkinson A, et al: Asso- Psychiatric Services 55:581–583, 2004 Hospital, Allentown, Penn, 1995 ciation between seclusion and restraint and patient-related violence. Psychiatric Ser- 38. Fisher WA: Elements of successful re- 20. Pennsylvania Mental Health and Substance vices: 55:1311–1312, 2004 straint and seclusion program and their ap- Abuse Services Bulletin: Management of plication in a large, urban, state psychiatric Incidents: SI-815 Incident Reporting and 29. Owen C, Tarantello C, Jones M, et al: Vio- lence and aggression in psychiatric units. hospital. Journal of Psychiatric Practice Risk Management Policy and Procedural 9:7–15, 2003 Changes, SMH-03. Allentown State Hospi- Psychiatric Services 49:1452–1457, 1998 tal, Allentown, Penn, Jun 1, 2003 30. Wynn R: Staff’s attitudes to the use of re- 39. Donovan A, Siegel L, Zera G, et al: Seclu- straint and seclusion in a Norwegian uni- sion and restraint reform: an initiative by a 21. Fiorello S: Developing and implementing a versity psychiatric hospital. Nordic Journal child and adolescent psychiatric hospital. statewide formulary system: one state’s ex- of Psychiatry 57:453–459, 2003 Psychiatric Services 54:958–966, 2003 perience. Formulary 30:808–811, 1995 31. Policy statement on the management of ag- 40. Donat D: An analysis of successful efforts 22. Spivak B, Shabash E, Sheitman B, et al: gressive behavior in psychiatric institutions to reduce the use of seclusion and restraint The effects of clozapine versus haloperidol with special reference to seclusion and re- at a public psychiatric hospital. Psychiatric on measures of impulsive aggression and straint. Washington, DC, American Acade- Services 54:1119–1123, 2003 suicidality in chronic schizophrenia pa- my of Child and Adolescent Psychiatry tients: an open, nonrandomized, 6-month Council, Oct 24, 2000 41. Jonikas J, Cook J, Rosen C, et al: A program study. Journal of Clinical Psychiatry to reduce use of physical restraint in psy- 64:755–760, 2003 32. Morrison EF: Violent psychiatric inpatients chiatric inpatient facilities. Psychiatric Ser- in a public hospital. Scholarly Inquiry for vices 55: 818–820, 2004 23. Citrome L, Volavaka J, Czobar P, et al: Ef- Nursing Practice: An International Journal fects of clozapine, olanzapine, risperidone, 4:65–82, 1990 42. SAMHSA action plan seclusion and re- and haloperidol on hostility among patients straint fiscal years 2004 and 2005. Washing- with schizophrenia. Psychiatric Services 33. Position Paper on Seclusion and Restraint. ton, DC, Substance Abuse and Mental 52:1510–1514, 1995 Alexandria, Va, National Association of Health Services Administration, Jun 2004

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