Behavioral facilities solve special needs for restraints
Best practices emerge from improvements
Hospitals that deal with psychiatric patients have unique problems when it comes to the use of restraint and seclusion. Hospital Peer Review talked with representatives of two such facilities to get their perspectives on this issue.
Martha K. Stephan, MBA, RN, CPHQ, the director of quality management at University Hospitals Health System’s Laurelwood Hospital & Counseling Centers in Willoughby, OH, says, "If legislation forbade the use of restraints, that would directly affect how we care for patients. It would affect their safety as well as the safety of the staff."
Laurelwood, a not-for-profit, freestanding hospital, has 160 licensed beds, 28 for treatment of chemical dependency and 132 for mental health. University Hospitals Health System provides a full continuum of services to patients of all ages, from acute inpatient to outpatient mental health counseling. A separate stabilization unit cares for adult patients who require more intense treatment, and restraints are required there more frequently.
"Other facilities have experienced some unfortunate incidents involving patient injuries and even death related to the use of restraints," says Stephan. "For example, vest restraints have been shown to be very dangerous, as some patients can squirm partway out of them. They then get caught in the restraint and can hang themselves." She says few facilities still use vest restraints, and Laurelwood discontinued their use eight years ago. "Another dangerous practice is to restrain the patient in a prone position. This can result in suffocation. This type of restraint has never been applied at Laurelwood."
HPR asked Stephan under what circumstances a patient might be restrained or secluded. She says nurses at Laurelwood try first to use nonrestrictive methods before they impose either seclu sion or restraint. They try to redirect the patient or "talk him or her down." Sometimes they will impose a "time out," which means the patient is given time away from the milieu. If a patient is intrusive and bothering others and he or she doesn’t respond to redirection, seclusion may be the only alternative, she says. In the event a patient is physically violent or threatening to another patient, the staff, or himself, the safest alternative is to restrain or seclude the patient.
Secluded patients receive steady surveillance
Stephan says when patients are placed in locked seclusion, they are under constant sur veillance via a video camera. They are checked in person by at least two staff members every 15 minutes, and an RN performs a physical assessment every two hours. All checks are documented. If a patient becomes threatening or violent, a "code 3" is called, and all units respond by sending staff to help. Every staff member involved in patient care at Laurelwood is trained in nonviolent physical crisis intervention techniques when they are hired, and their training is repeated annually. The training includes instruc tion in methods for recognizing agitation — pacing, tapping feet, glaring — as well as techniques for de-escalating the patient.
Among the staff at Laurelwood are RNs with psychiatric training, specially trained LPNs, and professional therapists with degrees in psychology, various therapies, or social work.
Laurelwood’s last Joint Commission on Accreditation of Healthcare Organizations survey was in April 1997. "We had three surveyors for three days: a physician, a nurse, and an administrator," says Stephan. "The physician stayed an extra day to survey our chemical dependency program, and there was a special surveyor for the partial hospitalization program." The state mental health department surveys the hospital every year as well.
HPR asked Stephan if JCAHO surveyors paid a lot of attention to restraints. "When we were surveyed, the Joint Commission had just implemented its new standards for seclusion and restraint, which are much more definitive than they had been in the past," she says. "Sur vey ors did want to see if the staff was appropriately monitoring seclusion and restraint." She says the surveyors JCAHO sends to Laurelwood typically have psychiatric experience. "The physician surveyor is always a psychiatrist, and the nurse surveyor has psychiatric experience and training."
"We have a comprehensive method for monitoring seclusion and restraint," she says. "The name of each patient who is put in seclusion or restraint is entered in a log. Data are collected and graphically displayed so that we can identify trends, but the trends generally seem to be related to patient acuity." A multidisciplinary committee meets monthly to review the data and address issues related to the potentially dangerous, high-risk procedure of restraint. Stephan emphasizes, "As mental health professionals, we are primarily responsible for ensuring a safe environment. Patients must be protected from harming themselves as well as others."
Citation prompts a PI project
John K. Stanwood, PhD, chief of psychology at the Hospital for Special Care (HSC) in New Britain, CT, says his facility initiated a performance improvement project regarding the use of restraints after a JCAHO citation.
"We began our improvement project in response to a JCAHO survey three years earlier in which we were cited for inconsistency in following our own new policies on restraints," he says. The New Britain facility developed a new policy when JCAHO changed its standard on restraints. "In reviewing our situation," says Stanwood, "we decided that instead of trying to patch together a policy to meet JCAHO’s changes, we would start from scratch, so we formed a committee and started reviewing all of our expectations." A difficulty the facility has always had is that HSC is a unique hospital. "Most of our beds are chronic care — we fill the niche between nursing homes and acute care hospitals — but we also do rehab." As a result, HSC staffers have to extensively reinterpret the guidelines that come out if they are to make sense in the special setting.
"We had changed our policy," Stanwood says, "but not everyone was being consistent, and the JCAHO surveyors picked up on that." A real breakthrough in organizing their improvement efforts came, he says, when they adopted what they call the OTE (Optimal Therapeutic Envi ron ment) philosophy: "Use the least restrictive approach to support the patient’s highest level of independence and functioning."
The improvement team flowcharted each unit’s process for the use of restraints or restrictive devices and held focus groups to discuss the processes. They identified these problems:
• a high and inconsistent use of restrictive measures;
• a lack of formal assessment and reassessment;
• a lack of formal education on application of devices;
• inadequate education in physical management techniques;
• inadequate number of personnel to respond to "Dr. Strong" calls — hands-on emergency interventions;
• inadequate patient and family education;
• a lack of formal improvement process;
• inadequate policies and protocols.
Team devises grid to drive decision making
The new OTE model calls for formal assessment and reassessment and incorporates new policies and protocols. "We devised an OTE grid that drives our decision making on what should be used on a patient — what is the least restrictive — and lays out the procedure for using something that is more restrictive." The grid puts in all the checks and balances along the way.
After the OTE had been up and running for about a year, the project team noted:
• a decrease in formalized behavioral plans in the facility’s long-term rehab unit — plans that focus on specific problem behaviors and physical interventions to deal with them;
• a decrease in the use of restraints as well as the number of "Dr. Strong" calls in all but the facility’s secured unit for long-term acquired brain injury survivors, the neurobehavioral program (in the neurobehavioral program, limb restraints were changed from leather to Velcro and the use of four-point restraints was reduced);
• a decrease in the number of incidences of employee injuries during use of physical management;
• a decrease in the number of adult restrictive interventions on rehab;
• an increase in the number of incidences of high restrictive intervention changed to low restrictive intervention;
• an increase in the percent of patients and families receiving education on restrictive measures.
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