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Seclusion & Restraint Draft Bulletin Re-Released for Comment
November 14, 2000

The Office of Mental Health and Substance Abuse Services has re-released the best practice bulletin regarding seclusion and restraint for comment to the stakeholder community. Written comments regarding the bulletin (attached below) are being accepted by the Department until December 10, and should be forwarded to :

Mr.James Myers
DPW/Office of Mental Health and Substance Abuse Services
Bureau of Policy & Program Development
PO Box 2675, Beechmont Building #32
Harrisburg, PA 17105

Providers wishing to include their comments in a letter from PCPA should send those comments to Rebecca Heidenheim at the Association no later than December 8 for inclusion in the document. PCPA requests that members who send individual letters to the Office of Mental health and Substance Abuse Services, please copy the Association.

DRAFT
The Use of Seclusion and Restraints in Community Mental Health Inpatient, Residential, and Partial Hospitalization Programs

SUBJECT:

Using positive approaches and interventions to move toward restraint-free facilities.

PURPOSE:

The purpose of this bulletin is to provide best practice standards on the use of seclusion and restraints in community mental health, inpatient, residential and partial hospitalization facilities. This bulletin will introduce ways to help create a positive and safe environment for the consumer. The bulletin will also provide uniform definitions for restrictive procedures, explaining the conditions under which seclusion or restraint should be employed. The bulletin will describe the information that should be included in the content of training, and will introduce ideas for developing a quality improvement and risk management plan.

SCOPE:

This bulletin applies to the following mental health facilities: Residential Treatment Facilities for Adults, Adult Long Term Structured Residence Programs, Crisis Residential Services, Residential Treatment Facilities for Children, Community Residential Rehabilitation Programs, Psychiatric Units in general hospitals, private Psychiatric Hospitals, and Partial Hospitalization Programs.

BACKGROUND:

In recent years, there has been a national movement toward the reduction in the use of seclusion and restraints in health care facilities. Risks associated with the use of seclusion and restraints include, but are not limited to: accidental death, injuries and emotional harm to both staff and consumer, continual disruption of the therapeutic relationship with consumer and family, and exposing the consumer and family to further trauma.

As a result of the above risks and fatalities, "Patient Freedom From Restraint Act," legislation (House BiI11313), (Senate Bill 736), and the "Children's Health Act of 2000," (H.R. 4365) have been introduced in Congress. Regulations have also been promulgated by the Health Care Financing Administration (HCFA) on the use of restrictive procedures (Federal Register/Vol. 64, No.127, Section C) in inpatient hospital settings.

The Pennsylvania Office of Mental Health and Substance Abuse Services is in full support of the national trend toward the reduction in the use of restrictive procedures. In fact, Pennsylvania has become a national leader in establishing policy, procedures, and staff training which has resulted in a reduction in the use of seclusion and restraints in the State Mental Hospital System. In furtherance of this effort, the Office of Mental Health and Substance Abuse Services is issuing this bulletin to establish best practice standards for community based mental health service providers to facilitate their efforts to reduce and ultimately eliminate the use of seclusion and restraints. Best practice standards are needed because community inpatient providers are permitted to use seclusion and restraints pursuant to the above referenced federal regulations, and while some of the Department's policies and regulations for community residential programs specifically prohibit the use of seclusion and restraints, other polices and regulations are silent on the issue. For example, Medical Assistance Bulletin 01-93-04, Children Residential Treatment Facility Policy and Procedures, Attachment 4, "Interim Guidelines for Residential Treatment Facilities," and 55 Pa. Code, Chapter 5320, Adult Long Term Structured Residence prohibit the use of seclusion and restraints for behavioral management. However, 55 Pa. Code, Chapter 5310, Community Residential Rehabilitation Services, and 55 Pa. Code, Chapter 5210 Partial Hospitalization are silent on the use of seclusion and restraints.

The Office recognizes that movement toward restraint-free facilities involves major system change. Progress will require changes in values, beliefs, and practices, such as orientation for new employees, intensive staff training, as well as supervisory oversight and strong executive leadership.

DISCUSSION/DEFINITIONS:

Seclusion and restraints should never be used as treatment or a substitute for treatment, nor should these procedures be used for punitive purposes, discipline, retaliation, or coercion. Seclusion and restraints should not be imposed for the control of the environment, or to prevent the disruption of the therapeutic milieu, or in lieu of inappropriate numbers of staff. Seclusion or restraint should only be used in an emergency as a safety measure when there is imminent danger of bodily harm to the consumer or others, and only when least restrictive methods have proven to be ineffective in each individual situation. Seclusion and restraints should be discontinued when the person demonstrates he/she has regained self-control. Seclusion does not include the use of a time-out room.

  • Seclusion is defined as restricting a child/adolescent/adult in a locked room, and isolating the person from any personal contact. The term "locked room" includes any type of door locking device such as a key lock, spring lock, bolt lock, foot pressure lock or physically holding the door closed, and the child/adolescent/adult is not free to walk out of the room.
  • Time-out room is defined as an unlocked room used in order to reduce stimulation and to assist the consumer to regain self-control. A staff member accompanies and is present in the time-out room with the consumer at all times.
  • Restraint is defined as any chemical, mechanical, or manual technique used for the purpose of restricting movement. Restraints do not include measures to promote body positioning to protect the consumer and others from injury, or to prevent the worsening of a physical condition. Devices also used for medical treatment such as helmets for prevention of injury during seizure activity, mitts, and muffs to prevent self-injury are not considered restraints.
    1. A chemical restraint is defined as a drug used to control acute, episodic behavior that restricts the movement of a consumer, which may also result in a significant lowering of the level of consciousness.

      When a physician orders a drug that is part of the ongoing individualized treatment plan, and has documented as such for treating the symptoms of mental, emotional, or behavioral disorders, the drug should not be construed as a chemical restraint.
    2. A mechanical restraint is defined as a device used to control acute, episodic behavior that restricts movement or function of a consumer or portion of a consumer's body. Examples of mechanical restraints are handcuffs that are locked around the wrists, elbow restraints, foot restraints, cloth harnesses applied to any portion of the body, and blanket wraps.
    3. A manual restraint is defined as a physical hands-on technique that restricts the movement or function of the consumer's body or portion of the consumer's body.

      Prompting, escorting or guiding a consumer to assist in the activities of daily living is not a manual restraint.

BEST PRACTICE STANDARDS

The Office of Mental Health and Substance Abuse Services is issuing the following best practice standards regarding the use of seclusion and restraints in community inpatient, residential programs, and partial hospitalization programs.

A. SECLUSION

1) The use of seclusion is not permitted by regulation in 55 Pa. Code, Chapter 3800, Child Residential and Day Treatment Facilities, #3800.206, and in 55 Pa. Code, Chapter 5320, Long Term Structured Residence, #5320,54 (a), nor should seclusion be used in adult residential treatment facilities, crisis residential services, community residential rehabilitation programs, and partial hospitalization programs.

2) Seclusion is permitted in private psychiatric hospitals and in psychiatric units in general hospitals. However, seclusion should only be used in an emergency as a safety measure when there is an imminent danger of bodily harm to the consumer or others, and only after less restrictive behavioral techniques have been tried and a physician has determined that continuation of less restrictive interventions poses a greater threat/risk to the consumer's health and safety than does the use of seclusion. Less restrictive behavior and physical interventions include the use of de-escalation techniques by trained staff, such as reducing environmental stimuli, escorting the consumer to a quiet room, and permitting time for the consumer to verbalize his/her concerns.

3) When seclusion is used in community psychiatric hospitals/units, the following best practice standards should be followed:

  • Seclusion should only be used for adults and adolescents between the age of 13 to 17. It should not be used for children under the age of 13.
  • Seclusion should only be used pursuant to a licensed physician's order.
  • A licensed physician's order should not exceed one hour for adults.
  • For adolescents between the age of 13 to 17 such orders should not exceed thirty minutes.
  • In emergency situations, if a physician is not present and a registered nurse initiates the use of seclusion for the protection of the consumer and/or others, then the physician on duty/on call should be contacted immediately, and a verbal order obtained.
  • A licensed physician should see the adult consumer within one hour after the initiation of seclusion, and within 30 minutes after initiation of seclusion for adolescents between the age of 13 to 17.
  • A licensed registered nurse should perform a face to face assessment every fifteen minutes to ensure the physical and emotional needs of the consumer are being met. (food, water, personal hygiene, etc.) The face to face assessment should include taking the consumer's blood pressure, heart rate, and respirations.
  • If seclusion is reordered, a licensed physician should perform a face to face reassessment of the consumer and write a new order. Each new order should not exceed one hour for adults and thirty minutes for adolescents.
  • Seclusion should not be used for consumers who exhibit suicidal or self-injurious behaviors. These individuals should be placed on constant 1:1 observation for suicide prevention. The purpose of 1:1 observation for suicide prevention is to protect the consumer from self-injury or death, to increase the consumer's control of self-destructive impulses and to provide an opportunity for the consumer to verbalize his/her thoughts and feelings. Staff need to be trained on crisis intervention in order to skillfully intervene 1:1 with the consumer, reassuring the consumer that he/she will not be left alone.
  • Seclusion should not be used for consumers who have any known medical condition, which precludes the use of seclusion.
  • Seclusion and restraints should not be used simultaneously.
  • PRN (Pro re nata-as required, whenever necessary) orders for seclusion should not be used.

B. MECHANICAL RESTRAINTS

1) The use of mechanical restraints is not permitted by regulation in 55 Pa. Code, Chapter 3800, Child Residential and Day Treatment Facilities, #3800.210, and in 55 Pa. Code, Chapter 5320, Long Term Structured Residence, #5320.54 (b), nor should mechanical restraints be used in adult residential treatment facilities, crisis residential services, community residential rehabilitation programs, and partial hospitalization programs.

2) The use of mechanical restraints is permitted in private psychiatric hospitals and in psychiatric units in general hospitals. However, mechanical restraints should only be used in these facilities in an emergency as a safety measure when there is an imminent danger of bodily harm to the consumer or others, and only after less restrictive behavioral techniques have been tried and a physician has determined that continuation of less restrictive interventions poses a greater threat/risk to the consumer's health and safety than does the use of mechanical restraints. Less restrictive behavioral and physical interventions include the use of de-escalation techniques by trained staff, such as reducing the environmental stimuli, escorting the consumer to a quiet room, and permitting time for the consumer to verbalize his/her concerns.

3) When mechanical restraints are used in community psychiatric hospitals/units in an emergency situation the following best practice standards should be followed:

  • Mechanical restraints should only be used for adults and adolescents between the age of 13 to 17. Mechanical restraints should not be used for children under the age of 13.
  • A consumer's history should be taken into consideration when a clinical decision is made to use mechanical restraints. For example, an adolescent/adult may have a history of physical or sexual abuse, and the use of restraints could cause further trauma.
  • Mechanical restraints should only be used pursuant to a licensed physician's order.
  • A licensed physician's order should not exceed one hour for adults.
  • For adolescents between the age of 13 to 17 such orders should not exceed thirty minutes.
  • In emergency situations, if a physician is not present and a registered nurse initiates the use of a mechanical restraint for the protection of the consumer and/or others, then the physician on duty/on call should be contacted immediately, and a verbal order obtained.
  • A licensed physician should see the adult consumer within one hour after the initiation of a mechanical restraint, and within thirty minutes after the initiation of mechanical restraints for adolescents between the age of 13 to 17.
  • Consumers in restraints should be placed on constant 1:1 observation to ensure that their physical and emotional needs are being met.
  • A licensed registered nurse should assess the consumer's blood pressure, heart rate, respirations, and observe skin areas for irritation every fifteen minutes.
  • If a mechanical restraint is reordered, a licensed physician should perform a face to face reassessment of the consumer and write a new order. Each new order should not exceed one hour for adults, and thirty minutes for adolescents between the age of 13 to 17.
  • Mechanical restraints should not be used for consumers who exhibit suicidal injurious behaviors. Consumers should be placed on constant 1:1 observation for suicide prevention. Staff need to be trained in crisis intervention in order to skillfully intervene 1:1 with the consumer.
  • Mechanical restraints should not be used for consumers who have any known medical condition, which precludes the use of such restraints.
  • Mechanical restraints should not be used simultaneously with seclusion, or manual restraints.
  • PRN (Pro re nata-as required, whenever necessary) orders for mechanical restraints should not be used.

B. CHEMICAL RESTRAINTS

1) The administration of chemical restraints is not permitted by regulation in 55 Pa. Code, Chapter 5320, Long Term Structured Residence, #5320.54 (b), nor should it be used in other adult and children community residential treatment facilities, crisis residential services, community residential rehabilitation programs, private psychiatric hospitals, psychiatric units in general hospitals, and partial hospitalization programs.

2) Drugs administered on a regular basis, as part of the individualized treatment plan, and for the purpose of treating the symptoms of mental, emotional or behavioral disorders, and for assisting the consumer in gaining progressive self-control over his/her impulses, are not considered chemical restraints.

3) PRN (Pro re nata-as required, whenever necessary) orders for chemical restraints should not be used.

B. MANUAL RESTRAINTS

1) The use of manual restraints is not permitted by regulation in 55 Pa. Code, Chapter 5320, Long Term Structured Residence, #5320.54 (b). The use of manual restraints that apply pressure or weight on the child/adolescents' respiratory system is not permitted by regulation in 55 Pa. Code, Chapter 3800, #3800.211 (b). The application of the prone position manual restraints for females who are pregnant is not permitted in regulation, #3800.211 (c).

2) When not specifically prohibited by regulation, manual restraints should only be used in community residential rehabilitation facilities, adult, children/adolescents residential treatment facilities, crisis residential facilities, partial hospitalization programs, and psychiatric inpatient facilities, in an emergency as a safety measure when there is imminent danger of bodily harm to the consumer or others, and only after less restrictive behavioral techniques have been tried. Less restrictive behavioral and physical interventions include the use of de-escalation techniques by trained staff, such as reducing environmental stimuli, escorting the consumer to a quiet room, and permitting time for the consumer to verbalize his/her concerns.

3) When applying a manual restraint in an emergency situation, the following best practice standards should be followed:

  • At least two staff persons should be involved in any hold that would immobilize a consumer. At no time should a staff person apply his/her weight on any portion of the consumer's body.
  • A staff person who is not involved with applying the restraint should observe and document the physical and emotional condition of the child/adolescent/adult at least every 10 minutes the manual restraint is applied.
  • The position of the manual restraint should be changed at least every five minutes after applying the manual restraint, continually assessing the consumer's emotional and physical response.
  • Manual restraints that apply pressure to the child/adolescent/adult's respiratory system should never be used.
  • Manual restraints should not be used on consumers who have medical or physical conditions where there is reason to believe that such use would endanger their lives or exacerbate a medical condition, such as fractures, and back injury.
  • Manual restraints should never be used simultaneously with seclusion or mechanical restraints.

RECOMMENDATIONS REGARDING BEST PRACTICE IN THE USE OF SECLUSION AND RESTRAINTS

1) CLINICAL INDICATORS

Seclusion or restraint should be employed only when other less restrictive interventions have been tried but have failed or are not able to handle the emergency situation. It should be made very clear that seclusion or restraints should never be used as punishment, or for the convenience of staff or to compensate for under staffing. Every attempt should be used to anticipate and de-escalate the behavior using methods of interventions less intrusive than seclusion and restraint.

2) ASSESSMENT

A comprehensive assessment should include a physical examination by a physician upon admission to determine any pre-existing medical problems. The physician and all members of the treatment planning team should be knowledgeable concerning any pre-existing medical problems an adolescent/adult may have that precludes the use of seclusion or restraint.

A comprehensive assessment should be performed to evaluate aggressive behaviors and triggers, as well as a review of family history. Ongoing assessment should be performed to determine the appropriateness of restraints, and consideration given to using alternatives.

3) TREATMENT PLANS

Individual treatment plans should have goals and interventions jointly defined by the consumer, family, and treatment team to eliminate the need for seclusion or restraints. Alternative interventions should be added to the treatment plan to reduce the need for seclusion or restraint. Examples of alternative interventions would be providing 1:1 care for the consumer when the consumer is experiencing increased agitation. Another example would be escorting the consumer to a time-out room before aggression is increased or out of control, and giving the consumer time to verbalize his/her feelings and concerns.

4) DEBRIEFING

When the consumer is released from seclusion or restraints, a debriefing should occur between the mental health professional and the consumer to develop an understanding of the precipitants which may have evoked the behaviors necessitating the use of seclusion or restraint and to develop effective coping mechanisms to avert future need for seclusion or restraint. The debriefing should occur whenever the consumer is able to have productive dialogue.

A one on one debriefing should also occur between the supervisor and mental health professional after seclusion or restraints are used in order for the mental health professional to review with his/her supervisor the processes.

5) DOCUMENTATION

The consumer's vital signs should be taken by medical personnel according to the prescribing physician's orders, and documented in the consumer's record.

Documentation should be maintained that all other forms of de-escalation techniques have been tried with the consumer but were documented unsuccessful. Treatment plan changes should be documented after each episode.

Documentation should be maintained in the consumer's record for the rationale, the duration, and the follow-up of the use of seclusion and restraints.

6) TRAINING

Staff Training for Community Residential and Inpatient settings should include the following prior to giving care:

  • All community residential facilities, partial hospitalization units, inpatient psychiatric units in general hospitals, and private psychiatric hospitals should train clinical staff on how to avoid the need to use restraints. The training should focus on communicating effectively with the consumers served, and staff should be trained to use neutral or passive language when attempting to diffuse an incident or modify behavior. In addition, a plan should be developed to review inappropriate staff communication in order to respect the dignity of the consumers served.
  • Clinical staff should receive at least 10 hours of training upon initial employment on alternatives that can be employed to avoid the use of seclusion or restraints, and training on the proper application of restraints.
  • Clinical staff should receive training on behavioral interventions which should include:
    • Listening Skills
    • De-escalation Techniques Conflict Resolution
    • Violence Prevention
    • Psychosis (command hallucinations directing the consumer to become violent)
  • Clinical staff should receive training on the proper application of manual holds appropriate to the age, weight, and diagnosis of the consumer served.
  • Clinical staff should be able to verbalize understanding of the training, and should be able to demonstrate the appropriate application of restraints prior to applying to a consumer.
  • Clinical staff should receive training on the developmental stages of children/adolescents/adults and the vulnerabilities of individuals to assess when seclusion or restraints are appropriate.
  • Clinical staff should be knowledgeable about the documentation to be included in the consumer's records. Documentation should include: Documenting the reason seclusion or restraints were used, explaining the de-escalation techniques that were employed.
  • Clinical staff should be able to demonstrate their skills and knowledge through a written exam and a return demonstration on the application of restraints.
  • Clinical staff should be able to annually attend inservice trainings on crisis management to help continue his/her training on the alternatives that can be employed to decrease the use of seclusion and restraints. On-going training in crisis management will help facilities to reach the desired outcome of becoming restraint-free.
  • A record of training should be kept including the person trained, date, source, content, and the length of each course.

CONTINUOUS PERFORMANCE IMPROVEMENT AND MONITORING:

Each facility should employ ongoing efforts directed toward the goal of reducing and eliminating the use of seclusion and restraints. A performance improvement and monitoring program designed to continuously review, assess, and analyze the facility's use of seclusion and restraints should be in place. Facilities should clearly document the attempt and failure of less restrictive alternatives and include justification for the use of seclusion or restraint. Consumer debriefing and clinical response to the use of seclusion or restraints should be documented in the consumer's medical record. Any revisions in the treatment plan that are necessary to avoid the further use of seclusion or restraint should be documented.

Any facility that uses seclusion or restraint should develop a comprehensive performance and risk management program to reduce the use of restrictive procedures and to minimize incidents that result in harm to persons in the facility. The performance and risk management plan should include:

  • A plan to address the prevention, detection, evaluation, and correction of any triggers which may lead to the use of seclusion and restraints.
  • A plan to measure hours in which seclusion and restraint were used.
  • A system to report, investigate, analyze, monitor, and track incidents resulting in injuries or death related to the use of seclusion and restraints.
  • A requirement to file a formal written incident report within 24 hours when an incident resulted from the use of seclusion or restraints. The report should include the name and diagnosis of the person, the time, date and place where the incident occurred, and any medical care administered, and follow-up. Follow -up would include: (Notification of the physician and family, a report given to the new facility if the resident needs to be transferred.)
  • A system to benchmark improvement in the decline of seclusion and restraints. Aggregate data, as well as patterns of seclusion and restraints should be reviewed with the quality management program with the objective of reducing and ultimately eliminating the use of seclusion and restraints.

    Please Note: A copy of the Incident report should be sent to the Office of Mental Health and Substance Abuse Services Regional Field Offices within 24 hours.

HARRISBURG FIELD OFFICE (717) 772-7160
Harrisburg State Hospital
PO Box 2675
Harrisburg, Pennsylvania 17105

SOUTHEAST FIELD OFFICE (610) 313-5844
Norristown State Hospital, Building 57
Stanbridge & Sterigere Streets
Norristown, Pennsylvania 19401

SCRANTON FIELD OFFICE (570) 963-4375
State Office Building
Room 321
100 Lackawanna Avenue
Scranton, Pennsylvania 18503

PITTSBURGH FIELD OFFICE (412) 880-0193
State Office Building
Room 413
300 Liberty Avenue
Pittsburgh, Pennsylvania 15222

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