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PCPA Response to Draft Seclusion and Restraint Bulletin
April 28, 2000

Following is PCPA's response to the Draft Seclusion and Restraint Bulletin from the Office of Mental Health and Substance Abuse Services.

For a copy of the draft bulletin or for more information, please contact Rebecca Heidenheim.

April 28, 2000

Ms. Bonnie Hodgson
Office of Mental Health and Substance Abuse Services
Department of Public Welfare, Beechmont Building
PO Box 2675
Harrisburg, PA 17105-2675

Dear Ms. Hodgson:

The Pennsylvania Community Providers Association (PCPA) represents over 200 organizations that offer services to persons with mental illness, mental retardation, addictive disease and other related concerns in community-based settings throughout Pennsylvania. As such, bulletins and regulations issued by the Office of Mental Health and Substance Abuse Services (OMHSAS) are important to and have great impact on the ability of these agencies to provide services to those populations.

This letter addresses concerns and comments raised by member agencies in response to the release of the draft bulletin, The Use of Seclusion and Restraints in Community Mental Health Inpatient and Residential Programs. Thank you for the opportunity to comment. Our members have indicated to us that they have also sent individual comments to you regarding the draft bulletin. The PCPA response will attempt to integrate those responses you have received from individual members, as well as responses from work groups and conference calls that have been held regarding this issue.

In general, the membership has responded in great support of the intent of the bulletin in decreasing the use of seclusion and restraint in all programs, whether of a residential nature or not. They have, however, indicated some concerns with specific recommendations made, and it is those that are addressed below.

Seclusion and restraint incidents are very difficult, for both the consumer and staff involved in the interaction. As such, the training provided and received by member organizations is heavily weighted in the areas of de-escalation techniques and crisis management to avoid the use of more restrictive methods. The majority of providers indicate that they use manual restraints only in an emergency measure, as a safety measure when there is imminent danger of bodily harm to the consumer or others in the milieu. PCPA recommends that OMHSAS review the following concerns when considering the use of seclusion and restraint in community-based settings.

General Comments

Nationally recognized training organizations use a variety of methods and programs in teaching crisis skills, de-escalation techniques, and methods of manual restraint. Most of these programs are recognized by accrediting bodies, such as JCAHO, as appropriate. These programs also teach, as a routine part of their training, prone position manual restraint. For a variety of reasons these are considered safer and more effective than other methods of manual restraint. However, limiting prone restraints to face up positions has unintended consequences that must be considered. First, staff is more susceptible to being spit on or bitten during a face up restraint, which has implications for infectious disease control. Second, at times continued eye contact may provoke further escalation of behaviors. Third, face up restraint inhibits a secure hold, which increases the risk of injury to consumer and staff. Finally, the face up prone position is assumed to be more traumatic for children who have been sexually abused and is not recommended by national training bodies.

While agencies would be delighted to have the resources to involve three staff each time a manual restraint is necessary, the realistic ability to do so does not exist. In smaller facilities, there may only be two staff present with the consumers during a shift. This is appropriate in a small unit. If an emergency arises that requires the use of manual restraint, the draft bulletin indicates that providers should not intervene unless a third person is there to observe and document concerns. Since this may be physically impossible it should be reconsidered.

Medical staff is not available full-time at many community-based programs; this is one of the features of the entire community-based system, that services look more "like home" than "like a hospital". As such, the requirement for a physician's evaluation and written order to occur within the first hour may not always be possible if the contracting physician cannot reach the unit in that amount of time. We suggest that other language and expectations regarding the support and intervention of medical staff be considered. We also recommend that the time frame for adolescents be the same as that for adults, 30 minutes is not feasible for small agencies who do not have easy access to a doctor 24 hours a day.

In the document, monitoring practices differentiate between children and adolescents based on age. We believe a functional definition based on the type of unit (adolescent or children) might be more appropriate. This would avoid a situation in which a 12 year old who happens to be on an adolescent unit would be treated differently than a 13 or 14 year old.

The bulletin indicates that chemical restraints must not be used simultaneously with other forms of restraint or seclusion/exclusion. While PCPA understands the reasoning behind this statement, there could be some instances when the simultaneous use of these interventions is necessary. For example, it may be necessary to use a chemical restraint with an adult in conjunction with a manual restraint, until the chemical restraint takes effect.

Rather than expecting a certain number of hours of training to be provided, since nationally recognized programs vary in their training approaches, PCPA suggests that the bulletin would be strengthened by requiring that trained staff demonstrate competency and mastery of skills to the trainer rather than simply attending training for a designated length of time.

PCPA members do not view seclusion and restraint interventions as treatment, but rather as emergency, short term procedures that at times are applied when other attempts to address issues, diffuse, and de-escalate behaviors have not proven effective. Therefore, the use of these techniques are not encouraged as they take away from the opportunity to provide treatment in the residential setting. PCPA supports the need to document the use of such procedures, but feels that this documentation must be kept as simple as possible and still be effective to gather required results. As always, time spent completing paperwork removes staff from the ability to interact with the consumer in question.

It appears that there may be inconsistencies between this bulletin and existing regulations regarding the use of exclusion and restraints. It is very important to providers that the Office review this document for consistency with current regulations and assure congruence between them, especially if this bulletin is determined to be a requirement for the Capital/Lehigh zone of HealthChoices, or any future HealthChoices counties.

Specific Comments

On Page 7, C. 2: of the draft, clarification appears on what is considered less restrictive interventions. The concept of less restrictive intervention first appears on page two and continues throughout the document. We suggest that the definition of this type of intervention be included with the definitions of seclusion, exclusion, and restraint earlier in the document.

During our review of the standards we identified several areas that were vague and/or need clarification.

Page 2: The definition of "time out room" and "exclusion" appear to be similar. Please clarify the difference between the two.

Page 2: In the initial paragraph defining restraint, the document explains that a restraint is a "technique used for the purpose of restricting movement." Our members would appreciate an expansion, and perhaps with examples, of what is meant by "restriction of movement."

Also on page 2, the discussion of those devices that are not considered restraints should be expanded upon. We found ourselves guessing what was meant and realized the paragraph really was not clear.

Page 2, 1): The definition of chemical restraint should be expanded to provide further clarity.

Page 4, 6: The use of seclusion or restraints is prohibited "for patients who...have any known medical condition which precludes the use of seclusion". The question arises, what kind of medical conditions would be considered to preclude the use of seclusion or restraints? To make a broad statement such as this without allowing for some flexibility could end up in the injury of a consumer or staff member. In those instances where a medical condition would preclude the use of seclusion, what would OMHSAS suggest as an appropriate intervention?

Page 10, 3): A debriefing is required "between the mental health professional and the patient." We want to point out that there may be an instance when this debriefing can not occur, such as when a client is hospitalized as a result of the incident precipitating the seclusion/restraint. It is also unclear who should be doing the debriefing. In the previously mentioned example, it may not be appropriate or possible for the staff involved in the incident to complete the debriefing and in which case another mental health professional can have the discussion with the consumer once they have stabilized. The latitude should be given to the community provider, in conjunction with the crisis or hospital staff to decide what approach is most fitting.

According to page 10, "All community residential facilities, inpatient psychiatric units in general hospitals, and private psychiatric hospitals need to train staff..." What staff is included in this requirement? Further clarification is needed to determine what staff must have this training. What are the expected time frames for this requirement? At hire and orientation, yearly? We would also like clarification on if the training requirements listed on page 11 apply to CRRs.

Finally, PCPA would like to have the opportunity to participate in the discussions surrounding the application or utilization of this bulletin. We feel it is critically important that providers have a voice in any decisions made since, next to the consumer, the provider would feel the greatest impact of such requirements and will be responsible to carry them out.

As we mentioned earlier, the membership has responded in great support of the intent of the bulletin in decreasing the use of seclusion and restraint in all programs, whether of a residential nature or not.

Again, Bonnie, thank you for providing PCPA with the opportunity to comment on the draft bulletin. We hope that the information provided is helpful to you in addressing the issues surrounding seclusion and restraint in residential settings. If you require clarification or further comment on this information, please do not hesitate to call at your convenience.

Regards,



Kris Ericson, MPsSc
Children's/MR Policy Specialist

Rebecca Heidenheim
Adult MH Policy Specialist

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