Seclusion and restraint (S/R) are major risk management issues for health care providers. In 2006, the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) attributed 153 deaths to S/R in the United States,1 with asphyxiation as the primary cause of death.2 There are no national statistics that fully capture the extent of physical and emotional trauma experienced both by patients and staff during and after episodes of S/R. The standards put forth by the Centers for Medicare and Medicaid Services (CMS)3 and JCAHO4 represent an effort to codify measures to reduce risk associated with S/R, so the standards themselves should be viewed as tools to reduce risk.
This article briefly reviews the federal standards regarding S/R and methods of reducing the risk associated with their use. CMS standards that went into effect February 6, 2007, will be emphasized; however, some of these standards vary from JCAHO standards. Where there are variances, clinicians are advised to follow the more stringent standards. Since JCAHO mandated behavioral standards for when S/R is used for behavioral reasons, behavioral health standards will be included. Clinicians are strongly encouraged to familiarize themselves with their state's standards for S/R.
As defined by CMS,S/R may only be used for the management of self- destructive or violent behavior to ensure the immediate physical safety of the patient or others. "Seclusion" occurs when a patient is involuntarily confined in a room or area and is physically prevented from leaving.
In comparison, a "time-out" is when a patient voluntarily stays in an unlocked room. A "restraint" is any manual method or physical device that immobilizes or reduces a patient's ability to move. The term is also used to describe the administration of a medication beyond its standard dose to manage or restrict a patient's freedom of movement. This does not include the administration of medication on an as-needed basis that targets specified symptoms.
For clarity, it is important to understand that there are physical interventions that are not considered to be restraints. For example, CMS does not consider prescribed devices, surgical dressings, protective helmets, and other methods that involve physically holding the patient for the purpose of medical examinations or that allow the patient to participate in activities without risk of physical harm as restraints.
Similarly, JCAHO does not include holding a child for less than 30 minutes (the holder must have proper training and has to be observed by another trained staff person throughout the session), a time-out for less than 30 minutes, and handcuffs or devices applied by law enforcement officers as S/R.
Federal standards for S/R
The role of leadership in reducing risk associated with S/R cannot be overstated. There has to be a strong institutional commitment to create a culture that values the reduction of S/R. As such, the chief of staff and the organization's leadership must communicate a philosophy for the use of S/R to the staff. The philosophy must, at minimum, convey the importance of preventing S/R by identifying situations that can lead to S/R and that if S/R is necessary, it is used because there is imminent risk and less restrictive means have failed.
The organization's philosophy must also stress the impact of S/R on patients and emphasize the commitment to patient safety and dignity when S/R is used. The leadership is obligated to provide staffing levels that are consistent with staff qualifications and patient needs, and mechanisms must be in place to monitor staff performance and address deficiencies.
Patients' rights are also set forth in the federal standards. S/R must not be used for coercion, discipline, or for the convenience of the staff. Patients have the right to have restraints applied only for immediate safety purposes and for the shortest period. On admission, patients and/or family should be educated about S/R with an eye toward identifying ways to reduce its use.
S/R must be ordered by a licensed independent practitioner (LIP). A LIP is any individual permitted to independently order S/R that is in accordance with state law and hospital policy. For example, JCAHO would allow licensed physicians, psychiatric clinical nurse specialists, registered nurses, and licensed social workers to order S/R if permitted by state law and the organization's policy.
The orders must include the reason for the restraints, the type of restraint (eg, plastic, leather, or soft), the number of restraints applied, and a time limit for the order. Restraints can be ordered for 4 hours for adults 18 years or older, 2 hours for those 9 to 17 years of age, and 1 hour for children younger than 9 years. As-needed S/R orders are not permitted.
Nurses are able to initiate S/R. The LIP should be notified immediately if there is a change in the patient's condition. Otherwise, the nurse has 1 hour to contact the LIP to obtain an order (verbal or written) and to discuss the patient's condition. In addition, if the LIP is not the attending physician, he or she should also be notified "as soon as possible" (the time frame for this is determined by the facility and is based on the needs of the patient population).
Staff must also document the behaviors that led to the episode of S/R and the measures taken to avoid S/R. Staff should notify the family if the patient has consented; and if multiple episodes of S/R have occurred, the unit's leadership should be notified.
JCAHO requires that an LIP perform the initial assessment within 1 hour of initiating S/R. If the patient is removed from S/R before the initial evaluation, an LIP must still perform an in-person evaluation within 24 hours. Reevaluations by an LIP or a qualified, trained individual designated by the organization must be performed every 8 hours for adults, 2 hours for children aged 9 to 17 years, and 1 hour for children younger than 9. If the reevaluator is not an LIP, an LIP must still perform an in-person evaluation every 8 hours for adults and every 4 hours for those aged 17 and younger until S/R is discontinued.
JCAHO standards require face-to-face monitoring for all patients in S/R. For patients in seclusion only, audio and visual equipment can be used after the first hour.CMS standards require that patients who are placed in seclusion and restrained must be continuously monitored by trained staff, either face-to-face or with audio and visual equipment. Monitoring staff must be able to immediately respond to the patient.
JCAHO expects patients to be checked initially andevery 15 minutes to determine comfort and readiness for discontinuing S/R. In addition, JCAHO mandates that within 24 hours of an S/R episode, there must be a debriefing with the patient and his or her treatment plan reevaluated.
1. Joint Commission. Sentinel Event Statistics. 2006. Available at: http://www.jointcommission.org/ SentinelEvents/Statistics/. Accessed May 15, 2007.
2. Preventing Restraint Deaths. Joint Commission Sentinel Event Alert. 1998;8. Available at: http://www. jointcommission.org/SentinelEvents/SentinelEventAlert/ sea_8.htm. Accessed May 15, 2007.
3. Department of Health and Human Services, Centers for Medicaid and Medicare Services. Federal Register. 2006;71:71378-71428.
4. Joint Commission. Comprehensive Accreditation Manual for Behavioral Health. Oakbrook Terrace, Ill: Joint Commission Resources; 2006.
5. O'Halloran RL, Frank JG. Asphyxial death during prone restraint revisited: a report of 21 cases. Am J Forensic Med Pathol. 2000;14:289-295.
6. Learning From Each Other: Success Stories and Ideas for Reducing Restraint/Seclusion in Behavioral Health.American Psychiatric Association; 2003. Available at: http://www.psych.org/psych_pract/treatg/pg/ learningfromeachother.cfm. Accessed May 15, 2007.
7. National Mental Health Information Center. Roadmap to Seclusion and Restraint Free Mental Health Services. Rockville, Md: Center for Mental Health Services, Substance Abuse and Mental Health Services Administration; 2005.
8. Colton D. Checklist for Assessing Your Organization's Readiness for Reducing Seclusion and Restraint. 2004. Available at: http://www.ccca.dmhmrsas.virginia.gov/ content/SR%20Checklist.pdf. Accessed May 15, 2007.
9. Sullivan AM, Bezman J, Barron CT, et al. Reducing restraints: alternatives to restraints on an inpatient psychiatric service-utilizing safe and effective methods to evaluate and treat the violent patient. Psychiatr Q. 2005; 76:51-65.
10. Donat DC. Impact of improved staffing on seclusion/restraint reliance in a public psychiatric hospital. Psychiatr Rehabil J. 2002;25:413-416.
11. D'Orio B, Purselle D, Stevens D, Garlow SJ. Reduction of episodes of seclusion and restraint in a psychiatric emergency service. Psychiatr Serv. 2004;55:581-583.
12. Fisher WA. Elements of successful restraint and seclusion reduction program and their application in a large, urban, state psychiatric hospital. J Psychiatr Prac. 2003;9:7-15.
13. Forster PL, Cavness C, Phelps MA. Staff training decreases use of seclusion and restraint in acute psychiatric hospital. Arch Psychiatr Nurs. 1999;13:269-271.
14. Jonikas JA, Cook JA, Rosen C, et al. A program to reduce use of physical restraint in psychiatric facilities. Psychiatr Serv. 2004;55:818-820.
15. Currier GW, Farley-Toombs C. Use of restraint before and after implementation of new HCFA rules. Psychiatr Serv. 2002;53:138.
16. Pollard R, Yanasak EV, Rogers SA , Tapp A. Organizational and unit factors contributing to reduction in the use of seclusion and restraint procedures on an acute psychiatric inpatient unit. Psychiatr Q. 2007;78:73-81.
17. Donat DC. An analysis of successful efforts to reduce the use of seclusion and restraint at a public psychiatric hospital. Psychiatr Serv. 2003;54:1119-1123.
18. Copeland ME. WRAP-Wellness Recovery Action Plan. Brattleboro, Vt: Peach Press; 1997.