Protocols in medical settings are allowed for specific situations (eg, intubations). For interventions that meet the definition of a restraint, an order must be obtained and documentation made of a patient assessment indicating the symptoms and diagnosis that triggered use of the protocol.
Staff must be trained and demonstrate competency in 7 key areas:
- The ability to identify factors that may trigger an episode of S/R.
- Nonphysical intervention skills.
- The ability to choose the least restrictive intervention for any given situation.
- Knowledge of the safe application and use of S/R.
- The ability to recognize when S/R can be discontinued.
- The ability to monitor the physical and psychological well-being of the patient, including how to recognize and respond to patient distress.
- Possess current certification in cardiopulmonary resuscitation and knowledge of first aid techniques.
Individuals providing staff training must be qualified personnel. The hospital must document personnel records at the completion of training, including a record of competency testing.
The hospital must report any death that occurs while S/R is used or within 24 hours after discontinuation of S/R. The hospital must also report any death that occurs within 1 week following the use of S/R where it is reasonable to assume that restraint or seclusion contributed to the patient's death.
CMS and JCAHO have not mandated a particular position for restraining patients. Restraining patients in a prone position can lead to an increased risk of death, especially if the patient is obese, abuses drugs, presents with agitated delirium and/or underlying cardiac or respiratory conditions, and there has been a prolonged state of agitation.5 Patient positioning should therefore be considered as part of a risk reduction program.Avoiding the need for S/R
A number of resources are available to assist facilities in reducing the use of S/R, including the American Psychiatric Association's Learning From Each Other6 and the Substance Abuse and Mental Health Services Administration's Roadmap to Seclusion and Restraint Free Mental Health Services.7
Throughout the literature, several key areas have been associated with reduction rates.8-14 These include adherence to S/R standards, administrative reviews, consistent supportive leadership, proper staffing levels, staff training and support, environmental factors, individualized treatment plans, effective communication with patients and their families, and debriefings after episodes of S/R.
Leadership that is focused on adherence to S/R standards15 and that is committed to following new CMS regulations16 has been associated with reductions in the number and duration of S/R episodes. Leadership that performs timely administrative reviews has also been demonstrated to reduce episodes of S/R.17
Staff must buy into any S/R reduction program for it to be effective. This requires consistent, supportive leadership that nurtures a well-trained staff and values minimal use of S/R. Staff can feel overwhelmed in their efforts to manage a challenging patient. Training to identify and manage a potentially violent patient, with emphasis on verbal de-escalation skills, is vital. Staff should be encouraged to cooperate with patients rather than to control them. It is important to have a medical staff that listens to patients' concerns and works in a collaborative manner.
A welcoming and comfortable environment can have a calming effect on patients. One suggestion is to provide a safe place that patients can go to relax. This can be a room with a comfortable recliner, blankets, and soft music to create a home-like atmosphere. Another suggestion is the use of service animals to help patients unwind and improve self-esteem.
Creating a culture in which patients participate in treatment decisions will empower them to take more responsibility for their behavior. One can foster a belief that patients have control over their behavior and, with help from staff, can make more appropriate decisions. To this end, when a patient enters the program, staff and physicians should:
- Inquire about prior history of being secluded and restrained.
- Identify methods of de-escalation that have and have not been effective in the past (eg, for some patients, time-outs can be very helpful to avoid S/R, but for more attention-seeking patients, this strategy is not effective).
- Inquire about the patient's history of abuse, because patients who filter their experiences through their abusive pasts might misinterpret communication by staff and may be particularly susceptible to feeling traumatized by S/R.
- Advanced directives can be used to facilitate this process.
Creating an adaptive treatment plan can prevent a crisis. It should be updated as the patient's status changes and it should give the patient options, not merely consequences. The Wellness Recovery Action Plan, developed by Mary Ellen Copeland, PhD, empowers patients to be more involved in controlling their problematic behaviors.18 Staff help patients develop daily maintenance plans that serve to remind them of what is needed to maintain a sense of mental wellness. Triggers and early warning signs are identified, and crisis plans are developed. The crisis plans outline what patients would want done when they feel out of control. Plans are also developed for postcrisis management.
Options for de-escalating patients can include a one-on-one session with staff; a time-out in a comfort room, separate from other patients; involvement in alternative activities; medication; and privacy. Having options and paying attention to the individual needs of a patient will maximize the effectiveness of the treatment plan.
Open communication is essential for all members of the patient's treatment team. It is essential that patients and their families are active participants in the treatment-planning process. When S/R is used, the patient should be given an explanation of why it was used and the patient's family should be informed, assuming consent has been provided. Caregivers should work to minimize barriers to good listening by reducing prejudices, identifying and working through anger, and learning to appreciate differences.
Debriefing has several functions. S/R can be a traumatic event for all involved--the patient, other patients who witness the event, and the staff. Debriefing is important for several reasons: it provides the opportunity to share thoughts openly and honestly and helps reincorporate the patient into the community after an episode of S/R. The patient can begin to identify problematic behaviors and work on finding alternatives to relieve stress. The other patients can assess if/how their behavior may have contributed to the crisis and find solutions to help keep the unit safe. In addition, staff can reassess the patient and his current treatment plan, which may need to be significantly revised.Conclusion
The use of S/R is occasionally necessary but can often be prevented. Each year, there are many S/R-related deaths and injuries. Physicians can play a key role in providing the necessary leadership to change the culture of their programs so that S/R episodes are reduced. This, in turn, will decrease patient morbidity and mortality and provide a safer and more positive environment for everyone. With some effort, risk associated with S/R can be significantly reduced and, in the process, patients can have a more therapeutic and empowering experience.