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Multisite Study of an Evidence-Based Practice to Reduce Seclusion and Restraint in Psychiatric Inpatient Facilities
Dow A. Wieman, Ph.D.; Teresita Camacho-Gonsalves, Ph.D.; Kevin Ann Huckshorn, Ph.D., M.S.N.; Stephen Leff, Ph.D.
Psychiatric Services 2014; doi: 10.1176/appi.ps.201300210
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Dr. Wieman, Dr. Camacho-Gonsalves, and Dr. Leff are with Human Services Research Institute, Cambridge, Massachusetts (e-mail: dwieman@hsri.org). Dr. Wieman and Dr. Leff are also with the Department of Psychiatry, Harvard Medical School, at the Cambridge Health Alliance. Dr. Huckshorn is with the Division of Substance Abuse and Mental Health, Delaware Health and Social Services, New Castle.

Copyright © 2014 by the American Psychiatric Association


Objective  This federally funded study examined implementation and outcomes of the Six Core Strategies for Reduction of Seclusion and Restraint (6CS) in 43 inpatient psychiatric facilities.

Methods  A prototype Inventory of Seclusion and Restraint Reduction Interventions (ISRRI) tracked fidelity over time. Outcome measures—seclusion and restraint events as percentages of total inpatient population and seclusion and restraint hours as percentages of total inpatient hours—conformed to licensed Behavioral Health Performance Measurement System specifications. Independent variables were facility and patient characteristics. Facilities were classified into five implementation types based on ISRRI scores: stabilized (N=28), continued (N=7), decreased (N=5), discontinued (N=1), or never implemented (N=2). For the stabilized group, linear modeling and random-effects meta-analysis compared the contribution of individual facilities to an overall effect. Subgroup analyses explored relationships between facility characteristics and outcomes. Dose-effect analysis tested the hypothesis that the stabilized group would have more positive outcomes.

Results  Overall, the stabilized group reduced the percentage secluded by 17% (p=.002), seclusion hours by 19% (p=.001), and proportion restrained by 30% (p=.03). The reduction in restraint hours was 55% but nonsignificant (p=.08). Individual facility effect sizes varied; some rates increased for some facilities. The dose-effect hypothesis was supported for two outcomes, seclusion hours and percentage restrained. The order of implementation group effects in relation to each outcome varied unpredictably.

Conclusions  The 6CS was feasible to implement and effective in diverse facility types. Fidelity over time was nonlinear and varied among facilities. Further research on relationships between facility characteristics, fidelity patterns, and outcomes is needed.

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Figure 1 Examples of five facility implementation categories based on Inventory of Seclusion and Restraint Reduction Interventions (ISRRI) scoresa

a Scores for 16 quarters (Q) are shown. The threshold of 20% is the ISRRI score hypothesized to be minimally necessary for the program to have an effect.

Figure 2 Mean scores on the Inventory of Seclusion and Restraint Reduction Interventions (ISRRI) of facilities in five implementation categoriesa

a The threshold of 20% is the ISRRI score hypothesized to be minimally necessary for the program to have an effect.

Figure 3 Dose-effect change in percentage of patients secluded or restrained and in hours of seclusion and restraint for facilities in five implementation categories

Figure 4 Forest plot of change in number of seclusion hours per 1,000 treatment hours from baseline to stabilized implementationa

a Adjusted for percentage Hispanic and percentage involuntary

Anchor for Jump
Table 1Seclusion and restraint outcomes at 28 facilities from preimplemention to stable implementation of a reduction initiativea
Table Footer Note

a Adjusted for patient characteristics

Table Footer Note

b Positive mean indicates decrease at stable implementation.



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