To the Editor: The Open Forum (1) in the February issue and an accompanying commentary (2) both made an important and fundamental point. Restraint and seclusion are emergency interventions that should be used as infrequently as possible and only when less restrictive methods are considered and are not feasible. There is much that hospital caregivers can do—other than resort to restraint and seclusion—to prevent and deescalate potentially dangerous situations so that patients can continue treatment successfully and effectively.
This is a message that was delivered by the professional and hospital communities in a landmark teaching tool called Learning From Each Other: Success Stories and Ideas for Reducing Restraint/Seclusion in Behavioral Health. The 42-page document was developed by the American Psychiatric Association, American Psychiatric Nurses Association, and National Association of Psychiatric Health Systems (NAPHS), with support from the American Hospital Association Section for Psychiatric and Substance Abuse Services. It is available on the Web sites of these associations, including the NAPHS site at www. naphs.org.
The hospital field has come a long way in changing both thinking about and practice of the use of restraint and seclusion, and the field now looks to the future. The final federal regulations are one aspect of this future view. All the protections incorporated by the Centers for Medicare and Medicaid Services (CMS) in the proposed rule on restraint and seclusion remain in effect—and are strengthened—in the final rule. The final rule ensures that only qualified, trained professionals can order and evaluate restraint or seclusion. It recognizes the skills and training of registered nurses as well as licensed independent practitioners as part of the clinical leadership team. The final rule also enhances patient safety because it comes with added CMS training requirements that will ensure more on-site professional expertise.
Many components beyond regulation have led to dramatic changes in clinical practice. Consumers' voices have been heard, professionals have worked to share knowledge, and cultures are being changed as hospital leaders continuously take action to ensure patient safety.
The field has undertaken a major effort to gather data to inform and improve clinical practice. The Hospital-Based Inpatient Psychiatric Services (HBIPS) core measures initiative has completed a year-long pilot-testing phase, with the goal of identifying measures that will be incorporated into the accreditation process of the Joint Commission (JC) as early as 2009. Several of the core measures being tested are related to restraint and seclusion. For the first time we will have national data to help facilities understand how they are operating in relation to their peers. The HBIPS was launched as a public-private partnership among NAPHS, the National Association of State Mental Health Program Directors (NASMHPD), the NASMHPD Research Institute, Inc., and the JC. These measures are being developed with the same scientific rigor as measures for heart failure and other medical conditions.
NAPHS members are committed to patient safety, to accountability, and to continuously improving practice. We look forward to continuing to work with our colleagues on these critical issues.
Dr. Borenstein is president of the National Association of Psychiatric Health Systems, Washington, D.C., and chief executive officer and medical director of Holliswood Hospital, Holliswood, New York.
LeBel J: Regulatory change: a pathway to eliminating seclusion and restraint or "regulatory scotoma"? Psychiatric Services 59:194—196, 2008
Sharfstein SS: Reducing restraint and seclusion: a view from the trenches. Psychiatric Services 59:197, 2008