0
Get Alert
Please Wait... Processing your request... Please Wait.
You must sign in to sign-up for alerts.

Please confirm that your email address is correct, so you can successfully receive this alert.

Articles   |    
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
View Author and Article Information

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

Abstract

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.

Abstract Teaser
Figures in this Article

Your Session has timed out. Please sign back in to continue.
Sign In Your Session has timed out. Please sign back in to continue.
Sign In to Access Full Content
 
Username
Password
Sign in via Athens (What is this?)
Athens is a service for single sign-on which enables access to all of an institution's subscriptions on- or off-site.
Not a subscriber?

Subscribe Now/Learn More

PsychiatryOnline subscription options offer access to the DSM-5 library, books, journals, CME, and patient resources. This all-in-one virtual library provides psychiatrists and mental health professionals with key resources for diagnosis, treatment, research, and professional development.

Need more help? PsychiatryOnline Customer Service may be reached by emailing PsychiatryOnline@psych.org or by calling 800-368-5777 (in the U.S.) or 703-907-7322 (outside the U.S.).

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.

+

References

De Hert  M;  Dirix  N;  Demunter  H  et al:  Prevalence and correlates of seclusion and restraint use in children and adolescents: a systematic review.  European Child and Adolescent Psychiatry 20:221–230, 2011
[CrossRef] | [PubMed]
 
Recupero  PR;  Price  M;  Garvey  KA  et al:  Restraint and seclusion in psychiatric treatment settings: regulation, case law, and risk management.  Journal of the American Academy of Psychiatry and the Law 39:465–476, 2011
[PubMed]
 
Huckshorn  KA:  Reducing seclusion restraint in mental health use settings: core strategies for prevention.  Journal of Psychosocial Nursing and Mental Health Services 42:22–33, 2004
[PubMed]
 
Position Statement on Seclusion and Restraint. Alexandria, Va, National Association of State Mental Health Program Directors, 1999. Available at www.nasmhpd.org/Policy/position_statement-posses1.aspx
 
Beghi  M;  Peroni  F;  Gabola  P  et al:  Prevalence and risk factors for the use of restraint in psychiatry: a systematic review.  Rivista di Psichiatria 48:10–22, 2013
[PubMed]
 
Hermann  R:  Improving Mental Healthcare: A Guide to Measurement-Based Quality Improvement .  Arlington, Va,  American Psychiatric Publishing, 2006
 
Scanlan  JN:  Interventions to reduce the use of seclusion and restraint in inpatient psychiatric settings: what we know so far—a review of the literature.  International Journal of Social Psychiatry 56:412–423, 2010
[CrossRef] | [PubMed]
 
Gaskin  CJ;  Elsom  SJ;  Happell  B:  Interventions for reducing the use of seclusion in psychiatric facilities: review of the literature.  British Journal of Psychiatry 191:298–303, 2007
[CrossRef] | [PubMed]
 
Lu  W;  Yanos  PT;  Silverstein  SM  et al:  Public mental health clients with severe mental illness and probable posttraumatic stress disorder: trauma exposure and correlates of symptom severity.  Journal of Traumatic Stress 26:266–273, 2013
[CrossRef] | [PubMed]
 
Robins  CS;  Sauvageot  JA;  Cusack  KJ  et al:  Consumers’ perceptions of negative experiences and “sanctuary harm” in psychiatric settings.  Psychiatric Services 56:1134–1138, 2005
[CrossRef] | [PubMed]
 
Curie  CG:  Doctor’s standing orders.  Psychiatric Services 56:1203–1204, 2005
[CrossRef] | [PubMed]
 
Achieving the Promise: Transforming Mental Health Care in America. Pub no SMA-03-3832. Rockville, Md, Department of Health and Human Services, President’s New Freedom Commission on Mental Health, 2003
 
Institute of Medicine:  Improving the Quality of Health Care for Mental and Substance-Use Conditions .  Washington, DC,  National Academy Press, 2006
 
Mental Health: A Report of the Surgeon General. Rockville, Md, US Department of Health and Human Services, US Public Health Service, 1999
 
Barnett  R;  Stirling  C;  Pandyan  AD:  A review of the scientific literature related to the adverse impact of physical restraint: gaining a clearer understanding of the physiological factors involved in cases of restraint-related death.  Medicine, Science, and the Law 52:137–142, 2012
[CrossRef] | [PubMed]
 
Lebel  J;  Goldstein  R:  The economic cost of using restraint and the value added by restraint reduction or elimination.  Psychiatric Services 56:1109–1114, 2005
[CrossRef] | [PubMed]
 
Sailas  E;  Fenton  M:  Seclusion and restraint for people with serious mental illnesses.  Cochrane Database of Systematic Reviews 2:CD001163, 2000
 
Stiefel  M;  Nolan  K:  A Guide to Measuring the Triple Aim: Population Health, Experience of Care, and Per Capita Cost .  Cambridge, Mass,  Institute for Healthcare Improvement, 2012
 
Institute of Medicine:  To Err Is Human: Building a Safer Health Care System . Edited by Kohn  L;  Corrigan  J;  Donaldson  M.  Washington, DC,  National Academy Press, 2000
 
Curie  CG:  SAMHSA’s commitment to eliminating the use of seclusion and restraint.  Psychiatric Services 56:1139–1140, 2005
[CrossRef] | [PubMed]
 
NRI Performance Measurement System: National Public Rates. Alexandria, Va, National Association of State Mental Health Program Directors Research Institute, May 2010. Available at www.nri-inc.org/reports_pubs/2010/National_Public_Rates.pdf
 
Currie  L:  Fall and injury prevention; in  Patient Safety and Quality: An Evidence-Based Handbook for Nurses . Edited by Hughes  RG.  Rockville, Md,  Agency for Healthcare Research and Quality, 2008
 
Azeem  MW;  Aujla  A;  Rammerth  M  et al:  Effectiveness of six core strategies based on trauma informed care in reducing seclusions and restraints at a child and adolescent psychiatric hospital.  Journal of Child and Adolescent Psychiatric Nursing 24:11–15, 2011
[CrossRef] | [PubMed]
 
LeBel  JL:  Coercion is not mental health care.  Psychiatric Services 62:453, 2011
[CrossRef] | [PubMed]
 
Six Core Strategies to Prevent Conflict and Violence: Reducing the Use of Seclusion and Restraint. Rockville, Md, Substance Abuse and Mental Health Services Administration, National Registry of Evidence-Based and Promising Practices. Available at www.nrepp.samhsa.gov/ViewIntervention.aspx?id=278. Accessed March 17, 2013
 
Proctor  E;  Silmere  H;  Raghavan  R  et al:  Outcomes for implementation research: conceptual distinctions, measurement challenges, and research agenda.  Administration and Policy in Mental Health and Mental Health Services Research 38:65–76, 2011
[CrossRef] | [PubMed]
 
Mowbray  C;  Holter  M;  Teague  G  et al:  Fidelity criteria: development, measurement, and validation.  American Journal of Evaluation 24:315–340, 2003
 
Cuddeback  GS;  Morrissey  JP;  Domino  ME  et al:  Fidelity to recovery-oriented ACT practices and consumer outcomes.  Psychiatric Services 64:318–323, 2013
[CrossRef] | [PubMed]
 
McHugo  GJ;  Drake  RE;  Whitley  R  et al:  Fidelity outcomes in the National Implementing Evidence-Based Practices Project.  Psychiatric Services 58:1279–1284, 2007
[CrossRef] | [PubMed]
 
Beidas  RS;  Aarons  G;  Barg  F  et al:  Policy to implementation: evidence-based practice in community mental health—study protocol.  Implementation Science 8:38, 2013
[CrossRef] | [PubMed]
 
Panzano  PC;  Sweeney  HA;  Seffrin  B  et al:  The assimilation of evidence-based healthcare innovations: a management-based perspective.  Journal of Behavioral Health Services and Research 39:397–416, 2012
[CrossRef] | [PubMed]
 
Massatti  RR;  Sweeney  HA;  Panzano  PC  et al:  The de-adoption of innovative mental health practices (IMHP): why organizations choose not to sustain an IMHP.  Administration and Policy in Mental Health and Mental Health Services Research 35:50–65, 2008
[CrossRef] | [PubMed]
 
Donat  DC:  Impact of a clinical-administrative review procedure on reducing reliance on psychotropic PRN medication.  Psychiatric Rehabilitation Journal 29:215–218, 2006
[CrossRef] | [PubMed]
 
Ashcraft  L;  Bloss  M;  Anthony  WA:  The development and implementation of “no force first” as a best practice.  Psychiatric Services 63:415–417, 2012
[CrossRef] | [PubMed]
 
Hardesty  S;  Borckardt  JJ;  Hanson  R  et al:  Evaluating initiatives to reduce seclusion and restraint.  Journal for Healthcare Quality 29:46–55, 2007
[CrossRef] | [PubMed]
 
Pollard  R;  Yanasak  EV;  Rogers  SA  et al:  Organizational and unit factors contributing to reduction in the use of seclusion and restraint procedures on an acute psychiatric inpatient unit.  Psychiatric Quarterly 78:73–81, 2007
[CrossRef] | [PubMed]
 
Torrey  WC;  Bond  GR;  McHugo  GJ  et al:  Evidence-based practice implementation in community mental health settings: the relative importance of key domains of implementation activity.  Administration and Policy in Mental Health and Mental Health Services Research 39:353–364, 2012
[CrossRef] | [PubMed]
 
References Container
+
+

CME Activity

There is currently no quiz available for this resource. Please click here to go to the CME page to find another.
Submit a Comments
Please read the other comments before you post yours. Contributors must reveal any conflict of interest.
Comments are moderated and will appear on the site at the discertion of APA editorial staff.

* = Required Field
(if multiple authors, separate names by comma)
Example: John Doe



Web of Science® Times Cited: 1

Related Content
Articles
Books
Dulcan's Textbook of Child and Adolescent Psychiatry > Chapter 62.  >
The American Psychiatric Publishing Textbook of Psychiatry, 5th Edition > Chapter 41.  >
Dulcan's Textbook of Child and Adolescent Psychiatry > Chapter 39.  >
The American Psychiatric Publishing Textbook of Psychiatry, 6th Edition > Chapter 6.  >
Dulcan's Textbook of Child and Adolescent Psychiatry > Chapter 39.  >
Topic Collections
Psychiatric News
APA Guidelines