Reduction of Episodes of Seclusion and Restraint in a Psychiatric Emergency Service

A review of the use of seclusion and restraint on acute care units found that the rate, duration, and methods vary considerably and that seclusion and restraint has not been adequately studied (1). The use of seclusion and restraint in psychiatric emergency services has received even less scrutiny.

Programs to reduce seclusion and restraint in acute care settings are often comprehensive. Characteristics of successful programs for reduction of seclusion and restraint include a high level of administrative endorsement, staff training, culture change, individualized treatment, and data analysis (2). Increased regulation of seclusion and restraint has been associated with a reduction in its use (3). Higher staff-to-patient ratios have been associated with a decrease in seclusion and restraint (4).

The main goal of the study was to determine whether a comprehensive plan focusing on early identification and management of problematic behaviors would be associated with a reduction in seclusion and restraint in a psychiatric emergency services unit. Another goal was to determine whether the plan would be associated with higher rates of compliance with hospital standards of seclusion and restraint. The data presented are rates for seclusion and restraint and compliance with hospital standards for the nine months before and after the plan was implemented.

Methods

The psychiatric emergency service at Grady Memorial Hospital in Atlanta has an average of 1,327 patient contacts per month. Patients can arrive at the psychiatric emergency services as walk-ins. Alternatively, their family, law enforcement, the city jail, or a mobile crisis team brings them in. The psychiatric emergency service at Grady is physically and administratively separate from the medical emergency service.

A triage nurse assesses patients to determine whether they can safely sit in the waiting area or if they need to be admitted to a secure observation unit. Patients who are suicidal, homicidal, disorganized, or agitated are admitted to the observation unit. Patients' dispositions are identified after a mental health clinician and a psychiatrist evaluate each patient. Seclusion and restraint is used only in the observation area and can occur at any time after admission.

Approximately 38 percent of psychiatric emergency service patients are admitted to the observation area. At any given time, there are seven to 22 patients in the observation unit. The most common diagnoses seen in psychiatric emergency services are substance use disorders (35 percent), psychotic disorders (25 percent), unipolar mood disorders (13 percent), bipolar disorders (11 percent), adjustment disorders (6 percent), and anxiety disorders (2 percent). The remaining 8 percent of the diagnoses each have an occurrence of less than 2 percent.

A multidisciplinary safety committee was formed to examine the psychiatric emergency service's seclusion and restraint program. The first goal of the committee was to reduce the number of episodes of seclusion and restraint in the psychiatric emergency services unit. The second goal was to improve compliance with hospital standards for seclusion and restraint. The safety committee produced a performance improvement plan that was implemented in October 2000. All training occurred in the month before implementation.

All psychiatry emergency services records were retrospectively reviewed. Staff collected monthly performance data on improvements in seclusion and restraint. Reporting on seclusion and restraint was the same throughout the study period. The data collected included the number of episodes of seclusion and restraint and the average rates of compliance with hospital standards. The results for each month were then given to the authors. Data were collected for nine months before and nine months after implementation, from January 2000 through June 2001.

An episode of seclusion and restraint was defined as starting with the initiation of seclusion and restraint and ending with release from the isolation room. If seclusion and restraint had to be reinstituted at any time, it was counted as a new episode. Compliance was determined by averaging the monthly rates of adherence for each of 21 hospital-based performance improvement measures. New regulations from the Joint Commission on the Accreditation of Healthcare Organizations (JCAHO) requiring one-to-one monitoring of patients in seclusion and restraint were instituted in January 2001, three months after implementation.

Data were analyzed with SPSS (PC), version 10.0 (5). Analysis of the monthly seclusion and restraint data included the means, standard deviations, and one-way analyses of variance for independent groups with the monthly restraint totals and rates of compliance as the dependent variables. All data were collected with the approval of the institutional review board at Emory University.

Results

The safety committee identified two key factors that they believed increased the likelihood of episodes of seclusion and restraint—ineffectual management of problematic behaviors and inadequate monitoring.

In response to the ineffectual management of problematic behaviors, a number of interventions were deployed. A response team for behavioral emergencies, or a code team, was developed. Each of the three 24-hour psychiatry units at Grady Memorial Hospital—one psychiatric emergency services unit and two inpatient units—was equipped with one two-way radio so that when an emergency code was called on any of the units, staff from each of the units would respond. All staff were required to be retrained in the preventive management of aggressive behavior. In the retraining, much greater emphasis was placed on the development of verbal deescalation skills to prevent aggressive behavior.

An agitation rating scale based on the Overt Agitation Severity Scale (6) and the Overt Aggression Scale (7) by Yudofsky and colleagues was developed. The rating scale was designed to assist in the identification of prodromal behaviors that increase the risk of violent or aggressive behavior. Patients identified as being most at risk were intensively managed with verbal deescalation methods, time-outs, and medication for specific target symptoms. Seclusion and restraint was to be a last resort.

Inadequate monitoring of patients' behaviors was managed by increasing existing video surveillance from four cameras to five. Trained clinical personnel continuously monitored the video. The purchase of one camera, one television monitor, and three two-way radios were the only significant expenses incurred.

During the study period the number of admissions to the observation area averaged 484 per month. No significant change was noted in the number of patients admitted to the observation unit during that time. The mean±SD for the number of episodes of seclusion and restraint per month was 65.2±9.4 before implementation and 38.1±12 after implementation (F=28.5, df=1, 16, p<.001), which represents a 39 percent reduction in the number of episodes of seclusion and restraint. New joint commission regulations instituted in January 2001 did not significantly alter the postintervention levels of seclusion and restraint.

Implementation was associated with greater compliance with performance improvement measures for seclusion and restraint. Before implementation, the mean monthly compliance rate was 96±.22 percent, and after implementation, it was 100±.23 percent (F=890.5, df=1, 16, p<.001).

Discussion and conclusions

The comprehensive plan to reduce the number of episodes of seclusion and restraint in the psychiatric emergency services unit was associated with a 39 percent reduction in episodes of seclusion and restraint and an increase in compliance with hospital standards. The study was limited in that the design was observational rather than experimental and several measures were taken to reduce seclusion and restraint, so that no single factor can be associated with the reduction. In addition, comparison studies of psychiatric emergency services' use of seclusion and restraint are lacking in the literature.

Unlike the study cited previously in which an increase in regulation was associated with a decrease in seclusion and restraint, the introduction of new JCAHO standards during the study period did not alter the rates of seclusion and restraint. The layout of the psychiatric and emergency services observation area at Grady Memorial Hospital made the requirement for one-to-one monitoring relatively easy to implement. Thus the new regulation may not have discouraged staff from using seclusion and restraint. Another explanation for this finding is that the staff's awareness of the need to lower the use of seclusion and restraint had already been maximized during the implementation phase of the study, making further reductions unlikely. Identification and management of problematic behaviors was therefore associated with a reduction in seclusion and restraint in a psychiatric emergency services setting.

Dr. D'Orio, Dr. Purselle, and Dr. Garlow are affiliated with the department of psychiatry and behavioral sciences at Emory University and the psychiatry department at Grady Memorial Hospital in Atlanta. Ms. Stevens is also with Grady Memorial Hospital. Send correspondence to Dr. D'Orio, Department of Psychiatry and Behavioral Sciences, Emory University, Medical Office Tower, Atlanta, Georgia 30308 (e-mail, [email protected]).