Educating Staff Key to Curbing Use of Restraints

A prospective study found that chemical restraint was added to only 28% of 298 consecutive patients restrained in an inner-city teaching hospital ED over a 1-year period (J. Emerg. Med. 2003;24:119–24). Patients were most frequently restrained on a cart with two physical restraints (59%), in the supine position (86%), with a low rate of minor complications (7%).

The federal requirement for face-to-face physician evaluation of an individual in restraints within 1 hour of the event has strengthened the focus on the safer use of seclusion and restraint. But there is no evidence that the “1-hour rule” has made restraint a safer intervention or changed practice since it was established in 1999, said Kevin Ann Huckshorn, R.N., director of the office of technical assistance for the National Association of State Mental Heath Program Directors (NASMHPD).

Promoting Prevention

NASMHPD has joined with others in calling for the application of the public health prevention model of primary, secondary, and tertiary prevention interventions to the practice of seclusion and restraint.

Primary prevention works to create an administrative and clinical treatment environment that minimizes the development of conflict.

Secondary interventions–such as comfort rooms and staff training on attitudes and behaviors in conflict settings–are focused on mitigating conflict or aggression once it occurs. Tertiary preventions address the most effective ways to mitigate damage done to patients, staff, and others who witness a seclusion and restraint event. An example is an event debriefing of all witnesses and the patient, with rigorous problem-solving activities.

Although participation by the private sector has been slow, public health care providers from all but two states have gone through NASMHPD's 21/2-day training sessions since they began in 2003. The sessions highlight six core strategies: leadership training, use of data, workforce development, prevention tools, consumer roles, and debriefing tools.

“Some states have really taken it on board,” Ms. Huckshorn said. “It's one thing to get an 'ah-ha moment,' but this was brilliant.”

The large-scale evaluation of the training will take place this year in an attempt to build an evidence-based practice, because “that is how you change clinical practice standards,” Ms. Huckshorn said.

The adoption of the Oregon model program, which also has prevention at its core, has virtually eliminated the use of seclusion and restraint in the psychiatric inpatient unit at Salem (Ore.) Hospital, said Maggie Bennington-Davis, M.D., medical director of the 24-bed, adult locked unit.

The model uses the basic tenets of the neurobiology of trauma and the development of community as set forth by author Sandra L. Bloom. The Salem team eliminated any rule that was based on staff convenience or that created a power struggle, and adopted an attitude based on patient satisfaction.

They created a social structure in which everyone is assumed to be respectful of the physical surroundings and of each other. The pressure to conform in this kind of culture is significant, and is passed on through a variety of verbal and behavioral cues that reach even those patients who have broken with reality, Dr. Bennington-Davis said.

Even when they are most ill, “people with schizophrenia … respond to the environment and the culture in ways I would never have predicted but have come to see repeated over and over again,” Dr. Bennington-Davis said.

“My theory is that we are tapping into the neurolinguistic part of our brain, our humanness.