Psychiatr Q DOI 10.1007/s11126-016-9428-0 ORIGINAL PAPER
Reduction of Seclusion and Restraint in an Inpatient Psychiatric Setting: A Pilot Study Ellen W. Blair1 • Stephen Woolley2 • Bonnie L. Szarek1 • Theodore F. Mucha1 • Olga Dutka1 • Harold I. Schwartz1 Jeff Wisniowski2 • John W. Goethe2
•
Ó Springer Science+Business Media New York 2016
Abstract The authors describe a quality and safety initiative designed to decrease seclusion/restraint (S/R) and present the results of a pilot study that evaluated the effectiveness of this program. The study sample consisted of consecutive admissions to a 120-bed psychiatric service after the intervention was implemented (October 2010– September 2012, n = 8029). Analyses compared S/R incidence and duration in the study sample to baseline (consecutive admissions during the year prior to introduction of the intervention, October 2008–September 2009, n = 3884). The study intervention, which used evidence-based therapeutic practices for reducing violence/aggression, included routine use of the Brøset Violence Checklist, mandated staff education in crisis intervention and trauma informed care, increased frequency of physician reassessment of need
& Ellen W. Blair [email protected] Stephen Woolley [email protected] Bonnie L. Szarek [email protected] Theodore F. Mucha [email protected] Olga Dutka [email protected] Harold I. Schwartz [email protected] Jeff Wisniowski [email protected] John W. Goethe [email protected] 1
The Institute of Living, Hartford Hospital, 200 Retreat Avenue, Hartford, CT 06106, USA
2
Burlingame Center for Psychiatric Research and Education, The Institute of Living, Hartford Hospital, 200 Retreat Avenue, Hartford, CT 06106, USA
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for S/R, formal administrative review of S/R events and environmental enhancements (e.g., comfort rooms to support sensory modulation). Statistically significant associations were found between the intervention and a decrease in both the number of seclusions (p \ 0.01) and the duration of seclusion per admission (p \ 0.001). These preliminary results support the conclusion that this intervention was effective in reducing use of seclusion. Further study is needed to determine if these prevention strategies are generalizable, the degree to which each component of the intervention contributes to improve outcome, and if continuation of the intervention will further reduce restraint use. Keywords Seclusion Restraint Psychiatric inpatients Trauma informed care Brøset Violence Checklist
Introduction Management of violent and aggressive behavior is a major challenge in psychiatry. Traditional approaches frequently include seclusion and restraint (S/R), interventions that can be traumatizing for both patients and staff. Alternative management strategies are needed [1–4]. The authors describe an intervention designed to decrease S/R and present the results of a pilot study that evaluated the effectiveness of this program.
The Intervention The intervention was based on published evidence-based therapeutic practices for reducing violence/aggression. Components included routine use of the Brøset Violence Checklist (BVC) [5–9], mandated staff education in crisis intervention and trauma informed care, [4, 10–12], increased frequency of physician re-assessment of the need for S/R [10, 13–16], formal administrative review of S/R events [4, 17] and environmental enhancements (e.g., comfort rooms to support sensory modulation) [3, 13, 18–22]. The BVC was incorporated into the required daily documentation [5–9] and was completed by a physician on admission and by nursing staff during each of the three nursing shifts throughout the hospitalization. This instrument assesses six behaviors associated with increased risk of violence: confusion, irritability, boisterousness, verbal threats, physical threats, and attacks on inanimate objects [5–7, 9]. Each of the six behaviors is scored ‘‘yes’’ (=1) or ‘‘no’’ (=0) and the sum score computed (range 0–6). The BVC sum score is interpreted as follows: ‘‘a sum of 0 suggests that the risk of violence is small; scores of 1 and 2 suggest that the risk of violence is moderate and preventive measures should be taken; and scores of 3 and more indicate that the risk of violence is very high, immediate preventive measures are required and plans for handling an attack should be activated’’ [7, p. 103]. The investigators added, with written permission from the BVC authors, a checklist of staff intervention options: verbal de-escalation, diverting activity, reduced stimulation, sensory modulation/comfort measures, medication, continuous supervision, S/R. This checklist was part of the required documentation for S/R events.
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Staff education included a standardized 8 h crisis intervention course that emphasized de-escalation techniques, a new method of nursing assignments to maximize staff presence in the milieu [4, 10, 11, 13] and training in ‘‘Risking ConnectionsÒ’’ (a two day program based on a trauma-informed model of care, the goal of which is to reduce staff behaviors that can exacerbate ‘‘trauma reactions’’ in patients) [21]. There were also changes in hospital policy and procedures about the physician order for renewal of S/R: the frequency of physician review was increased to every 2 h from every 4 h for patients over age 18 (frequency for patients \18 remained every 2 h). Changes in the S/R protocol required that the Medical Director and the Director of Nursing examine all S/R events to determine if a formal administrative review was needed (based on severity and outcome) and that they personally conduct all such reviews, the format for which included questions about staff knowledge of the patient (e.g., BVC scores, history of violence, medications prescribed), the specific de-escalation interventions used and the communication about the patient’s status prior to the event. Environmental enhancements included assessing the patient’s ‘‘sensory diet’’ on admission (e.g., identifying personalized coping strategies for decreasing anxiety/agitation) and creating comfort rooms (e.g., areas with calming lights, sensory items, music) [21, 22].
Methods The study site was the 120-bed psychiatric inpatient service of a large urban hospital. The facility’s IRB approved the study and its Research Committee provided partial funding. Baseline data (e.g., the number and duration of S/R events and demographic data) were from all consecutive admissions during the year prior to introduction of the intervention (October 2008–September 2009, n = 3884). The study sample consisted of all consecutive admissions after the intervention was fully implemented (October 2010–September 2012, n = 8029). The investigators compared the frequency and duration of S/R events for violence/aggression in the study sample to baseline data. Descriptive statistics were used to characterize the sample demographically and by frequency and duration of S/R events. The unit of analysis was an episode of hospitalization (i.e., for patients admitted more than once, each admission was examined as an independent episode of care). Analyses included Chi square analyses to compare S/R incidence and t tests to compare S/R duration in the study versus baseline periods (n = 8029 vs. 3884 hospitalizations). Data were analyzed with SPSSÒ (V19).
Results The age distribution of patients in the baseline data (n = 3884) was 4.9 % B 12 years old, 85.9 % 13–65 and 9.2 % C 66; 49.7 % of patients were female and 50.3 % male; race distribution was 15.9 % black, 23.9 % Spanish/Hispanic, 56.3 % white, and 3.9 % other. In the study sample the demographics were similar: the age distribution (n = 8029) was 5.0 % B 12 years old, 87.2 % 13–65 and 7.8 % C 66; 48.5 % of patients were female and 51.5 % male; race distribution was 16.5 % black, 23.6 % Spanish/Hispanic, 55.3 % white, and 4.6 % other. The intervention was associated with a statistically significant reduction in the rate of seclusion events (study period 213/8029 = 4.4/100 admissions vs. baseline
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358/3884 = 9.2/100 admissions, p \ 0.01), a 52 % reduction. Rates of restraint events decreased 6 % (non-significantly, p = 0.44): baseline 213/3884 = 5.5/100 admissions, study period 412/8029 = 5.1/100 admissions. By contrast, duration of seclusions per admission during the study period was reduced by 27 % and duration of restraints per admission was increased by 52 %. Mean seclusion event duration exceeded mean restraint event duration during the baseline period (337.7 vs. 286.0 min, p = 0.02) and during the study period, although not significantly (516.2 vs. 445.0 min, p = 0.27). Comparing baseline to the study period, the seclusion rate decreased and the mean seclusion duration increased from 337.7 to 516.2 min (p \ 0.01). Likewise, from baseline to post-intervention the mean duration of restraints increased from 286.0 to 445.0 min (p \ 0.01). In the BVC assessments the most common behavior associated with S/R was irritability (96 % of events), followed by boisterousness (78 %), verbal threats (63 %) and confusion (50 %). The most common staff interventions employed in S/R events were verbal deescalation (90 %), medication administration (84 %) and decreased stimulation (80 %). A formal administrative review was conducted in 46.2 % of all events (190 of 411 events, 50.6 % of which were seclusion and 49.4 % restraint events). In events for which formal reviews were conducted the mean BVC score was 2.58 (in the ‘‘high risk’’ category of Brøset scores); in 85.6 % (n = 174) of these the patient had a known history of aggression and in 99.3 % (n = 120) the patient had a history of positive response to comfort/sensory interventions.
Discussion The associations found between the intervention and S/R are generally consistent with earlier reports [2, 3, 10, 11, 13, 15, 23–27]. The finding regarding use of restraint (only a 6 % non-significant reduction) suggests that a more violent self/other injurious subgroup exists for which seclusion may be contraindicated, and that may not respond as well to current interventions [26, 27]. To understand more fully why these interventions did not reduce restraint in the same way it did for seclusion requires further study. The present study supports routine assessment of potentially violent behaviors [5–9, 28– 31], increased presence of staff in the milieu [10, 13, 16, 23, 24, 30–32], environmental enhancements and staff education about de-escalation techniques [4, 10, 14–16, 21, 22, 26, 27, 32]. Strengths of this study include the sample size and the large number of variables assessed. Limitations include that the components of the intervention were introduced sequentially (limiting inferences about the effect of each individual component) and that there were no explicit criteria in the study protocol that determined when a formal administrative review of S/R events would be conducted.
Conclusion These results support the conclusions from previous studies that improved reporting and an intense focus by senior leadership on S/R, such as formal administrative reviews, are essential elements in S/R reduction strategies [4, 11, 17, 20]. Further study is needed to determine if these prevention strategies are generalizable, the degree to which each
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component contributes to improve outcomes, and if continuation of this intervention will further reduce restraint use. Compliance with Ethical Standards Conflict of Interest We have no potential conflict of interest. Ethical Approval This article does not contain any studies with human participants performed by any of the authors.
References 1. Knutzen M, Mjosund NH, Eidhammer G, Lorentzen S, Opjordsmoen S, Sandvik L, Friis S: Characteristics of psychiatric inpatients who experienced restraint and those who did not: A case-control study. Psychiatric Services 62(5):492–497, 2011. 2. Cornaggia CM, Beghi M, Pavone F, Barale F: Aggression in psychiatry wards: A systematic review. Psychiatry Research 189(1):10–20, 2011. 3. Borckardt JJ, Madan A, Grubaugh DC, Pelic C, Hardesty, S, Hanson R, Herbert J, Cooney H, Benson A, Frueh, B: Systematic investigation of initiatives to reduce seclusion and restraint in a state psychiatric hospital. Psychiatric Services 62(5):477–483, 2011. 4. Huckshorn K: Building a better mental health work-force: 8 core elements. Journal of Psychosocial Nursing and Mental Health Services 45(8):24–34, 2007. 5. Almvik R, Woods P, Rasmussen K: The Brøset Violence Checklist: Sensitivity, specificity, and interrater reliability. Journal of Interpersonal Violence 15(12):1284–1296, 2000. 6. Linaker OM, Busch-Iversen H: Predictors of imminent violence in psychiatric inpatients. Acta Psychiatrica Scandanavica 92(4):250–254, 1995. 7. Woods P, Almvik R: The Brøset Violence Checklist (BVC). Acta Psychiatrica Scandanavica Supplementum 106(412):103–105, 2002. 8. Almvik R, Rasmussen K,Woods P: Challenging behaviour in the elderly-monitoring violent incidents. International Journal of Geriatric Psychiatry 21(4):368–74, 2006. 9. Clarke DE, Brown AM, Griffith P: The Broset Violence Checklist: clinical utility in a secure psychiatric intensive care setting. Journal of Psychiatric and Mental Health Nursing 17(7):614–20, 2010. 10. Barton SA, Johnson MR, Price LV: Achieving restraint-free on an inpatient behavioral health unit. Journal of Psychosocial Nursing and Mental Health Services 47(1):34–40, 2009. 11. Huckshorn K: Six core strategies for reducing seclusion and restraint use Ó, National Association of State Mental health Program Directors, 2006. http://www.nasmhpd.org/docs/NCTIC/Consolidated_Six_ Core_Strategies_Document.pdf. Accessed 24 Oct 2014. 12. Knox DK, Holloman GH Jr: Use and avoidance of seclusion and restraint: Consensus statement of the American Association for Emergency Psychiatry project Beta seclusion and restraint workgroup. Western Journal of Emergency Medicine 13(1):35–40, 2012. 13. Delaney KR, Johnson ME: Keeping the unit safe: Mapping psychiatric nursing skills. Journal of the American Psychiatric Nurses Association 12(4):198–207, 2006. 14. Bjorkdahl A, Olsson D, Palmstierna T: Nurses’ short-term prediction of violence in acute psychiatric intensive care. Acta Psychiatrica Scandanavica 13(3):224–229, 2006. 15. Livingston G, Kelly, L Lewis-Holmes E, Baio G, Morris S, Patel N, Omar R, Katona C, Cooper C: Nonpharmacological interventions for agitation in dementia: A systematic review of randomised controlled trials. British Journal of Psychiatry 205(6):436–442, 2014. 16. Wong SCP, Gordon A, Gu D: Assessment and treatment of violence-prone forensic clients: An integrated approach. British Jouranl of Psychiatry 49:66–74, 2007. 17. Donat DC: An analysis of successful efforts to reduce the use of seclusion and restraint at a public psychiatric hospital. Psychiatric Services 54(8):1119–1123, 2003. 18. Heinze C, Dassen T, Grittner U: Use of physical restraints in nursing homes and hospitals and related factors: A cross-sectional study. Journal of Clinical Nursing 21(7–8):1033–40, 2012. 19. Johnson ME, Delaney KR: Keeping the unit safe: The anatomy of escalation. Journal of the American Psychiatric Nurses Association 13(1):42–52, 2007. 20. Nolan KA, Citrome L: Reducing inpatient aggression: Does paying attention pay off? Psychiatric Quarterly 79(2):91–5, 2008.
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Psychiatr Q 21. Roley SS, Clark GF, Bissell J, Brayman SJ, Commission on Practice: Applying sensory integration framework in educationally related occupational therapy practice (2003 statement). American Journal of Occupational Therapy 57(6):652–9, 2003. 22. Nackley VL: Sensory diet application and environmental modifications: A winning combination. Sensory Integration Special Interest Section Quarterly 24(1):1–4, 2001. 23. Muskett C: Trauma-informed care in inpatient mental health settings: A review of the literature. International Journal of Mental Health Nursing 23(1):51–9, 2014. 24. Janner, M, Delaney, KR: Safety issues on British mental health wards. Journal of the American Psychiatric Nurses Association 18(2):104–11, 2012. 25. Yao, X Li Z, Arthur D, Hu L, An F, Cheng G: Acceptability and psychometric properties of Brøset Violence Checklist in psychiatric care settings in China. Journal of Psychiatric and Mental Health Nursing 21(9):848–855, 2014. 26. Stewart D, Van der Merwe M, Bowers L, Simpson A, Jones J: A review of interventions to reduce mechanical restraint and seclusion among adult psychiatric inpatients. Issues in Mental Health Nursing 31(6):413–424, 2010. 27. Smith, G, Davis, R, Bixler, E, Lin, H, Altenor, A, Alternor, R, Hardentstine, B, Kopchick, G: Pennsylvania state hospital system’s seclusion and restraint reduction program. Psychiatric Services 56(9):1115–1122, 2005. 28. Bader S, Evans SE, Welsh E: Aggression among psychiatric inpatients: The relationship between time, place, victims and severity ratings. Journal of the American Psychiatric Nurses Association 20(3):179–86, 2014. 29. van de Sande R, Nijman HLI, Noorthoorn, EO Wierdsma AI, Hellendoom E, van der Staak C, Mulder CL: Aggression and seclusion on acute psychiatric wards: Effect of short-term risk asessment. British Journal of Psychiatry 199(6):473–478, 2011. 30. Benedictis L, Dumais A, Sieu N, Mailhot M, Letourneau G, Tran M, Stikarovska I, Bilodeau M, Brunelle S, Cote G, Lesage A: Staff perceptions and organizational factors as predictors of seclusion and restraint on psychiatric wards. Psychiatric Services 62(5):484–491, 2011. 31. Goulet MH, Larue C, Stafford MC, Durnais A: Profiles of patients admitted to a psychiatric intensive care unit: Secluded with or without restraint. Canadian Journal of Psychiatry 58(9):546–550, 2013. 32. Johnson ME: Violence on inpatient psychiatric units: State of the science. Journal of the American Psychiatric Nurses Association 10(3):113–121, 2004.
Ellen W. Blair, APRN, PMHCNS-BC holds a Bachelor of Science Degree in Nursing from Adelphi University and a Master of Science in Psychiatric Nursing from the Yale School of Nursing. Ms. Blair is a Doctorate in Nursing Practice candidate (2017) at the University of St. Joseph, West Hartford, CT. Ms. Blair has been lead author on several peer-reviewed journal articles, written two book chapters and presented numerous times in her field of professional expertise. Ms. Blair has been the recipient of several awards for outstanding nursing practice and contributions to the field. Since 2009, she has been the Director of Nursing at the Institute of Living, Hartford Hospital. Stephen Woolley, DSc, MPH has professional healthcare experiences including 35 years of research. He has advanced training in biology, epidemiology, biostatistics, and program administration/evaluation at the University of Connecticut (MS), Yale University (MPH), and Boston University (DSc). He has held positions at Rockefeller University (New York, NY), Yale University, the Connecticut Health Information Center and Institute for Community Research (Hartford, CT), Boston University, Massachusetts General Hospital, and the Institute of Living/Hartford Hospital (Senior Scientist since 1997). He has been an investigator/principal investigator in more than 25 funded healthcare investigations, and has contributed to presentations at more than 50 scientific/professional national meetings and to approximately 20 peerreviewed publications. Bonnie L. Szarek, RN, BA graduated from nursing school in 1971 and has been at the Institute of Living (Hartford, CT) for 45 years. From 1979 to 2010, she served as a Research Nurse and Project Coordinator. She received her BA in psychology from Central Connecticut State University (New Britain, CT) in 1991. Since 2010, she has been serving as a Clinical Research Associate. Over more than 3 decades, she has contributed to study design, data collection and analysis, and manuscript preparation. Her data analysis examined prescribing practices, metabolic syndrome, genetics, and psychiatric outcomes. She has been the co-author of more than 20 peer-reviewed publications.
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Psychiatr Q Theodore F. Mucha, MD, DFAPA received a Bachelor of Science degree from Franklin and Marshall College, and completed his Psychiatric Residency training at the Institute of Living. He is also a graduate of Western New England Institute for Psychoanalysis. He joined the medical staff of The Institute of Living in 1970. Dr. Mucha held the position of Medical Director until his retirement in November 2013 and Associate Professor, Department of Psychiatry, the University of Connecticut School of Medicine. He has numerous publications and is the recipient of several awards for outstanding teaching. Olga Dutka, RN, MSN, MBA, CHC has worked in psychiatry for over 33 years, in numerous clinical and administrative capacities: staff nurse, supervisor, educator, unit director, research clinician, utilization management director, quality director, compliance and privacy manager, home care nurse, and consultant. She is currently the Director of Professional and Clinical Education for the Behavioral Health Network of Hartford HealthCare. She holds her Master’s degree in Nursing from Saint Joseph College and Master’s degree in Business Administration from the University of Connecticut. Her certifications include Healthcare Compliance via the HCCA Certification Board and a Six Sigma Black Belt from the Central Connecticut State University. Harold I. Schwartz, MD currently serves as Psychiatrist-in-Chief at The Institute of Living, Vice President of Behavioral Health at Hartford Hospital, and as regional Vice President of Hartford HealthCare. He is a Professor of Psychiatry at the University of Connecticut School of Medicine and an Adjunct Professor of Psychiatry at Yale. He graduated from the Columbia University College of Physicians and Surgeons in 1979 and completed his residency training at Cornell’s Payne Whitney Clinic, and completed a fellowship in Forensic Psychiatry at New York University/Bellevue Hospital Center. He has published over 80 articles, book chapters or books, primarily on issues at the interface of psychiatry, law, ethics, and public policy. Jeff Wisniowski, MPH received his Masters of Public Health with a concentration in Urban Public Health from Northeastern University. He is currently a medical student enrolled in the University of New England College of Osteopathic Medicine. John W. Goethe, MD completed his undergraduate education at Hampden-Sydney College, HampdenSydney, Virginia and obtained his MD at the Medical College of South Carolina, Charleston, SC. He completed his internship and residency at Tulane University School of Medicine, New Orleans, LA. Since 1983, he has been the Director of the Burlingame Center for Psychiatric Research and Education at the Institute of Living in Hartford Ct.
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Reduction of Seclusion and Restraint in an Inpatient Psychiatric Setting: A Pilot Study Ellen W. Blair1 • Stephen Woolley2 • Bonnie L. Szarek1 • Theodore F. Mucha1 • Olga Dutka1 • Harold I. Schwartz1 Jeff Wisniowski2 • John W. Goethe2
•
Ó Springer Science+Business Media New York 2016
Abstract The authors describe a quality and safety initiative designed to decrease seclusion/restraint (S/R) and present the results of a pilot study that evaluated the effectiveness of this program. The study sample consisted of consecutive admissions to a 120-bed psychiatric service after the intervention was implemented (October 2010– September 2012, n = 8029). Analyses compared S/R incidence and duration in the study sample to baseline (consecutive admissions during the year prior to introduction of the intervention, October 2008–September 2009, n = 3884). The study intervention, which used evidence-based therapeutic practices for reducing violence/aggression, included routine use of the Brøset Violence Checklist, mandated staff education in crisis intervention and trauma informed care, increased frequency of physician reassessment of need
& Ellen W. Blair [email protected] Stephen Woolley [email protected] Bonnie L. Szarek [email protected] Theodore F. Mucha [email protected] Olga Dutka [email protected] Harold I. Schwartz [email protected] Jeff Wisniowski [email protected] John W. Goethe [email protected] 1
The Institute of Living, Hartford Hospital, 200 Retreat Avenue, Hartford, CT 06106, USA
2
Burlingame Center for Psychiatric Research and Education, The Institute of Living, Hartford Hospital, 200 Retreat Avenue, Hartford, CT 06106, USA
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for S/R, formal administrative review of S/R events and environmental enhancements (e.g., comfort rooms to support sensory modulation). Statistically significant associations were found between the intervention and a decrease in both the number of seclusions (p \ 0.01) and the duration of seclusion per admission (p \ 0.001). These preliminary results support the conclusion that this intervention was effective in reducing use of seclusion. Further study is needed to determine if these prevention strategies are generalizable, the degree to which each component of the intervention contributes to improve outcome, and if continuation of the intervention will further reduce restraint use. Keywords Seclusion Restraint Psychiatric inpatients Trauma informed care Brøset Violence Checklist
Introduction Management of violent and aggressive behavior is a major challenge in psychiatry. Traditional approaches frequently include seclusion and restraint (S/R), interventions that can be traumatizing for both patients and staff. Alternative management strategies are needed [1–4]. The authors describe an intervention designed to decrease S/R and present the results of a pilot study that evaluated the effectiveness of this program.
The Intervention The intervention was based on published evidence-based therapeutic practices for reducing violence/aggression. Components included routine use of the Brøset Violence Checklist (BVC) [5–9], mandated staff education in crisis intervention and trauma informed care, [4, 10–12], increased frequency of physician re-assessment of the need for S/R [10, 13–16], formal administrative review of S/R events [4, 17] and environmental enhancements (e.g., comfort rooms to support sensory modulation) [3, 13, 18–22]. The BVC was incorporated into the required daily documentation [5–9] and was completed by a physician on admission and by nursing staff during each of the three nursing shifts throughout the hospitalization. This instrument assesses six behaviors associated with increased risk of violence: confusion, irritability, boisterousness, verbal threats, physical threats, and attacks on inanimate objects [5–7, 9]. Each of the six behaviors is scored ‘‘yes’’ (=1) or ‘‘no’’ (=0) and the sum score computed (range 0–6). The BVC sum score is interpreted as follows: ‘‘a sum of 0 suggests that the risk of violence is small; scores of 1 and 2 suggest that the risk of violence is moderate and preventive measures should be taken; and scores of 3 and more indicate that the risk of violence is very high, immediate preventive measures are required and plans for handling an attack should be activated’’ [7, p. 103]. The investigators added, with written permission from the BVC authors, a checklist of staff intervention options: verbal de-escalation, diverting activity, reduced stimulation, sensory modulation/comfort measures, medication, continuous supervision, S/R. This checklist was part of the required documentation for S/R events.
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Staff education included a standardized 8 h crisis intervention course that emphasized de-escalation techniques, a new method of nursing assignments to maximize staff presence in the milieu [4, 10, 11, 13] and training in ‘‘Risking ConnectionsÒ’’ (a two day program based on a trauma-informed model of care, the goal of which is to reduce staff behaviors that can exacerbate ‘‘trauma reactions’’ in patients) [21]. There were also changes in hospital policy and procedures about the physician order for renewal of S/R: the frequency of physician review was increased to every 2 h from every 4 h for patients over age 18 (frequency for patients \18 remained every 2 h). Changes in the S/R protocol required that the Medical Director and the Director of Nursing examine all S/R events to determine if a formal administrative review was needed (based on severity and outcome) and that they personally conduct all such reviews, the format for which included questions about staff knowledge of the patient (e.g., BVC scores, history of violence, medications prescribed), the specific de-escalation interventions used and the communication about the patient’s status prior to the event. Environmental enhancements included assessing the patient’s ‘‘sensory diet’’ on admission (e.g., identifying personalized coping strategies for decreasing anxiety/agitation) and creating comfort rooms (e.g., areas with calming lights, sensory items, music) [21, 22].
Methods The study site was the 120-bed psychiatric inpatient service of a large urban hospital. The facility’s IRB approved the study and its Research Committee provided partial funding. Baseline data (e.g., the number and duration of S/R events and demographic data) were from all consecutive admissions during the year prior to introduction of the intervention (October 2008–September 2009, n = 3884). The study sample consisted of all consecutive admissions after the intervention was fully implemented (October 2010–September 2012, n = 8029). The investigators compared the frequency and duration of S/R events for violence/aggression in the study sample to baseline data. Descriptive statistics were used to characterize the sample demographically and by frequency and duration of S/R events. The unit of analysis was an episode of hospitalization (i.e., for patients admitted more than once, each admission was examined as an independent episode of care). Analyses included Chi square analyses to compare S/R incidence and t tests to compare S/R duration in the study versus baseline periods (n = 8029 vs. 3884 hospitalizations). Data were analyzed with SPSSÒ (V19).
Results The age distribution of patients in the baseline data (n = 3884) was 4.9 % B 12 years old, 85.9 % 13–65 and 9.2 % C 66; 49.7 % of patients were female and 50.3 % male; race distribution was 15.9 % black, 23.9 % Spanish/Hispanic, 56.3 % white, and 3.9 % other. In the study sample the demographics were similar: the age distribution (n = 8029) was 5.0 % B 12 years old, 87.2 % 13–65 and 7.8 % C 66; 48.5 % of patients were female and 51.5 % male; race distribution was 16.5 % black, 23.6 % Spanish/Hispanic, 55.3 % white, and 4.6 % other. The intervention was associated with a statistically significant reduction in the rate of seclusion events (study period 213/8029 = 4.4/100 admissions vs. baseline
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358/3884 = 9.2/100 admissions, p \ 0.01), a 52 % reduction. Rates of restraint events decreased 6 % (non-significantly, p = 0.44): baseline 213/3884 = 5.5/100 admissions, study period 412/8029 = 5.1/100 admissions. By contrast, duration of seclusions per admission during the study period was reduced by 27 % and duration of restraints per admission was increased by 52 %. Mean seclusion event duration exceeded mean restraint event duration during the baseline period (337.7 vs. 286.0 min, p = 0.02) and during the study period, although not significantly (516.2 vs. 445.0 min, p = 0.27). Comparing baseline to the study period, the seclusion rate decreased and the mean seclusion duration increased from 337.7 to 516.2 min (p \ 0.01). Likewise, from baseline to post-intervention the mean duration of restraints increased from 286.0 to 445.0 min (p \ 0.01). In the BVC assessments the most common behavior associated with S/R was irritability (96 % of events), followed by boisterousness (78 %), verbal threats (63 %) and confusion (50 %). The most common staff interventions employed in S/R events were verbal deescalation (90 %), medication administration (84 %) and decreased stimulation (80 %). A formal administrative review was conducted in 46.2 % of all events (190 of 411 events, 50.6 % of which were seclusion and 49.4 % restraint events). In events for which formal reviews were conducted the mean BVC score was 2.58 (in the ‘‘high risk’’ category of Brøset scores); in 85.6 % (n = 174) of these the patient had a known history of aggression and in 99.3 % (n = 120) the patient had a history of positive response to comfort/sensory interventions.
Discussion The associations found between the intervention and S/R are generally consistent with earlier reports [2, 3, 10, 11, 13, 15, 23–27]. The finding regarding use of restraint (only a 6 % non-significant reduction) suggests that a more violent self/other injurious subgroup exists for which seclusion may be contraindicated, and that may not respond as well to current interventions [26, 27]. To understand more fully why these interventions did not reduce restraint in the same way it did for seclusion requires further study. The present study supports routine assessment of potentially violent behaviors [5–9, 28– 31], increased presence of staff in the milieu [10, 13, 16, 23, 24, 30–32], environmental enhancements and staff education about de-escalation techniques [4, 10, 14–16, 21, 22, 26, 27, 32]. Strengths of this study include the sample size and the large number of variables assessed. Limitations include that the components of the intervention were introduced sequentially (limiting inferences about the effect of each individual component) and that there were no explicit criteria in the study protocol that determined when a formal administrative review of S/R events would be conducted.
Conclusion These results support the conclusions from previous studies that improved reporting and an intense focus by senior leadership on S/R, such as formal administrative reviews, are essential elements in S/R reduction strategies [4, 11, 17, 20]. Further study is needed to determine if these prevention strategies are generalizable, the degree to which each
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component contributes to improve outcomes, and if continuation of this intervention will further reduce restraint use. Compliance with Ethical Standards Conflict of Interest We have no potential conflict of interest. Ethical Approval This article does not contain any studies with human participants performed by any of the authors.
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Ellen W. Blair, APRN, PMHCNS-BC holds a Bachelor of Science Degree in Nursing from Adelphi University and a Master of Science in Psychiatric Nursing from the Yale School of Nursing. Ms. Blair is a Doctorate in Nursing Practice candidate (2017) at the University of St. Joseph, West Hartford, CT. Ms. Blair has been lead author on several peer-reviewed journal articles, written two book chapters and presented numerous times in her field of professional expertise. Ms. Blair has been the recipient of several awards for outstanding nursing practice and contributions to the field. Since 2009, she has been the Director of Nursing at the Institute of Living, Hartford Hospital. Stephen Woolley, DSc, MPH has professional healthcare experiences including 35 years of research. He has advanced training in biology, epidemiology, biostatistics, and program administration/evaluation at the University of Connecticut (MS), Yale University (MPH), and Boston University (DSc). He has held positions at Rockefeller University (New York, NY), Yale University, the Connecticut Health Information Center and Institute for Community Research (Hartford, CT), Boston University, Massachusetts General Hospital, and the Institute of Living/Hartford Hospital (Senior Scientist since 1997). He has been an investigator/principal investigator in more than 25 funded healthcare investigations, and has contributed to presentations at more than 50 scientific/professional national meetings and to approximately 20 peerreviewed publications. Bonnie L. Szarek, RN, BA graduated from nursing school in 1971 and has been at the Institute of Living (Hartford, CT) for 45 years. From 1979 to 2010, she served as a Research Nurse and Project Coordinator. She received her BA in psychology from Central Connecticut State University (New Britain, CT) in 1991. Since 2010, she has been serving as a Clinical Research Associate. Over more than 3 decades, she has contributed to study design, data collection and analysis, and manuscript preparation. Her data analysis examined prescribing practices, metabolic syndrome, genetics, and psychiatric outcomes. She has been the co-author of more than 20 peer-reviewed publications.
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Psychiatr Q Theodore F. Mucha, MD, DFAPA received a Bachelor of Science degree from Franklin and Marshall College, and completed his Psychiatric Residency training at the Institute of Living. He is also a graduate of Western New England Institute for Psychoanalysis. He joined the medical staff of The Institute of Living in 1970. Dr. Mucha held the position of Medical Director until his retirement in November 2013 and Associate Professor, Department of Psychiatry, the University of Connecticut School of Medicine. He has numerous publications and is the recipient of several awards for outstanding teaching. Olga Dutka, RN, MSN, MBA, CHC has worked in psychiatry for over 33 years, in numerous clinical and administrative capacities: staff nurse, supervisor, educator, unit director, research clinician, utilization management director, quality director, compliance and privacy manager, home care nurse, and consultant. She is currently the Director of Professional and Clinical Education for the Behavioral Health Network of Hartford HealthCare. She holds her Master’s degree in Nursing from Saint Joseph College and Master’s degree in Business Administration from the University of Connecticut. Her certifications include Healthcare Compliance via the HCCA Certification Board and a Six Sigma Black Belt from the Central Connecticut State University. Harold I. Schwartz, MD currently serves as Psychiatrist-in-Chief at The Institute of Living, Vice President of Behavioral Health at Hartford Hospital, and as regional Vice President of Hartford HealthCare. He is a Professor of Psychiatry at the University of Connecticut School of Medicine and an Adjunct Professor of Psychiatry at Yale. He graduated from the Columbia University College of Physicians and Surgeons in 1979 and completed his residency training at Cornell’s Payne Whitney Clinic, and completed a fellowship in Forensic Psychiatry at New York University/Bellevue Hospital Center. He has published over 80 articles, book chapters or books, primarily on issues at the interface of psychiatry, law, ethics, and public policy. Jeff Wisniowski, MPH received his Masters of Public Health with a concentration in Urban Public Health from Northeastern University. He is currently a medical student enrolled in the University of New England College of Osteopathic Medicine. John W. Goethe, MD completed his undergraduate education at Hampden-Sydney College, HampdenSydney, Virginia and obtained his MD at the Medical College of South Carolina, Charleston, SC. He completed his internship and residency at Tulane University School of Medicine, New Orleans, LA. Since 1983, he has been the Director of the Burlingame Center for Psychiatric Research and Education at the Institute of Living in Hartford Ct.
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