Reducing Behavioral Restraint & Seclusion & SB 130

Report
The Basics of Behavioral
Restraint and Seclusion
Leslie Morrison
Director, Investigations Unit
Disability Rights California
(510) 267-1200
[email protected]
February 2013
1
Defining Terms

Restraint
Restricting freedom of movement,
physical activity or normal
access to one’s body



Medical
Postural/Supportive
Behavioral



Physical force; manual holds
Mechanical device, material
or equipment
Chemical [drugs]
Not:



2
Briefing holding to calm or
comfort
Brief assistance to redirect or
prompt
Devices used from
transportation or security

Seclusion
Involuntary confinement alone
in a room or an area from
which the resident is
physically prevented from
leaving
Doesn’t matter if door is
locked or even closed
Not:


Voluntary time out
Restriction to area
consistent with unit
rules or an individual’s
treatment plan
What is “chemical restraint”?
Medication used as a restriction to
manage an individual’s behavior,
generally unplanned and in
emergency/ crisis.

Not medication routinely prescribed to treat
individual’s psychiatric condition to improve
functioning.

Not necessarily all PRNs but often PRNs are
used.

Often used in combination with other forms
of restraint or seclusion.
3
What we know about restraint
and seclusion…


Have no therapeutic value or basis in clinical knowledge.
Does not positively change behavior



Is traumatic and potentially physically harmful to staff and the individual.
Does not keep people safe.





Restraint and seclusion is often staff’s first, automatic response to difficult behavior.
Generally stems from a power struggle.
Mostly used for loud, disruptive, non-complaint [but not violent] behavior.

4
May cause death even when done “safely” and correctly.
Leaves lasting psychological scars.
Decision is almost always arbitrary, idiosyncratic, and generally avoidable.
Facility culture (staff role perceptions, training, program philosophy, facility
leadership) has greater influence on the use of restraint & seclusion than
clinical factors.


May increase negative behavior and decrease positive behavior.
Lack of training in managing behavioral crisis contributing factor 90% of JCAHO
restraint deaths.
Myths/Assumptions

Keeps people (staff
& consumer) safe

Only used when
absolutely
necessary and for
safety reasons


Staff can recognize
potentially violent
situations
Higher worker injury rate than in lumber,
construction and mining
Most often used for non-compliance,
inappropriate behavior or power struggle


Reality
Known to cause injury, death and last
psychological trauma;


vs.
(1) study 73% (560 consumers) not dangerous but
“inappropriate” at time restrained/secluded
Nurses agree on use 22% of time; mental
health professionals can only predict
violence potential 53% of time; least
clinically experienced were most restrictive

Staff know how to deescalate

De-escalation used < 25% of time;



Most frequent antecedent was staff-initiated
encounter = staff escalate;
Lack of training in managing behavioral crisis
contributing factor 90% of JCAHO restraint deaths;
1/3 of staff surveyed didn’t get mandatory crisis
training

Used without bias and
only in response to
objective behavior

Cultural and social bias, staff role
perception, administrator attitudes

Therapeutic and based
on clinical knowledge

No controlled studies, no measure of
efficacy or therapeutic value; shown to
increase negative behavior

Restraint/seclusion
used for safety not
punishment

(6) studies = 58-75% perceived as
punishment
6
Whose Pre-disposed?

No “typical” patient profile




√ Staff profile





No consistent demographics
No consistent clinical characteristics
Although individuals w/trauma or abuse history at greater
risk…
Mostly used for loud, disruptive, non-complaint behavior
Generally stems for power struggle
Based on cultural bias & staff perception
Belief that it is safe/harmless & reduces risk of injuries
√ Facility culture




Automatic response to difficult behavior
Insufficient alternatives
Insufficient staff training in de-escalation
Little to no focus on reduction; not seen as a critical event/
treatment failure
7
Dangers


Physiological











Death

Asphyxiation

Strangulation

Aspiration

Cardiac and/or respiratory arrest
Fractures, dislocation/sprains
Lacerations, abrasions
Injury to joints and muscles,

Dislocation of shoulder and other joints,


Hyperextension or hyperflexion of the arms,
Overheating, dehydration, exhaustion,
Exacerbation of existing respiratory problems,
Decreased respiratory efficiency,
Decrease in circulation to extremities,

Deep vein thrombosis,
Pulmonary embolism,
Cardiac and/or respiratory arrest.
Psychological







Last psychological trauma
Loss of dignity
Triggering flashbacks
Recurrent nightmares, intrusive thoughts,
avoidance behaviors,
Enhanced startle response,
Feelings of guilt, humiliation,
embarrassment, hopelessness,
powerlessness, fear, and panic
Compromised ability to trust and engage
with others,
Environmental

Creates a violent and coercive
environment that undermines forming
trusting relationships
Risks with Medication

Sedation contributing to respiratory
depression & arrest
8
Conditions on Use

Only used:
◦ in emergencies,
◦
◦
◦
◦
to prevent imminent risk of physical harm
when other less restrictive alternatives have failed,
for the least amount of time necessary, and
in least restrictive way.

Never for coercion, discipline, convenience or retaliation by staff

Only by staff with specific, current training and demonstrated
competence in application

Only upon MD order OR, in emergency, at discretion of RN
◦
◦

Face to face assessment by MD or specially trained RN/PA
◦
◦

Never as a standing order
Limits on order duration
within one hour [at hospital];
other timeframes apply for other settings
Requires certain level of monitoring or observation
Where & What are the Standards?

Federal law


Hospitals
Residential Facilities for
Adolescents

What standards?




State Law and Regulations

By facility type



Joint Commission

Not all facilities
By facility type



Duration of orders
Type of observation
frequency of monitoring
MD consultation &
oversight
Documentation
requirements
Staff training elements
Reporting requirements,
data collection
Quality Improvement
criteria
10
Additional State Requirements
Health & Safety Code §1180

Prohibits risky practices:

Obstruct airway or impair
breathing





Intake assessment with
consumer input

Pressure on back or body weight
against back or torso;
Anything covering mouth;
Restraint w/known medical or
physical risk if believe it would
endanger life or exacerbate
medical condition;
Prone with hands restrained
behind back;
Containment as extended
procedure







Post-Incident Debriefing


If prone, must observe for distress
Prone mechanical restraint with
those at risk for positional
asphyxiation, unless written
authorization by MD.



Advanced directive on deescalation or use of R vs. S
Early warning signs/
triggers/precipitants,
Techniques that help person
maintain/regain control,
Pre-existing medical
conditions, trauma history.
ID & understand precipitant(s);
Alternatives/other methods of
responding;
Revise plan to address root
cause;
Was it necessary & done right?
Data
11
How does a facility prevent R/S?
CHANGE THE CULTURE:
From Control → to Empowerment

Involvement by top leadership



Create a vision and culture that prevents the risk of conflict
and violence and respects personal liberties
Maintain sufficient staffing & programming
Keep reduction in use & duration as constant priority and
focus

Integrating the principles of recovery and trauma informed
care

Implement restraint/seclusion prevention tools &
alternatives



12
Trauma assessments
Crisis plans
Comfort rooms
Sensory modulation tools

Workforce development
Build relationships
Avoid power struggles
Built into staff competencies and performance evaluations
On-going training (not only point in time)




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Rigorous debriefing of every incident with involvement of senior
administration

Use data to inform practices
Public reporting & posting
Rigorous analysis


Actively Recruit & Involve Consumers and Families


Peer advocates in debriefing
Facility committees & positions
13
Principles of Trauma-Informed Care

Program and services based on:



Respect individuals.


Understanding vulnerabilities and triggers of trauma survivors
that can be triggered in traditional service delivery systems
Designed to be supportive and avoid re-traumatization
Keep them informed, connected and hopeful about their recovery
Work collaboratively in a way that empowers the individual.



Learning together vs. Helping (one individual has agenda for the
other)
Relationship vs. the Individual
Responding out of Hope (caring, patient, & supportive) vs.
Reacting out of Fear (rule driven, reactive, restrictive)
Public Health Model
focus on prevention NOT how to do more safely or better
Universal Precautions
Administrative & clinical
treatment
environment that
minimizes potential
for conflict by
anticipating risk
factors





Trauma informed care
Recovery Model
Stigma awareness
Early assessment of
risk factors
Organizational values
Secondary Intervention
Immediate & effective early
intervention strategies to
minimize conflict
and aggression
when they occur
o Individual assessment of risk
Tertiary
Intervention
After incident,
rigorous problem
solving, mitigate
effects, take
corrective action

o Individual crisis plans to teach
emotional self-management
o De-escalation skills


Post S/R
interventions to
mitigate effects
Debriefing
Corrective Action
o Staff training on attitude &
self-awareness during conflict
o Sensory modulation tools
o Comfort rooms
15

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