Pilot Project in NY State Reduces Use of Seclusion, Restraint in Facilities Serving Children
Among the lessons learned is that sustained success over a long-term period requires a cultural change at all levels of the institution and active involvement of facility leadership at every stage of the effort.
Three New York State mental health treatment facilities have demonstrated significant decreases in their use of restraint and seclusion for children with severe emotional disorders, as part of a state pilot project reported May 1 in Psychiatric Services in Advance.
Six Core Principles Employed by Facilities
The facilities participating in the New York State pilot project to reduce use of seclusion and restraint used NASMHPD’s “Six Core Strategies for Reducing Seclusion and Restraint.”
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Leadership toward organizational change: This first strategy is considered core to reducing the use of seclusion and restraint (S/R) through the consistent and continuous involvement of senior facility leadership. Leadership strategies include defining and articulating a vision, values, and philosophy that expects S/R reduction; developing and implementing a targeted facility or unit-based performance improvement action plan (similar to a facility “treatment plan”); and holding people accountable to that plan.
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Use of data to inform practice: This core strategy suggests that successfully reducing the use of S/R requires the collection and use of data by facilities at the individual unit level.
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Workforce development: This strategy suggests the creation of a treatment environment whose policy, procedures, and practices are based on the knowledge and principles of recovery and the characteristics of trauma-informed systems of care. The purpose of this strategy is to create a treatment environment that is less likely to be coercive or trigger conflicts and, in this sense, is a core primary prevention intervention.
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Use of S/R prevention tools: This strategy includes the use of assessment tools to identify risk for violence and S/R history; the use of a universal trauma assessment; tools to identify persons with high-risk factors for death and injury; the use of de-escalation surveys or safety plans; the use of person-first, nondiscriminatory language in speech and written documents; environmental changes to include comfort and sensory rooms; sensory modulation interventions; and other meaningful treatment activities designed to teach people emotional self-management skills.
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Consumer roles in inpatient settings: This strategy involves the full and formal inclusion of consumers, children, families, and external advocates in various roles and at all levels in the organization to assist in the reduction of seclusion and restraint.
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Debriefing techniques: This core strategy recognizes the usefulness of a thorough analysis of every S/R event. It values the fact that reducing the use of S/R occurs through knowledge gained from a rigorous analysis of S/R events and the use of this knowledge to inform policy, procedures, and practices to avoid repeats in the future.
The three participating facilities each reduced restraint and seclusion episodes per 1,000 client-days over a five-year period by more than 60 percent. The report, which describes the project implementation and outcomes, also describes specific “lessons learned” that can inform ongoing efforts to create environments that reduce restraint and seclusion.
The New York State Office of Mental Health (OMH) focused on children’s facilities because children in OMH facilities were five times as likely as adults to be placed in restraint or seclusion. For the study, OMH invited three facilities in the central and western regions of New York that were among the highest users of restrictive interventions in the state to participate in the Positive Alternatives to Restraint and Seclusion (PARS) project. Participating facilities included an OMH-operated children’s psychiatric center (facility 1), an OMH-licensed children’s residential treatment facility (facility 2), and the unit of an OMH-licensed private psychiatric hospital serving children and adolescents (facility 3).
As part of the project, the three facilities participated in an in-depth intervention to reduce use of restraint and seclusion that included training, on-site mentors and peer specialists, and on-site consultation from the National Association of State Mental Health Program Directors (NASMHPD) Office of Technical Assistance. The principal tool used by the three facilities was the Six Core Strategies for Reducing Seclusion and Restraint Use developed by NASMHPD (see box).
Episodes of restraint and seclusion were defined as events where restrictive interventions were used, regardless of duration. Facilities tracked episodes online in a secure module of the New York State Incident Management and Reporting System, including patient information, precipitating actions, and length of episode. The OMH Bureau of Quality Improvement assisted the facilities in analyzing data to identify when targeted interventions were needed, such as at particular times of the day or at transition points in the program, when rules contributed to tension, or when staff members had high rates of using restraint and seclusion.
The use of restraint and seclusion was significantly reduced at all three sites over the course of the project; the figures for absolute number of seclusion and restraint incidents from January 2007 through December 2011 are as follows: facility 1 showed a decrease from 67 incidents to 25; use decreased at facility 2 from 63 to 7 incidents; and incidents at facility 3 decreased from 99 to 13.
Moreover, all three facilities derived some “lessons learned” to decrease the use of restraint and seclusion for dissemination to other facilities in the state. Among them:
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To achieve success in reducing use of restraint and seclusion, treatment facility providers and leadership must thoroughly examine their own culture and practices.
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Creating the culture of change necessary to reduce the use of restraint and seclusion means making major changes at all levels of an organization and requires a major commitment over an extended period.
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Conducting an effective post-event debriefing plays a critical role in reducing the use of restraint and seclusion but requires ongoing commitment and willingness to learn.
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Manager treatment of staff affects how staff members treat persons served.
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Consumer input and involvement in decision making are critical to improving a facility’s culture and reducing use of restraint and seclusion.
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Staff from facilities participating in a project such as PARS can play a key role in disseminating alternatives to restraint and seclusion throughout the state.
“All three facilities continued to implement key components of the PARS initiative after termination of grant-funded activities, and OMH initiated multiple activities to disseminate lessons learned during the project to all inpatient and residential treatment programs throughout the state mental health system,” stated lead author Jennifer P. Wisdom, Ph.D., M.P.H., of George Washington University and her colleagues at the New York State OMH in the Psychiatric Services report.
Child psychiatrist and past APA Treasurer David Fassler, M.D., said there has been a significant and sustained effort to reduce the use of seclusion and restraint in the psychiatric treatment of children and adolescents. “This article provides further evidence that comprehensive training with an emphasis on prevention and alternative interventions can help inpatient and residential programs achieve this objective,” he told Psychiatric News. “As the authors noted, the implementation of such strategies entails considerable cultural and organizational change. Success requires enhanced communication, consistent leadership, accurate data, and a major commitment by all staff over an extended period.
“The study represents a valuable addition to the growing literature documenting the efficacy of such efforts across diverse clinical settings,” Fassler added. ■
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Published online: 16 June 2015
Published in print: June 6, 2015 – June 19, 2015
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