Variability in Psychiatric Facility Seclusion and Restraint Rates as Reported on Hospital Compare Site

After I excluded 69 critical access hospitals and 58 hospitals with missing hospital type, there were 7,589 rows of data for 1,659 hospitals in the data set, including 7,555 nonmissing seclusion rates and 7,582 nonmissing restraint rates. In the data cleaning process, 62 cases were identified and corrected where patient-hours were apparently reported instead of patient-days, and 331 discrepant denominators were corrected by setting the apparently erroneous value equal to the other measure’s value. In addition, 162 rows of data were removed altogether, in most cases because of erroneous denominators, and several individual restraint rates and seclusion rates were set to missing.

The final data set comprised 7,427 rows of data for 1,642 hospitals. These data included 7,416 nonmissing restraint rates and 7,398 nonmissing seclusion rates. Thus 99% of the original hospitals were retained, as were 97.9% of the original set of nonmissing restraint and seclusion rates. The data included restraint rates for all 5 study years for 1,276 hospitals (78%) and seclusion rates for all 5 study years for 1,254 hospitals (77%). Hospitals averaged 4.5±1.0 years of restraint data and 4.5±1.0 years of seclusion data. Counts of hospitals by type and ownership are provided in Table 1. Two-thirds (1,088) were acute care hospitals. All but 12 of the government hospitals in the sample were nonfederal (159 state, 89 local, and 83 hospital district or authority).

The potential drawbacks of for-profit health care notwithstanding (9, 13, 14), for-profit hospitals reported markedly lower rates of both seclusion and restraint than did government and nonprofit hospitals for 2013–2017. Without more detailed data, it is impossible to quantify the extent to which findings such as this are attributable to differences in patient mix between for-profit, government, and nonprofit hospitals. By way of comparison, in a study of responses to injurious assaults on psychiatric units in hospitals participating in the NDNQI, the estimated odds of use of seclusion were lower in for-profit hospitals than in nonprofit hospitals after the analysis controlled for hospital, unit, patient, and assault characteristics, but they were not lower than the odds of seclusion in government hospitals (5). The analyses of NDNQI data also found that when seclusion was used in federal government hospitals, patients tended to spend longer in seclusion compared with nonfederal government, nonprofit, and for-profit hospitals. Other findings from that study were that the odds of restraint with a device were no lower in for-profit hospitals and that episodes of restraint with a device in for-profit hospitals tended to be shorter than in federal government hospitals but longer than in nonfederal government hospitals. Interestingly, odds of pharmacological restraint were higher in for-profit hospitals compared with government and nonprofit hospitals. Because the NDNQI collects data only on use of seclusion and restraint in response to patient assaults resulting in injury, inconsistencies with this study’s findings are not surprising.

The steady decline in above-the-median rates of seclusion and restraint reported to CMS for 2013–2017 is consistent with a decline in rates observed in a previous study of HBIPS data reported to the Joint Commission by 891 hospitals from October 2008 through July 2016 (10). These earlier findings are extended here by examination of annual rates through 2017 for a larger sample (1,642 hospitals) and by using HBIPS data from a different database. In another large-scale study of 2007–2013 NDNQI data on responses to injurious assaults on 438 adult psychiatric units, duration of physical restraint episodes and the percentage of restraints involving a device (out of all physical and pharmacological restraints) declined substantially over the study period, and there was some evidence of a decrease in duration of seclusion episodes (11).

Although it appears that hospitals are making some progress in curbing the use of seclusion and restraint, there is room for further improvement. In 2017, two-thirds of hospitals reported seclusion rates of ≤0.09 hours per 1,000 patient-hours, and two-thirds reported restraint rates of ≤0.15 hours per 1,000 patient-hours. Ten percent of hospitals (90th percentile), however, reported rates roughly five times as high as these 67th percentile rates, and 5% (95th percentile) reported rates over 10 times as high. One nonprofit acute care hospital accounted for the five highest seclusion rates observed, reporting (in chronological order) rates of 224, 181, 174, 123, and 55 seclusion hours per 1,000 patient-hours. It is encouraging that the rates decreased over time, but it seems excessive for patients to be spending, on average, over 1 hour out of every 20 in seclusion. Another nonprofit acute care hospital reported restraint rates that declined from 96 hours to 55 hours per 1,000 patient-hours during the study period. Again, the trend is encouraging, but patients should not be spending an average of 5.5% of their time—over 1.3 hours per day—in physical restraint.

Patient populations vary across hospitals, to be sure, but it seems unlikely that differences of the magnitudes noted above can be fully explained by individual patient characteristics and behavior alone. Even in responses to injurious assaults, taking into account the number of people injured, the level of most severe injury, the type of person suffering the most severe injury (patient, clinical health care staff, etc.), and the assaultive patient’s admission status (voluntary or involuntary) and gender, substantial variability has been found across hospitals in use of seclusion and restraint (5). In the absence of stronger regulatory guidelines, including benchmarks, this wide variation in clinical practice is not surprising.

There is also much room for improvement in the reporting of data on seclusion and restraint. The HBIPS measures are a helpful start, but more detailed data are needed. Every episode of seclusion involves at least two decisions: a decision to place the patient in seclusion and a decision about when to end the seclusion episode. Similarly, every episode of physical restraint involves a decision to restrain and a decision to stop restraining. Thus, a hospital’s use of seclusion and physical restraint can be quantified in terms of frequency of use and episode duration. Both elements are important, but they are not measured separately by the HBIPS measures. As a result, a hospital that uses seclusion or restraint with atypically high frequency but short duration and a hospital that uses seclusion or restraint with atypically low frequency but long duration may both report hours of seclusion or restraint per 1,000 patient-hours that are within the typical range. Ideally, both hospitals would be identifiable as outliers and would recognize that the frequency or duration of their seclusion or restraint episodes may need to be reduced.

The NDNQI collects quarterly data on frequency of seclusion and restraint use and on duration of seclusion episodes and restraint episodes involving a device. Those data are limited to responses to injurious assaults, but the approach is instructive. CMS should similarly collect and report quarterly data on prevalence of seclusion and restraint (e.g., episodes per 1,000 patient-days) and duration of seclusion and restraint episodes. For duration, selected percentiles (e.g., 50th, 75th, and 90th) should be reported, as well as the maximum episode duration. Simply summing hours spent in seclusion or restraint across patients, as for the HBIPS measures, can obscure unacceptably long episodes.

Furthermore, the quality of the data reported by hospitals to CMS and posted by CMS on Hospital Compare deserves more attention. Many errors could be avoided either by redefining the HBIPS “denominator” element to match the denominator used in computing the rate (i.e., patient-hours) or by redefining the rates in terms of hours per 1,000 patient-days to match the existing denominator. In addition, incentives for hospitals to report HBIPS data may need to be contingent on the reporting of accurate data.

The collection and public reporting of HBIPS data by CMS represent a meaningful step toward improving the quality and safety of psychiatric care. These data allow for analyses of interhospital variability and nationwide trends, comparisons among hospitals of different types and ownership, and identification of hospitals with unusually high rates of seclusion or restraint. As a potential resource for health care consumers, patient safety organizations, regulatory agencies, and researchers, these data deserve more attention and further development.

Despite making some progress, many hospitals continue to report very high rates of seclusion and restraint. Seclusion and restraint rates above the median declined substantially during the 2013–2017 study period, but marked variability in these above-the-median rates remains. It is unlikely that this variability can be fully accounted for by patient-level factors. Data reporting to CMS should be made more rigorous and be expanded to include frequency of seclusion and restraint use and duration of seclusion and restraint episodes.