NEWS & NOTES

Legislation that would regulate the use of restraints and seclusion in mental health facilities was introduced in both houses of Congress in late March. The bills were drafted largely in response to a series of investigative articles published in the Hartford (Conn.) Courant last fall that documented 142 deaths of psychiatric patients nationwide from the misuse of restraints and seclusion over the last decade.

Senators Joseph Lieberman (D.-Conn.) and Christopher Dodd (D.-Conn.) are sponsors of separate bills in the U.S. Senate. The House bill, which is sponsored by Representatives Diana DeGette (D.-Colo.), Rosa DeLauro (D.-Conn.), and Pete Stark (D.-Calif.), is considered to be tougher and more comprehensive than the Senate bills and is favored by advocacy groups such as the National Alliance for the Mentally Ill (NAMI) and the National Mental Health Association (NMHA).

Titled the Patient Freedom From Restraint Act, the House bill would cover all patients with mental illness and developmental disabilities and troubled youth receiving treatment funded by Medicaid or Medicare or other federal sources. Like the Senate bills, it limits use of restraints to emergency situations in which the physical safety of a patient or staff member is in jeopardy, and it calls for minimum uniform standards for seclusion and restraint.

The major difference between the House and Senate bills is in their reporting requirements. The House bill requires all restraint-related deaths and serious injuries to be reported to federal and state agencies and, if the facility is accredited, to the Joint Commission on the Accreditation of Healthcare Organizations (JCAHO). In contrast, the Senate bills allow a facility to determine for itself whether a death or injury constitutes an “unexpected occurrence” that requires it to be reported.

Some advocacy groups such as NAMI and NMHA favor the stricter reporting requirements, noting that without them facilities will not be truly accountable for abuses and that patients and families will continue to be denied information. They point to New York State, where mandatory reporting and investigation of all restraint-related deaths have led to sharp declines in such deaths over the past five years.

Supporters of the Senate bills agree that reporting deaths and serious injuries is important to uncover abuses. However, many also agree with the position taken by JCAHO, which seeks to protect the confidentiality of information gathered by facilities during investigations of restraint-related deaths. In a statement supporting the Senate bills, Dennis S. O'Leary, M.D., the president of JCAHO, noted that “reporting is only the first step toward substantive improvements in protecting patients' rights and improving their safety, but to get there, health care organizations must be able to examine deaths fully and honestly in a nonpunitive environment.”

Staff training is a key focus of the House bill and of Senator Dodd's bill. The House bill requires facilities to provide annual training to all staff in state-of-the-art patient management techniques, including proper use of restraint and seclusion. Senator Dodd's bill requires the Secretary of Health and Human Services to draft regulations that would ensure adequate staffing in mental health facilities as well as staff training in the appropriate use of restraints and alternatives to restraints.

When the legislation was introduced, the American Psychiatric Association issued a statement condemning the inappropriate use of restraint and seclusion, but it stopped short of supporting any legislation. The APA statement points out that none of the bills commit resources to training staff and to ensuring adequate staffing. It calls such a commitment “an important part of the appropriate federal legislative and regulatory response.”

The APA statement further notes that “inappropriately placing restrictions on health care professionals' use of interventions that help guarantee their safety as well as the safety of patients in their care is unwise. Governmental regulations will directly place patients, nurses, other hospital staff, and visitors into greater threat of assault and violence.”

The series of investigative articles in the Hartford Courant grew from a local inquiry into the death at a Connecticut psychiatric hospital of an 11-year-old boy whose chest was crushed during a restraint procedure. The Courant's investigation found that of the 142 deaths over the last decade, more than a quarter were of children under 17—nearly twice the proportion of children in mental health institutions. Few of the deaths resulted in legal prosecution.

The Courant investigators also learned that few reporting requirements exist. Suspecting that the 142 deaths reflected a much larger number, the newspaper hired a research specialist from the Harvard School of Public Health to make statistical projections. Based largely on incidents in New York State, where reporting is required, the specialist estimated that 50 deaths of psychiatric patients each year were attributable to misuse of restraints and seclusion. However, noting that New York closely monitors these procedures, the specialist projected an annual death rate as high as 150.

The investigation found that many of the patients died when restraint procedures such as face-down floor holds were administered by staff who were not adequately trained in their use. Although most facilities require that a physician order use of restraints as part of a treatment plan and that a supervisor oversee all procedures, the techniques themselves are generally applied by mental health technicians and aides, who are among the least-trained and lowest-paid workers in the health care system

American Psychiatric Association guidelines recommend that at least five people be involved in any physical restraint of a patient—one for each limb plus someone to watch. However, in several incidents uncovered by the Courant's investigation, restraints were executed by only one or two people.

The newspaper report noted that cost controls have led many facilities to cut staff to a bare minimum. Such minimal staffing requires constant shifting of workers from unit to unit, which means that workers do not get to know patients and may be more likely to react with fear, the report noted.

At the request of Senators Lieberman and Dodd, the General Accounting Office is preparing a nationwide study on the use of restraints and seclusion and the reporting of deaths and injuries resulting from these procedures.

A practice guideline for the treatment of patients with delirium is being released this month by the American Psychiatric Association, the tenth in a series of practice guidelines developed by APA since 1993. The practice guideline appears as a supplement to the May issue of the American Journal of Psychiatry.

Approved by the APA board of trustees in December 1998, the guideline was drafted by an APA work group on delirium chaired by Paula Trzepacz, M.D., of Pittsburgh, Pennsylvania. It is based on a comprehensive review of the literature on delirium, the clinical and research expertise of the six work group members, and comments from 12 organizations and 83 individuals who reviewed various drafts of the guideline.

The guideline states that delirium is characterized by disturbance of consciousness with reduced ability to focus, sustain, or shift attention. It is accompanied by a change in cognition, such as memory deficit, disorientation, or language disturbance, or the development of a perceptual disturbance that is not better accounted for by dementia.

Between 10 and 30 percent of persons hospitalized for medical illness develop delirium. Among elderly persons who are hospitalized, the prevalence ranges from 10 to 40 percent; among hospitalized AIDS patients, from 30 to 40 percent; and among patients with terminal illness, up to 80 percent. Delirium is frequently due to substance use or withdrawal. Although the majority of patients recover fully, delirium may progress to stupor, coma, seizures, or death, particularly if untreated.

The guideline states that psychiatric management is the cornerstone of treatment and describes ten tasks that the psychiatrist should ensure are performed for all patients with delirium. Among them are coordinating care with other physicians treating the patient, ordering diagnostic tests to identify and correct the etiologic factors behind the delirium, initiating interventions for general medical conditions that may be life threatening, and providing prompt treatment of reversible causes of delirium, such as hypoglycemia, hypoxia or anoxia, and hyperthermia.

Because behavioral disturbances, cognitive deficits, and other manifestations of delirium may endanger patients or others, the psychiatrist should assess the patient's suicidality and violence potential and implement or advocate interventions to minimize these risks. Whenever possible, means other than restraints, such as sitters, should be used to prevent delirious patients from harming themselves or others, since restraints can increase agitation or carry risks for injuries.

The symptoms of delirium are treated primarily with medication, most often with the high-potency antipsychotic haloperidol, the guideline states. No large controlled prospective studies have been conducted for somatic treatments other than haloperidol. Studies indicate that benzodiazepines are ineffective in general cases of delirium; however, they are the treatment of choice for delirium related to alcohol or benzodiazepine withdrawal.

Copies of the Practice Guideline for the Treatment of Patients With Delirium can be ordered from American Psychiatric Press, Inc., 1400 K Street, N.W., Washington, D.C. 20005; phone, 1-800-368-5777. The cost is $22.50 per copy.

A recent publication from the Center for Substance Abuse Treatment calls for collaboration between treatment professionals to ensure that criminal offenders with substance abuse problems receive treatment while in jails and prisons and that appropriate treatment continues when they make the transition to the community.

Entitled Continuity of Offender Treatment for Substance Use Disorders From Institution to Community, the publication presents best-practice guidelines developed by a consensus panel of 15 experts from the criminal justice and treatment systems. It points out that on any given day in the United States, some 1.7 million men and women are incarcerated in jails and prisons. Studies suggest that 80 percent of these individuals have substance-related problems, but prison-based programs provide treatment to about only 51,000 inmates annually, less than 13 percent of those for whom it is indicated.

Even offenders who receive some form of treatment while incarcerated are likely to relapse to substance abuse and crime when they are released. Little transitional planning occurs other than a referral to a community treatment program, the guidelines note. Studies indicate that offenders with substance use disorders are the most likely to be repeatedly incarcerated, and that they are also responsible for a disproportionate amount of violent crime.

The consensus panel acknowledges that too few correctional institutions have established treatment programs and that for too long incarceration was regarded as a solution to addiction. Many believed that an offender who has been abstinent throughout incarceration does not need treatment. Recent shifts in public policy aimed at breaking the cycle of substance use and crime have focused attention on treatment of offenders and have created new resources for institutional treatment and other programs. However, the panel notes that this influx of funds is often earmarked either for institutional services or for community services, and not for the types of collaborations between systems that are critical to ensuring treatment retention of offenders.

Improving the transition of offenders to the community and ensuring continuity of treatment is the particular focus of the guidelines, which emphasize that no matter what type or intensity of treatment is provided in the correctional facility, its emphasis should be on preparing the offender for continued treatment in the community after release.

The guidelines describe three basic program models used in some jurisdictions to provide transitional services for substance-abusing offenders who are being released from incarceration—outreach, reach in, and third party. In an outreach model, the correctional institution designates staff to make linkages to treatment services and self-help groups in the community. In the reach-in model, community programs assume primary responsibility for initiating services. Some jurisdictions contract with a third party to coordinate some or all transitional services.

Within any of these models, the guidelines favor a case management approach to coordinating services for released offenders. The ideal program would have a full-time case manager working in conjunction with a transition team of staff members from each system.

To community treatment agencies that already provide some substance abuse services to offenders, the panel offers guidelines for improving the postrelease transition process. Agency-level guidelines are also included to help administrators in the criminal justice and substance abuse treatment systems create effective transitional programs. They cover policy and procedural issues, such as role clarification and interagency agreements, and describe opportunities and obstacles that may be encountered when working with state legislatures to support transitional programs.

Continuity of Offender Treatment for Substance Use Disorders From Institution to Community is number 30 in the Center for Substance Abuse Treatment's Treatment Improvement Protocol (TIP) series. All TIPs are available on the CSAT Web page at www.samhsa.gov. They can be ordered free of charge by contacting the National Clearinghouse for Alcohol and Drug Information at 800-729-6686.