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In 1998, there have been a number of highly visible incidents where
children and adults died while being restrained in psychiatric settings.
A 1998 study commissioned by the Hartford Courant on the use of restraints
estimates that between 50-150 deaths each year follow the use of seclusion
and restraint. These media accounts have fueled extensive discussion and
review of seclusion and restraint issues among consumers, family members,
and professional groups.
The National Mental Health Association (NMHA) was founded in 1909 by a
former psychiatric patient, Clifford Beers, who was horrified by the physical
abuse (at time, fatal) he witnessed and experienced in the back wards of
a state hospital in Connecticut. In addition, NMHA takes its symbol from
a 350 pound bell cast from melted down shackles and chains used earlier
this century to tether patients.
NMHA continues to advocate for improved access to the best treatment in
the least restrictive setting possible. Too many Americans with severe mental
illnesses still do not have access to the best community-based services.
This puts them at risk for experiencing psychiatric crises and over-reliance
on acute care services.
Overuse and abuse of restraints and seclusion are symptoms of poor quality
care in facilities, poor state oversight, and misdirected public policy.
State and federal agencies must take a greater role in assuring the safety
and protection of children and adults who experience these interventions.
NMHA supports the following principles regarding the use of seclusion and
restraints in psychiatric settings:
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Use of seclusion and restraint should be based on an individual’s
medical need.
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Seclusion and restraint should be used only after other less
restrictive techniques have been tried and failed, and only in response
to violent behavior
that creates extreme threats to life and safety.
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Facilities should have written procedures governing the use
of restraints. These procedures should require the documentation of
alternative,
less intrusive
intervention approaches that were tried and the rationale why these
failed or were not appropriate.
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Facilities should never use seclusion or restraint as punishment
or for the convenience of staff.
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Use of restraints should always be approved by senior medical staff
and be well-documented and justified in a consumer’s file.
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Seclusion and restraints should be used only for the amount
of time needed to restore safety and security of the consumer and others.
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Facilities should be sufficiently staffed to reduce the need
for physical and chemical restraints and the use of seclusion.
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All staff should be trained and demonstrate competence in non-physical
intervention techniques and in safe use of restraint.
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Facilities must be held accountable for all uses of seclusion
and restraints, collect data and report it to the appropriate state
agency or
regulatory bodies. Failure to produce appropriate data, or adhere
to clinical guidelines should result in sanctions.
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Facilities should apply the use of advanced directives, where
they exist, that address the use of seclusion and restraint.
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When possible, consumers should be informed that specific behaviors
may result in the use of restraint or seclusion and the criteria
for discontinuation of restraints or seclusion. Cooperation of the
consumer with the procedure
should be sought.
NMHA ACTION
NMHA urges the Health Care Financing Administration (HCFA) to consider
more prescriptive requirements concerning the use of seclusion and restraints
in its rule on hospitals’ participation in the Medicare and Medicaid
programs. In April, 1998, NMHA supported standards suggested by HCFA addressing
physician authorization, procedures for utilizing seclusion and restraint,
time limits on the administration of seclusion and restraint, and requirements
for checking patients in seclusion and restraints. These standards, and
others that support the principles listed above, need to be included in
HCFA’s final regulatory language.
In addition, NMHA calls upon state mental health authorities, or the appropriate
state agency that licenses facilities, to develop regular monitoring and
enforcement mechanisms for the use of seclusion and restraint in hospital
and mental health care facilities. States should assume responsibility for
tracking the use of seclusion and restraint in the hospitals and facilities
within their jurisdiction, investigating all anomalies, and imposing severe
sanctions on facilities that do not report data to the appropriate state
agencies or that use seclusion and restraints inappropriately. Furthermore,
NMHA calls upon state mental health directors, in collaboration with professional
mental health groups in the states, to develop models and practice guidelines
that outline the appropriate use of seclusion and restraint for state hospitals
and mental health care facilities.
BACKGROUND ON THE USE OF SECLUSION AND RESTRAINT
If properly used, seclusion and restraint can be a safe and appropriate
intervention with mental health consumers who are violent or injurious to
themselves or others. But appropriate training and careful monitoring are
necessary to avoid misuse and ensure patient safety. The use of seclusion
and restraint procedures place staff and consumers at high risk for physical
injury. The emotional impact of seclusion and restraint can also be severe.
Great care must be taken to protect the dignity and psychological well-being
of children and adults who experience these interventions.
Despite regulations governing the use of seclusion and restraint in most
states and psychiatric facilities, problems abound. There are no clear,
uniform standards or practice guidelines on restraint use across the county
and no minimum training standards for those who administer it. Recent newspaper
stories have reported the following:
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In April, a jury in Florida awarded $18 million to a brain
damaged man who had been kept in restraints for much of his three year
stay
in a state hospital.
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Gloria Huntley, a patient at Central State Hospital in Virginia,
spent hundreds of hours restrained to her bed and died as a result
of inadequate medical care for a resulting heart and lung infection.
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An 11 year old boy died in a Connecticut facility when his
chest was crushed while he was being restrained.
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The Hartford Courant reported that the injury rate to staff
during the use of restraints was higher than that found among lumber
workers, construction
workers, and miners.
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Due to accounts like these, a number of professional and advocacy groups
have called for a broader review of the use of seclusion and restraints
with children and adults in psychiatric settings and the establishment
of some national guidelines. For example:
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In December of 1997, the Health Care Financing Administration
released proposed regulations governing the use of seclusion and
restraint as part
of proposed rules regarding conditions of hospital participation
in Medicare and Medicaid Programs.
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The U.S. Center for Mental Health Services has begun a five-state
pilot program to collect restraint and seclusion data.
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The U.S. Department of Veterans Affairs is tracking deaths
more closely.
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The AMA House of Delegates passed a resolution calling for
the need for development of updated national guidelines for the safe
and clinically appropriate use of seclusion and restraint techniques
with
both children
and adolescents in psychiatric settings.
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The American Academy of Child and Adolescent Psychiatry is
drafting a policy statement on the use of seclusion and restraints and
is
making plans to develop practice guidelines for its members.
WHY WE NEED CHANGE:
CURRENT PROBLEMS IN THE SYSTEM
A number of issues give rise to increased use of seclusion and restraint.
Among these issues are inadequate staff training, cutbacks in facility staffing,
the lack of oversight and monitoring, and the difficulty in holding facilities
or people who abuse these techniques legally accountable. Surveys in states
show wide variability around seclusion and restraint procedures and a lack
of oversight and monitoring.
INADEQUATE STAFF TRAINING
Despite regulations calling for the approval of a physician in most states
and facilities, the people who make and execute critical decisions to
use physical force are often aides, the least-trained and lowest-paid
workers in the field. Also, in some facilities, physicians give staff
the order to restrain as needed. The Hartford Courant reports that only
three states license aides in psychiatric facilities. Consequently, interventions
may be employed by staff without adequate or appropriate training. In
addition, staff are often moved around from unit to unit within facilities.
And less desirable shifts use less trained, part-time workers. A recent
survey of state policies conducted by the National Association of State
Mental Health Program Directors found that most states specified that
staff must be trained in safe and proper seclusion techniques and training
must be documented in the staff files. But only two states provided specific
guidelines on the content of such training.
INADEQUATE STAFFING
Physical restraint procedures require the participation of a number of
staff if they are to be conducted safely. Yet cutbacks in staff at many
institutions—sometimes due to managed care--make it difficult to
have an appropriate and safe number of people involved in the restraint
of a single person. The Hartford Courant investigation revealed that rules
requiring a supervisor to oversee physical restraints are often ignored
by facilities. Restraint, seclusion and other coercive measures are used
more for control and management of the environment than in patient therapy.
THE NEED FOR BETTER DATA COLLECTION
The federal government does not collect data on how many patients are
killed during restraint procedures. Neither do state regulators or accreditation
agencies. Only New York requires the reporting of usage rates for restraints
and investigates all deaths. The state no longer allows each hospital
to decide which deaths are questionable enough to report. It publishes
the numbers, a practice that has resulted in restraint-related deaths
in the past five years being cut nearly in half as compared with the
preceding five years.
THE NEED FOR FEDERAL MONITORING AND OVERSIGHT
Statutory standards for monitoring seclusion and restraint vary from
state to state. The National Association of State Mental Health Program
Directors conducted a state survey in the early 1990s on existing state
policies, procedures, and regulations for the use of seclusion and restraint
with children and adults. Results showed that 19 out of 36 states who
responded had no definition for seclusion and 23 had no definition for
restraint in their regulations. Two states had no written regulations
whatsoever on the use of restraints. Eleven states said there had been
clinical problems with the implementation of their states’ regulations.
Nine states did not enumerate the circumstances under which restraint
could be used. States differed in how specific the documentation must
be to support the use of seclusion and restraint. 13 states did not mention
who was empowered to order seclusion or restraint. Only four states indicated
who is responsible for ending the seclusion and restraint use. Most regulations
did not comment on the use of PRN orders for seclusion or restraint.
Many advocates believe that constant or frequent monitoring is needed and
that Joint Commission on the Accreditation of Healthcare Organizations (JCAHO)
oversight is ineffective at protecting people from abuses. They also believe
that the federal Protection & Advocacy system, which is charged with
investigating charges of abuse in facilities, has too little funding and
too broad of a charge. Comprehensive and independent government oversight
and monitoring is needed.
THE NEED FOR UNIFORM STANDARDS
Due to the lack of uniform standards for seclusion and restraint, hospitals
and other psychiatric facilities are left to reinvent procedures or learn
the hard way. Many advocates believe that dangerous techniques such as
face-down floor holds should be banned and that CPR training should be
required for all direct-care workers in psychiatric facilities.
LACK OF ACCOUNTABILITY FOR ABUSES
There is an understandable reticence on the part of facilities to report
problems. Facilities try to cover up or obscure the circumstances of a
restraint-related death, for example, to guard against litigation. There
is no protection for whistle blowers. Additionally, medical examiners
rarely connect the death of a patient to the use of restraints and rule
the death a homicide. Prosecutors rarely pursue arrests in restraint deaths,
and they frequently accept plea bargains to minor charges. Restitution
comes mainly through civil court, rather than criminal prosecution. There
is no real way to hold the corporate structure accountable.
SPECIAL CONSIDERATION FOR CHILDREN
The use of seclusion and restraints in the treatment of children and
adolescents requires special attention. Nearly 26 percent of the deaths
uncovered by the Hartford Courant were children, even though they constitute
less than 15 percent of the population in psychiatric and mental retardation
facilities (less than 15 percent). A 1995 study from New York found children
almost twice as likely as adults to be restrained. Of the 36 states responding
to the NASMHPD survey, only 12 had regulations on seclusion that specifically
mention children. In 30 of the states, the same regulations apply to the
use of seclusion in adult and child psychiatric facilities. Six have separate
policies and procedures specifically addressing children. While all states
allowed the emergency use of seclusion, only 50 percent permitted the
use of seclusion as a therapeutic treatment modality. Most states did
not differentiate between time out and other behavior modification techniques
and seclusion.
| Effective Period
This policy was approved by the NMHA Board of Directors on June
11, 2000. It will remain in effect for five (5) years and is
reviewed as required by the NMHA Prevention and Adults Mental
Health Services Committee. However, this policy was reviewed
on December 10, 2005 and extended for an additional year.
Expiration: December 10, 2006
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National Mental Health Association
2000 North Beauregard Street, 6th Floor
Alexandria, VA 22311
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