1 The Basics of Behavioral Restraint and Seclusion Leslie Morrison Director, Investigations Unit Disability Rights California (510) February 2013

2 Defining Terms Restraint 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: Briefing holding to calm or comfort Brief assistance to redirect or prompt Devices used from transportation or security Seclusion Seclusion Involuntaryalone physically prevented from leaving 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 May increase negative behavior and decrease positive behavior. Is traumatic and potentially physically harmful to staff and the individual. Does not keep people safe. May cause death even when done “safely” and correctly. Leaves lasting psychological scars. Decision is almost always arbitrary, idiosyncratic, and generally avoidable. Facility culture Facility culture (staff role perceptions, training, program philosophy, facility leadership) has greater influence on the use of restraint & seclusion than clinical factors. 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. Lack of training in managing behavioral crisis contributing factor 90% of JCAHO restraint deaths. 4

Myths/Assumptions Reality Myths/Assumptions vs. Reality Keeps people (staff & consumer) safe Only used when absolutely necessary and for safety reasons Staff can recognize potentially violent situations Known to cause injury, death and last psychological trauma; Higher worker injury rate than in lumber, construction and mining Most often used for non-compliance, inappropriate behavior or power struggle (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 de- escalate Used without bias and only in response to objective behavior Therapeutic and based on clinical knowledge Restraint/seclusion used for safety not punishment 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 Cultural and social bias, staff role perception, administrator attitudes No controlled studies, no measure of efficacy or therapeutic value; shown to increase negative behavior (6) studies = 58-75% perceived as punishment 6

Whose Pre-disposed? No “typical” patient profile No consistent demographics No consistent clinical characteristics Although individuals w/trauma or abuse history at greater risk… √ √ Staff profile 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

8 Dangers Physiological 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 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 Environmental Creates a violent and coercive environment that undermines forming trusting relationships Risks with Medication Risks with Medication Sedation contributing to respiratory depression & arrest

Conditions on Use Only used 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. coercion, discipline, convenience retaliation Never for coercion, discipline, convenience or retaliation by staff training competence Only by staff with specific, current training and demonstrated competence in application order Only upon MD order OR, in emergency, at discretion of RN ◦ Never as a standing order ◦ Limits on order duration Face to face Face to face assessment by MD or specially trained RN/PA ◦ within one hour [at hospital]; ◦ other timeframes apply for other settings monitoringobservation Requires certain level of monitoring or observation

Where & What are the Standards? Federal law Hospitals Residential Facilities for Adolescents State Law and Regulations By facility type Joint Commission Not all facilities By facility type 10 What standards? Duration of orders Type of observation frequency of monitoring MD consultation & oversight Documentation requirements Staff training elements Reporting requirements, data collection Quality Improvement criteria

11 Additional State Requirements Health & Safety Code §1180 Prohibits risky practices: Obstruct airway or impair breathing 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 If prone, must observe for distress Prone mechanical restraint with those at risk for positional asphyxiation, unless written authorization by MD. Intake assessment with consumer input Advanced directive on de- escalation or use of R vs. S Early warning signs/ triggers/precipitants, Techniques that help person maintain/regain control, Pre-existing medical conditions, trauma history. Post-Incident Debriefing ID & understand precipitant(s); Alternatives/other methods of responding; Revise plan to address root cause; Was it necessary & done right? Data

12 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 priority and focus 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 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) Rigorous debriefing of every incident with involvement of senior administration Use data to inform practices Public reporting & posting Rigorous analysis Consumers Actively Recruit & Involve Consumers and Families Peer advocates in debriefing Facility committees & positions 13

Principles of Trauma-Informed Care Program and services based on: Understanding vulnerabilities and triggers of trauma survivors that can be triggered in traditional service delivery systems Designed to be supportive and avoid re-traumatization Respect individuals. 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 vs. Responding out of Hope (caring, patient, & supportive) vs. Reacting out of Fear (rule driven, reactive, restrictive)

15 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 Tertiary Intervention After incident, rigorous problem solving, mitigate effects, take corrective action Post S/R interventions to mitigate effects Debriefing Corrective Action Secondary Intervention Immediate & effective early intervention strategies to minimize conflict and aggression when they occur o Individual assessment of risk o Individual crisis plans to teach emotional self-management o De-escalation skills o Staff training on attitude & self-awareness during conflict o Sensory modulation tools o Comfort rooms