The Basics in Restraint and Seclusion

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The Basics in Restraint and Seclusion

• Leslie Morrison
• Director, Investigations Unit
• Disability Rights California
• [phone]
• Leslie.Morrison_at_disabilityrightsCA.org

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What is restraint?

• Restriction of freedom of movement, physical
  activity or normal access to ones body
• Medical
• Used during surgical diagnostic, dental or other
  medical procedure
• Used for proper body position balance or
  alignment or to improve mobility
• Behavioral
• In emergency situations for an unanticipated
  outburst of aggressive or violent behavior that
  poses an immediate, serious risk of physical harm
  
• Physical force manual holds
• Mechanical device, material or equipment
• Chemical drugs

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What isnt considered a restraint?

• Briefly holding a individual to calm or comfort
• Brief interactions to redirect or assist with
  activities of daily living.
• Devices used for security or transport

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What is chemical restraint?

• Medication used as a restriction to manage an
  individuals behavior or to restrict individuals
  freedom of movement is not a standard treatment
  or dosage for individuals medical/physical
  condition
• Medication given involuntarily in an emergency
  to control aggressive or violent behavior.
• Not medication routinely prescribed to treat
  individuals 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.

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What is seclusion?

• Involuntary confinement of a person alone in a
  room or an area where the person is physically
  prevented from leaving
• Doesnt matter if door is locked or even closed
• Doesnt include voluntary time out
• Doesnt include restriction to area consistent
  with unit rules or an individuals treatment plan

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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
• May cause death even when done safely and
  correctly
• Leaves lasting psychological scars
• Decision is almost always arbitrary,
  idiosyncratic, and generally avoidable
• Most frequent antecedent to use of mechanical
  restraint was staff initiated encounter
• Mostly used for loud, disruptive, non-complaint
  behavior
• Generally stems from a power struggle.

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Conditions on Use

• Only used
• in emergencies,
• when other less restrictive alternatives have
  failed,
• for the least amount of time necessary, and
• in least restrictive way
• to prevent imminent risk of physical harm.
• Never for coercion, discipline, convenience or
  retaliation by staff
• Only by staff with specific, current training and
  demonstrated competence in application
• Only upon MD order OR, in emergency, at
  discretion of RN
• Never as a standing order
• Limits on order duration
• Face to face assessment by MD or specially
  trained RN/PA
• within one hour at hospital
• other timeframes apply for other settings

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Where are standards?

• Federal law
• Hospitals
• Residential Facilities for Adolescents
• State Law and Regulations
• By facility type
• Joint Commission on Accreditation of Healthcare
  Organizations (JCAHO)
• Not all facilities
• By facility type

• 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

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Health Safety Code 1180

• 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

• 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.

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Public Health Modelfocus on prevention NOT how
to do more safely or better

• Tertiary Intervention
• After incident, rigorous problem solving,
  mitigate effects, take corrective action
• Application of R/S
• Debriefing

• Universal Precautions
• Environment that minimizes potential for conflict
  by anticipating risk factors
• Organizational values
• Trauma informed care
• Stigma
• Early assessment of risk factors
• Recovery Model

• Secondary Intervention
• Immediate effective early intervention
  strategies to minimize conflict and aggression
  when they occur
• Individual assessment of risk
• Individual crisis plans to teach emotional
  self-management
• De-escalation skills
• Staff training on attitude self-awareness
  during conflict
• Sensory modulation tools
• Comfort rooms

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6 Core Strategies

• 1. Leadership Toward Organizational Change
• Create vision clarify values
• 2. Use Data to Inform Practices
• Core Data
• Post Publicly
• 3. Develop the Workforce
• Competencies Performance Evals
• Training

• 4. Implement Seclusion/Restraint Prevention Tools
• Trauma Assessment Risk
• Safety Plans Triggers
• 5. Actively Recruit Involve Consumers and
  Families
• 6. Make Debriefing Rigorous