Successful SR Reduction Experiences

1
Improving Safety and Reducing Violence
Implementing Trauma Informed Care

• Successful S/R Reduction Experiences
• What Worked?
• November 7, 2007

2
The Pennsylvania Seclusion Restraint Reduction
Program
Donna Ashbridge, RN, MS Chief Executive
Officer Danville State Hospital Danville,
Pennsylvania
Gregory M. Smith, MS Chief Executive
Officer Allentown State Hospital Allentown,
Pennsylvania
3
The PA State Hospital System

• The Pennsylvania State Hospital System is
• the largest provider of inpatient psychiatric
• care in the Commonwealth.
• The system is comprised of
• 8 state hospitals
• 3 regional forensic units at Mayview, Norristown,
  Warren State Hospitals
• 1 restoration center serving older individuals
  with persistent mental illness

4
The PA State Hospital System

• Full-time civil and forensic staff 4,719
• Typical unit (32 beds) in civil hospitals is
  staffed with 2 RNs 3 psychiatric aides on 1st
  2nd shifts
• People served 2,130
• Civil 1,800 Forensic 200 LTC 130.
• Gender 64 men, 36 women, Avg. age 42
• gt1,000 civil admissions discharges/year
• Provides 65,000 days of care/month

5
Who Pennsylvania Serves

• 68 diagnosis of schizophrenia or related
  psychotic disorder
• 50 co-occurring substance use diagnosis
• 10 diagnosis of MR/DD
• 30 in civil hospitals have a criminal
  history
• 50 in civil hospitals have an LOR of 2 years

6
PA State Hospital SystemIs Reduction Possible?
Is Elimination Possible?

• Restraint use early 1990s
• 140,000 hours of restraint/year
• Equivalent to 16 consumers in restraint 24
  hours/day, 365 days/year
• Seclusion use early 1990s
• 96,000 hours of seclusion/year
• Equivalent to 10 consumers in seclusion 24
  hours/day, 365 days/year

7
PA State Hospital SystemCritical Factors in
Change

• State Leadership
• Established goals, and supported staff to make
  changes
• 1990s 5 Deputy Directors, 3 Medical Directors
  all promote change, make S/R elimination top
  priority
• 1996 Charles Curie declares S/R a treatment
  failure
• 1999 S/R orders limited to 1 hour,
• Incrementally decreased - 2005 max
  order 15
• - 2006 PA DHHS declares statewide goal of S/R
  elimination across multiple agencies serving
  array of populations
• (NETI, 2006 Smith et al 2005)

8
PA State Hospital SystemCritical Factors in
Change

• Resources re-deployed, no new money
• Primary Prevention
• Implemented universal risk assessment
• Created consumer-centric culture of care
• Meaningful treatment alternatives created
• Consumer choices
• Elimination of rules for staff convenience
• Awareness of re-traumatization
• Respectful care

9
PA State Hospital SystemCritical Factors in
Change

• Secondary Prevention
• Increased training in de-escalation, not S/R
  techniques
• Psychiatric Emergency Response Teams implemented
  all hospitals
• Tertiary Prevention
• Patient, staff administrative debriefing -
  every incident reviewed by executive team
  advocate daily
• (NETI, 2006 Smith et al, 2005)

10
PA State Hospital SystemCritical Factors in
Change

• Data
• Active use of data from performance measurement
  system supports quality improvement process
• Collect data on all episodes of S/R
• Separate system for recording psych use of PRN
  STAT medication use
• Reporting based on a 1-page incident report
  format
• Consumer perspective Report

11
PA State Hospital SystemCritical Factors in
Change

• Facility CEO Leadership
• Sets/keeps the standard for positive,
  non-offensive culture
• Reviews every restraint event and follows-up.
• Gets directly involved in debrief process
  following a restraint event with treatment team.
• Identifies organizational barriers that impede
  efforts to eliminate SR.
• Makes non-restraint approach a basis for MD
  hiring
• Adopts patient centered policies/procedures.
• Involves employee unions in the change.
• Celebrates success.

12
Pennsylvania State Hospital Use of
SeclusionCivil Forensic Services1990 Through
2006
13
Pennsylvania State Hospital Use of Mechanical
RestraintCivil Forensic Services1990 Through
2006
14
Pennsylvania Today

• November, 2003 State Hospital system
• (civil side) achieved first seclusion-free month
  in 100 year history
• 7 / 8 State Hospitals have been seclusion-free
  for more than one year
• June 2, 2005 Danville State Hospital becomes
  first hospital to go 2 years without using S/R.
  Now, Allentown Torrence State Hospitals are
  S/R-free, too. (NETI, 2006 Smith et al, 2005)

15
PennsylvaniaContact Information

• Gregory M. Smith, M.S.
• Chief Executive Officer
• Allentown State Hospital
• 1600 Hanover Avenue, Bldg. 11
• Allentown, PA 18109-2498
• (717) 772 - 7609
• grsmith_at_state.pa.us