Transcript The Basics in Restraint and Seclusion

The Basics in Restraint and
Seclusion
Leslie Morrison
Director, Investigations Unit
Disability Rights California
(510) 267-1200
[email protected]
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What is restraint?
Restriction of freedom of movement, physical
activity or normal access to one’s body
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Medical
◦ Used during surgical diagnostic, dental or other medical procedure
◦ Used for proper body position balance or alignment or to improve
mobility
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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 isn’t 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 individual’s behavior or to restrict
individual’s freedom of movement & is not a
standard treatment or dosage for
individual’s medical/physical condition
[Medication given involuntarily in an emergency to
control aggressive or violent behavior.]
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.
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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
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Doesn’t matter if door is locked or even
closed
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Doesn’t include ‘voluntary’ time out
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Doesn’t include restriction to area
consistent with unit rules or an individual’s
treatment plan
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What we know about restraint and
seclusion…
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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;
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 Most frequent antecedent to use of mechanical restraint was
staff initiated encounter;
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Mostly used for loud, disruptive, non-complaint behavior;
Generally stems from a power struggle.
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Conditions on Use
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Only used:
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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.
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Never for coercion, discipline, convenience or retaliation by staff
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Only by staff with specific, current training and demonstrated competence in
application
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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

Requires certain level of monitoring or observation
Where are standards?

Federal law
◦ Hospitals
◦ Residential Facilities for
Adolescents
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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 deescalation or use of R vs. S
◦ Early warning
signs/triggers/precipitants,
◦ Techniques that help person
maintain/regain control,
◦ Pre-existing medical conditions,
trauma history.
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Post-Incident Debriefing
◦ ID & understand precipitant(s);
◦ Alternatives/other methods of
responding;
◦ Revise plan to address root
cause;
◦ Was it necessary & done right?
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Data
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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 Model
focus on prevention NOT how to do more safely or better
Universal Precautions
Environment that
minimizes potential
for conflict by
anticipating risk
factors
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Organizational values
Trauma informed care
Stigma
Early assessment of
risk factors
Recovery Model
Tertiary Intervention
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
After incident, rigorous
problem solving,
mitigate effects, take
corrective action
[Application of R/S]
 Debriefing
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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
4. Implement
Seclusion/Restraint
Prevention Tools
 Trauma Assessment; Risk
 Safety Plans; Triggers
5. Actively Recruit & Involve
Consumers and Families
3. Develop the Workforce
 Competencies; Performance
Evals
 Training
6. Make Debriefing
Rigorous
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