NEW YORK – The use of seclusion and restraint among psychiatric inpatients was successfully reduced by a program involving staff education, changes in policy and practice, and improved communication with patients, Dr. David J. Hellerstein said in a poster presentation at the American Psychiatric Association's Institute on Psychiatric Services.
Although a standard of care has evolved that generally limits the use of the “last resort” measures of seclusion and restraint to instances of imminent harm to the patient or others, the actual use of these practices varies widely, he wrote.
The 58-bed New York State Psychiatric Institute (NYSPI) in upper Manhattan has a large research population as well as the typical state hospital population of patients with schizophrenia and other severe mental illnesses.
Before the program began in 2000, the rates of seclusion and restraint at NYSPI were the highest among the New York Office of Mental Health hospitals, according to Dr. Hellerstein, who is medical director of the psychiatry clinical trials program at Columbia University Medical Center, New York.
This high use was attributed to NYSPI's status as an acute-care hospital that is also a research facility where clinical trials are conducted and patients may be taken off medication at times.
The program includes several components:
▸ Decrease in time of initial restraint or seclusion order from 4 to 2 hours.
▸ Staff education and in-service training.
▸ Relaxation of no-smoking policy.
Some other studies have reported increased rates of injury with reductions in use of restraint and seclusion. In this study, emphasis was also placed on helping staff members manage patients' agitation, psychosis, and potential for violence.
After the program was implemented, there were statistically significant reductions in the mean number of patients secluded–3.18 to 1.13 patients per month–and in length of seclusion–1.28 to 0.09 hours per 1,000 patient-hours, he reported.
The reduction in restraint and seclusion has been maintained through 5 years of follow-up, suggesting that a “culture change” has occurred at NYSPI, he said. Culture change in this context has been described as emphasizing staff sensitivity and training in noncoercive methods of de-escalating possible violence (J. Psychiatr. Pract. 2003;9:7–15).
No increase has been seen in rates of injury to the staff, Dr. Hellerstein said.
Future steps to be taken include the implementation of patient involvement in coping plans and the eventual elimination of the use of restraint, he wrote.