MONITORING RESTRAINT USE
to
IDENTIFY BEST PRACTICES
Roderick Shaner, M.D.
rshaner@dmh.lacounty.gov
Alysa Solomon, Ph.D.
asolomon@dmh.lacounty.gov
Los Angeles County Department of Mental Health
and
The Saks Institute for Mental Health Law at
University of Southern California
Policy and Ethics
April 22, 2011
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SAMHSA National Action Plan on
Seclusion and Restraint
Revised and Adopted May 2003
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The use of seclusion and restraint on persons with
mental health and/or addictive disorders has resulted in
deaths and serious physical injury and psychological
trauma. In 1998, the Harvard Center for Risk Analysis
estimated deaths due to such practices at 150 per
annum across the nation.
SAMHSA has set forth a vision to reduce and ultimately
eliminate the use of seclusion and restraint practices for
all age groups in behavioral health care settings both
institutional and community-based. The agency
recognizes that these are to be used solely as safety
interventions designed to protect consumer and staff
safety. The focus is on identifying and encouraging the
application of alternatives to prevent such use.
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SAMHSA National Action Plan on Seclusion
and Restraint: 5 Domains
Data Collection
 Evidence-Based Practices and Guidelines
 Training and Technical Assistance
 Leadership and Partnership Development
 Rights Protection
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April 02, 2010 - For immediate release:
Massachusetts Sweeps First-Ever National Award
for Reducing and Eliminating Restraint and
Seclusion
 BOSTON — Massachusetts swept the first-ever
awards given by the U.S. Substance Abuse
Mental Health Services Administration
(SAMHSA), recognizing sustained restraint and
seclusion reduction and prevention work. Five of
the ten awards were given to Massachusetts'
facilities, including Taunton State Hospital and
the nine child/adolescent statewide programs
operated by the Department of Mental Health
(DMH).
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SB 130 (Chesbro) 2003
Legislative findings
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(a) The use of seclusion and behavioral restraints is not
treatment, and their use does not alleviate human
suffering or positively change behavior.
(b) Good milieu programs, interesting activities, and
attention to every person's need for sufficient space all
contribute to an environment in which the use of
seclusion and behavioral restraints can be minimized.
(g) It is the intent of the Legislature in enacting this act to
achieve a reduction in the use of seclusion and
behavioral restraints in facilities in California.
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SB 130 (Chesbro) 2003
(became CA Health and Safety Code1180.3)

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(a) This section shall apply to psychiatric units of general acute care
hospitals, acute psychiatric hospitals, psychiatric health facilities, crisis
stabilization units, community treatment facilities, group homes, skilled
nursing facilities, intermediate care facilities, community care facilities, and
mental health rehabilitation centers.
c) (1) The secretary or his or her designee shall take steps to
establish a system of mandatory, consistent, timely, and publicly
accessible data collection regarding the use of seclusion and
behavioral restraints in all facilities described in subdivision (a)
that utilize seclusion and behavioral restraints.
It is the intent of the Legislature that data be compiled in a manner
that allows for standard statistical comparison and be maintained for
each facility subject to reporting requirements for the use of
seclusion and behavioral restraints.
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SB 130 (Chesbro) 2003
1180.4
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(k) A person in a facility described in subdivision (a) of
Section 1180.2 and subdivision (a) of Section 1180.3 has
the right to be free from the use of seclusion and
behavioral restraints of any form imposed as a means of
coercion, discipline, convenience, or retaliation by staff.
This right includes, but is not limited to, the right to be
free from the use of a drug used in order to control
behavior or to restrict the person's freedom of
movement, if that drug is not a standard treatment for the
person's medical or psychiatric condition.
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California Psychiatric Association
Revised position statement 2011
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Seclusion and restraints are not treatment.
Properly designed mental health facilities, with
adequate staffing with trained mental health
personnel, should be used to make the use of
seclusions and restraints unnecessary in almost all
behavioral emergencies.
In the absence of proper design and staffing, however,
preventing responsible physicians from ordering
seclusion and restraint during serious behavioral
emergencies is a misguided practice that exposes
patients, staff, and the community to grave risks.
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Changing S&R use at DMH
The expressed concerns
Environmental safety
 Liability
 Patient safety
 Personal/moral responsibility for fellow
man.
 Therapeutic effects
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Ending DMH MHC S&R (1)
POLICY
2-3.1 Aggressive client behavior: Forceful actions directly expressed physically
or verbally by a client that have caused or may indicate the potential for
causing bodily injury in LAC-DMH outpatient clinics and programs should be
clinically managed in a manner that maximizes safety for everyone, respect
for the client, and recognition of the therapeutic mission of our services.
3.2 LAC-DMH staff may not use mechanical restraint or involuntary seclusion to
clinically manage aggressive client behavior.
3.2.1 In situations in which there is immediate risk to life, staff may
intervene as necessary in order to mitigate that risk, including
calling 911 for emergency assistance.
3.3 While the following procedures apply to adults, those under the age of 18
should also be managed without seclusion and restraints, but in accordance
with recognized responsibilities to act in specific situations in order to
protect children from harm.
ttp://dmhhqportal1/Document%20Library/IIPP.pdf
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Ending DMH MHC S&R (2)
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In a situation in which a client or individual
wishes to leave the clinic, staff shall not
attempt to physically detain that person or
physically impede the way to the exit.
Rather, staff shall attempt to safely and
respectfully convince the client to stay,
discussing the reasons for staying,
alternatives and possible repercussions.
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Ending DMH MHC S&R (3)
In situations in which the client placed on an
involuntary hold wishes to leave the
clinic:
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Every attempt shall be made to convince the patient to
stay.
In situations in which the patient is likely to leave,
notify the program head or designee, and request
assistance from law enforcement when indicated.
In situations in which there is immediate risk to life,
staff may, but shall not be required to, intervene as
necessary in order to mitigate that risk, including calling
911 for emergency assistance.
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The rationale for LAC DMH review
of inpatient S&R

DMH has statutory responsibility for
reporting S&R in LPS designated facilities

California Welfare & Institutions Code (WIC):
5326.1
DMH considers quality of care in LPS
facility designation and re-designation
 DMH will monitor restraint use in LPS
designated facilities to determine quality of
care issues
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The challenge for LAC DMH review
of inpatient S&R
Collect useful data
 Define comparison methodology among
diverse hospitals
 Determine outliers
 Determine opportunities for improvement
 Determine interventions
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Incident Rate by LPS Hospital FY 2009
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LACDMH’s Progress (con’t)
Revision of Denial of Rights form
 New data collection/reporting process
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Consult with National Association of State
Mental Health Program Directors
(NASMHPD), National Research Institute, Inc
(NRI) www.nri-inc.org
Begin with LPS Designated settings
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Formulas for Calculating
Comparison Rates

The choice of formulas depended on the
assumption of the underlying distribution and
assumes that non-normal distributions are used
for fair comparison. These formulas include
statistical adjustments used to approximate a
normal distribution. These formulas are taken
from Joint Commission requirements for
calculating comparison rates. Please email us
for a copy of the formulas.
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Joint Commissions

Joint Commission along with NASMHPD is
now requiring all accredited psych
hospitals via the ORYX system to report
hours of Seclusion and Restraint use as
part of their core measures:
http://www.jointcommission.org/accreditati
onprograms/hospitals/oryx/
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Roadmap to Seclusion and
Restraint Reduction
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SAMHSA’s Roadmap to Seclusion and Restraint
Free Mental Health Services:
http://www.samhsa.gov/samhsa_news/VolumeXI
V_4/article13.htm
UK’s National Institute for Clinical Excellence
(NICE) Guidelines:
http://www.nice.org.uk/niceMedia/pdf/2005_003_
NICE_launches_clinical_guideline_disturbed_viol
ent_behaviour.pdf
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Health Reform Notes

Eligibility = Enrollment

LAC/DMH holds responsibilities for California laws
Health & Safety Code 1180 & 11.80.6 which address
the imposition of behavioral restraints and the right to
be free from the use of a drug used in order to control
behavior for individuals with psychiatric conditions
during enrollments.
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Debrief
This will extend to individuals with substance abuse
issues without psychiatric conditions.
This will be explicit on LA County’s 1115 Waiver.
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Health Reform Notes (con’t)
Patient will have the ability to choose their
health care provider.
 Health providers will no longer cover billing
for those held in mechanical restraint over
10 minutes and in psychiatric crisis;
providers will have to know how to deescalate individuals who are presenting.
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Additional Websites

Center for Medicare and Medicaid Services Final Interim Rule
Available:
http://www.cms.gov/CFCsAndCoPs/downloads/finalpatientrightsrule.
pdf
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Restraint and Seclusion – A Risk Management Guide:
http://www.nasmhpd.org/general_files/publications/ntac_pubs/RS%20RISK%20MGMT%2010-10-06.pdf
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Crisis Prevention Institute:
http://www.crisisprevention.com/
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Therapeutic Crisis Intervention: http://rccp.cornell.edu/TCIpage1.htm
Hartford Courant articles :http://articles.courant.com/1998-1017/news/9810170180_1_mental-retardation-psychiatric-restraints
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