Reducing Behavioral
Restraint & Seclusion &
SB 130
Leslie Morrison, MS, RN, Esq.
Protection and Advocacy, Inc.
Investigations Unit
Leslie.Morrison@pai-ca.org
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Six Core Strategies
Culture Change
1. Leadership toward Organizational Change
Articulating [& living by] a mission & philosophy of reduction
& elimination
Management oversight of every S/R event (“witnessing”)
Holding people accountable
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Reduction action plan
Performance improvement team
2. Use of Data to Inform Practice: publicly available
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# of incidents, duration, injuries, [stat involuntary med use]
By unit, shift, day, staff member
Set improvement goals from baseline
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National Technical Assistance Center
&
National Association of State Mental Health Program Directors
DMH RESTRAINT STATISTICS
Frequency and Duration per 1000 Hospital Hours
2005
1st Quarter 2005
Facility
ASH
MSH
NSH
PSH
Total # of
Episodes
Duration per
1000 Hosp
Hrs
Seclusion
22
0.13
Restraint
253
Walking
2nd Quarter 2005
Mean
Duration in
Hours
Total # of
Episodes
Duration per
1000 Hosp
Hrs
Mean
Duration in
Hours
16.5
56
0.41
20.20
3.02
32.55
283
2.38
23.52
75
0.22
8.0
83
0.20
6.90
Seclusion
46
0.04
1.2
4
0
1.30
Restraint
830
2.40
4.3
694
2.13
4.44
Walking
90
0.60
9.9
26
0.08
4.60
Seclusion
279
1.45
12.4
209
0.95
11.10
Restraint
444
4.49
24.2
562
6.05
26.23
Walking
185
0.83
10.7
214
0.92
10.50
Seclusion
341
1.11
9.4
311
0.93
9.20
Restraint
821
4.26
15.0
612
2.57
12.90
Walking
793
1.82
6.6
554
1.12
6.20
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Napa State Hospital
Total Restraint or Seclusion Hours
30000
Total S/R
Hours
25000
24442.7
19294.3
Restraint
20000
17430.2
16183.6
15000
14740
Walking
10732.2
10000
9360.2
6443.2
3471.3
Seclusion
4898.5
3484.1
2241.6
1980.1
2312.7
5000
3729.7
3528.4
1485.6
1431.4
Jan-March April-June July-Sept.
2004
2004
2004
Oct-Dec.
2004
866.4
302.4
Jan-March
2005
0
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3. Workforce Development
“Culture Change” “Trauma Informed Care” “Recovery”
l Training
l Job Description
l Performance Evaluation
l Involvement of/equal partnership w/consumers, family
members, advocates
4. Use S/R Reduction Tools
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Risk Assessment: trauma history, risk for violence, medical risks
De-escalation plans: identifying emotional triggers; developing
awareness of interpersonal & environmental stressors
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Comfort Rooms
Daily Meaningful Activities
National Technical Assistance Center &
National Association of State Mental Health Program Directors
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5. Consumer/Family/Advocate Roles in Inpatient
Settings
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Full & formal inclusion in S/R reduction roles: Director of
Advocacy Svc, Peer Specialist, Consumer Advocate
6. Debriefing Techniques
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Immediate post-event debriefing: assure safety, interview all
involved, return to ‘pre-crisis’ milieu
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Treatment team review: root cause analysis
National Technical Assistance Center &
National Association of State Mental Health Program Directors
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Center for Medicaid & Medicare Services
Webcast
“Reducing the Use of Seclusion & Restraint in
Psychiatric Facilities”
[aired Sept. 23rd but available for viewing]
“This broadcast was designed to provide a brief overview
of the history of this initiative, emerging findings on
effectiveness, a review of the core theories and
literature that added support to the development of the
6 core strategies and recommendations for
administrative and practice change.”
http://cms.internetstreaming.com
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SB 130 /
Health & Safety Code § 1180
“The use of seclusion and behavioral restraints is
not treatment, and their use does not alleviate
human suffering or positively change behavior.”

Treatment failure
“The commitment of managers and staff is
essential to changing the culture of those
facilities and reducing he use of seclusion and
behavioral restraints.”
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Involving clients
Good milieu programs & attention to person’s needs
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Components
1.
2.
3.
4.
Alternatives
l Technical assistance & training programs with
consumer involvement
l Intake assessment
l Proactive interventions
Safeguards
Data
l Mandatory, consistent, timely, publicly accessible
Debriefing
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Oversight Structure
ultimately falls to HHS
HHS
DMH
DDS
DHS
DSS
State Hospitals
Developmental Centers
Hospitals
Acute Psychiatric Hospitals
Community Care Facilities
PHF
Community Treatment
Facilities
Chemical Dependence
Recovery Hosp.
Adult Residential Facilities
Special Treatment Program
at IMD
Regional Centers
Skilled Nursing Facilities,
including IMDs
Group Homes
Intermediate Care
Facilities (ICF)
Residential Treatment
Facilities
Mental Health Rehad. Ctrs
Certify Social Rehab.
Program at RTFs & CTFs
Community Service
Vendors
Standards for some ICFs
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1.
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Alternatives
Intake assessment with consumer input
Advanced directives to de-escalate, early warning signs/triggers,
techniques that help person maintain/regain control, preexisting medical conditions, trauma history,
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Proactive interventions
Avoidance, crisis management, responding to reasons underlying
behavior, conflict resolution, effective communication, positive
early intervention
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Technical assistance & training programs with consumer
involvement
Alternatives (above); trauma mitigation, minimizing duration, &
ensuring safety when R/S
H&S § § 1180.3(b)(2) & 1180.4(a)
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2. Safeguards
Prohibited:
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Restraint that obstructs airway or impairs breathing
Physical/manual restraint of person w/known medical/physical risks
Prone with hands restrained behind back
Containment as extended procedure
Prone mechanical restraint with those at risk for positional asphyxiation,
unless written authorization by MD
Avoid prone containment
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1 staff to observe for physical distress
Constant face-to-face observation when in seclusion AND restraint
unless facility currently okay to use video
Right to be free from use of a drug to control behavior or restrict
freedom of movement & not standard treatment for condition
H&S § 1180.4
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3.
Data
A mandatory, consistent, timely, publicly accessible
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Number of incidents
Duration of incident
Deaths of patients occurring while or proximately related to S/R
Serious injuries to patient and staff
Number of involuntary emergency medications
Available on internet
Currently only state facilities reporting
H&S §1180.3(c)
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Physical, Non-ambulatory Restraint
per 1000 hospital hours
by State Hospital
8
NSH
7
6.89
6
6.05
PSH
5
4.49
4.26
System
4
3.67
3.72
3.33
2.57
3.02
MSH
3.77
2.57
2.38
2.4
2.27
2.21
3
2.58
2.29
2.13
2.77
2.25
1.61
1.47
1.11
2
1
0.63
ASH
0
Jan-March
2004
April-June
2004
July-Sept.
2004
Oct.-Dec.
2004
JanuaryMarch 2005
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4.
Debriefing
ASAP [within 24 hours] with resident, involved staff &
supervisor
Purpose: How to avoid a similar incident in future?
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Assist resident
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Assist staff
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Identify precipitant
Suggest safe, constructive methods for responding
Understand precipitants
Develop alternative to help resident
Revise treatment interventions to address root cause
Assess if S/R was necessary & done consistent with
training & policies
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H&S §1180.5
What’s Happened Since SB 130?
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Use, injuries & deaths reportedly & seemingly
decreasing
State facilities publishing some data
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All other facilities – no data published
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HHS promises to move forward with mandated
reporting from all facilities
No technical assistance or training programs
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Improvements recommended
Trending over time? Comparing with other facilities?
State facilities revised training but w/out consumer
involvement
Continued problems with culture change
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Definitions
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Behavioral Restraint – restraint used as an
intervention when a person presents an immediate
danger to self or to others:
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mechanical – using a mechanical device, material or
equipment attached/adjacent to person’s body that restricts
freedom of movement
physical – use of a manual hold to restrict freedom of
movement of or normal access to all/part of persons’ body
and is used as a behavioral restraint
excludes medical, postural, devices to prevent injury or
improve mobility
Containment – brief physical restraint to effectively
gain quick control of person who is aggressive or
agitated or who is a danger to self or others
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Facilities l
General Acute Care Hospitals
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Not ERs yet
Acute Psychiatric Hospitals
Psychiatric Health Facilities (PHFs)
Crisis Stabilization Units (23 hour)
Community Treatment Facilities
Group Homes
Skilled Nursing Facilities
Intermediate Care Facilities
Community Care Facilities
Mental Health Rehabilitation Centers
State Facilities
Seclusion – involuntary confinement of a person alone in a room
or an area from which the person is physically prevented from
leaving; Excludes timeout
Serious Injury – any significant impairment of the physical
condition as determined by medical personnel, includes burns,
lacerations, bone fractures, substantial hematoma, or injuries to 18
internal organs