The Basics in Restraint and Seclusion

1. The Basics in Restraint and Seclusion Leslie Morrison Director, Investigations Unit Disability Rights California (510) 267-1200 Leslie.Morrison@disabilityrightsCA.org

2. What is restraint? Restriction of freedom of movement, physical activity or normal access to one’s body • Medical • Used during surgical diagnostic, dental or other medical procedure • Used for proper body position balance or alignment or to improve mobility • 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”]

3. 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

4. What is “chemical restraint”? Medication used as a restriction to manage an individual’sbehavioror to restrict individual’s freedom of movement & is not a standard treatment or dosagefor 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.

5. What is seclusion? Involuntary confinement of a person alone in a room or an area where the person is physically prevented from leaving • Doesn’t matter if door is locked or even closed • Doesn’t include ‘voluntary’ time out • Doesn’t include restriction to area consistent with unit rules or an individual’s treatment plan

6. What we know about restraint and seclusion… • 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; • Most frequent antecedent to use of mechanical restraint was staff initiated encounter; • Mostly used for loud, disruptive, non-complaint behavior; • Generally stems from a power struggle.

7. Conditions on Use • Only used: • 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. • Never for coercion, discipline, convenience or retaliation by staff • Only by staff with specific, current training and demonstrated competence in application • Only upon MD orderOR, 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

8. Where are standards? • Federal law • Hospitals • Residential Facilities for Adolescents • 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

9. Intake assessment with consumer input Advanced directive on de-escalation or use of R vs. S Early warning signs/triggers/precipitants, Techniques that help person maintain/regain control, Pre-existing medical conditions, trauma history. Post-Incident Debriefing ID & understand precipitant(s); Alternatives/other methods of responding; Revise plan to address root cause; Was it necessary & done right? Data 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. Health & Safety Code §1180

10. Universal Precautions Environment that minimizes potential for conflict by anticipating risk factors Organizational values Trauma informed care Stigma Early assessment of risk factors Recovery Model Tertiary Intervention After incident, rigorous problem solving, mitigate effects, take corrective action [Application of R/S] Debriefing Public Health Modelfocus on prevention NOT how to do more safely or better • 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

11. 1. Leadership Toward Organizational Change Create vision; clarify values 2. Use Data to Inform Practices Core Data Post Publicly 3. Develop the Workforce Competencies; Performance Evals Training 4. Implement Seclusion/Restraint Prevention Tools Trauma Assessment; Risk Safety Plans; Triggers 5. Actively Recruit & Involve Consumers and Families 6. Make Debriefing Rigorous 6 Core Strategies