A CHRONICLE OF SECLUSION AND RESTRAINT IN AN INTERMEDIATE-TERM CARE FACILITY

Adolescent Psychiatry, 2003 by Petti, Theodore A, Somers, John, Sims, Linda

The use of a rigid behavioral protocol using ambulatory wrist-to-waist restraints in combination with psychoeducational interventions was instrumental in helping Chantelle transfer external control measures to internal ones. In addition, her work in language therapy enabled better self-expression, which increased her ability to manage conflict and to engage more insightfully with psychotherapy. This case is meant to illustrate when restraint is the "least restrictive alternative for managing aggression" (Troutman et al., 1998, p. 557).

The intellectual level of youth admitted to the YS program has steadily dropped into the borderline range. This change has had a major impact on the S&MR rate. Many of these patients, like Chantelle, have developmental receptive and expressive language disorders. The proportion of families able to work regularly with staff for their children's transition back to home and community has decreased markedly. The average length of stay had climbed to a year and more.

Our YS is located within a heavily bureaucratized state hospital. It consists of 42 beds, 31 of which are devoted to middle and high school populations. The patients are housed in three clinical units by school classification. In relation to the other Indiana state hospital programs serving youth, YS provides the only services for adolescent girls, is one of two hospitals providing inpatient services to elementary-age children, and is one of three programs serving adolescent boys.

During the period in which major effort was devoted to decreasing the S&MR rates and duration of use, many changes occurred. These included adjusting to the closing of another state hospital that led to the subsequent expansion of beds from 34 to 42 and a significant upheaval in staff composition. The eight additional beds were used to create a unit to house boys and girls of middle-school age. This unit had significantly higher rates of S&MR than did the other two units. Two years into this report, LCH moved away from the university campus and into a former Veterans Administration Hospital.

The new facility, a designated historical site, was notable for its "soft" interior as contrasted with the institutional hardness of the former state hospital, and for environmental blind spots that reduced the ability to monitor patients. In addition, the hospital itself experienced erosion in numbers of professional and direct care staff after the relocation. We unofficially estimate the turnover as about 60% due to replacement of LCH YS staff by those with greater seniority from the closed non-university-affiliated hospital. This merging of staff culminated in a significant blending of two different cultures. The occasional confusion and lack of consistency resulting from the merging process contributed to the perceived increasing need for restrictive interventions.

The use of S&MR became increasingly more problematic with these changes. Risk management data showed that YS accounted for over 70% of hospital S&MR episodes even though it represented only 30% of total hospital beds. Additionally, the data indicated that the high use of S&MR correlated significantly with staff and patient injuries. These factors raised concern in all involved, including consultants and evaluators during formal accreditation procedures.