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

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

INTERVENTIONS AND STRATEGIES EMPLOYED OVER SEVEN YEARS

Youth Service leadership committed itself in 1995 to decrease escalating S&MR rates. Multiple efforts were made to achieve this goal by focusing attention on the extant culture supporting excessive S&MR utilization. Presented sequentially, many of the approaches are similar to those attempted by other hospitals and residential treatment centers. In retrospect, they mirror and adhere to the principles presented in AACAP's (2002) practice parameter addressing this issue. Early interventions from 1995 are discussed in the following sections.

A Mandate from on High

The hospital superintendent requested that the entire hospital decrease S&MR rates. She voiced concern about the escalating rates on Youth Service.

Feedback on Performance

An improvement of organizational performance (IOP) office systematically collected S&MR data from July 1996. Feedback to staff of S& MR rates were routinely provided quarterly, then monthly, and finally on a weekly basis in 1999.

Accentuating the Positive

A strength-based treatment approach was initiated to deal with the changing nature of the population served. In-service training was conducted hospital wide, and consultants with relevant expertise were invited to assist in using strength-based strategies and techniques.

Outside Assistance

A group was developed to provide an outside perspective, promote family and community involvement, and guide policies and procedures. This began as an effort to develop a parent advisory group in an attempt to elicit their views for YS direction. But we were rarely able to engage parents in this endeavor. The group began to evolve into an advisory group of advocates, consumers, and members of YS clinical leadership. It ceased to exist during early parts of the move but was later reconstituted after the move.

More Assistance

Consultation was obtained from a senior Indiana Division of Mental Health administrator/nurse with extensive experience in long-term psychiatric care of juveniles. Concrete suggestions regarding YS structure and procedures were provided, and attempts were made to implement the recommendations.

Decreases in S&MR frequency were noted during 1995 and early 1996. The YS leadership felt that significant progress was being made until announcement of the hospital relocation in mid-1996. Improvement had been seen even as changes of staff occurred, with the blending of a traditional state hospital (which had closed under a cloud of allegations) and a university-affiliated hospital with a major research and training mission. However, S&MR rates soon escalated, beginning in July 1996. Figures 1 (mechanical restraint) and 2 (seclusion) illustrate restrictive incidents from July 1996 through December 2001. Data collection prior to that time was insufficient for evaluation purposes. Interventions A, B, and C are noted in the figures. Figures 3 (restraint) and 4 (seclusion) provide the data in hours of restrictive intervention.

Following announcement of the impending move away from the academic campus, patients and staff became anxious and apprehensive. The tensions of moving and subsequent perception by both patients and staff of an unsafe environment in the new facility led to even more dramatic increases in S&MR rates, as demonstrated in Figures 1 through 4. The hospital relocated in November 1996. In the new facility, YS occupied the space formerly used as a nursing home for veterans. The youth learned quickly that they could punch holes in walls, climb into the space above dropped ceilings, and hide from staff in environmental blind spots. This arrangement significantly increased acuity and made behavior management extremely difficult.