Child & Adolescent Psychiatry : Seclusion and Restraint Reform: An Initiative by a Child and Adolescent Psychiatric Hospital

Concerns about injury to psychiatric patients through seclusion and restraint practices have prompted national reforms. In 1999 the Center for Medicare and Medicaid Services (CMS) drafted the Interim Final Rule governing the appropriate use of seclusion and restraint (1). Various individual institutions have concurrently implemented performance improvement programs with measures that include nursing and milieu staff training, administrative procedures, and management protocols, affecting every level of inpatient mental health care.

Riverview Hospital is the largest public child and adolescent psychiatric facility in Connecticut, consisting of eight units authorized for 107 beds, with an average of 270 admissions each year. Patients range in age from five to 18 years. The average length of stay is 29 weeks. In 1999, Riverview transformed its previous performance improvement efforts by instituting a new program. In this column we describe the program, its aims, and how these aims were carried out.

Core elements of the Riverview program

The program is known as "ABCD," the acronym for its four core elements: autonomy, belonging, competence, and doing for others. The program, based on the work of Brendtro (2) and Ryan and associates (3), deemphasized the former token-economy system and shifted the focus toward verbal feedback to patients and the formation of positive relationships between line staff and patients, thus promoting autonomy. Belonging was fostered by emphasizing staff-patient coaching relationships, patients' membership in the milieu, and the idea that violent and aggressive behavior violates social norms. The children were also given developmentally appropriate tasks—schoolwork, artwork, and group projects—that helped them feel a sense of accomplishment and build self-confidence and competence. Finally, the children learned about doing for others by contributing to the larger milieu through activities such as shared responsibility for group tasks or mentoring new patients.

Implementation

From its inception, the program aimed to include all staff involved in patient care and to promote collaboration between them—administrators, physicians, nurses, psychologists, social workers, and counselors. This approach was instrumental to the acceptance of the program in the organization (4). Before the program began, a development committee was created, composed of administrators joined by staff members chosen for their role in and ability to represent the hospital's organizational culture. Thus, ultimately, the program was generated by the staff for the staff.

Nationally, the various types of health care workers struggle to improve seclusion and restraint practices within their own domains of care. However, the value of partnerships across disciplines should not be underestimated. The collaboration at Riverview is an example of how valuable those strategic partnerships can be.

Monitoring of seclusion and restraint

Implicit in the program was oversight and central monitoring of all seclusion and restraint episodes. Riverview's seclusion and restraint rates were compared with rates of other institutions through use of the BASIS-32 Plus Performance Measurement System (5). For internal monitoring, a hospital database was developed to analyze seclusion and restraint rates on an ongoing basis, both for individual units and for the entire hospital. This data collection allowed the administration to accurately assess how well the program was working, set new improvement goals, and provide feedback to staff.

An innovative approach to feedback was the creation of a "unit dashboard" resembling a car dashboard. Centrally posted in a staff area, it displayed current rates of frequency and duration of seclusion and restraint in each unit, as well as the unit's goal rates. Thus all staff members were aware of their own performance and of what goals still needed to be met. The process allowed for timely feedback, continuous improvement, midcourse corrections, and ongoing dialogue about barriers to change.

Fidelity measures and consultations

The development committee rated each unit on fidelity to the core features of the revised milieu program. Committee members spent time on each unit observing milieu practices, individual attitudes toward the program, and how frequently the program's core values were used to guide interventions. The data were then used to complete a structured internal rating instrument. The fidelity mesures provided feedback about adherence to the program. These measures were inspired in part by an earlier survey of staff's perceptions of support for their autonomy and for their job performance; staff members who felt supported in their autonomy were less likely to use seclusion or restraint (unpublished manuscript, Lynch MF, Plant R, Ryan RM, 2000).

All units received consultations conducted by development committee members to provide reinforcement, continuing education, and support for unit staff. Consultants used the feedback from the fidelity measures to provide a forum for staff to discuss concerns about program effectiveness, reinforce the program's philosophy, and allow staff to perfect program-based skills.

Preliminary results

The ABCD program proved successful in its first two years: the number of episodes of seclusion and restraint and their cumulative duration decreased by 26 percent and 38 percent, respectively (6). Riverview's seclusion and restraint rates were also compared with specified group targets—values that achieved or exceeded performance guidelines set by the Joint Commission on Accreditation of Healthcare Organizations—through participation in the BASIS-32 Plus Performance Measurement System (5). At the time of ABCD implementation, rates were well above specified goals, and after 20 months, rates for both seclusion and restraint decreased significantly to a point within the targets (p<.001). Use of the BASIS-32 Plus system allowed for both comparison of seclusion and restraint rates with specified target rates and comparison of Riverview's outcomes with those of other facilities participating in BASIS-32 Plus. By facilitating comparisons between numerous institutions, BASIS-32 Plus lays the groundwork for future nationwide collaboration.

A nation's response

Although reductions in the use of seclusion and restraint at a single institution are valuable, nationwide reductions should be the ultimate goal. To this end, the Substance Abuse and Mental Health Services Administration recently funded five national demonstration projects to reduce the use of seclusion and restraint through a comprehensive staff training program. Connecticut sites include Riverview Hospital. A standardized curriculum will be used in pilot training programs at various institutions, which will then be linked nationally to determine which curriculum components are most effective. As data are gathered, a national curriculum can be created—an approach that could be especially beneficial to smaller hospitals lacking staffing and resources to design their own programs.

Conclusions

The issue of the use of seclusion and restraint remains at the forefront of psychiatric care today. Federal legislation may have facilitated the enforcement of regulations for these practices, but regulations have done little to change institutions' organizational philosophies. The ABCD program is an institution-specific response that addresses the need to change the culture surrounding the use of physical interventions, specifically for a child and adolescent clinical population. The program has effected change at the most basic level—within the milieu. The power of the program lies in the collaboration it has fostered between all groups associated with mental health care: the government, physicians, nurses, and other members of the treatment team. The program is a powerful mechanism for change and thus provides a valuable lesson for community mental health care providers.

Ms. Donovan is a medical student at Yale University School of Medicine in New Haven, Connecticut. Dr. Siegel, Mr. Zera, and Dr. Plant are with the Riverview Hospital for Children in Middletown, Connecticut. Dr. Martin is with the Child Study Center at Yale University School of Medicine, with which Dr. Siegel and Dr. Plant are also affiliated. Address correspondence to Dr. Martin at Yale Child Study Center, 230 South Frontage Road, P.O. Box 207900, New Haven, Connecticut 06520-7900 (e-mail, andres.martin@ yale.edu). Charles Huffine, M.D., is editor of this column.