The Basics in Restraint The Basics in Restraint and Seclusionand Seclusion

Leslie MorrisonDirector, Investigations UnitDisability Rights California(510) 267-1200Leslie.Morrison@disabilityrightsCA.org

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What is What is restraintrestraint?? Restriction of freedom of movement,

physical activity or normal access to one’s body

MedicalMedical ◦ Used during surgical diagnostic, dental or other medical

procedure◦ Used for proper body position balance or alignment or to

improve mobility

Behavioral 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”]

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What isn’t considered a What isn’t considered a restraint?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

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What is “What is “chemical chemical restraintrestraint”?”?

Medication used as a restriction to manage an individual’s behavior or to restrict individual’s freedom of movement & is not a standard treatment or dosage for 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.

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What is What is seclusionseclusion??

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

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What we What we knowknow about about restraint and seclusion…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.

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Conditions on UseConditions on Use Only usedOnly 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 coercion, discipline, convenience or retaliationretaliation by staff

Only by staff with specific, current trainingtraining and demonstrated competencecompetence in application

Only upon MD orderorder OR, in emergency, at discretion of RN◦ Never as a standing order◦ Limits on order duration

Face to face 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 monitoringmonitoring or observationobservation

Where are Where are standards?standards?Federal law

◦ Hospitals◦ Residential Facilities for

AdolescentsState Law and

Regulations◦ By facility type

Joint Commission on Accreditation of Healthcare Organizations (JCAHO)◦ Not all facilities◦ By facility type

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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

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Health & Safety Code §1180Health & Safety Code §1180 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.

Public Health ModelPublic Health Modelfocus on prevention NOT how to do more safely or focus on prevention NOT how to do more safely or

betterbetter

Universal Universal PrecautionsPrecautions

Environment that minimizes potential for conflict by anticipating risk factors

Organizational values

Trauma informed care

Stigma Early assessment

of risk factors Recovery Model

Tertiary Tertiary InterventionIntervention

After incident, rigorous problem solving, mitigate effects, take corrective action

[Application of R/S] Debriefing

Secondary InterventionSecondary 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

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6 Core Strategies 6 Core Strategies 1. LeadershipLeadership Toward

Organizational Change Create vision; clarify

values

2. Use DataData to Inform Practices

Core Data Post Publicly

3. Develop the WorkforceWorkforce Competencies;

Performance Evals Training

4. Implement Seclusion/Restraint Prevention ToolsPrevention Tools

Trauma Assessment; Risk

Safety Plans; Triggers

5. Actively Recruit & Involve ConsumersConsumers and Families

6. Make Debriefing Debriefing Rigorous