A program to reduce use of physical restraint in psychiatric inpatient facilities

Department of Psychiatry, University of Illinois at Chicago, 104 South Michigan Avenue, Suite 900, Chicago, IL 60603, USA.
Psychiatric Services (Impact Factor: 1.99). 08/2004; 55(7):818-20. DOI: 10.1176/
Source: PubMed

ABSTRACT The authors describe a program to reduce the use of physical restraint on three psychiatric units of a university hospital. One component of the program involved interviewing patients to determine their stress triggers and personal crisis management strategies. The second consisted of training staff members in crisis de-escalation and nonviolent intervention. During the first two quarters after implementation of the program, physical restraint rates declined significantly and remained low on all three units for the remainder of the year after implementation. Hospitals should consider instituting comprehensive staff training that encourages adaptive patient behaviors and nonviolent staff intervention to reduce the physical and mechanical restraint of children and adults in inpatient facilities.

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    ABSTRACT: Paper Felice Loi, Karl Marlowe, Dominic McLernon-Johnson Millharbour PICU, Tower Hamlets Centre for Mental Health, Mile End Hospital, London, UK Perspective: PracticeKeywords: Broset Violence Checklist; seclusion; violence; psychiatry Abstract Background. Violence is common on acute psychiatric wards. Although seclusion is usually employed as last resort treatment to contain high risky behaviors, its implementation is clouded with uncertainty due to the lack of pragmatic psychometric tools. The Broset Violence Checklist (BVC) is a reliable and validated instrument to predict imminent violence, it is not used to assess the appropriateness of the use of seclusion. Methods. Developed an 8-item modified version of the BVC, the East London Modified-Broset (ELM-Broset). It was retrospectively analyzed for its sensitivity and specificity with regards to secluding high-risky psychiatric inpatients (n = 43; incident n = 313), and to compare it to the BVC for the same inpatient group. Data analyses were carried out using logistic regression and ROC Curves. Results. The ELM-Broset showed good accuracy in predicting the use of seclusion with a sensitivity: 88.2%; specificity: 76.3%; AUC = 0.88; p <0.000; 95% C.I. [0.83, 0.94]; as compared to the predictive value of the standard BVC: sensitivity 82%; specificity: 55%; AUC = 0.74; p = 0.000; 95% C.I. [0.66; 0.82]. Pairwise comparison of the ROC curves showed a statistically significant difference: Δ = 0.148; SE: 0.022; p < 0.0001; 95% C.I. [0.10, 0.19]; with large effect size: Z = 6.63. Conclusions. The ELM-Broset is a sensitive and specific psychometric instrument which can be used to guide the decision-making process when implementing seclusion for high risk psychiatric inpatients.
    Fourth International Conference on Violence in the Health Sector Towards safety, security and wellbeing for all, pp 304 - 309; 10/2014
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    ABSTRACT: Mechanical restraint (MR) is a major infringement on the psychiatric patient’s autonomy. MR can cause physical and mental harm but may be necessary, e.g. to avoid putting an individual’s health at risk. The nursing staff is tasked with protecting the life and health of not only the individual patient but also other patients and relatives. A situation can occur in which staff is obligated to use force and occasionally MR, e.g. if a patient is very aggressive, violent, self-destructive or suicidal. Although MR is legal, the European Committee for the Prevention of Torture and Inhuman or Degrading Treatment or Punishment concluded, in two reports from 2002, 2008, and 2014 that no medical justification exists for applying instruments of physical restraint to psychiatric patients for days and that doing so amounts to ill treatment. Although the number of MR episodes should be reduced as much as possible, how this goal should be accomplished is quite unclear. Despite the growth in available research in the area decisive evidence is still lacking. No studies have investigated which of the many MR-preventive factors are the most effective in practice, in Denmark and Norway. Therefore, the overall objective of this thesis was to generate knowledge of non-medical MR-prevention. The four studies that contributed to this objective had separate purposes. First, a systematic review of international research papers was conducted to identify evident and effective MR-preventive factors; this review served as a basis for developing a questionnaire examining the degree to which MR-preventive factors have been implemented in psychiatric units and the numbers of MR episodes in those units. Second, a comparative investigation of European countries was conducted to identify a country comparable to Denmark to include in the cross-country questionnaire survey. Third, the collected questionnaire data were analysed to identify the associations between the MR-preventive factors and the number of MR episodes. Finally, the data were analysed to identify if the MR-preventive factors could explain the difference in the number of MR episodes between Denmark and Norway. Three MR-preventive factors were significantly associated with a low frequency of MR episodes in Denmark and Norway: a mandatory review of MR episodes (64% fewer MR episodes), patient involvement (58% fewer MR episodes), and crowding (46% fewer MR episodes). Further, we identified five MR-preventive factors with confounding effects (reducing the difference between countries), which may explain in part why Denmark used 92% more MR compared with Norway. These factors included: staff education (51% of the effect), substitute staff (17% of the effect), work environment (15% of the effect), patient-staff ratio (11% of the effect), and identification of patients’ crisis triggers (10% of the effect). These results have increased our understanding of the ability of specific MR-preventive factors to reduce the number of MR episodes in Denmark and Norway, thereby generating knowledge in the field of MR-prevention. These findings have not been identified via randomised controlled trials (RCTs), and although some biases could be present, the questionnaire was thoroughly developed to include several potential confounders. Furthermore, similar results have been demonstrated in previous international studies. These factors are not likely to have adverse effects on the patients or staff. Rather, the potential positive effects of these factors on the prevention of MR episodes may reflect a general strengthening of the care and treatment environments. Therefore, further investigation into the effects of implementing the following within Danish and Norwegian practices is recommended: mandatory review, patient involvement, less crowding, higher staff education, less substitute staff use, better work environment, increased number of staff per patient, and the identification of the patient’s crisis triggers.
    03/2015, Degree: PhD, Supervisor: Mette Brandt-Christensen
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    ABSTRACT: This study aims to identify whether selected patient and ward-related factors are associated with the use of coercive measures. Data were collected as part of the EUNOMIA international collaborative study on the use of coercive measures in ten European countries. Involuntarily admitted patients (N = 2,027) were divided into two groups. The first group (N = 770) included patients that had been subject to at least one of these coercive measures during hospitalization: restraint, and/or seclusion, and/or forced medication; the other group (N = 1,257) included patients who had not received any coercive measure during hospitalization. To identify predictors of use of coercive measures, both patients' sociodemographic and clinical characteristics and centre-related characteristics were tested in a multivariate logistic regression model, controlled for countries' effect. The frequency of the use of coercive measures varied significantly across countries, being higher in Poland, Italy and Greece. Patients who received coercive measures were more frequently male and with a diagnosis of psychotic disorder (F20-F29). According to the regression model, patients with higher levels of psychotic and hostility symptoms, and of perceived coercion had a higher risk to be coerced at admission. Controlling for countries' effect, the risk of being coerced was higher in Poland. Patients' sociodemographic characteristics and ward-related factors were not identifying as possible predictors because they did not enter the model. The use of coercive measures varied significantly in the participating countries. Clinical factors, such as high levels of psychotic symptoms and high levels of perceived coercion at admission were associated with the use of coercive measures, when controlling for countries' effect. These factors should be taken into consideration by programs aimed at reducing the use of coercive measures in psychiatric wards.
    Social Psychiatry 04/2014; DOI:10.1007/s00127-014-0872-6 · 2.58 Impact Factor


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