Reducing the use of seclusion and restraint in psychiatric emergency and adult inpatient services- improving patient-centered care

Abstract

The reduction of seclusion and restraint (S/R) use has been given national priority by the US government, The Joint Commission, and patient advocacy groups. It is associated with high rates of patient and staff injuries and is a coercive and potentially traumatizing intervention. The New York City Health and Hospitals Corporation (HHC) is the largest municipal health care system in the country, with 11 HHC facilities operating psychiatric emergency services and inpatient psychiatric services. HHC operates 1117 adult inpatient psychiatric beds with an average length of stay of 22.2 days that generated over 19,000 discharges in 2009. In 2009, there were over 36,000 psychiatric emergency services visits. HHC's Office of Behavioral Health provides strategic leadership, planning, and support for the operations and quality objectives of these services. In January 2007, the corporate office initiated the Seclusion and Restraint Reduction Initiative, with a sequenced, intensive series of interventions and strategies to help focus the behavioral health leadership and staff on the need for continued culture change toward a more patient-centered and safe system of psychiatric emergency and adult inpatient care. From 2007 to 2009, there was a substantial decline in HHC's overall rate of S/R incidents in inpatient units. The more substantial impact was in the reduced overall time spent in S/R; the reduced frequency of use of S/R; and the reduced likelihood of patient injury from S/R use.

Figure 1

Frequency of restraint per 1000 patient hours.

Figure 2

Frequency of seclusions per 1000 patient hours.

Figure 3

Patient injuries in psychiatric emergency services.

Figure 4

Mean duration (in minutes) per restraint episode.

Figure 5

Mean duration (in minutes) per seclusion episode.