Successful SR Reduction Experiences

1
Creating Violence Free and Coercion Free Service
Environments for the Reduction of Seclusion and
Restraint

• Successful S/R Reduction Experiences
• What Worked?

2
The Pennsylvania Seclusion Restraint Reduction
Program
Donna Ashbridge, RN, MS Chief Executive
Officer Danville State Hospital Danville,
Pennsylvania
Gregory M. Smith, MS Chief Executive
Officer Allentown State Hospital Allentown,
Pennsylvania
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The PA State Hospital System

• The Pennsylvania State Hospital System is
• the largest provider of inpatient psychiatric
• care in the Commonwealth.
• The system is comprised of
• 8 state hospitals
• 3 regional forensic units at Mayview, Norristown,
  Warren State Hospitals
• 1 restoration center serving older individuals
  with persistent mental illness

4
Pennsylvania Department of Public Welfare Office
of Mental Health Substance Abuse Services
The Pennsylvania State Hospital System
Warren
Clark Summit
Danville
Allentown
Torrance
Mayview
Wernersville
Norristown
South Mountain
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The PA State Hospital System

• Full-time civil and forensic staff 4,719
• Typical unit (32 beds) in civil hospitals is
  staffed with 2 RNs 3 psychiatric aides on 1st
  2nd shifts
• People served 2,130
• Civil 1,800 Forensic 200 LTC 130.
• Gender 64 men, 36 women, Avg. age 42
• gt1,000 civil admissions discharges/year
• Provides 65,000 days of care/month

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Who Pennsylvania Serves

• 68 diagnosis of schizophrenia or related
  psychotic disorder
• 50 co-occurring substance use diagnosis
• 10 diagnosis of MR/DD
• 30 in civil hospitals have a criminal
  history
• 50 in civil hospitals have an LOR of 2 years

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PA State Hospital SystemIs Reduction Possible?
Is Elimination Possible?

• Restraint use early 1990s
• 140,000 hours of restraint/year
• Equivalent to 16 consumers in restraint 24
  hours/day, 365 days/year
• Seclusion use early 1990s
• 96,000 hours of seclusion/year
• Equivalent to 10 consumers in seclusion 24
  hours/day, 365 days/year

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PA State Hospital SystemCritical Factors in
Change

• State Leadership
• Established the goal, maintained it, supported
  staff to
• make changes, and continues to advance the
  effort
• - 1990s 5 Deputy Directors, 3 Medical Directors
  all promote change, make S/R elimination top
  priority
• 1996 Charles Curie declares S/R
• a treatment failure
• - 1999 S/R orders limited to 1 hour,
• Incrementally decreased - 2005 max order
  15 minutes
• (NETI, 2006 Smith et al, 2005)

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PA State Hospital SystemCritical Factors in
Change(continued)

• 2005 PA DPW initiates Office of Children, Youth
  Family restraint reduction effort for C/A
  residential programs
• 2006 PA DPW initiates Dept-wide initiative
  Alternatives to Coercive Techniques with
  statewide goal of all PA serving systems to
  be restraint-free
• (Ibid)

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PA State Hospital SystemCritical Factors in
Change

• Resources redeployed, changed staff/patient ratio
  but no new money
• Primary Prevention
• Implemented universal risk assessment
• Created consumer-centric culture of care
• Meaningful treatment alternatives created
• Consumer choice
• Elimination of rules of convenience
• Awareness of re-traumatization
• Respectful care

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PA State Hospital SystemCritical Factors in
Change

• Secondary Prevention
• Increased training in de-escalation, not S/R
  technique
• Psychiatric Emergency Response Teams implemented
  all hospitals
• Tertiary Prevention
• Patient, staff administrative debriefing -
  every incident reviewed by executive team
  advocate daily
• (NETI, 2006 Smith et al, 2005)

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PA State Hospital SystemCritical Factors in
Change

• Data
• Active use of data from performance measurement
• system supports quality improvement process
• Collect data on all episodes of S/R
• Separate system for recording psych use of PRN
  STAT medication use
• Reporting based on a 1-page incident report
  format
• Dedicated section to record consumer perspective
• Closure codes for recording team actions for
  every incident
• 30 indicators of performance measurement
• Monthly summary report on prior months incident
  data

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PA State Hospital SystemCritical Factors in
Change

• Facility CEO Leadership
• Sets and keeps the standard for positive,
  non-offensive culture
• Reviews every restraint event and follows-up.
• Responds to code orange emergencies.
• Gets directly involved in debrief process
  following a restraint event with treatment team.
• Identifies organizational barriers that impede
  efforts to eliminate SR.
• Makes non-restraint approach a basis for medical
  appointments.
• Adopts patient centered policies/procedures.
• Involves employee unions in the change.
• Celebrates success.

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PA State Hospital SystemSeclusion Mechanical
Restraint Use1990 - 2004
(NETI, 2006 Smith et al, 2005 Data from the PA
State Hospital Risk Management System)
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Pennsylvania Today

• November, 2003 State hospital system (civil
  side) achieved first seclusion-free month in 100
  year history
• 7 / 8 state hospitals have been seclusion-free
  for more than one year
• June 2, 2005 Danville State Hospital becomes
  first hospital to go 2 years without using S/R.
  Now, Allentown state hospital is S/R-free, too.
• (NETI, 2006 Smith et al, 2005)

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Pennsylvania Today

• Psychiatric use of PRN medication orders
  discontinued on March 1, 2005
• Psychiatric use of STAT orders part of monthly
  risk management review process
• The PA Goal Plan
• All PA state hospitals will be S/R-free
• by January 1, 2007
• (NETI, 2006 Smith et al, 2005)

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PennsylvaniaContact Information

• Gregory M. Smith, M.S.
• Chief Executive Officer
• Allentown State Hospital
• 1600 Hanover Avenue, Bldg. 11
• Allentown, PA 18109-2498
• 717 772 7609
• grsmith_at_state.pa.us