Patient Characteristics and Setting Variables Related to Use of Restraint on Four Inpatient Psychiatric Units for Youths Kathleen R. Delaney, D.N.Sc., R.N. Louis Fogg, Ph.D.
Objectives: This study examined the characteristics of children and adolescents who were restrained during brief inpatient psychiatric treatment and identified whether restraint use was related to the characteristics of the youths or to the setting—time of day, day of the week, place, or programming. Incidents related to restraint use were also examined. Methods: Charts were reviewed for 100 youths who were admitted to four inpatient units between December 1998 and January 2000. Results: Thirty-one youths were not restrained, 57 were restrained once or twice, and 12 were restrained three or more times. Youths were significantly more likely to be restrained if they were male, had multiple admissions to the facility during the study period, remained in the hospital longer, had been given a diagnosis of a psychotic disorder, or had a previous psychiatric hospitalization. Youths who were restrained were also more likely to be enrolled in special education or to be in foster care or in custody of the Department of Children and Family Services. Also, these youths were more likely to have a history of voicing suicidal ideation and attempting suicide. No single setting variable was significantly related to restraint use. Incidents that prompted restraint generally involved agitation, threats, or assaults. Conclusions: Youths who were at greatest risk of being restrained during brief inpatient treatment shared particular characteristics related to greater use of inpatient services, guardianship arrangements, special education placement, and history of suicide attempts. Inpatient staff members should remain particularly alert to the processing and regulation problems of these groups of patients. (Psychiatric Services 56:186–192, 2005)
F
or the past ten years the use and misuse of physical restraint has received tremendous attention within and outside of psychiatry (1). Regulatory agencies and professional groups agree that restrictive interventions should be used in only the most extreme situations, those in which patients pose a danger to themselves or others (2,3). The
standards set by regulatory agencies and the growing awareness of the potential dangers of restraint use (4) place increasing pressure on child and adolescent psychiatric units to reduce the use of locked seclusion and restraint (5). It is ironic that for an issue that is discussed with such tremendous urgency, we know very little about the
Dr. Delaney and Dr. Fogg are affiliated with the College of Nursing at Rush University Medical Center in Chicago. Dr. Delaney is also with the department of psychiatric nursing at Rush University Medical Center, 600 South Paulina, Chicago, Illinois 60201 (email,
[email protected]). 186
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use of restraint during the brief inpatient hospitalization of youths, what type of youth is most likely to be restrained, how often youths are restrained, and why they are restrained. Table 1 lists past studies of seclusion and restraint among youths in brief psychiatric treatment (6–11). The rates and patterns of locked seclusion and restraint among these youths have not been examined in U.S. institutions in the past ten years. Yet much has changed in the past decade. Ten years ago the use of seclusion and restraint for behavioral control was a more accepted practice (12). In 1990 Millstein and Cotton (8) reported that 60 percent of all children who were admitted to their hospital were placed at least once in locked seclusion. In a subsequent publication Cotton (13) endorsed the therapeutic benefits of this practice. Today there is almost zero tolerance for the use of restraint and locked seclusion (14,15). New guidelines have been developed for handling aggressive youths (3,16), all in adherence with federal regulatory restraint policies (17). Without recent data it is not possible to determine whether restraints are being used in line with current regulations, that is, to prevent dangerous behavior and serious property damage when other less coercive interventions have failed (17). In the past studies cited above, length of stay averaged 75 days; now it hovers at about 11 days (18). With the dramatic shift in length of stay, it is questionable whether the ten-year-old timing and setting patterns apply—
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Table 1
Summary of studies of seclusion and restraint, 1989–1995 Number of youths Time frame
Incidence of seclusion or restraint
Characteristics of youths who were secluded or restrained
Patterns of seclusion or restraint
Study
Type of unit
Length of stay
Swett et al., 1989 (6)
Child unit in state hospital
Mean of 173 days
176
All admissions for one year
46 percent restrained; 57 percent secluded
Not examined
Seclusions and retraints were prompted when youths showed imminent harm to others or themselves.
Garrison et al., 1990 (7)
Child unit in general hospital
Mean of 41 days
99
All admissions in a calendar year
50 percent secluded or restrained in some manner
Secluded or restrained youths were younger, male, or tested high for aggression; older patients were more likely to be placed in mechanical restraints
Restraints or seclusions or both were prompted by assault, self-injury, and property damage. Rates of seclusion or restraint were higher during shift changes and during periods of low programming.
Millstein et al., 1990 (8)
Child unit in general hospital
Mean of 75 days
102
All admissions for 30 months
16 percent secluded at least once; 44 percent secluded three or more times
Secluded youths had a history of suicide attempts, previous admission, abuse, and aggression; had low coping skills; or had neurocognitive deficits
Seclusions increased during day shift, when the milieu was busy and stimulating, and at therapeutically demanding times.
Atkins et al., State hospital 1992 (9) housing eight separate child units
Mean of 144 days
408
All admissions for one calendar year
60 percent secluded at least once; 15 percent more than twice per month, which accounted for 73 percent of the seclusions
Youths secluded two or more times were more likely to be male, be nonwhite, have previous admissions, or have a disruptive behavior disorder
Mean duration of seclusion, five hours
Goren et al., Child inpa1993 (10) tient unit in medical center
Mean of 175 six months
All youths who were restrained or secluded during the three-year study period
28 percent of youths who were admitted to the hospital had one incident of seclusion or restraint; 25 percent of the study group were secluded five or more times; 32 percent of the study group were placed in restraints more than once
Secluded or restrained youths were male, younger, or given a diagnosis of behavior disorder
Seclusion and restraint was prompted by aggression toward others, noncompliance, and self-harm.
Earle et al., Three child 1995 (11) state hospital facilities
60 percent 257 of sample stayed longer than six months
One time inspection of youths residing in units
33 percent secluded at least once; 7 percent secluded two or more times, which accounted for 50 percent of the seclusions
Youths secluded were older, had longer stays, or had an organic or developmental disability
Seclusions were prompted by youths’ being agitated, demonstrating threatening behavior, and assalting others. Rates of seclusion were higher in the morning hours and on Mondays.
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for example, that seclusion or restraint occurs more often at the beginning and end of a youth’s hospitalization. Finally, it is unclear what kind of situations prompt restraint use in brief psychiatric treatment or whether there is a type of youth at risk of being restrained, either once or multiple times. The purpose of this retrospective study was to examine the current practice of restraint use among youths in brief psychiatric treatment. To this end, 100 charts of hospitalized youths were reviewed. Demographic and clinical characteristics in three groups of youths were compared: those who were never restrained, those who were restrained one or two times, and those who were restrained three or more times during their hospitalization. Also examined were the setting (time of day, day of week, place, and programming) and incidents related to restraint use.
Methods Study site The study was conducted at a freestanding psychiatric hospital that operates four psychiatric units that were designed for the brief hospitalization of children and adolescents. The hospital is located in a large metropolitan area and admits youths from the inner city and surrounding areas. During the year before the study period, the average length of stay on each unit was approximately 12 days, after scattered outliers were corrected for (length of stay longer than 45 days). The units operate with a neurobehavioral view of youths’ maladaptive behaviors. The hospital is located in a state that continues to allow the seclusion and restraint of youths in accordance with federal regulation. At the time of the study, the facility was undertaking a rigorous restraint reduction program that examined the root causes and patterns of restraint use throughout the facility. As part of the program, staff members from each of the four units were trained in deescalation strategies. Finally, all the units operated under the management philosophy of using restraint only in situations that posed a serious danger to the patient or others and when other less restrictive measures had failed. 188
Procedure Approval of Rush University Medical Center’s institutional review board was obtained before initiating the study. This study examined the charts of youths who were hospitalized at the study site between December 1998 and January 2000, so that select variables—age, race or ethnicity, caretaker history, aggression six months before admission, and psychiatric history—could be compared. First, a list was compiled of every youth who was restrained during this period at the study site. A total of 69 youths had been restrained during this period. Among these 69 youths, 12 had been restrained three or more times. Next, a group of 31 youths
In this study, youths who had a psychotic disorder were at greatest risk of being restrained.
were randomly selected from a list of patients who were hospitalized during this period but were never restrained. Excluded from our study were youths who were hospitalized less than 48 hours. The charts of each patient selected for the study were reviewed, and additional information was collected for each restraint incident. For participants with multiple admissions during the study period, data for the first admission was used to determine the basic demographic characteristics, psychiatric history, education placement, and previous aggression. The procedure called for notation of any change in guardianship or living arrangements between admissions, but none occurred. PSYCHIATRIC SERVICES
Instruments Two data collection instruments were used in this study: a chart audit form and a scale that rated aggression in the six months before hospitalization. The chart audit form was designed to collect history of maltreatment, history of aggressive behavior six months before admission, and diagnostic and demographic data. Also categorized on the form were the restraint incident, the behavior or incident that prompted restraint, and the interventions that were attempted before using restraint. Restraint was defined as involuntary restriction of the patient’s movement by the use of mechanical devices on four limbs of the patient’s body. The 17 patient-specific categories (demographic characteristics and history) and incident-specific categories (place, time, and restraint episode descriptors) listed on the chart audit form were modeled after a form described by Way (19) for restraint studies in the New York State psychiatric hospital system and used in subsequent large-scale studies of restraint on child and adolescent units (7,20). The youth’s preadmission aggression was scaled with a tool that categorizes a youth’s aggression on the basis of his or her behavior six months before hospitalization (21). Possible ratings range from 1 to 6, with higher ratings indicating more severe aggression that resulted in the victim’s serious injury (level 5) or death (level 6). The anchors for each aggression level include a description of the behavior as well as its potential lethal consequences.
Results As shown in Table 2, the sample of 100 youths was predominately male (66 percent) and African American (77 percent). The mean±SD age was 13.9±2.39 years, ranging from seven to 19 years. Most youths in the sample were insured through Medicaid (77 percent). Approximately half (49 percent) lived with at least one biological parent, and a majority (51 percent) lived in nontraditional or custodial living situations. A majority (53 percent) had previous psychiatric hospitalizations, and 29 percent had multiple admissions during the study period. At the time of discharge, 83
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Table 2
Characteristics of 100 youths who were in brief inpatient psychiatric treatment, by whether they were restrained Never restrained (N=31) Variable
N
Gender Male Female Race or ethnicity White Black Hispanic Other Length of stay (mean±SD days) Admissions in the study period Single Multiplea Previous psychiatric hospitalizations No Yesa Education placement Regular class Special education Therapeutic day school In foster care or in custody of the Department of Children and Family Services No Yes History of suicide attempt or voicing ideation None Ideation Ideation and attempt Diagnosisb Mood disorders Behavior disorders Psychotic disorders a b
%
Restrained once or twice (N=57)
Restrained three or more times (N=12)
N
N
%
%
17 14
55 45
39 18
68 32
10 2
83 17
7 21 1 4 12±8
23 68 3 6
4 47 4 0 28±35
7 82 7 4
1 9 2 0 47±40
8 75 17 0
29 1
97 3
36 20
63 35
4 8
33 67
22 9
71 29
22 32
39 56
0 12
18 13 0
58 42 0
25 26 3
44 46 5
27 4
87 13
38 19
16 10 5
52 32 16
14 14 1
48 48 4
Test statistic Kendall’s tau=2.05
df
p 2
