Unnecessary Restraint and Seclusion of Psychiatric Patients Is Ethical Concern
Many hospitals report high seclusion and restraint rates of psychiatric patients, according to the authors of a new study.1
“Large-scale research on use of seclusion and restraint in psychiatric care nationally is surprisingly scarce,” says Vincent Staggs, PhD, the study’s author.
Staggs analyzed data from 1,642 hospitals gathered between 2013 and 2017, using the CMS Hospital Compare site. “The CMS data on seclusion/restraint haven’t received much attention from researchers,” notes Staggs, an associate professor of pediatrics at the University of Missouri - Kansas City School of Medicine.
A dearth of data makes it impossible to know what practices are acceptable vs. unacceptable. “A starting point would be having a sense of what is typical in terms of both frequency and duration of seclusion and restraint episodes,” Staggs says.
What is typical is not necessarily ethical. “There are calls to eliminate mechanical restraint altogether,” Staggs notes.2,3
The available CMS data at least give some idea of what typical and atypical seclusion and restraint rates look like. This is a way to identify facilities that clearly are outside the normal range. However, Staggs found hundreds of errors in the data. “In the absence of accountability and incentives for accurate reporting, I suppose this shouldn’t be too surprising,” Staggs says.
Sixty-seven percent of hospitals reported comparably low rates of seclusion and restraint. Ten percent of hospitals reported rates five to ten times higher than even the facilities at the upper limit of the “normal” range. “When we see this kind of extreme variability in healthcare practices, it suggests there are opportunities to improve care by standardizing practice,” Staggs offers.
The problem is there are no recommendations quantifying what is considered an unacceptably high rate of seclusion or restraint. “Without such guidelines, these outlier facilities may not even realize their practices are so far outside the norm,” Staggs notes.
Violation of patient autonomy and the possibility of harming people (physically or psychologically) are major ethical concerns. Restraint and seclusion can become necessary, as a last resort, to protect patients or staff in extreme situations. “But it seems clear, from the duration of some of the reported episodes, that use of these measures goes well beyond what might be needed in an emergency,” Staggs reports.
The power differential between staff and vulnerable psychiatric patients is a major ethical concern. “We need better regulation, oversight, and accountability in this aspect of inpatient psychiatric care,” Staggs concludes.
Sometimes, the stage is set for needless escalation before patients even arrive at the hospital. “This really begins at the point of contact in the community. All too often, people are handcuffed and brought to the hospital in the back seat of a police car,” says Robert L. Trestman, PhD, MD, professor and chair of psychiatry and behavioral medicine at Virginia Tech Carilion School of Medicine and Carilion Clinic in Roanoke.
EMS technicians’ use of ketamine on agitated people is a controversial practice.4 The American Society of Anesthesiologists issued a statement firmly opposing the use of ketamine “to chemically incapacitate someone for a law enforcement purpose and not for a legitimate medical reason.”5
“It’s all part of a fabric. Our culture is uncomfortable dealing with conflict resolution in general. We very quickly resort to brute force,” Trestman observes.
Some rural EDs in critical access hospitals have only a single PA or nurse practitioner available. That clinician might lack any training at all in de-escalation skills. Even in large urban EDs with far more resources, overwhelmed staff may not know how to manage agitated people. Providers resort to whatever is necessary to protect people in the immediate time frame. “If a shot of something is going to be safer than someone taking a swing at a clinician or attempting to commit suicide, that’s what they are going to do,” Trestman says.
Hospital policies aimed at reducing the use of restraint or seclusion are only useful if staff actually know about the policies and can follow them. Likewise, training is only useful if it is practiced; whether that means simulated exercises, videotaped practice interviews, or feedback on active listening skills. “People in crisis need to be seen by somebody clinical, to feel they are being respected, and to be heard,” Trestman says.
Many times, these elements can prevent the use of force. There always are going to be rare exceptions, such as if someone is grossly psychotic. “Even there, body language and level of stimulation matters,” Trestman notes.
EDs are bright, loud, and crowded. Creating a quieter space within the department is one way to create a more humane and safe environment. If restraint and seclusion are the default for ED providers, says Trestman, “more people are likely going to be hurt.”
This means problems for hospitals, since health department investigations, CMS audits, and accreditation problems with The Joint Commission all are definite possibilities. “There will be more resources bogged down in preparing for audits, paying for corrective actions, and paying out for wrongful death injury lawsuits,” Trestman says.
Calling for security often is the first instinct if a patient shows signs of agitation. “Everyone — not just clinicians, but even environmental services — should know the basics of how to be humane and to do so under pressure,” Trestman says.
Someone who yells, “I’m tired of being ignored!” might be confronted by a uniformed security guard moments later. Too often, situations like that escalate to a dangerous confrontation. Trestman says that in this kind of case, anyone (including environmental services staff who happen to be nearby) can help de-escalate the situation. A staff person could say, “You are right. Let me go find someone. I will be back as soon as I can. But are you OK right now?”
“From a purely pragmatic, administrative perspective, it’s in everyone’s best interests — financially, ethically, and clinically — to avoid unnecessary restraint and seclusion,” Trestman says.
REFERENCES
- Staggs VS. Variability in psychiatric facility seclusion and restraint rates as reported on Hospital Compare site. Psychiatr Serv 2020;71:893-898.
- Mental Health America. Position statement 24: Seclusion and restraints.
- Substance Abuse and Mental Health Services Administration. Promoting alternatives to the use of seclusion and restraint. Issue brief #1: A national strategy to prevent seclusion and restraint in behavioral health services. March 2010.
- Schutz CH. Ketamine for pre-hospital control of agitated delirious patients: Promising but not yet ready for prime time. West J Emerg Med 2014;15:742-743.
- American Society of Anesthesiologists. ASA statement on the use of ketamine for a non-medical purpose. July 15, 2020.
Violation of patient autonomy and the possibility of harming people (physically or psychologically) are major ethical concerns. But there are no recommendations quantifying what is considered an unacceptably high rate of seclusion or restraint. Without such guidelines, outlier facilities may not even realize their practices are outside the norm.
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