Guidance issued on use of restraints, seclusion

Two leading professional organizations have issued guidelines to help minimize the use of restraints and seclusion in behavioral health services. The guidelines suggest it may not be possible, or even necessary, to eliminate the use of restraints and seclusion altogether, and each instance must be carefully justified and monitored.

The advice was prompted in part by a recent analysis of sentinel events by the Joint Commission on Accreditation of Healthcare Organizations. Restraints and seclusion have drawn increased attention from family members and consumers in recent years, and regulatory bodies such as the Joint Commission are increasingly looking at restraint and seclusion as a sign of poor quality of care. Federal hearings on restraints and seclusion are planned for this year.

The Chicago-based American Hospital Asso ciation (AHA) and the National Association of Psychiatric Health Systems (NAPHS) in Washing ton, DC, issued the guidelines recently to help hospitals prevent death and injury related to the use of restraints or seclusion. Ethics committees could play a role in revising or writing policies in hospitals related to restraints.

The AHA and NAPHS serve on the Joint Commission’s board-level task force on restraint and seclusion, which is holding public hearings this spring and will make recommendations on any needed changes to current restraint and seclusion standards. The groups also are working with the American Psychiatric Association in Washington, DC, to identify best practices.

This is the advice from the AHA and NAPHS:

• A patient’s overall treatment should be based on a comprehensive, individualized treatment plan that includes appropriate patient and family involvement.

• Hospitals and other treatment settings serve individuals with severe mental illnesses and substance abuse problems who are, at times, dangerous to themselves or others.

• Restraint and seclusion should be used as infrequently as possible and only when less-restrictive methods are considered and are not feasible.

• Restraint and seclusion are emergency interventions that aim to protect patients in danger of harming themselves or others and to enable patients to continue treatment successfully and effectively.

• Prevention of injury and death is essential.

• Hospitals and other treatment settings must ensure that staff are well-trained and continuously educated regarding the proper use of restraint and seclusion. Detailed policies, procedures, and systems must be developed with input from physicians and other mental health professionals, and they must be understood and followed by all staff.

To improve and reduce the use of restraints and seclusion in your facility, the AHA and NAPHS suggest you organize a team to make a systemwide assessment of your restraint and seclusion policies and procedures. The team should include key clinical staff such as the medical director, quality assurance director, program directors, director of nursing, and intake director, along with key administrative staff such as the administrator, marketing or public relations director, security director, and others.

This type of review should be part of your organization’s continuous quality improvement process, with the review conducted frequently. Frequent reviews will help ensure that policies are up-to-date and followed by all staff.

Groups favor these program components

The AHA and NAPHS conclude that restraint and seclusion can be life-saving and injury-sparing emergency interventions when used properly. They recommend the following:

• policies and procedures on how to employ restraint and seclusion safely (including understanding the risks and benefits of intervening or not intervening);

• a process for continuously reevaluating the need for restraint or seclusion;

• a process for continuous monitoring to ensure patients’ safety and other needs are met;

• a policy requiring that a physician (or other licensed practitioner as permitted by state law) should authorize use of restraint or seclusion in a timely manner. This licensed clinician must be involved in the decision to continue the use of restraint or seclusion;

• consideration of the safe and appropriate use of medication as an alternative to restraint and seclusion and in reducing the length of any episode;

• a system for assessing and understanding the needs of patients before they enter treatment;

• well-trained and adequate numbers of staff to handle the complexity of the patients served;

• a clinical strategy for intervening as early as possible before behavior has escalated to a point requiring seclusion or restraint;

• a system for carefully and routinely monitoring use of restraint and seclusion so you can evaluate ways to reduce its use in the future.

In reviewing your current policies and procedures, the AHA and NAPHS suggest looking at these factors:

• assessment activities (e.g., preadmission screening, history of aggressive behavior or assault, previous experience of restraint or seclusion, history of trauma, review of triggers, and input of family and others);

• development of an individualized, comprehensive, multidisciplinary treatment plan that addresses issues identified during the assessment process with focused attention to the needs of special populations (children, adolescents, elderly, and developmentally disabled);

• role of patients, family, and others, as appropriate, in the development of the treatment plan;

• consideration of the use of medication in the ongoing and emergency treatment of the patient;

• staff development with special emphasis on management strategies, assessment, identification of early signs of behavioral change, early intervention/crisis prevention techniques, de-escalation techniques, specific implementation of restraint or seclusion procedures (with opportunities for regular drills or practice), safe care and observation of patients in restraint or seclusion, review and analysis of restraint and seclusion episodes with attention to impact on patients, staff, and others;

• comprehensive plan for monitoring performance improvement that includes appropriate goals for reducing use of restraint and seclusion, collection and analysis of aggregate data with attention to trends, and analysis of efficacy and appropriateness;

• review of accrediting and regulatory bodies’ requirements (Joint Commission, the Health Care Financing Administration, state law, local departments of health, etc.);

• review of the procedures for reporting routine information as well as for reporting critical and sentinel events;

• plan for soliciting and incorporating feedback, as appropriate, from consumers and families regarding their experience of restraint and seclusion;

• plan for managing concerns or complaints of patients, family members, and consumer groups regarding restraint and seclusion.


Kathleen McCann, RN, DNSc, Director of Clinical Services, National Association of Psychiatric Health Systems, 1317 F. St., N.W., Suite 301, Washington, DC 20004. Phone: (202) 393-6700, ext. 11. Free copies of the guiding principles may be obtained from NAPHS by calling (202) 393-6700, ext. 15.

Karen Milgate, Senior Associate Director of Policy, American Hospital Association, 325 Seventh St. N.W., Washington, DC 20004. Telephone: (202) 626-4628.