title: Cluster-randomized controlled trial of reducing seclusion and restraint in secured care of men with schizophrenia.
abstract: OBJECTIVE
  This randomized controlled trial studied whether seclusion and restraint could be prevented in the psychiatric care of persons with schizophrenia without an increase of violence.
  
  
  METHODS
  Over the course of a year, 13 wards of a secured national psychiatric hospital in Finland received information about seclusion and restraint prevention. Four high-security wards (N=88 beds) for men with psychotic illness were then stratified by coercion rates and randomly assigned to two equal groups. In the intervention wards, staff, patients, and doctors were trained for six months in applying six core strategies to prevent seclusion-restraint; six months of supervised intervention followed. Poisson's regression analyses compared monthly incidence rate ratios (IRRs) of coercion and violence (per 100 patient-days).
  
  
  RESULTS
  The proportion of patient-days with seclusion, restraint, or room observation declined from 30% to 15% for intervention wards (IRR=.88, 95% confidence interval [CI]=.86-.90, p<.001) versus from 25% to 19% for control wards (IRR=.97, CI=.93-1.01, p=.056). Seclusion-restraint time decreased from 110 to 56 hours per 100 patient-days for intervention wards (IRR=.85, CI=.78-.92, p<.001) but increased from 133 to 150 hours for control wards (IRR=1.09, CI=.94-1.25, p=.24). Incidence of violence decreased from 1.1% to .4% for the intervention wards and from .1% to .0% for control wards. Between-groups differences were significant for seclusion-restraint-observation days (p=.001) and seclusion-restraint time (p=.001) but not for violence (p=.91).
  
  
  CONCLUSIONS
  Seclusion and restraint were prevented without an increase of violence in wards for men with schizophrenia and violent behavior. A similar reduction may also be feasible under less extreme circumstances.
authors.forename: Anu
authors.initials: A
authors.lastname: Putkonen
authors.forename: Satu
authors.initials: S
authors.lastname: Kuivalainen
authors.forename: Olavi
authors.initials: O
authors.lastname: Louheranta
authors.forename: Eila
authors.initials: E
authors.lastname: Repo-Tiihonen
authors.forename: Olli-Pekka
authors.initials: OP
authors.lastname: Ryynänen
authors.forename: Hannu
authors.initials: H
authors.lastname: Kautiainen
authors.forename: Jari
authors.initials: J
authors.lastname: Tiihonen
mesh_terms: D000328:Adult; D006778:Hospitals, Psychiatric / Q000458:organization & administration / Q000592:standards*; D006801:Humans; D008297:Male; D008875:Middle Aged; D017063:Outcome Assessment, Health Care; D010356:Patient Isolation / Q000706:statistics & numerical data*; D012149:Restraint, Physical / Q000706:statistics & numerical data*; D012559:Schizophrenia / Q000628:therapy*; D013997:Time Factors; D014754:Violence / Q000517:prevention & control*