Correlation between reduction of seclusion and restraint and assaults by patients in Pennsylvania's state hospitals.
OBJECTIVE
This prospective study assessed the use of seclusion and restraint in the Pennsylvania state hospital system from 2001 through 2010. It also examined the correlation between declining use of containment procedures and assaults by patients on other patients and staff.


METHODS
The 12,900 anonymized records involving the 1,801 unique, civilly committed individuals who were physically or mechanically restrained and secluded in the nine civil hospitals during this study period were entered into a database. The data set included demographic and diagnostic information about the patients and the cause and effect of the procedures. These data were compared with rates of patient-to-patient and patient-to-staff assaults to determine any correlation between changes in use of containment and assaults.


RESULTS
From 2001 to 2010, the use of mechanical restraint significantly declined from .37 to .08 episodes per 1,000 days (p<.018), and the use of seclusion significantly declined from .21 to .01 episodes per 1,000 days (p<.001). Persons with an axis I diagnosis of psychotic disorder accounted for 44% of containment procedures used during this study. Patient-to-patient assaults declined slightly, and patient-to-staff assaults were unaffected.


CONCLUSIONS
Decreasing the use of containment procedures did not increase assaults. Better leadership, data transparency, use of clinical alerts, workforce development, policy changes, enhanced use of response teams, implementation of dialectical behavior therapy, and discontinuation of the psychiatric use of PRN orders contributed to the change in use of containment procedures. A philosophical change to a recovery model of psychiatric care and services was the driving force behind this transformation.
Mr. Smith is affiliated with the Pennsylvania Department of Public Welfare, Allentown State Hospital, Allentown (e-mail: gregs@ptdprolog.net ). Ms. Ashbridge and Dr. Davis are with the Department of Administration and Mr. Steinmetz is with the Department of Quality Assurance, Pennsylvania State Hospital System, Harrisburg. A version of this article was presented at the European Conference on Violence in Clinical Psychiatry, Ghent, Belgium, October 23-26, 2013, and at the Congress on Seclusion and Restraint Reduction, Emergis Behavioral Health Center, Kloetinge, the Netherlands, October 28, 2013.
Gregory M
GM
Smith
Donna M
DM
Ashbridge
Robert H
RH
Davis
William
W
Steinmetz
D000293:Adolescent; D000328:Adult; D005260:Female; D006778:Hospitals, Psychiatric / Q000706:statistics & numerical data*; D006783:Hospitals, State / Q000706:statistics & numerical data*; D006801:Humans; D007297:Inpatients / Q000523:psychology / Q000706:statistics & numerical data*; D008297:Male; D010356:Patient Isolation / Q000523:psychology / Q000706:statistics & numerical data*; D010414:Pennsylvania; D011446:Prospective Studies; D012149:Restraint, Physical / Q000523:psychology / Q000706:statistics & numerical data*; D014754:Violence / Q000523:psychology / Q000706:statistics & numerical data*; D055815:Young Adult