performance improvement through monitoring seclusion and restraint practices

Administration and Policy in Mental HealthVol. 25, No. 5, May 1998

PERFORMANCE IMPROVEMENT THROUGHMONITORING SECLUSION AND RESTRAINTPRACTICES

Daniel Chandler, Teresa Nelson, and Colette I. Hughes

ABSTRACT: With the increasing development of legal and clinical standards for seclusionand restraint, measurement of compliance with legal and clinical standards is an importantcomponent of mental health performance improvement processes. The authors report ona systematic sample of 229 episodes of seclusion and/or restraint use in 46 facilities re-viewed by county patients' rights advocates in seven California counties for compliance withstandards. Lack of compliance with requirements regarding seclusion and restraint wassubstantial in four areas: legality of the orders, employment of less restrictive alternatives,legal grounds for initiating and continuing the orders, and nursing care during restraint orseclusion.

Seclusion is the involuntary isolation of the patient from others in aroom or area of a room. Physical restraint is the restriction of patientmovement through physical devices or techniques including belts, posies,ties and physical holding (Soloff, 1987).

This paper profiles seclusion and restraint practices in psychiatric facili-ties in seven California counties and identifies the extent of complianceand noncompliance with legal and care standards. The review of compli-ance was performed by county patients' rights monitors following the di-rections of independent policy researchers under a contract with Protec-tion & Advocacy, Inc., a federally and state funded agency charged withprotecting the rights of the disabled, including psychiatric patients in insti-tutional settings (Olley & Ogloff, 1995; Sundram, 1995).

Although seclusion or restraint (or both) can be necessary and effective

Daniel Chandler, Ph.D., is an independent policy research consultant Teresa Nelson, J.D., is Directorof Public Interest Programs, Stanford University Law School. Colette Hughes, J.D., is Managing Attor-ney Oakland Office, Supervising Attorney Investigations Unit, California Protection & Advocacy, Inc.

Address for correspondence: Daniel Chandler, Ph.D., 436 Old Wagon Road, Trinidad, CA 95570.

525 © 1998 Human Sciences Press, Inc.

526 Administration and Policy in Mental Health

interventions in violent or potentially violent situations, they can also causeserious physical and emotional harm to patients, especially when used forlong periods, for inappropriate reasons or without adequate monitoringand care (Marks, 1992; Betemps, Buncher, & Oden, 1992). The potentialseriousness of restraint and seclusion use is demonstrated by recent deathsin California. Between 1992 and 1997 Protection & Advocacy, Inc. (PAI)reviewed or investigated a series of separate incidents in which seclusionand/or restraint contributed to eight patient deaths. Since no require-ment exists for reporting seclusion or restraint related deaths to PAI thismay be an under count. Given these and lesser risks, the adequacy of pro-visions regulating seclusion and restraint and the level of compliance withthese provisions are of serious consequence.

Seclusion or restraint can be more distressing and dangerous if extended induration.

The perspective of agencies monitoring seclusion and restraint practicesstarts with the law. In 1972, the federal district court in Wyatt u Stickney setforth the basic limitations on the use of seclusion and restraint. The courtheld first that patients had a right to be free from physical restraint andisolation which can be denied only when necessary to protect the patientor others from injury; it cannot be used as punishment, for the conveni-ence of the staff or, if less restrictive alternatives are available, to controlthe danger. Seclusion or restraint could be authorized only by written or-der of a qualified professional, limited to 12 hours. The decision requiredthat patients in seclusion and restraint must be observed minimally everyhalf hour and provided the opportunity for motion and exercise.

Ten years later in Youngberg u Romero (1982), the U.S. Supreme Courtrecognized the federal constitutional right to freedom of movement, in-cluding the right to be free of unnecessary, excessive restraint. But theCourt also acknowledged that this right was not absolute and, to someextent, was in conflict with other patient interests in treatment and safety.The Court gave considerable discretion to professionals to determinewhen and to what extent restraint was necessary to assure safety from in-jury. It also held that decisions made by appropriate professionals in theexercise of "professional judgment" were presumptively correct.

Most states, including California, have statutes and regulations whichadopt the basic Wyatt requirements for the use of seclusion and restraint.California regulations vary slightly by facility type but basically require thatseclusion and restraint may be used only when alternative methods are notsufficient to protect the patient or others from injury and only as long asnecessary to protect the patient or others from injury. Orders for seclusion

Daniel Chandler, Teresa Nelson, and Colette I. Hughes 527

and restraint can only be made by designated professionals (a physician or,in some cases, a psychologist) and must state the date, time, and reasonfor seclusion or restraint. Telephone orders must be signed within 24hours, and as needed (PRN) orders are not permitted. Emergency use ofseclusion or restraint requires staff to obtain a physician's order within 1hour after the event Observation of secluded or restrained patients byclinical staff must occur every 15 minutes.

Because of the potentially serious consequences of restraint and seclu-sion, concern about compliance with laws, regulations, and policies is wide-spread among administrators and clinicians as well as advocacy groups.However, published studies have only indirectly reflected this interest, fo-cusing instead on the client and facility variables associated with high andlow rates of seclusion and restraint. Studies have documented rates of se-clusion and/or restraint use occurring in between 2% and 66% of patients(Soloff, 1985). A limited amount is known about the factors causing suchvariation. However, a number of studies have found that the overall seclu-sion rate of a facility has an explanatory effect over and above client vari-ables (Carpenter, Hannon, McCleery, & Wanderling, 1988). Okin's (1985)prospective study of seven Massachusetts state hospitals found that thewide variability in use of seclusion could not be explained by patient de-mographic characteristics, legal status, diagnoses, or violence-related be-havior preceding hospital admissions but was related to facility location.Way and Banks (1990) went further and attributed the widely varying ratesin the 19 New York state hospitals studied to milieu factors such as staffinglevels and treatment philosophies since the rates were not explained bypatient age, gender, race, length of stay or legal status. Similarly, the lengthof time patients spend in seclusion and restraint in VA hospitals was foundby Be temp et al. (1992) to vary widely by facility.

From the standpoint of monitoring the legal use of seclusion and/orrestraints, the most striking finding of empirical studies is their wide use incontrolling non-violent behavior. A review by Soloff, Gutheil, and Wexler(1985) of 10 empirical studies found that in 9 studies the most commonreasons for seclusion were nonviolent behavior patterns. These were vari-ously described as "agitated, uncontrolled behavior," "nonviolent behaviordisruptive to therapeutic environment," and "escalating agitation." Thesenon-violent and non-threatening behaviors comprised between 20 and54% of the precipitating events reported. In another recent study, re-searchers were unable to classify the charted reason for many restraintepisodes because they were too vague (Roper, Coutts, Sather, & Taylor,1985). A recent survey of former state hospital patients found 73% be-lieved they had not been dangerous at the time of seclusion or restraint(Ray, 1996). Prospective studies have also documented that threat and vio-lence are often dealt with without use of seclusion and restraints, raising


questions about which other factors determine a staff decision to use seclu-sion or restraint (Sheridan, Henrion, Robinson, & Baxter, 1990; Soloff,1981).

Another branch of the literature, however, partially fills this gap, as em-pirical studies have documented significant reductions in the use or dura-tion of seclusion or restraint as a result of training, modification of physi-cal plant, and changes in philosophy. These studies, however, have focusedon elderly clients, especially in nursing homes (Sundel, Garrett, & Horn,1994), on the developmentally disabled (Davidson, Hemingway, & Wy-socki, 1984), on adolescents (Kalogjera, Bedi, Watson, & Meyer, 1989), orlong-term clients in state hospitals (Craig, Ray, & Hix, 1989). Little isknown about the need for, or ability of short-term community facilities toreform their seclusion and restraint practices.

Taken together the empirical studies and the reduction studies suggestthat seclusion and restraint may be used considerably more than is neces-sary and thus raise the issue whether such usage exceeds the legally per-missible.

BACKGROUND

Rates of involuntary treatment in California are high (Meisel & Chand-ler, 1988), and seclusion and restraint are often used. In 1993, there were82,812 involuntary 72 hour evaluation-treatment episodes (California De-partment of Mental Health, 1996). In the same year, 23,171 incidents ofseclusion and 26,989 incidents of restraint were reported to the state (Cali-fornia Office of Patients Rights, 1994).

This review encompassed seven California counties. The 1993 popula-tions, involuntary admissions, and seclusion and restraint rates for theseven counties are presented in Table 1. In 1993, the 7,882 seclusion epi-sodes from these counties represented 34.0% of the statewide total, andthe 10,863 restraint episodes 40.4% of statewide restraint episodes.

Assuring compliance with seclusion and restraint law and regulation inCalifornia falls not only to the California facility licensing agencies but, ona local level, to county mental health patients' rights advocates who havestatutory responsiblity for monitoring seclusion and restraints for psychi-atric patients. This review of practices was conducted by local patients'rights advocates, who as part of their statutory authority have access tomental health facilities, records and patients for the purpose of monitor-ing compliance with standards (Welfare and Institutions Code § 5520, 5540).Guidance for the monitoring and analysis of the results was performed bythe first two authors of this paper, under contract with PAI, which providesongoing technical assistance and legal backup to the local advocates.


TABLE 1Seven California Counties: Population, Involuntary Admissions,

and Seclusion /Restraint Episodes and Sample Size

County

ABCDEFG

a1993Population

236,700676,100192,200

1,552,200697,900409,900

9,244,700

b1992-93Involuntary

Episodes

1,7182,799

6194,1561,0231,300

24,494

c1993SeclusionEpisodes

3091,373

253828600291

4,228

c1993RestraintEpisodes

491,006

100696d

325278

8,409

SampleSize

20303019292576

" From California Department of Finance. b From Denial of Patients' Rights in California: 1993 Report byOffice of Patients' Rights, 1994, Oakland, CA: Protection & Advocacy, Inc. cFrom Summary of Involun-tary Detentions by Category: Fiscal Year 1992-93, Department of Mental Health, 1996, Sacramento, CA:Author. dEstimated from quarter one data.

The goals of the practices review were to (1) profile the extent of com-pliance with state law and regulations governing seclusion and restraint,and (2) attempt to understand the pattern of non-compliance in terms ofvariables that could be of use to county patients' rights monitors and ad-ministrators.

METHOD

The target population is all seclusion and restraint episodes in Californiapsychiatric facilities. The monitoring sample was designed to be able toreasonably conclude that practice patterns discovered in the review werewide-spread. Patient Rights Advocates in seven counties volunteered to par-ticipate in the monitoring. Although not selected randomly, the threerural, two suburban, and two urban counties do represent a broad cross-section of the state.

During January 1993 cases were selected using two different samplingmethods. In the largest county, advocates recorded information on themost recent seclusion and/or restraint episode, if any, recorded in thechart of any client the advocate represented in an involuntary certificationhearing. In California any client held involuntarily past 72 hours receives ahearing in front of a judge or officer of the court, and the patient advocateassists the client. Thus, in this county all clients assisted by the advocate


during the sampling period who had been restrained or secluded wereincluded in the sample, a total of 76 episodes.

In six other counties, advocates selected the sample from a listing ofchart numbers of patients who were secluded and/or restrained duringOctober, November, or December of 1992. In five counties, episodes weresampled systematically so as to generate about 30 cases. In the sixth,County D, the advocate limited the sampled facilities to the main county-operated psychiatric unit and the two private facilities having respectivelythe fewest and the most seclusion/restraint episodes; three other privatefacilities were not sampled. This rater also excluded from the sample epi-sodes of short duration. (Therefore the mean hours of seclusion/restraint,reported later, omit County D.) With either sampling method, when therewere multiple episodes of seclusion or restraint recorded for the same cli-ent only the most recent was used for analysis.

Table 1 shows the sample size in each county as well as the total numberof seclusion and of restraint episodes during 1993. At the end of the find-ings section the sum of the seclusion and restraint episodes for eachcounty have been used to weight the stratified (county) samples for a pre-sentation of compliance rates in the seven counties. The unweighted com-pliance rates are presented first, however, and unweighted data are usedfor all analyses. Ideally, all counties would have participated or cluster sam-pling would have been used to determine the counties selected. Since thatwas not possible, the overall target population (all California seclusion andrestraint episodes) is better represented by the unweighted sample, sinceweighting by the very large number of seclusion and restraint episodes inthe two urban areas over balances the many small and medium sized coun-ties that are not proportionately represented in the sample. While less de-sirable than a probability sample, the use of inferential statistics when thesampled population is not clearly specifiable is common in both physicaland social science (Tukey, 1986). Standard errors and confidence intervalshave been adjusted to account for the stratification of the sample bycounty in both types of analysis (Eltinge & Scribney, 1996).

A standardized data collection form was used by advocates in eachcounty. For each incident the advocate inspected the physician's orders,nursing notes, medication orders, and other relevant sections of the pa-tient's chart. Facility policies and procedures regarding restraint and seclu-sion, daily census data, and recent facility denial of rights reports were alsoreviewed in order to provide raters context for the chart reviews. The datacollection instrument called for a summary judgment by data collectorsregarding compliance with standards—for example, a judgment by thepatients' rights advocate regarding whether the initial justification for se-clusion/restraint conformed to the law. It also required filling in specific


checklists—for example, a checklist on information required to appear inseclusion or restraint order documentation.

Sampling

At the time of the monitoring, psychiatric inpatient care in Californiahad three components. Care for most seriously mentally ill patients wasprovided by county governments in public hospitals or through contractswith private facilities. Other publicly funded inpatient care, often for lessseverely or persistently ill patients, was provided through the fee-for-serviceMedicaid system independent of county government. Finally, private payand insurance patients make up the third component. Counties varywidely in the extent to which they provide services themselves rather thancontracting and the extent to which publicly-funded clients use the fee-for-service Medicaid system. The large number of facilities studied (46) andthe diverse licensure and funding of the facilities makes this sampleunique in the literature on seclusion and restraint, as previous studies haveeither focused on one facility or on a type of facility—usually state hospi-tals.

The sample included 229 episodes of seclusion and/or restraint. Seclu-sion was used in 65.5% of the episodes, restraint in 41.0%, and seclusionand restraint in 30.6%. In 64.4% of the episodes the patient was white, and50.7% of the episodes involved males. Legal status was recorded as volun-tary in 11.2% of the episodes—although use of seclusion or restraints isnot authorized by law for voluntary clients. Forty-eight percent of the epi-sodes occurred in facilities licensed as Acute Psychiatric Hospitals, 45.3%in General Acute Hospitals, and 6.7% in specialized Skilled Nursing Facili-ties. Only 35.5% of the episodes were in publicly operated as opposed toprivately operated facilities.

RESULTS

Overall Compliance

In the seven counties, 62.4% of seclusion and/or restraint cases com-plied with the requirements that seclusion and restraint be ordered by aphysician and that the order contain date, time, signature, type of restraintor seclusion and reason for restraint or seclusion (Table 2). In 9.7% of theepisodes the order was PRN or "as needed," which is specifically prohibitedunder California law.

Raters were also asked to look for documentation that specific less re-strictive measures were tried before seclusion and/or restraint. Examplesof such alternative measures are time out, redirection, and one-to-one


TABLE 2Percentage of Episodes Documented as Meeting

Seclusion/Restraint Standard in Seven California Counties

MD order completeOrder not a PRN

Less restrictive tried first

Initial S/R judged justi-fiedDocumented threatDocumented dan-

gerous act

S/R judged justifiedthroughout

Observation and careCheck done every 15

minutesFluids offered each

hourToileting offered each

hourMeals offered 3 times

a day

EstimatedProportion

in Population

.624

.903

.570

.739

.651

.515

.343

.962

.420

.392

.802

Standard Error

.029

.028

.032

.028

.030

.031

.030

.014

.039

.042

.035

95%Confidence

Interval

.567 .681

.847 .958

.506 .634

.684 .794

.591 .710

.455 .576

.284 .402

.934 .990

.342 .498

.309 .475

.723 .871

care. Administration of medication was not included as a less restrictivealternative. In the seven counties some 57.0% of the episodes containeddocumentation of less restrictive measures being tried first. Based on overallsummary rater judgments, in about one third of the cases where alternativeswere not tried, or 11.4% overall, alternatives would have been appropriate.

Raters judged that initiation of 73.9% of the seclusion and/or restraintepisodes were justified under the law—that is, the rater's summary judg-ment was that the standard of dangerousness was met. However, chart doc-umentation that the specific criteria in the law were met was less frequent,with 65.1% having a physical or verbal threat documented, and only 51.5%having a physical threat or action documented.


Joint Commission on Accreditation of Healthcare Organizations stan-dards at the time stated: "Implementing a time-limited order for restraintor seclusion does not require application of the intervention for the entireperiod if the patient demonstrates a reduction in the behaviors that led tohis/her being placed in restraint or seclusion" (1991). Documentationthat seclusion and/or restraint was necessary throughout the episode toprotect the patient or others from injury, however, was present in only34.3% of episodes. As confirmation, raters recorded the number of hoursthat a client was documented to be "calm," "sleeping," "resting," or "coop-erative." For each of these behaviors the low figure was one quarter of anhour and the high ranged from 16 hours to 31. Overall, 15.3% of episodescontained documentation of 1 hour or more of one or more of at leastone of these behaviors. The mean number of hours in the sample fordocumented "calm" behaviors was 3.4 hours and 3.7 hours for docu-mented "cooperative" behaviors.

Finally, raters were asked to record the documentation of a number ofnursing procedures. JCAHO standards applicable at the survey time re-quired that "Appropriate attention is paid every 15 minutes to a patient inrestraint or seclusion, especially in regard to regular meals, bathing, anduse of the toilet" (1991). In California, observational checks every 15 min-utes are required by law. The study found that there was virtually alwayschart documentation that patients were checked every 15 minutes andusually that patients were offered meals hourly. However, the documenta-tion that patients were offered fluids and toileting even once an hour waspresent in only 40% of the episodes (Table 2).

Time in Seclusion or Restraints

Seclusion or restraint can be more distressing and more dangerous ifextended in duration. Both seclusion and restraint hours ranged from 1 to48. The mean number of seclusion hours (excluding County D, whereshorter episodes were not sampled) was 8.6 and the mean hours in re-straint was 8.3.

Observation and nursing care becomes more important with long pe-riods of restraint and/or seclusion. In the 35 episodes of seclusion lasting12 hours or more, charts documented the at least hourly offer of meals90.0% of the time, but toileting only 52.0% of the time and fluids only44.4% of the time. The N (19) for episodes of restraint lasting 12 hours ormore is too small for a similar analysis.

Another concern is whether the duration of seclusion/restraint episodesis predicted by whether the use of seclusion or restraints was justifiedunder the law. A multiple regression model was fitted with duration ofseclusion as dependent variable. Whether alternatives were tried, whetherseclusion/restraint was initially justified, and whether they were justified


throughout were the independent variables and gender, race, and legalstatus were control variables. The model was not statistically significant;nor was a similar model for duration of restraints.

Relationship to Other Variables

A logistic regression model was estimated for each of the four basic com-pliance variables (order meets legal standards, less restrictive tried first,initial seclusion or restraint justified, ongoing seclusion or restraint justi-fied) . Patient variables entered into the model were involuntary admission(voluntary was the omitted category), male (female omitted), and white(non-white omitted). Facility variables entered in the model were privateoperation (public omitted), licensure as General Hospital or Skilled Nurs-ing Facility (acute psychiatric facility omitted). Counties were classed asrural (three under 500,000), as suburban (two were 500,000 to 1 million),and two as urban (over 1 million), the omitted category.

The final model for each of the dependent variables was highly signifi-cant; that is, prediction of results on each of the four main measures wasimproved by using these patient, facility, and county variables. Urban (andto a lesser degree suburban) counties in general were much more likely tobe compliant than were rural counties (Table 3). The largest differencewas in whether the continued use of seclusion or restraints was judged nec-essary: in urban counties this was the case 59% of the time vs. only 22% inrural counties. Likewise, facilities licensed as General Acute Hospitals (andto a lesser degree, Skilled Nursing Facilities) were more likely to be com-pliant than were facilities licensed as Acute Psychiatric Hospitals. For ex-ample, all the requirements for a legal order were met 72% and 80% ofthe time in General Acute Hospitals and Skilled Nursing Facilities, respec-tively, but only 51% of the time in Acute Psychiatric Hospitals. Male vs.female and voluntary vs. involuntary differences did not show consistentdifferences. Race was dropped from the model due to multicollinearity.

Weighted Estimates

The analyses above use the original sample to estimate rates of compli-ance and non-compliance. By weighting the estimates by the sum of allseclusion and restraint episodes occurring in each of the seven samplingstrata during 1993 it is possible to more accurately estimate the proportioncomplying in this particular set of seven counties. Because weighting givesthe more compliant urban counties more influence, the point estimatesare in general somewhat higher for this seven county estimate than in thesample itself, but the order of magnitude remains the same: the physiciansorder met all legal criteria 72% of the time (rather than 62% in the sam-ple itself); less restrictive alternatives were tried 53% of the time (versus57%); the initial use of restraints was justified under the law 77% of the


TABLE 3Predictors of Four Measures of Compliance

with Seclusion/Restraints Standards

Predictor

Private oper-ationPublic opera-tion

Acute psychi-atric licenseGeneralacute license

Skilled nurs-ing license

RuralMetropolitanUrban

WhiteOther

MaleFemale

VoluntaryInvoluntary

Compliance Measures

Legal OrderProportion"

.537***

.771

.511

.722***

.800**

.478

.672

.731***

.611b

.661

.596

.646

.435

.629*

Less RestrictiveTried Proportion

.607**

.500

.505

.663***

.500

.616

.586

.518

.613

.471

.505*

.635

.636

.554

Initially JustifiedProportion

.711

.787

.757

.703

.867

.622

.814***

.786**

.714

.763

.730

.754

.619

.738

JustifiedThroughoutProportion

.369

.297

.302

.374*

.500**

.216

.193

.589***

.338

.353

.343

.347

.500

.321*

"Proportions are not adjusted for the effects of covariates. bRace was dropped from the model due tomulticollinearity.*p < .10, **p < .05, ***p < .01. Tests of significance are based on logistic regression models. In each,Private operation is contrasted to the (omitted) Public operation; General Acute and Skilled Nursingare contrasted to the omitted Acute Psychiatric licensure; two Metropolitan counties (500,000 to 1million population) and two Urban counties (over one million) are contrasted to the omitted threeRural counties (under 500,000 population); male is contrasted to the omitted female, white to theomitted "other races" and involuntary admission to the omitted voluntary.


time (rather than 74%); and the seclusion or restraint was documented asjustified throughout the period 46% of the time (rather than 34%).

DISCUSSION

This monitoring was limited by our inability, due to the use of volunteerpatients' rights advocates as raters, to select counties and episodes usingrigorous probability sampling. However, the close approximation to ran-dom selection within counties, the inclusion of 46 different facilities, andthe fact that one third to two fifths of all seclusion or restraint episodesoccur in these counties, suggest that the results can be taken as broadlyrepresentative of practices in California. In confirmation, the compliancerates for the four basic measures changed relatively little when the samplewas weighted by the number of seclusion and restraint episodes in eachcounty during 1993.

Time and resource constraints imposed other methodological limita-tions: there was no pretest of the monitoring instrument, and it was notpossible to train the raters face-to-face and test for reliability. It might alsobe thought that use of advocates as raters would bias results. However,both in responding to patient requests for assistance and in monitoringadherence to regulations, advocates are regularly called upon to judgewhether restraint and seclusion procedures meet applicable standards.

A serious interpretive problem is judging whether lack of documentedcompliance may reflect charting omissions rather than patients' rights is-sues. Arguing against the omission interpretation are the several standardswhere documentation was present but indicated non-compliance. First, in9.7% of the episodes reviewed there was documentation of authorizationby PRN, which is specifically prohibited by law. Second, in 11.2% of theepisodes there was documented seclusion and/or restraint used for pa-tients whose legal status was voluntary—an unauthorized use. Finally,15.3% of the charts contained documentation that during seclusion/re-straints the patient was calm, cooperative, resting or sleeping for at least 1hour—behaviors that are not compatible with continued imminent dan-ger.

CONCLUSIONS

Lack of compliance with legal requirements regarding seclusion and re-straint appeared high in these seven California counties. The overall judg-ment method (highest compliance) and the checklist method (lowestcompliance) showed initiation of seclusion and/or restraint when it wasnot justified under the law in between 25 and 48% of the episodes. These


results are consistent with other empirical studies cited earlier showingfrequent use in non-dangerous situations. However, in other studies thesepatterns have not been explicitly tied to applicable legal, regulatory, andclinical standards.

The legal standards that govern the initial and continuing justificationof restraint or seclusion and the use of less restrictive measures affordconsiderable discretion to the clinical staff to interpret and implementthem. Overall, it appears that the more specific the requirement (such as15 minute observation) the higher is the documented compliance. Com-pliance is lowest with clinical standards that are not specifically set forth inCalifornia law—especially nursing care and assessment for release, eventhough they are part of the applicable JCAHO standards.

A more general problem is that the official hospital policies followed byfacility staff often do not accord with the legal requirements. A review bythe authors of the policy manuals in 16 of the facilities showed a generalpattern: policies often do not track the law well (for example, a third au-thorized restraint or seclusion for property damage or threat to the thera-peutic environment); less restrictive alternatives are rarely defined; andmany policies fail to make clear the requirement for ongoing assessmentfor release.

In addition to the specificity and fidelity of the standards, a second im-plementation factor stands out: seclusion and restraint practices in ruralcounties (and to some extent suburban counties) were much more likelyto be out of compliance than were practices in large, urban counties. Atthe time of the monitoring, 43 out of 58 California counties were under500,000 in population. Compliance was also less likely in specialty psychi-atric programs (Acute Psychiatric Hospitals) than in General Acute Hospi-tals. Knowledge of both these factors could be of help in focusing monitor-ing of, and education about, seclusion and restraint standards.

Protection and Advocacy, Inc. took three types of action in consequenceof the monitoring (and complaints received regarding seclusion and re-straint practices). First, it worked to introduce legislation in California thatclarified many standards and required more clinical oversight of seclusionand restraint. In legislative hearings information from this survey, partic-ularly on length of seclusion and restraint in different types of hospitals,was useful. The bill was enacted by the legislature, but was vetoed by thegovernor (California Senate Bill 895, 1994).

Second, PAI organized county advocates to raise awareness of seclusionand restraint issues and provide training in seclusion and restraint lawsand the use of less restrictive alternatives. A manual for use by advocateswas produced and is available from PAI (Daar & Nelson, 1992). In thejudgment of PAI, increased monitoring and staff training activities by advo-cates have improved practices.


Finally, PAI assisted in developing new health industry standards for theuse of seclusion and restraint by participating in a revision of Joint Com-mission on the Accreditation of Health Organization standards. The newguidelines (JCAHO, 1996a) contain stronger provisions for reducing theuse of seclusion and restraint. Highlights of the new standards call forcreating a culture that emphasizes prevention and alternatives, requirethat orders for restraint and seclusion be time limited, and provide forcontinuous (or no less than every 15 minutes) patient monitoring, reas-sessment and provision of care. An orientation video is available (JCAHO,1996b).

With the increasing development of legal and clinical standards for se-clusion and restraint, measurement of compliance is an important compo-nent of mental health performance improvement processes. The use ofaggregate data across facilities and geographical regions can assist in iden-tifying the need for improvement of policy, procedures and staff educa-tion.

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