Successful S/R Reduction Experiences What Worked?

1. Creating Violence Free and Coercion Free Service Environments for the Reduction of Seclusion and Restraint Successful S/R Reduction Experiences What Worked?

2. The Pennsylvania Seclusion & Restraint Reduction Program Donna Ashbridge, RN, MS Chief Executive Officer Danville State Hospital Danville, Pennsylvania Gregory M. Smith, MS Chief Executive Officer Allentown State Hospital Allentown, Pennsylvania

3. The PA State Hospital System • The Pennsylvania State Hospital System is • the largest provider of inpatient psychiatric • care in the Commonwealth. • The system is comprised of: • 8 state hospitals • 3 regional forensic units at Mayview, Norristown, & Warren State Hospitals • 1 restoration center serving older individuals with persistent mental illness

4. Pennsylvania Department of Public Welfare Office of Mental Health & Substance Abuse Services The Pennsylvania State Hospital System Warren ClarkSummit Danville Allentown Torrance Mayview Wernersville Norristown SouthMountain

5. The PA State Hospital System • Full-time civil and forensic staff: 4,719 • Typical unit (32 beds) in civil hospitals is staffed with: 2 RNs & 3 psychiatric aides on 1st & 2nd shifts • People served: 2,130 • Civil 1,800; Forensic 200; LTC 130. • Gender: 64% men, 36% women, Avg. age: 42 • >1,000 civil admissions & discharges/year • Provides ~ 65,000 days of care/month

6. Who Pennsylvania Serves • 68% diagnosis of schizophrenia or related psychotic disorder • 50% + co-occurring substance use diagnosis • 10% + diagnosis of MR/DD • 30% in civil hospitals have a criminal history • 50% in civil hospitals have an LOR of 2+ years

7. PA State Hospital SystemIs Reduction Possible? Is Elimination Possible? • Restraint use early 1990s • 140,000 hours of restraint/year • Equivalent to 16 consumers in restraint 24 hours/day, 365 days/year • Seclusion use early 1990s • 96,000 hours of seclusion/year • Equivalent to 10 consumers in seclusion 24 hours/day, 365 days/year

8. PA State Hospital SystemCritical Factors in Change State Leadership Established the goal, maintained it, supported staff to make changes, and continues to advance the effort: - 1990s 5 Deputy Directors, 3 Medical Directors all promote change, make S/R elimination top priority • 1996 Charles Curie declares S/R “a treatment failure” - 1999 S/R orders limited to 1 hour, Incrementally decreased - 2005 max order = 15 minutes (NETI, 2006; Smith et al, 2005)

9. PA State Hospital SystemCritical Factors in Change(continued) • 2005 PA DPW initiates Office of Children, Youth & Family restraint reduction effort for C/A residential programs • 2006 PA DPW initiates Dept-wide initiative: Alternatives to Coercive Techniques with statewide goal of all PA serving systems to be restraint-free (Ibid)

10. PA State Hospital SystemCritical Factors in Change • Resources redeployed, changed staff/patient ratio – but no new money • Primary Prevention: • Implemented universal risk assessment • Created consumer-centric culture of care • Meaningful treatment alternatives created • Consumer choice • Elimination of rules of convenience • Awareness of re-traumatization • Respectful care

11. PA State Hospital SystemCritical Factors in Change • Secondary Prevention: • Increased training in de-escalation, not S/R technique • Psychiatric Emergency Response Teams implemented all hospitals • Tertiary Prevention: • Patient, staff & administrative debriefing - every incident reviewed by executive team & advocate daily (NETI, 2006; Smith et al,2005)

12. PA State Hospital SystemCritical Factors in Change Data Active use of data from performance measurement system supports quality improvement process • Collect data on all episodes of S/R • Separate system for recording psych use of PRN & STAT medication use • Reporting based on a 1-page incident report format • Dedicated section to record consumer perspective • Closure codes for recording team actions for every incident • 30+ indicators of performance measurement • Monthly summary report on prior month’s incident data

13. PA State Hospital SystemCritical Factors in Change Facility CEO Leadership Sets and keeps the standard for positive, non-offensive culture • Reviews every restraint event and follows-up. • Responds to code “orange” emergencies. • Gets directly involved in debrief process following a restraint event with treatment team. • Identifies organizational barriers that impede efforts to eliminate SR. • Makes non-restraint approach a basis for medical appointments. • Adopts patient centered policies/procedures. • Involves employee unions in the change. • Celebrates success.

14. PA State Hospital SystemSeclusion & Mechanical Restraint Use1990 - 2004 (NETI, 2006; Smith et al, 2005; Data from the PA State Hospital Risk Management System)

16. Pennsylvania Today • November, 2003: State hospital system (civil side) achieved first seclusion-free month in 100+ year history • 7 / 8 state hospitals have been seclusion-free for more than one year • June 2, 2005: Danville State Hospital becomes first hospital to go 2 years without using S/R. Now, Allentown state hospital is S/R-free, too. (NETI, 2006; Smith et al,2005)

17. Pennsylvania Today • Psychiatric use of PRN medication orders discontinued on March 1, 2005 • Psychiatric use of STAT orders part of monthly risk management review process • The PA Goal & Plan: All PA state hospitals will be S/R-free by January 1, 2007 (NETI, 2006; Smith et al, 2005)

18. PennsylvaniaContact Information Gregory M. Smith, M.S. Chief Executive Officer Allentown State Hospital 1600 Hanover Avenue, Bldg. #11 Allentown, PA 18109-2498 717 – 772 – 7609 grsmith@state.pa.us