2000 Winner
Commonwealth of Pennsylvania
Innovations in American Government Awards
Innovations in American Government Awards

In October 1998, the Hartford Courant published a five-day expose on the alarming number of deaths that occurred during or immediately after the application of restraint or seclusion therapy in mental hospitals nationwide. The article represented a significant change in the practice of mental health. Seclusion and Restraint, perennially understood as a form of therapy, now transpired as a symptom of failed mental health treatment.

In 1998, the staff of the mental ward at Allentown State Hospital in Pennsylvania faced a space problem. Needing more beds for patients, they decided to take their seclusion rooms out of service and convert them into bedrooms. In order to manage the situations that usually resulted in seclusion, they developed psychiatric emergency teams that could respond to behavior issues and de-escalate situations through verbal intervention and other non-invasive techniques. Eventually, the program expanded through other wards and into other hospitals across the state.

A few of the requirements under the new program are: routine risk assessments for patients, expansion of active treatment within hospitals, policies that require better documentation and monitoring of the use of restraint and, finally, regular data collection and benchmarking of the use of seclusion and restraint within all hospital settings. These changes create a new and significant transparency in the State's mental health practices.

At the individual level, physicians must be the ones to order seclusion or restraint, orders must be limited to one hour, and the program requires direct physician contact with the patient in less than 30 minutes. Patients being restrained can't be left alone, and chemical restraints are prohibited. A full debriefing of all staff involved also follows each restraint or seclusion.

Most important, however, the new policy calls for the active involvement of the patients themselves in their overall treatment, a change that has created much stronger partnerships between the patients and their caregivers. That, in combination with the reduction in the use of restraint and seclusion, has helped break the cycle of aggression that has become all too common among the institutionalized.

The impact of the program has been considerable. As of the year 2000, the incidence of seclusion and restraint in all of Pennsylvania hospitals has been reduced 74 percent from the average in 1997. Also, when restraint or seclusion has occurred, the length of time the measures have been used has reduced by an amazing 96 percent. Alternatively, over the same time period, the incidence of patients injuring staff has not risen significantly.

The program is innovative in its acceptance of both changing convention seclusion and restraint is not a therapy, and pragmatic management the seclusion rooms are needed for beds. The leadership of the program is also innovative in the way it fostered the program's bottom-up creation. An idea that began as a solution concerning bed space in the ward of one hospital was recognized as successful and implemented in two short years throughout the State's nine hospitals.

Although the program has reduced instances of restraint and seclusion significantly, Pennsylvania's goal is to completely remove this "therapy" from its hospitals. Understanding that seclusion and restraint actually detracts from the patient's wellness, the State is implementing a staff-training program that encourages the "unlearning" of these traditional approaches to treatment, hoping to fortify the permanence of this positive shift in Pennsylvania's mental health care.

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