DEPARTMENT OF BEHAVIORAL AND DEVELOPMENTAL SERVICES (BDS)

Policy Regarding the Prevention of Seclusion and/or Restraint Informed by

the Clients Possible History of Trauma in Facilities Operated By BDS

98-CS-103 Issue Date:July 11, 2002

I. Policy Statement

Seclusion or restraint, including chemical restraint, for clients supported directly by BDS staff and institutions are intended to be used only as a last resort when there is no alternative measure available to staff to maintain safety.

It is the policy of Maine’s BDS to take all reasonable steps to ensure that, when it is necessary to implement Seclusion and Restraint Procedures, it shall be done not only in accordance with Joint Commission for Accreditation of Healthcare Organizations (JCAHO), Rights of Recipients, and other regulations, but also given the high prevalence of trauma in the population served by BDS, it shall be based on a presumption that the client may have a history of trauma. For all clients, procedures shall be implemented to determine what constitutes a traumatizing or a retraumatizing experience for him/her, and the client’s understanding of what helps him/her to deescalate the crisis.

BDS adopts this Protocol for Seclusion and Restraint for all clients supported directly by BDS staff and institutions. However, as stated in the Rights of Recipients, seclusion or restraint cannot be utilized in any outpatient setting. In addition, under no circumstances can locked door seclusion be used with clients who have mental retardation or developmental disability. Further requirements and information governing the use of seclusion and/or restraint can be found in the following regulations:

· 14-193 CMR 1 Rights of Recipients of Mental Health Services

· 14-197 CMR 5 Regulations for the Use of Behavioral Procedures,

Including Restraints

· 14-472 CMR 1 Rights of Recipients of Mental Health Services

Who Are Children in Need of Treatment

II. Rationale

Traumatic events – that is, experiences that threaten one’s sense of integrity or survival – can be associated with a variety of subsequent psychiatric symptoms for which victims may receive acute mental health treatment. These symptoms can include self-injury, assaultiveness, and suicidality, which occasionally require emergency interventions such as seclusion or restraint, typically in an acute care setting in order to ensure client and community safety. Every reasonable effort should be made to recognize, understand and respond appropriately to a client’s symptomatology and its etiology so that services that do not meet the needs of the client or that contribute to retraumatization can be avoided to the greatest extent.

The procedures outlined below have been demonstrated to reduce the incidence of the use of seclusion and/or restraint in various behavioral care settings. These procedures detail the individual client assessment that shall be done prior to an episode of seclusion and/or restraint, in order to obtain information from the client about what helps him/her deescalate in times of crisis and to avoid potential retraumatization.

III. Procedures

1. These procedures shall guide BDS staff treating clients in a variety of settings to ask for information:

a. Identifying specific circumstances that elicit potentially harmful behavior and

b. Understanding what responses can help the client de-escalate and avoid restraint.

2. Attached to this policy statement are two forms which have been developed to assist in the client’s assessment prior to an episode of Seclusion or Restraint:

a. Trauma Assessment for use by BDS Facilities/Staff and

b. Personal Safety Form for use by BDS Facilities/Staff

3. These forms are provided for guidance (not necessarily for use in their present format) to assist clinicians to gather information that may be relevant such as:

a. Whether the client has a history of exposure to events that involved actual or threatened death or serious injury to self or others. This would include, for example, surviving rape, combat, torture, genocide, natural disasters, and fires;

b. Whether the client has a history being physically or sexually abused in childhood or adolescence;

c. What particular approaches or strategies will be most helpful to the client in order to reduce agitation and distress, and avoid using restraint or seclusion,

d. What kind of restraint or seclusion, if needed, would be most helpful and least traumatic for the client, and

e. Whether there are indications for the gender, race, or ethnicity of staff who might administer and monitor restraint or seclusion, if used.

4. Emphasis is placed on conducting the trauma history assessment in a sensitive manner that fosters the clinical recovery of the client and continued support from the client’s social network. For non-verbal clients or children who are too young or unable to provide this information, much of the information may be available from parents, guardians or other historians rather than from the client directly. Communication facilitation (example, providing a signing interpreter) must be offered for any client who needs this.

5. Both of the attached forms are written so that they may be completed either by the client or by staff. In accordance with BDS’s mission of assuring client participation in all treatment decisions, it is considered essential to capture the client’s self-knowledge and wishes, whenever possible, in the assessment process. Information obtained through the forms should be reviewed by the acute care staff or treatment team to determine its clinical application. The information should then be incorporated into the client’s treatment plan, with client participation.

6. In order to incorporate the assessment information into a treatment plan, the program or facility may need to consider new approaches or interventions for assisting in the de-escalation of the client (such as pounding clay, exercise opportunities, or others noted on the Personal Safety Form). Certain modifications of common existing methods of restraint or related issues are considered essential by BDS to achieve the stated goal of eliminating re-traumatization of clients during and around the use of seclusion and restraint. These include the following:

a. Facilities and programs should have available a variety of interventions so that the option most helpful and least intrusive for a particular client may be used. Restraint requiring the client’s legs to be spread apart should be eliminated;

b. A client will have opportunity to do his/her own personal hygiene at least every 2 hours unless to do so would result in the client’s harming him/herself or others;

c. Clients in restraint should either be able to observe continually a functioning clock or be able to find out the time by asking staff in attendance;

d. The staff person attending a client in restraint should be the opposite gender of the client’s identified perpetrator(s) of abuse, unless client preference dictates otherwise;

e. Individuals who have been secluded or restrained and staff who have participated in these interventions usually should participate in debriefings following each episode in order to review the experience and to plan for earlier, alternative interventions;

f. Staff should receive training and supervision regarding:

i. The prevalence of abuse survivors among BDS clients,

ii. The psychological, medical and behavioral consequences of abuse and

iii. The spectrum of appropriate interventions

7. In pursuit of the goal of prevention and reduction of the use of seclusion and restraint, DBDS shall maintain effective quality improvement programs that review trends in seclusion and/or restraint use.

Attachments:

Trauma Assessment for BDS Facilities/Staff

Personal Safety Form for BDS Facilities/Staff

________________________________________ July 11, 2002

Lynn F. Duby, Commissioner

State of Maine

Department of Behavioral and Developmental Services (BDS)

Personal Safety Form for BDS Facilities/ Staff

This form is a guide to gathering information with clients for the development of strategies to de-escalate agitation and distress so that restraint and seclusion can be averted. It should be used with all clients in conjunction with the Trauma Assessment Form. It is recommended for use in inpatient facilities, psychiatric emergency rooms, crisis stabilization and other diversion units. The information obtained should be incorporated into the treatment plan for this client.

1. It is helpful for us to be aware of the things that can help you feel better when you’re having a hard time. Have any of the following ever worked for you? We may not be able to offer all these alternatives but I’d like us to work together to figure out how we can best help you while you’re here.

	Voluntary time out in your room		Listening to music
	Voluntary time out in quiet room		Reading a newspaper/ book
	Sitting by the nurses station		Watching TV
	Talking with another consumer		Pacing the halls
	Talking with staff		Calling a friend
	A warm drink		Calling your therapist
	Eating something		Pounding some clay
	Punching a pillow		Exercise
	Writing a diary/ journal		Using ice on your body
	Deep breathing exercises		Putting hands under cold water
	Going for a walk with staff		Lying down with cold face cloth
	Taking a hot shower		PRN medication
	Wrapping up in a blanket		Other?

2. Is there a person who has been helpful to you when you’re upset? (Y/N) Would you like them to come and visit you? (Y/N) Can we assist in this process? (Y/N) If you are in a position where you are not able to give us information to further your treatment, do we have your permission to call and speak to:

___________________________________________________(Name)____________________(Phone)

If you agree that we can call to get information, sign below:

Client signature________________________Witness_______________________Date:______________

3. What are some of the things that make it more difficult for you when you’re already upset? Are there particular “triggers” that you know will cause you to feel or act more upset?

	Being touched		Being isolated
	Bedroom door open		People in uniform
	Particular time of day (when?)		Time of the year (when?)
	Loud noise		Yelling
	Not having control/ input (explain)		Other (please list)

4. Have you ever been restrained in a hospital or other setting, for example, in a crisis stabilization unit or at home?

	Physically/ Mechanically	Chemically
When?
Where?
What happened?

5. If you are escalating or in danger of hurting yourself or someone else, we may need to use a physical, or mechanical restraint. We may not be able to offer you all of these alternatives but if it becomes necessary, we’d like to know your preferences.

Time out in your room
Quiet room (unlocked)		Seclusion (locked door)**
Physical hold	Safety coat	Other
3-point restraint*	Face up?	Face down?
4-point restraint with legs together*	Face up?	Face down?

* These restraints are not allowed for people with mental retardation

** Locked door seclusion is not allowed for people with mental retardation

6. Do you have a preference regarding the gender of staff assigned to you during and immediately after a restraint? Women Staff___ Men Staff___ No Preference___

7. Is there anything that would be helpful to you during a restraint? Please describe.

____________________________________________________________________________________

8. We may be required to administer medication along with physical restraints. In this case, we would like to know what medications have been especially helpful or harmful to you? Please describe.

Helpful:______________________________________________________________________________

Harmful:_____________________________________________________________________________

9. We do room checks here to make sure you are okay at night. We are trying to make these room checks as non-intrusive as possible. Is there anything that would make room checks more comfortable for you?

____________________________________________________________________________________

Please incorporate the information obtained in the Personal Safety Form

into the treatment plan for this client

State of Maine

Department of Behavioral and Developmental Services (BDS)

Trauma Assessment for BDS Facilities/ Staff

This form serves as a guide to taking a trauma history. It is recommended for use as part of the intake assessment. After clinical review, this information should be incorporated into the treatment plan, with client participation. It should be used in conjunction with the Personal Safety Form.

1) Sometimes, people have been hurt or frightened by others in the past. Some have lived through terrible experiences such as abuse, rape, combat, or injuries. If we know about these experiences, we may be better able to help you. Are you willing to answer a few questions to help us understand more about your personal experience with such things?

(If the client is unwilling, or uncertain whether to proceed, please gently explore the basis for his or her refusal and attempt to address any concerns about the process).

2) Have you ever been physically hurt or threatened by another? (e.g., hit, punched, slapped, kicked, strangled, burned threatened with object or weapon, etc.)?

Yes___ No___

If yes, in the past?___ Is it still going on?___ Are you able to say by whom?___

Someone known to you or a stranger?__________

Details______________________________________________________________________________

3) Do you have a history of unwanted sexual contact by another? (e.g. unwanted kissing, hugging, touching, nudity, attempted intercourse? Yes___ No___

If yes, in the past?___ Is it still going on?___ Are you able to say by whom?___

Someone known to you or a stranger?___

Details:_______________________________________________________________________________

4) Have you ever been raped, or had sex against your will? Yes___ No___

If yes, when?___ Are you able to say by whom?___ Someone known to you or a stranger?_________

Details:_______________________________________________________________________________

5) Have you lived through a disaster (like a flood, tornado, or plane crash)? Yes___ No___

If yes, please give age and circumstances:____________________________________________________

______________________________________________________________________________________

6) Are you a combat veteran, lived through war as a civilian in another country, or experienced an act of terrorism?

Yes___ No___