Pennsylvania: No seclusion, PRN or restraint.

wonderbee, BSN, RN · Jun 26, 2008

How do they deal with a large male, admitted via the police in handcuffs,very psychotic and an extensive history of violence?
Most of the western world has tried and trusted routine. Restraint, PRN and seclusion. However Pennsylvania does none of the above.
Whatever they have discovered in Pennsylvania please share the knowledge.

Not restraint or seclusion free. Just used sparingly. The deck is stacked in favor of the patient, and against staff who are at risk. There are lots of staff injuries.

kiwipsychnurse · Jun 26, 2008

The research paper I have states that there was no increase in staff injuries.

If your from one of these hospitals in PA I would love to talk to you, I have a few questions.

oldladyRN · Jun 27, 2008

Please keep in mind that you are only hearing half of the story.

I used to work at a facility that collected big, big $$ from the state of Pennsylvania by "housing" their kids. I use that term because they weren't really doing anything therapeutic for them. These were kids that their own state didn't have room for (not enough jails or psych facilities), so Texas held out their arm like Lady Liberty herself and said, "Come on down!!" These kids were horrible. We had both girls and boys, and they were all adjudicated. Their past offenses ranged from armed robbery to stabbing Grandma w/a butcher knife. The main diagnosis for all of them was "oppositional defiant disorder", which is a joke. (my parents knew the cure for that, why didn't someone just ask??)

These kids badly assaulted staff ad nauseum and there was virtually nothing we could do. We could restrain them and give them emergency meds (po or IM), but we couldn't put them in locked seclusion. Placing one of them in locked seclusion would cost the facility a day's pay for that patient from the State of Pennsylvania. There finally came a day when the kids got out (they picked the lock, duh), took over the campus, assaulted staff and other patients alike, and were finally hauled off by the police. Good riddance.

I understand that there is a big movement out there to completely eliminate restraints and seclusions, but it's just not realistic. Safety must be the priority.

kiwipsychnurse · Jun 27, 2008

The reason I am quoting PA is that at present whenever research is quoted it seems to come from the state of PA. I'm realistic about restraint and seclusion. I personally teach restraint training to our nursing staff.

What worries me is at present in New Zealand there seems to be a watering down of your restraint techniques.

When you read that the 5 of the 9 PA state hospitals have gone Restraint, secluison and PRN free. I dont believe it. Basically they have said they have cured mental illness. Either that or they are very selective of which patients they admit.

I'm aware that you have private psych hospitals in PA. I'm gusssing that the really hard to manage/extreamly violent patients are kept out of the state hospitals to make there books look good and keep the dollars flowing.

oldladyRN · Jun 27, 2008

I don't think I was clear in my post. I'm in Texas, not Pennsylvania. The State of Pennsylvania farms out their psych admits because they can't manage them on their own. When they are admitted to an out-of-state facility, the facility signs an agreement stating that they (the facility) will not place these kids in locked seclusion. The kids come down here KNOWING that they can't be locked, and they throw it in your face 24/7. I did, however, end up locking a couple of them in seclusion at different times d/t safety issues and their increased violence. They would actually shout at me through the locked door, "you can't lock me, you b*&%$!!", and I said, "I just did." Once they found out that this nurse didn't give a hoot about the facility losing a day of pay from Pennsylvania, things got a little more under control while I was on duty.

kiwipsychnurse · Jun 27, 2008

I don't think I was clear in my post. I'm in Texas, not Pennsylvania. The State of Pennsylvania farms out their psych admits because they can't manage them on their own. When they are admitted to an out-of-state facility, the facility signs an agreement stating that they (the facility) will not place these kids in locked seclusion. The kids come down here KNOWING that they can't be locked, and they throw it in your face 24/7. I did, however, end up locking a couple of them in seclusion at different times d/t safety issues and their increased violence. They would actually shout at me through the locked door, "you can't lock me, you b*&%$!!", and I said, "I just did." Once they found out that this nurse didn't give a hoot about the facility losing a day of pay from Pennsylvania, things got a little more under control while I was on duty.

Thanks for that. So thats how they keep their seclusion figures down, they farm the hard to manage patients to other states. Very interesting.

Ghostwriter129 · Dec 21, 2008

Pennsylvania's state hospital system should not be confused with its Juvenile Justice System. The state hospital system is an adult civil and forensic system of care with a total of about 1,900 beds statewide. Seculsion and mechanical restraint use are still permitted but most hospitals have discontinued the use of these measures. Each month mechanical restraint is used less than 5 times and seclusion is used perhaps once or twice in the 8 hospitals and 3 foresnic centers. Physical restraint events average about 110 applications systemwide each month. Our system rules prohibit the use of any floor control to support a person in crisis. If staff end up on the floor restraining person then they must disengage. No prone or supine restraint permitted. The use of Psychiatric Emergency Response Teams (PERT) account for this change. Pennsylvania is very transparent in its use of these traumatizing techniques a publishes a monthy report since 2000 on adverse events occurring to people severd in the hospital system.

Regarding staff or patient injures from assault, during the span 2000-2007, systemwide their was no increase in assaults with injury. Staff get hurt by patient related assaults 4 ways; 1) unexpected blow/hit from behind, hit w/ a chair etc. 2) Separating patients engaged in an assault of a peer or staff, 3) Stopping a person who is engaged in SIB (self-injurius behavior) 4) restraing/secluding a person in crisis. If you can push/reduce the use of S/R your hospital/agence assaults should go down. PERT teams are the most effective means of supporting patients in crisis.

Regarding the use of PRN orders for Psychiatric indications, the hospitals sytem (civil/forensic) stopped using them in March 2005. Unscheduled medications for psychaitric indications are only available by STAT MD order. We have a doc on campus/on duty 24/7 in our hospitals to make it work. PRN orders over expose people to unnecessary psychotropic meds. They benefit staff more than patients. Read the literature. Do you know of one nurse who ever received training on the use of PRN orders?

Finally, DO NO HARM! Read the literature and don't depend on the war stories.

http://www.springerlink.com/content/867xw30861535534/

wonderbee, BSN, RN · Dec 30, 2008

Can you provide me a link to the research paper please?

I work at an acute care hospital. The closest state facility is over a hundred miles away because Pennsylvania has decided to close most of its state hospitals in an effort to have its psych population absorbed into the community. In my opinion, it's not working well. The communities are not very accepting and are fearful so we hold on to our patients for a very long time. They go to our transitional unit which now performs the function of the old state hospital. It's like a shell game.

It's impossible to not use locked seclusion but it is a last resort. PRNs aren't uncommon so I don't know where that statistic comes from. We have safety officers who respond like a code team. That intervention often means the difference between a locked and an open seclusion situation. It is a skill to know when to call for the team. The earlier, the better the result. It's important to catch an escalating client before it gets to the overt violence stage.

wonderbee, BSN, RN · Dec 30, 2008

As regarding staff injuries, I have been assaulted 4 times in one year. None of them serious. Two of them were from MR patients with latent responses. They gave no indication of what was coming. One happened in the course of restraining a patient who was assaulting a co-worker, the other was while getting accuchecks out on the unit. The patient came at me face to face while my hands were full and beat me over the head repeatedly with her open hands. There were other close calls. We are well trained in crisis intervention ourselves, having taken a two-day hands on self-defense course with emphasis on safety for both the patient and the staff member.

kiwipsychnurse · Dec 30, 2008

Ghostwriter, thanks for your reply to my original question. What I have learn't from your post is:

Seclusion and mehanical restraint are still permitted to be used in Pennsyvania and seclusion is utilised once or twice a month state wide?

Physical restraint is used approx 110 times a month, about 1300 times a year. 11 hospitals. 1300 divided by 11= 118 times per month per hospital.

If engaged in restraint and you end up on the floor you disenage? Then what? The person you are restaining jumps up and it all starts over again. I would really like to see this in action. Staff restraining a large male, after an assault, the restrainers go to the floor and someone yells disengage!! I'm surprised your staff are not getting seriously injured.

You state that "if you can push/reduce the use of seclusion your assualts should go down". Approx 118 restraints per month per hospital is not really a great indicator that assaults are on the decrease. As you state "read the literature". Be great if you could provide some link that backs up your statement.

PRN use. So they stopped the charting of PRN, but a doc is there to 24/7 to chart if needed. Does not really sound like you stopped the nurses giving out PRN, they just need to call the doctor in to give it out. I imagine he/she is very busy.

The final link you provided is an article that you need to log in to read or purchase it.