The Use of Seclusion on an Inpatient Crisis Intervention RENEE
L. BINDER,
M.D.
Director, CrISIS Intervention Langley Porter Neuropsychiatric San Francisco, California
Unit Institute
Because the use of seclusion is controversial, a retros’pective study of 50 patIents was designed to examine how seclusion is actually being used on a short-term inpatient crisis Intervention unit. It was found that 44 per
cent
secluded during their stay. to be a factor in whether a patient was secluded, but elderly patients and depressed patients were less likely to be secluded. Most of the secluslons occurred on the first day of hospital-
Neither
of the patients
were
sex nor race seemed
ization, with the four most tation, uncooperativeness, lence. The author speculates on the crisis unit is related patient
population
patIent
stay.
as well
common anger,
reasons being agiand history of yb-
that the use of seclusion to the characteristics of the as to the short duration of
uThe use of seclusion for psychiatric inpatients is controversial. Although it is used on many inpatient units, both staff and patients have mixed feelings about it. On the negative side, seclusion is perceived as a denial of the patient’s civil rights,’ as a controlling, punitive procedure,’ and as an anxiety-provoking experience for staff and patients.’ On the positive side, seclusion is perceived as a therapeutic tool to decrease sensory stimuli for the excited or hyperesthetic patient,4 as a method for providing safety and external controls for the sui-
Dr. Binder is also assistant professor of psychiatry at the University of California, San Francisco. Her address at Langley Porter is 401 Parnassus Avenue, San Francisco, California 94143. She acknowledges the assistance of Carroll M. Brodsky, M.D., and Frank J. Jonelis, M.D., in preparing this paper. 1 R. C. Fitzgerald and I. Long, “Seclusion in the Treatment and Management of Severely Disturbed Manic and Depressed Patients,” Perspectives In Psychiatric Care, Vol. 11, April-June 1973, pp. 59-64. 2 H. W. Dunham and S. K. Weinberg, The Culture of the State Mental Hospital, Wayne State University Press, Detroit, 1960. ‘A. H. Stanton and M. S. Schwartz, The Mental Hospital, Basic Books, New York City, 1954. R. K. Kilgalen, ‘The Effective Use of Seclusion,” Journal of Psychiatric Nursing and Mental Health Services, Vol. 15, January 1977, pp. 22-25.
266
HOSPITAL
& COMMUNITY
PSYCHIATRY
Unit
cidal or homicidal patient,’ and as an effective aversive technique for the depressed patient.’ The present study was designed to examine the use of seclusion on an inpatient crisis intervention unit. It was structured to answer such questions as, What percentage of patients are actually secluded? Is it possible to generalize about them in terms of sex, race, age, and diagnosis? If a patient is brought to the unit by police or has a history of violence, is he more likely to be secluded? Why are patients secluded-for treatment, or for control and management? What are the reasons for secluding a patient more than once? When during hospitalization is seclusion used, and does the timing convey something about why it is used? What is the average length of seclusion, and why are some patients secluded for longer or shorter times? The study was undertaken on the 1 1-bed crisis intervention unit at Langley Porter Neuropsychiatric Institute. The unit has contracted with the catchment area’s community mental health center to provide all inpatient services for the area, which comprises approximately 190,000 persons. All catchment-area patients who need inpatient care are admitted, whether or not they are potentially violent. Patients may be on an involuntary or voluntary status, and some are brought to the unit by the San Francisco police. Patients are held involuntarily if they are a danger to themselves, are a danger to others, or are gravely disabled as defined in the state’s Lanterman-Petris-Short Act of 1969. The average number of admissions is 30 per month, and the average stay is just over six days. Patients are treated with liberal doses of psychotropic medications as well as with individual and family crisis-oriented therapy. At the time of the study, the unit was staffed by two full-time psychiatrists and one half-time psychiatrist, one social worker, two half-time occupational therapists, and 23 nursing staff members. Eleven of the nursing staff were on the day shift, eight on the evening shift, and four on the night shift. ‘T. C. Cutheil, “Observations on the Theoretical Basis for Seclusion of the Psychiatric Inpatient,” American Journal of Psychiatry, Vol. 135, March 1978, pp. 325-328. #{149} D. A. Wells, “The Use of Seclusion on a University Hospital Psychiatric Floor,” Archives of General Psychiatry, Vol. 26, May 1972, pp. 410-413.
In recent years there have been only two written directives about the use of seclusion on the unit. One was issued in September 1976, after a recently admitted patient struck a nurse. It reads, Seclusion is to be used whenever a patient is presented to the unit and there is a history of or threat of violence, or whenever one of the staff doing the admission becomes aware of impending violence. Interviewing can take place in the seclusion room, and the patient can be kept there while being amply medicated. . . . When a prospective patient has been brought in by police, there should be an initial assessment with regard to potential violence; if seclusion is indicated, it should be carried out before the police leave.” The second directive is contained in the Langley Porter procedures manual and is dated September 1974. It reads, Confinement of patients in locked rooms and physical restraints shall be used only when they are necessary to prevent injury to the patient or others, and when alternative methods are not sufficient to accomplish the purpose.” A patient is admitted to the unit by the on-duty psychiatric resident. There is almost always an order for seclusion p.r.n., largely because the admission order sheet is a checklist rather than a sheet of paper on which orders must be written. The resident merely has to check the line that says seclusion p.r.n.” (Such an order was written for all the patients in the study.) The actual decision of when and if to seclude is made by the nursing staff. They may either put the patient in seclusion themselves or call for help from security personnel. Nursing staff then record the reasons for seclusion in the nursing notes of the patient’s chart. They also observe the patient at 15-minute intervals and document the observations on a special seclusion record. ‘ ‘
“
not secluded. The remaining 82 per cent (41 patients) were Caucasian; 81.8 per cent (18) of those secluded were Caucasian. As for age, 30 per cent (15) of the patients were over 40; 10 per cent (5) of those secluded were over 40. On further analysis, it was found that 18 per cent (9) of the patients were over 50, and none of them were secluded. Thus neither sex nor race seemed to be a significant factor in whether a patient was secluded, but the older a patient was, the less likely he was to be secluded. The total sample encompassed 25 diagnostic categories; the patients who were secluded fell into 11 of those categories (see Table 1). Patients with a variety of diagnoses were secluded, but those whose illness had a strong depressive component were less likely to be secluded. Patients with a diagnosis of paranoid schizophrenia were slightly more likely to be secluded. (Twenty-eight per cent of the patients had such a diagnosis, and 36.4 per cent of those secluded were in this category.) Fifty per cent (25) of the patients were brought to the unit by the police, and 60 per cent of those (15) were secluded. Of the total patients secluded, 68. 1 per cent (15 of the 22) were brought in by the police. All patients who had a history of violence were secluded, except for
“
TABLE
were
1
SECLUSION
EPISODES
The research was based on a retrospective study of 50 charts, reviewed in order of patients’ admission for the period from October 1 through November 16, 1976. Data were recorded on each patient, and if the patient had been secluded, data were recorded about the seclusion episode, based on nursing notes and seclusion records. During the study period, there were 28 incidents of seclusion involving 22, or 44 per cent, of the 50 patients. Five of the 22 patients, or 10 per cent, were secluded more than once. The mean length of seclusion was 15.7 hours, with a minimum of one hour and a maximum of 72 hours. Data comparisons give some perspective on whether patients with certain demographic characteristics tended to be secluded more often than others. The data showed that 38 per cent of the 50 patients (or 19) were women, and that 40.9 per cent of those who were secluded (or 9) were women. As for race, 16 per cent of the patients (8) were black, and 18.2 per cent of those secluded (4) were black. The single Asian patient was
in the
total
sample
and
patients
who
by diagnosis N in total
Diagnosis Paranoid
schizophrenia
Chronic
undifferentiated
schizophrenia
Alcohol
addiction excited
Schizo-affective, Acute
THE
Patients
secluded,
alcohol
Hysterical
intoxication personality
Simple
schizophrenia
Acute
schizophrenic
Nonpsychotic
episode
OBS
with
schizophrenia
Antisocial Senile
personality dementia
Psychosis disorder
retardation
Psychosis
with
excessive
Hysterical
neurosis,
drug
1
1
1
1
1
1
1
1
1
1
1
1 1
1 1
1 1
reaction
1
1
adjustment paranoid associated
state
1
with
intoxication
1
neurosis
Schizo-affective, Psychotic
2
drinking
dissociative
Depressive
2
undiagnosed
Habitual
Involutional
4
2
1 1
condition
Psychosis
11
1 depressed
depressive
1
reaction
1
melancholia Manic-depressive, depressed
1
Involutional
VOLUME3O
secluded
endocrine
Mental
Marital
8
1
with
physical
N
14
drug
intoxication
Residual
sample
NUMBER
4 APRIL
1
1979
267
two who were ages 72 and 89. Violence was defined as doing damage to persons or property. Seventy-five per cent of the incidents of seclusion (21) took place on the first day of hospitalization. Of the 28 incidents, 13 were initiated on the evening shift (3:30 p.m. to 11 p.m.), nine were initiated on the day shift, and six were initiated on the night shift. It is not clear whether the higher figure for the evening shift was because of a seclusion-prone staff constellation, because fewer nursing staff are on duty evenings than days, or because patients may be more agitated in the evenings when there are not as many activities. Many justifications for seclusion were listed in the nursing notes and seclusion records. As Table 2 shows, the four most common were agitation, uncooperativeness, anger, and history of violence. Patients were also secluded when staff felt threatened by them, verbally or nonverbally. Five patients were secluded more than once, one three times and the rest twice. In three of the five cases, the second seclusion was for fewer hours and seemed to have less provocation. In the other two cases, the second seclusion lasted longer than the first. The two longest seclusions were for 65 and 72 hours. The reasons for the 65-hour seclusion were listed as “
Threw
urine
at staff,
history
of violence,
IM meds,
attempted to hit staff, yelled obscenities at staff, agitated, uncooperative, broke glass vase, pounding on seclusion room door. The reasons for the 72-hour Seclusion were listed as “Threw water at staff, hit staff gently, threw tray with dinner all over room, agitated, uncooperative, IM meds, beating on wall with fists, delusional, yelling, fearful, attempt to elope from seclusion. ‘ ‘
COMPARISONS
WITH
OTHER
UNITS
The use of seclusion on the unit, for 44 per cent of the admissions, can be compared with seclusion practices on other psychiatric units. Wells reported on a university hospital psychiatric unit where 4 per cent of the patients were secluded at some time during their stay.’ Wadeson and Carpenter described a National Institute of Mental Health clinical research unit where seclusion was used relatively frequently,” although they gave no percentages.’ To understand the differences in the incidence of seclusion, we need to look at the differences and similarities between the units. Psychotropic medications were used liberally on both the crisis intervention unit and on Wells’ unit. On the NIMH research unit, little medication was used, which was the reason given for the widespread use of seclusion there. On the crisis intervention unit, there were only three cases in which seclusion was used because medications could not be; thus inability to use medication “
7
Ibid. T. Carpenter, “Impact of Nervous and Mental pp. 318-328.
#{149} H. Wadeson and Room Experience,”Journal
November
268
1976,
W.
HOSPITAL
& COMMUNITY
of the Disease,
TABLE
2
seclusion
Reasons records
for seclusion
in nursing
notes
Reason
Frequency
Agitation
16 14
Uncooperativeness
Anger History Yelled
9
8
at staff
Refusing p.o. meds Delusional Disoriented or confused Hostile, sarcastic, rude Physically resistive Hit
inanimate
object,
7
6 5 4 4
to staff such
as knocking
furniture or hitting counter with fist Attempted to hit staff History of alcoholism (now intoxicated) Fearful Threatened staff verbally Meds not used because of intoxication other reason Speech
has violent
Searched
staff
3 3
3 or 3
2 2
nonverbally,
as by
behavior
gently
Had difficulty Suicidal
4 4
content
Threw water or urine at staff Will not respond to verbal limits Attempting to go AWOL Patient states he is fearful of hurting self or others Hit staff
over
in seclusion
Threatened
Sexual
and
12 of violence
settling
at night
ideation
shaking
fist
2
2 1
1 1 1 1 1 1
does not explain the rate of seclusion there. However, medication effect may help explain why the majority of seclusions on this unit and Wells’ unit occurred on the first day. Medications often were instituted on admission, but seclusion might well be used for management until medications have taken effect. The four most common reasons for seclusion on the crisis unit were agitation, uncooperativeness, anger, and history of violence, and on Wells’ unit the primary reason was uncontrollable violent behavior. This cornbination suggests once again that staff are fearful of potentially dangerous patients and use seclusion as a way of containing them, possibly until medication can take effect. The unit’s list of reasons for seclusion offer some evidence that seclusion at times is used as a weapon of retaliation and control (as is also suggested in the work of Dunham and Weinberg’). For example, four patients were secluded when they were “hostile, sarcastic, rude to staff.” The two longest seclusions involved incidents in which staff’s dignity was affronted-in one case urine and in the other case water was thrown at staff. How can one explain the findings that elderly patients and depressed patients were less likely to be secluded? The former might be explained by the fact
Seclusion Vol. 163, #{149} Dunham
PSYCHIATRY
listed
and
Weinberg,
op. cit.
that staff respect the aged, who are approximately the age of their parents, or that elderly patients are not seen as dangerous or threatening. The second explanation would also hold for the low incidence of seclusion of depressed patients, whose aggressive impulses are directed inward and who therefore are not considered threatening. In contrast, paranoid patients are more likely to be secluded since they are seen as dangerous. Why were 44 per cent of the patients on the crisis unit secluded, compared with only 4 per cent on Wells’ unit? The explanation may lie in certain differences between the two units. On Wells’ unit, 41 per cent of the patients were psychotic; on the crisis unit, 74 per cent were psychotic. In addition, 50 per cent of the patients were brought in by the police, and almost 25 per cent had a history of violence before admission. Wells does not comment on these important factors. There is something frightening about a patient brought in by a policeman, especially in handcuffs; thoughts about dangerous prisoners come to mind. Because the patients are unscreened, staff have greater difficulty making predictions about them and therefore may react more rapidly to provocation that is seen as a sign of impending violence. And the acutely and severely disturbed patient may note that staff are frightened, which may trigger or reinforce aggressive behavior. Patients stayed on Wells’ unit about three and a half weeks, compared with one week on the crisis intervention unit. Because the staff on the crisis unit will not be taking care of any patients over a long period, they may be less cautious about engaging in the kind of interaction that would adversely affect the longer-term therapeutic situation, such as putting the patient in seclusion. And the patient might be more ready to explode than to work something through if he knows that his stay will be short-term and he will not have to relate to the staff for very long. Staff’s and patients’ expectations might readily lead to explosions. One can also speculate that staff who will not have the satisfaction of engaging in a longer-term therapeutic venture, with its greater possibility for relationship and professional gratification, might take out some of their frustrations in their professional interaction with patients. Whether or not the crisis intervention unit is representative of other short-term crisis units is an area open for further study.#{149}
Utilization Review and Resident Education
JAMES H. SPENCER, JR., M.D ClinicalAssociate Professor of Psychiatry MARLIN R. MAUSON, M.D. Assistant Professor of Psychiatry Cornell University Medical College New York, New York The reasons for psychiatric hospitalization are not always taught clearly and formally to psychiatric residents; screening criteria employed in utilization review can be a toolfor helping residents gather data and make decisions about the admission or continued stay of patients. On the admitting and inpatient units of the Payne Whitney Psychiatric Clinic, residents use sets of criteria for admission and for continued stay, with accompanying guidelines and clinical examples, as part of their training. The authors outline principles used in developing the criteria, Including the belief that they should be applicable Independent of diagnosis. They suggest that In a teaching hospital screening criteria should be taken as standards, and that they should be
developed then
as part
Introduced
#{149}Utilization review cedure in hospitals
of the educational Into
utilization
program
and only
review.
is fast becoming an established prothroughout the country. In many
Dr. Mattson also is assistant medical director of the Payne Whitney Psychiatric Clinic, 525 East 68th Street, New York, New York 10021.
VOLUME
30 NUMBER
4 APRIL
1979
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