Tuesday, February 5, 2008

Local hospitals say restraint use is down

From the Portland Tribune

Some facilities institute Salem-style changes, but not all users convinced

Donita Diamata (with daughter London and dog Bella) says she was secluded and tied to a bed four years ago at Providence Portland Medical Center. Area hospitals say they’re adopting policies that reduce the use of restraints, but Diamata says that if she ever needs to be hospitalized, she wants to be taken to Salem instead.

Donita Diamata, who has suffered from depression and an eating disorder and is now a mental health advocate, has had inpatient stays at Providence St. Vincent Medical Center, Providence Portland Medical Center and at Oregon Health & Science University, as well as Salem Hospital.

And even though she lives in Portland, Diamata says she has instructed friends that if she ever needs to be hospitalized for psychiatric care again, they should make sure she is not taken to a Portland hospital.

That’s because of what happened to Diamata four years ago, she says.

Diamata says she was secluded in a room in the emergency department at Providence Portland for four days and friends later told her that when they came to visit her in the psychiatric unit after the seclusion, her hands were tied to the bed.

She says she cannot recall the alleged restraint because medications had put her in a hallucinatory state.

She says books were taken away from her if she didn’t do what nurses instructed. She says she’s seen patients end up in restraint for talking too loudly at OHSU.

“I was in a room where restraints were hanging over the bed,” she says. “It was like a reminder that if I didn’t behave that would be my fate, too.”

In fact, she recalls a nurse at a Portland hospital who she says tried to convince her that physical restraint could be a positive experience.

“She said, ‘No, no, it can actually be a beautiful thing,’ ” Diamata says. “She said restraint is like getting a group hug.”

Officials at several of Portland’s six hospitals with inpatient psychiatric units – and some independent observers – say Portland hospitals have changed since Diamata was last a patient, and that they have significantly reduced their use of restraint and seclusion.

But exactly how much is a bit of a mystery.

None of the Portland hospitals is willing to say how many restraints and seclusions they do each year, despite repeated requests by the Portland Tribune.

The closest they’ve come is an e-mail from the Oregon Association of Hospitals and Health Systems, the lobbying organization for the state’s hospitals.

That e-mail said that the Portland-area hospitals had combined their data on restraint of mentally ill patients. The e-mail said that data showed the use of restraint in Portland facilities had dropped “about 60 percent” in the past five years.

“A typical Portland-area psychiatric unit would use restraint about once a month,” according to the e-mail.

When the Tribune asked that seclusion data also be sent, the association representative said that would not be possible because each hospital kept its seclusion data in a different form.

But recent revelations following the August death of 50-year-old psychiatric patient Glenn Shipman Jr. at Legacy Emanuel Hospital & Health Center raise questions about how far Legacy and the other area hospitals have come in changing their culture of care.

Shipman was asphyxiated at Legacy Emanuel’s psychiatric unit after staff there held him face down against the floor for at least 10 minutes in a position called prone restraint.

Shipman, who weighed 450 pounds and suffered from schizophrenia, refused to cooperate with nurses prior to his takedown and death, according to the federal report.
Restraint called a last resort

To many who work in the psychiatric units of hospitals, restraint and seclusion are necessary tools to deal with patients who often are out of control and frequently dangerous.

Restraining a patient, either by physical force as occurred in Shipman’s case, with leather or plastic cuffs that tie a patient to a bed, or with a special device called a Posey vest, often is partnered with seclusion, which usually refers to putting a patient in an isolated, locked room, often for long periods.

In the past five years there have been 136 attacks on staff by patients at Legacy Emanuel, according to John Reid, director of security at the hospital. The majority of those were staff members being punched, kicked or spit upon, Reid says.

“Health care workers don’t complain about those things,“ Reid says. “Unfortunately, it’s become part and parcel of being a health care worker. When you’re trying to get control of a situation, you do what you need to do to control a patient and protect the patient and the staff.”

Reid says that restraint is used only as a last resort, and that every time a restraint takes place the hospital follows up with a full analysis of the events.
Salem system used as model

Deborah Gaspar, chief nursing officer at Legacy Emanuel, says that Emanuel has looked at the model that Maggie Bennington-Davis helped institute at Salem Hospital – where restraints and seclusions were reduced from 260 to zero in just two years – and incorporated many of its principles.

Cindy Scherba, manager of the psychiatric care unit at OHSU, says that her hospital uses “a person-centered model” to engage patients that uses many of the same elements as the Salem program, including changes in the physical space to present a more comforting environment and twice-a-day community meetings that involve both staff and patients.

“Sometimes patients scare each other,” Scherba says. “(The community meetings) are a place they can feel safe and talk about real issues.”

According to Herb Ozer, who directs Behavioral Health Services for Providence Health and Services, both Providence Portland Medical Center and Providence St. Vincent Medical Center have trained their psychiatric staff in the same model Salem uses.

Jeff Rogers, a civil commitment investigator for Washington County Behavioral Health Program, is a frequent visitor to all the area psychiatric units, and he says he’s seen tremendous positive change in the way patients are treated.

But he also says that the flood of psychiatric patients coming to the hospitals through emergency departments has increased the stress level on the people who work in the psychiatric units.

“The acuteness of the cases seems to be greater, the complexity of the cases seems to be greater, and the pressure on the system from intake to discharge seems to be higher on everyone,” Rogers says. “There’s a lot of pressure on people to make really quick decisions.”

Reporting has had effect

As far as Diamata is concerned, Portland hospitals may have improved in the ways they deal with psychiatric patients, but they haven’t changed enough.

Diamata, who was director of consumer services at Cascadia Behavioral Healthcare until 2006, says that within the past year she has visited friends at Portland hospitals, and the change didn’t impress her. And, she says, the local psychiatric units still use seclusion.

Seclusion, she says, can be nearly as bad as restraint. “It’s traumatic and it’s insulting, and you feel like you’re in a cage,” Diamata says of seclusion.

Diamata and a host of national experts agree that hospital psychiatric units should be required to report their restraint and seclusion data to state health authorities, and that those numbers should be available for public comparison.

Susan Stefan, senior staff attorney for the Center for Public Representation, a Massachusetts-based organization that advocates for people with mental illness, says that the few states that have required hospitals to report their restraint and seclusion data have all experienced a similar result – the numbers of restraints and seclusions dropped.

“You’ve got comparisons so you can look across at the hospitals and say one is way out of line. It drives the rates down,” she says.

Beckie Child, board president of Mental Health America of Oregon, a statewide advocacy group, says she would welcome the data being made public, along with more change at Portland hospital psychiatric units.

Child, who was secluded a number of years ago at the now-closed Woodland Park Hospital in Northeast Portland, says she’s visited friends in many of the Portland psychiatric units, and the staff members “still don’t get it.”

“It’s not just about not using seclusion and restraint; it’s about making personal connections with individuals,” she says.