In psychiatric hospitals, seclusion and restraint are strategies of last resort, to be used only with those deemed a danger to themselves or others and when other efforts fail.
But use of such tactics varies dramatically. One hospital in New Hampshire reports 106 hours of restraint per 1,000 hours of patient care, while 417 facilities, including some in San Diego County, report zero hours.
To encourage improvement, the Centers for Medicare & Medicaid Services now publishes those rates so anyone can see how 1,640 of the nation’s inpatient psychiatric facilities — 89 them in California — stack up on key measures of care for the severely mentally ill. The rates are reported for 2014.
These facilities provide about two-thirds of psychiatric hospitalizations, or about 442,000 psychiatric admissions in 2008 (the latest year available) — with lengths of stay that averaged about 7.5 days, down from 29 days three decades earlier. General acute care hospitals without dedicated psychiatric units provide the remaining one-third.
Patients include those with illnesses such as schizophrenia or bipolar disorder, often lifelong conditions, people whose voices are telling them to kill themselves or someone else, whose conditions mean “you can’t protect yourself; you’re fraught with a desire to take your life,” said Kathleen McCann, director of quality and regulatory affairs for the National Association of Psychiatric Health Systems in Washington, D.C.
McCann said when patients persist in violent behavior and other means are ineffective, seclusion and restraint remain the only options.
“Nobody has ever said the number should be zero,” she said. “But it’s the assumption that lower rates of restraint and seclusion indicate a better approach to care.”
It’s important for such facilities to have their results reported, McCann said, not necessarily to help patients choose a facility when they need help, but to raise quality level of all facilities.
“Unfortunately, the position that a lot of psychiatric patients are in is a lot different than who’s going to do your knee replacement. Virtually all our patients are admitted (in an emergency situation), and they often sit there for days before any (psychiatric) bed is available. They don’t sit there with their iPad trying to see what’s the rate on restraint and seclusion at one place rather than another,” McCann said. Often they are brought there by law enforcement officials or paramedics.
Some facilities have been able to reach zero consistently, while others face challenges with more difficult populations.
Los Angeles County + University of Southern California Medical Center uses more seclusion and restraint per 1,000 hours of patient care than any other psychiatric facility in the state, according to the CMS data. Those rates are 9.01 and 6.72 hours, respectively.
Dr. Brad Spellberg, the chief medical officer, said there are many reasons. His psych hospital, the largest in the state, “by default” takes more “combative and aggressive patients” because private hospitals refuse to accept them. And, “when we attempted to reduce restraints, assaults increased dramatically,” Spellberg said.
Also, recent California prison realignment policies have resulted in the discharge of more mentally ill prisoners with histories of violence to his facility.
Additionally, many patients are homeless and “have a history of assaultive behavior, a history of medication non-compliance and history of drug use, e.g. methamphetamine, which are factors that increase their assaultive behavior.”
Pressure on psychiatric hospitals is exacerbated by the fact that statewide, California has an extreme shortage of inpatient psychiatric beds.
That’s true for San Diego County, which an October California Hospital Association report said has 697 beds, far fewer than the 1,600 recommended for a population of 3.2 million. The recommended “absolute minimum” ratio is one bed per 2,000 population.
Psychiatric hospitalization rates per 100,000 population have been increasing nationally for all age groups except the elderly.
Nevertheless, better care is a target for federal payment. Scores are now viewable for 10 facilities in San Diego County: Alvarado Parkway Institute, Aurora San Diego, Sharp Mesa Vista and units embedded in Tri-City Medical Center, Paradise Valley Hospital, Pomerado Hospital, UC San Diego Health, Sharp Grossmont Hospital, Scripps Mercy Hospital and Palomar Medical Center.
San Diego County facilities score well on most psychiatric measures. But overall, the county is not perfect. For example, Grossmont and Pomerado hospitals did not use restraint on any patients, but Palomar Medical Center and Alvarado Parkway Institute used restraints an average of .11 hours per 1,000 hours of patient care.
Sharp Mesa Vista spokesman John Cihomsky credited a county collaboration for driving down rates of seclusion and restraint “significantly below the state and national average rates” in 2015. “More current data from 2015, due to be reported by CMS in December, show the Sharp Mesa Vista seclusion rate at 0.01 hours per 1,000, compared to the state average of 0.25 hours. Similarly, the hospital’s restraint use rate is at 0.03 hours per 1,000; the state average is 0.38 hours.”
According to a CMS manual on the measures, the use of physical restraints or seclusion “increases a patient’s risk of physical and psychological harm” and are intended for use “only if a patient is in imminent danger to him/herself or others and if less restrictive interventions have failed.” Use of seclusion and restraint are “not intended to address staff shortages or to be used as a form of discipline or coercion.”
Another measure seeks to assure psychiatric hospitals screen their patients for abuse of alcohol constituting a substance abuse disorder (SUD).
“Individuals with the most serious mental illnesses have the highest rates of such disorders,” the agency’s brochure said. It adds that alcohol abuse often goes undiagnosed and untreated. And it leads to lower rates of medication adherence and greater functional impairment.
Also measured are hospitals’ rates of preparing a continuing care plan, and whether that plan is forwarded to the next provider after discharge.
Andrew Sperling, director of legislative advocacy for the National Alliance on Mental Illness in Washington, D.C., said the federal measures are fine, but are “a small slice” of what’s important to improve care for this population.
NAMI hopes measures reflecting what happens to patients after discharge will soon be developed, and nationally, quality forum committees are trying to make that happen.
We'll let you know when big things happen.