State hospitals restrain psychiatric patients at high rate

As the state works to improve its mental health system, new federal data shows that hospitals in Connecticut restrain psychiatric patients at more than double the average national rate, with elderly patients facing restraint at a rate seven times the national average.

In addition, the state lags behind in providing adequate post-discharge continuing care plans for psychiatric patients, especially teens and the elderly. Connecticut's 28 inpatient psychiatric units and hospitals developed continuing-care plans for less than 70 percent of patients they discharged from October 2012 to March 2013 - indicating that thousands of patients may have left facilities without adequate treatment and medication plans.

A C-HIT analysis of the federal data, released by the Centers for Medicare & Medicaid Services for the first time, shows that Connecticut ranks in the top fourth of states (11th highest) in the use of physical restraints in inpatient psychiatric facilities, and is the third highest in restraining patients 65 and older.

Two psychiatric units - at Bridgeport Hospital and Masonicare Health Center in Wallingford - have the 10th and 12th highest rates of restraint use, respectively, among the 1,753 psychiatric facilities nationwide that are included in the federal reports, which cover October 2012 through March 2013.

Lawrence + Memorial Hospital in New London has a relatively low restraint rate - 0.09 hours per 1,000 patient hours, which is significantly lower than the national average of 0.39 hours. But it also has a low rate of developing adequate continuing care plans for discharged patients - 50 percent of cases, compared to a national average of 73.5 percent of cases.

The William W. Backus Hospital in Norwich, meanwhile, has a high rate of restraint -1.11 hours per 1,000 hours - and a low rate of developing adequate discharge plans, at 39.2 percent.

State and federal guidelines - tightened over the past 15 years, partly in reaction to deaths in Connecticut facilities - say that restraints should be used only in cases of imminent physical danger to a patient or others. They call for less restrictive interventions when patients are acting out aggressively.

But the data show that Bridgeport Hospital, Masonicare and three other Connecticut hospitals - Waterbury, Hartford, Danbury - restrain patients at more than triple the national rate.

James McGaughey, director of the state Office of Protection and Advocacy for Persons with Disabilities, said he was disturbed by both the high rate of restraint use and the low rate of post-discharge plans.

"The numbers are pretty compelling," he said. "Some of our hospitals have done a significant amount of work on this, but clearly there's more to be done."

He suggested that the state Department of Public Health, which oversees hospitals and is charged with reviewing annual reports of restraint and seclusion, should "get a little less timid in looking at this." Hospitals rarely have been cited or penalized in recent years for improperly using restraints, a review of inspection reports shows.

McGaughey noted that the state-run Connecticut Valley Hospital has pursued a reduction in restraints and seclusion that has cut its restraint rate significantly in the last five years. The new data show CVH's rate at 0.52 hours per 1,000 patient hours - below the statewide rate of 1 hour per 1,000. The national average is 0.39.

"It's ironic that our one remaining large state hospital has done such a good job of reducing restraint and seclusion, but you have some very different results at private institutions," McGaughey said of CVH, which was cited for excessive restraint use in 2007 by the U.S. Justice Department. "What it shows is that it's possible to address this issue, but you need leadership to effect this kind of culture change."

Mental health advocates say seclusion and restraint should be avoided because they are traumatic and dangerous to patients and staff.

Alternatives include individualized aggression-management plans, the use of "comfort rooms" or time-out spaces, and one-on-one interventions. Among the innovations at CVH are 22 "comfort rooms," designed to calm agitated patients, and a reduction in the time interval that a physician's order of restraint or seclusion can remain in effect, according to a state report.

Officials at Connecticut hospitals with high rates of restraint say they are working to reduce those incidents, and they stressed that even minimal mobility restrictions, such as soft wrist restraints or brief therapeutic holds, are counted in the federal numbers.

Robert Bernstein, executive director of the Bazelon Center for Mental Health Law, a national advocacy group that successfully sued Connecticut in 2006 to stop housing psychiatric patients in three nursing homes, said he worried that progress made in the early 2000s to reduce restraints might be slipping in some hospitals because of staff shortages and "pushback" from clinicians.

"Some of the procedures put in place may have been weakened, because it's a lot of work" to use alternative interventions, he said.

Connecticut vs. the nation

Nationally, the states with the highest restraint use are Minnesota, Washington, South Dakota, Tennessee and New Hampshire. For patients 65 and older, only Nevada and New Hampshire have rates higher than Connecticut, which restraints elderly patients at an average of 7.69 hours per 1,000 hours. Thirty-five states have rates of less than 1 per 1,000 hours; the national average is 1.01 hours per 1,000 hours.

The federal data shows Connecticut psychiatric facilities fare well in some categories, including lower-than-average rates of restraint for children and teenagers. Five hospitals reported no use of restraints for any age group: Sharon, MidState Medical Center, Bristol, John Dempsey and Natchaug hospitals.

And Connecticut's rate of keeping patients in seclusion is lower than the national average, with half of the state's psychiatric facilities reporting that they did not use seclusion at all. Nationally, South Dakota, Montana and Washington report the highest use of seclusion, defined as involuntary confinement where a patient is prevented from leaving.

But the state's over-65 restraint rate is fueled by excessive rates at Masonicare (35.99 hours), Bridgeport Hospital (37.92) and Hartford's Institute of Living (9.19).

Officials at those hospitals say they have taken steps in the year since the data-reporting period ended to reduce restraint use.

This is the first time that quality measures from psychiatric facilities have been made available by CMS. The federal agency does not penalize facilities for high rates of restraint or inadequate discharge plans. Instead, an agency spokeswoman said, the public reporting is intended to encourage quality improvements and help consumers to make informed decisions.

At Bridgeport Hospital, Dr. Ryan O'Connell, vice president for performance and risk management, said the hospital's geriatric psychiatric unit serves many patients with dementia and behavioral problems who cannot be managed in other facilities. About 18 months ago, he said, the hospital put in place an "action plan" to reduce restraints, including using "comfort" rooms. Also, in January, a new policy was implemented requiring that the nurse manager be called before any patient is restrained.

"We realized we were going in the wrong direction with restraints" and have since seen a "dramatic drop" in their usage, O'Connell said.

Hartford Hospital's Institute of Living, which has a geriatric unit for complex dementia patients, has made similar changes over the past few years, nursing director Ellen Blair said. She said restraints are now rarely used, and only for patient safety. The institute requires that a physician's restraint order be reviewed every two hours, rather than every four, which is the standard of care.

Masonicare's acute psychiatric unit serves geriatric patients who frequently are referred because of difficult behaviors and aggression, said spokeswoman Margaret Steeves. When restraints are needed, the hospital uses "the least restrictive restraint, which is typically a seat belt," she said. Masonicare has an interdisciplinary team reviewing restraint use.

Statewide, the Connecticut Hospital Association has been working with the state Department of Public Health to minimize the use of restraints, said Dr. Mary Cooper, the group's vice president and chief quality officer. She said the new federal data "indicate that there is more work to be done in this area" and will help to identify best practices.

This story was reported under a partnership with the Connecticut Health I-Team (www.c-hit.org).

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