Ontario Shores Centre for Mental Health Sciences, Whitby, Ontario, Canada.
Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada.
Int J Ment Health Nurs. 2017 Oct;26(5):482-490. doi: 10.1111/inm.12379.
The executive-level witnessing and review of restraint events has been identified as a key strategy for restraint minimization. In the present study, we examined the changes in restraint practices at a tertiary-level mental health-care facility with implementation of an initiative, in which representatives from senior management, professional practice, peer support, and clinical ethics witnessed seclusion and restraint events, and rounded with clinical teams to discuss timely release and brainstorm prevention strategies. Interrupted time series analysis compared the change from pre-implementation (14 months prior) to postimplementation (35 months' following) in the number of incidents/month, total hours/month, and average hours/incident/month for each of seclusion and mechanical restraint. With implementation, there was a step decrease in average hours/seclusion (-28.3 hours/seclusion, P < 0.001) and total seclusion hours (-1264.5 hours, P = 0.002). The postimplementation rate of decrease of -0.9 hours/incident/month was different than the pre-implementation rate of increase of 0.7 hours/incident/month for mechanical restraint (P = 0.03). Pre-implementation, there was a rate of decrease of 6.1 incidents/month (P < 0.001) and 4.5 incidents/month (P = 0.001) for seclusion and mechanical restraint, respectively. Postimplementation, there was a rate of increase of 0.3 incidents/month and a rate of decrease of 0.05 incidents/month for seclusion and mechanical restraint, respectively, both of which were different than pre-implementation (seclusion: P < 0.001, mechanical restraint: P = 0.002). In conclusion, the total hours of seclusion and average hours per seclusion and per restraint incident were reduced, demonstrating the value of leadership witnessing and daily rounds in promoting restraint minimization in tertiary-level mental health care.
领导层对约束事件的见证和审查已被确定为减少约束的关键策略。在本研究中，我们考察了在一家三级精神保健机构实施一项倡议后约束实践的变化情况，该倡议要求高级管理人员、专业实践、同伴支持和临床伦理代表见证隔离和约束事件，并与临床团队一起讨论及时释放和集思广益预防策略。中断时间序列分析比较了实施前（14 个月前）和实施后（35 个月后）每个隔离和机械约束事件/月的事件数量、总时间/月和平均时间/事件/月的变化。实施后，平均隔离时间（-28.3 小时/隔离，P < 0.001）和总隔离时间（-1264.5 小时，P = 0.002）均呈阶梯式下降。实施后机械约束的下降速度为每月减少 0.9 小时/事件，与实施前每月增加 0.7 小时/事件不同（P = 0.03）。实施前，每月分别减少 6.1 次隔离事件（P < 0.001）和 4.5 次机械约束事件（P = 0.001）。实施后，每月分别增加 0.3 次隔离事件和减少 0.05 次机械约束事件，这两种情况都与实施前不同（隔离：P < 0.001，机械约束：P = 0.002）。总之，隔离总时间和平均每次隔离和每次约束事件的时间都有所减少，这表明领导层见证和日常查房在促进三级精神保健中减少约束方面具有价值。
