Multidimensional approach to restraint minimization: The journey of a specialized mental health organization

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.