This is our session on Considerations in the Use of Seclusion or Restraint, and we're introducing a new APA resource document on that topic. I'm Jackie Hobbs. I'm chairing this session. I just recently moved to the University of Washington in Seattle. I'll be the new program director there. Previously was at the University of Florida for many years and was program director there. I want to introduce my colleagues here for the day. So Beto, you want to introduce yourself? Sure. I am Jose Arreola-Vigil. I'm an assistant professor at the University of Texas in Houston. I'm also a part of the Diversity, Equity, and Inclusion Committee there and the Patient Access and Safety Workgroup as part of the DEI initiative there in the Department of Psychiatry and Behavioral Sciences at UT Health. Hi, good afternoon. My name is Eric Chung. I'm an associate professor of psychiatry at UCLA David Geffen School of Medicine and chief medical officer for the UCLA Resnick Neuropsychiatric Hospital, a 74-bed inpatient facility treating patients of all ages. Thank you. I'm Molly Finnerty at New York University, NYU Langone Medical Center in Child and Adolescent Psychiatry. I'm an associate research professor there. Thank you. And you'll also be hearing a little bit via video from our colleague Jeff Rado and he'll introduce himself in just a bit. And we also, first of all, we have no conflicts of interest to declare and we really are excited to have everyone here and we just wanted to get a sense of the room and what kinds of things people do. So how many are psychiatrists? Lots of psychiatrists. Do we have any inpatient people, people working in inpatient? Yeah, emergency settings? Yeah, a little bit of everything. We have any advanced practitioner, nurses, PAs. What about trainees, students or residents? Cool, great. Glad you're here. All right, anything else the panel wanted to know? Good, very helpful. So the objectives for today. So we want to distinguish the use of seclusion or restraint and analyze their risks. We wanted to review and employ seven practical considerations that we'll be talking through today in the use of seclusion or restraint and the management of patients with a behavioral crisis. We want to help you to utilize useful, helpful resources to support medical decision-making regarding seclusion or restraint and hopefully you'll get to sort of evaluate APA's new resource document on this topic. So just to give you a little bit of background, back in November 2020, the APA Assembly approved an action paper entitled The Selection of Seclusion, Restraint and How to Choose Between These Modalities. This was authored, one of the major authors was Dr. Jorge Cortina. I don't know if he's here today. I don't know if he wants to tell anyone. But we wanted to make sure that it was very well known that he was an author on that paper. Then the APA delegated to the Patient Safety Workgroup the task of developing a resource document based on this action paper to help guide the use of seclusion or restraint. And really the focus was on patient experience, preference and also weighing all of that with clinical considerations. So the resource document was finally approved by the Joint Reference Committee on February 2022. And these are just the links and we'll show you at the end how you can request. We did put some preliminary slides out on the app but we've made a few little tweaks to those. So if you want the final presentation, we'll be happy to share that with you. So there is the actual resource document. There's also a link to all APA resource documents. So if you're not familiar with those, they can be very helpful. And there was also an APA blog post. That's another very helpful resource for members as well. So first of all, we just want to throw out, we're going to do this a few times. We're not going to do formal polling or anything, but just want to, you know, get some thoughts out, get you thinking about this topic. So think about at my facility or institution, wherever you may work, I am concerned that the use of restraint or seclusion is too high. I am concerned that there is bias or discrimination in the use of seclusion or restraints. It is a challenge to access reliable and efficient data on seclusion or restraint use in order to drive quality improvement. And finally, I am concerned that our policies and protocols are not strong enough to guide the avoidance of seclusion, restraint or seclusion. So just food for thought. And I'm going to turn it over to Molly. So I'm Molly Finnerty-Zased from New York University Langone Medical Center and Child and Adolescent Psychiatry. And I'm going to talk a little bit about the importance of data, that when thinking about seclusion and restraint, in order to understand how it's being used in your institution, it's really important, you know, for those working in hospitals and ERs, there's your own experience and exposure to it. But really taking a step back and seeing what the data looks like can be really important. So I'm going to provide an example from a large state hospital system that has 23 hospitals. They have quality goals to reduce or eliminate seclusion and restraint. They have policies limiting the use of seclusion and restraint and ongoing monitoring. So some of the questions that were raised in this system and where they asked for an evaluation was, you know, what are the proportion of inpatients that have seclusion and restraint events? So it's a little bit different. Normally when you do track seclusion and restraint, it's like counts of events, but this is saying counts of people. So of all the people that walk through our doors, how many of, what percent of the people have that experience, right? And then once or more times. And then is there any differences in the way adults, child, or disparities by race or ethnicity or sex? And the data sources are the EMR and also there's reporting that has to happen for every seclusion or restraint event in this state system. So this is looking at three different populations and saying, you know, well, what do those populations look like, right? So there's an adult non-forensic civil population where about a third of the adult patients are female and it's about 40% white and others are, you know, in the second most common group is black followed by Hispanic. By contrast, in child and adolescent, there are more than half female children in that setting and the preponderance are white with lower proportions of other groups. And then in the adult forensic population, there's very few women. It's nearly 90% men in psychiatric inpatient forensic care and the largest group in this particular population is black. So there's differences in the populations that are served. So the first question was, you know, how does seclusion and restraint vary in these populations by gender? And so for adult in the civil non-forensic population and in the forensic population, interestingly, women are more likely to have the experience of being restrained. However, in the child and adolescent inpatient populations, they're less likely and women, female sex here is the orange bars, less likely to be restrained and those are significant differences there. For seclusion, no significant differences by sex. How does restraint look in the inpatient populations by race and ethnicity? And here we look at for the Hispanic group, those are those identifying as Hispanic or Latinx and that's the group you get assigned to and then the others are white non-Latinx, black non-Latinx and Asian non-Latinx. So what you can see for the adult civil and adult forensic, when the forensic population there in the middle has more restraint events in general, but there are no significant differences by race or ethnicity that were observed. However, interesting in the child group, there are significant differences and there are, and as we recall, that population is predominantly white and more females than males. But for the black and Hispanic youth and adolescents that happen to be there, there are significantly higher incidents of restraint. So how does it look for seclusion? Actually, a very similar pattern for the adults where there aren't huge differences by race or ethnicity. Just for the adult civil population, it's a small but significant difference where the black group is a little bit more likely to have a seclusion event. But again, for the kids, there is an increased likelihood for the black and Hispanic group. So those data were 2019 and we sometimes use 2019 as the before times, before COVID came and I don't know what it did to your hospitals, but so those were the before times. So now we jump forward to 2022. And the good news here is that you can see that restraint is trending down for all populations. So forensic is still higher, but it's trending down and kids are still a bit higher, but they're trending, everybody's trending down and those differences are significant for women now no longer significantly different from men in the civil adult population. And we can see for kids overall, there's a significant reduction in 2022. What does it look by race ethnicity? So a similar story of everybody trending down, which is the good news. And what you can see is that for kids overall, again, there's a trend down and for the white group, which remember there's just a bigger N there. So they were able to achieve significance and not shown, but for seclusion, the black group for kids was significantly reduced in 2022. So I think the point of starting out with this kind of view at the data is that it's important to look and we did get approval from the medical director of the state to prove this, but some people are a little gun shy, like you don't always like what you see when you look at your data, especially for kids. They thought like the first response was, well, we don't seclude or restrain kids in our hospital. It's like, well, we don't restrain kids in our hospital. It's like, well, you might, you might, it's just you don't know until you look, right? You don't know until you look and you don't always like what you see, but you can't change what you don't acknowledge. And it's a really important way to think about this work is that it's an important intervention that we still do use in many of our hospitals in this country. and it's one that we should use with caution and it's one that we have to make sure that we're monitoring. How often is this happening to the folks that we serve? So yeah, I think that's it. Thank you. So these are the seven key considerations in the use of seclusion or restraint that are spelled out in the resource document that was put together by the Patient Safety Workgroup. The seven domains begin with the first. Decision support algorithms can help guide the use of seclusion compared to restraint and it's important to understand the clinician's role in the application of either of them and it can lead to more appropriate use of the interventions. The third is understanding the risk can reduce harm when using either of them. And the fourth is advocating for availability of environmental interventions including seclusion rooms can minimize the need for restraint use. The fifth is that patient experience of seclusion restraint is important to keep in mind and to understand in depth. And the sixth is a culturally competent trauma-informed and patient-centered approach is necessary to make decisions about which type of intervention to use. The seventh is that patient preferences and advanced directives are critical when considering the use of seclusion or restraint. Those are the seven in a nutshell and then we'll go into detail on each of them in relatively quick fashion. So the first one relates to decision support algorithms that can guide the use of seclusion or restraints. Some basics of definitions and principles to be sure that we're all on the same page. Really when you're talking about the use of seclusion or restraint, you're talking about the management of patient behaviors, agitated patient behaviors, which is a hyper aroused state ranging in severity where the individual exhibits excessive repeated and purposeless motor or verbal behaviors. And importantly in the document we emphasize that the goal in the management of agitation is not to subdue the patient, it's help to the patient regain control over their own behaviors to engage further in their treatment or evaluation. By definition, seclusion is the involuntary confinement of a patient alone in a room or area where they're not able to leave, even if it's not a locked setting. If they're not able to leave, it's considered seclusion. Restraint is any manual method, physical or mechanical, device, material that would immobilize or reduce the ability of a patient to move freely. A couple more here. Basic principles that we put into the Patient Safety Workgroup document is that all patients have the right to be free from restraint or seclusion imposed as coercion, discipline, convenience, or retaliation by staff. And seclusion or restraint may be used only when less restrictive interventions have been determined to be ineffective. You'll recognize, those of you who work in hospitals, that a lot of this overlaps greatly with the CMS and Joint Commission requirements. Seclusion and restraint must be discontinued at the earliest possible time and facilities should maintain clear policies and procedures and training protocols related to this. I think what we are attempting to do here with the document is to provide that framework to help to evaluate current facility protocols. That's at least how we are using this at UCLA, where I come from, to determine if we are really at the state-of-the-art with helping staff to understand when and how and which intervention to use. And we in my institution are on a pathway to begin to eliminate the use of seclusion and restraint altogether. And I think these are the types of framework and interventions that can help. So decision support algorithms are helpful. And even though it's relatively basic when you look down through this decision support algorithm, it's quite important to remember that psychiatrists are by and large not the first person to respond to an event. And really what I think our role as a profession, as psychiatrists, is to be sure that the institution as a whole, including all the staff who are engaged, oftentimes nurses and nursing care partners, are following protocols that are clearly established. So things like these decision support algorithms can help with the training and can be embedded into policy. This is one that is adapted from a document of Project BETA. If you're not familiar with that, that's from the Academy Emergency Psychiatrists Association, Project BETA. And it was one of the most comprehensive consensus guidelines on management of agitated patients. And so this was adapted from that. It begins with a patient who is acting dangerously at the top. First step is to attempt verbal de-escalation, offer voluntary medication if indicated. And then the next decision point is to figure out whether that was effective. If yes, your crisis is on the way to resolving and you go to the bottom. If no, the next question is would the patient be a danger to self or others in seclusion? This is leading you to the preference for seclusion because if they would not be a danger to self or others, you can proceed to figure out whether they can sit quietly in an unlocked room or will require locked seclusion here. If they would be danger to self or others in seclusion, that's when you go to the right here and require restraints and potentially involuntary medication administration. At the very end, after all of this cascade, is monitor the patient, complete clinical evaluations that are required oftentimes by regulatory agencies, discontinue the intervention at the earliest opportunity, and then importantly review that treatment plan and consider interventions to avoid the future repetition of this cycle. Verbal de-escalation is talked about as one of the key elements to avoid seclusion restraint use altogether. And I think at this point I would offer that although the APA action paper was asking us to focus on the use of seclusion versus restraint, I think this work group really was interested in the reduction and elimination of those interventions altogether, even though we were also addressing the importance of seclusion as a potentially less harmful intervention than restraint. So first line treatment, so to speak, is verbal de-escalation effective for a majority of patients in a behavioral health crisis within five minutes. This really should be baked into all staff training. Everyone who interacts with the patient should know something about verbal de-escalation. And some might actually be especially proficient at that. And different hospitals have taken those types of individuals and put them in special response or code teams. Sometimes they're called behavioral intervention teams, BIT or behavioral intervention response teams, BERT or PERT, lots of different names, essentially acting like a code team as in a code blue, but for a behavioral response situation. Teaching verbal de-escalation requires a good amount of support. We offer the Eraser Mnemonic here on the right-hand side, and I think it's actually included in the documents as well for download. Just one way of helping individuals all across the spectrum who are interacting with patients to learn the techniques of verbal de-escalation and to reinforce it, beginning with E, eyeballing the patient. R, respecting the patient's space. A, a single provider does the talking and builds rapport so as to not overwhelm the individual in crisis. And S is sensible learning. E is establish expectations and set boundaries. And R is offer reasonable choices to the patient. The details are within there that you can read at a later time. But developing some sort of easy tool for individuals to continue to practice verbal de-escalation is quite important. Environmental interventions are also important. Decreasing stimulation, promoting calming, finding avenues to avoid restraint use altogether. A lot of this has to do with facility capabilities and considering this when you're building a new facility or able to adapt your current one. Use of quiet rooms and sensory rooms. Access to things like weighted blankets are best. Oftentimes they're very helpful for individuals with developmental disabilities or autism. And aromatherapy. Engagement and activities are evidence-based to reduce the need for restraint use or seclusion use altogether. So adequate access to outdoor space and recreation group therapy, art therapy. And close observation or one-to-one really ought to be one of your last resorts. High intensity, high resource utilization to assign a one-to-one and something that we try very hard in my facility to avoid. But if you're going to have a one-to-one, you might as well have somebody who's really good at verbal de-escalation doing that. And in ED medical units, we oftentimes find this where I work, having protocols where you have patients who are at risk of requiring restraint, typically in that setting, seclusion not available in many of them. Having protocols that will remove unnecessary medical equipment and objects that they can use to harm self or others is important. So final comment here about pharmacologic treatment. We're not going to go in depth on this, but we do recognize that it's important in the treatment algorithm whether seclusion restraint is being picked. And there have been some other sessions here at the APA that address the particular agents that might be best indicated for different situations. But I want to reinforce again that whether using seclusion or restraint or pharmacologic treatment, the purpose here is to help the individual regain control over their own behaviors. It's not to subdue them or render them kind of unconscious. The goal is to calm the patient, enable their safe and effective participation in assessment and treatment. The medications may induce sleepiness or sedation, but that's not the primary objective. And the choice of medication should clearly be informed by the patient's history and the cause of agitation. Some examples are given there. Voluntary is typical as first-line preferred. Involuntary is used as a last resort. And then in the document itself, we made mention of avoiding the term chemical restraint, which is a relatively controversial term at any rate. And the preferred term is pharmacologic treatment of agitation, in our opinion. Thanks, Eric. And if anyone wants, I do have a few paper copies of the eraser mnemonic handout if anyone wants it at the end. I'm happy to share that with you, but it is also in the app. So we'll move on to consideration number two, understanding of the clinician's role in seclusion or restraint, that it can lead to more appropriate use of these interventions. And, you know, really the the graphic there is to really think about this as a team effort. As Eric mentioned, you know, the physician, the psychiatrist is often not there or not there at the beginning of many of these events. But, you know, we need to be involved in that process at some point. And, you know, the clinician, the APA has provided an interactive presentation on this topic of seclusion or restraint and also it talks about the clinician's role. I would really recommend this. It's on the SMI advisor site, free. You just sign up for an account and you can get this. It's a very sort of interactive, module-based sort of thing. You can come and go as it works for you. You don't have to complete it all or at, you know, you can do it at your own pace. And I think the key takeaways from that are that it's important to know the history of seclusion or restraint and its use in psychiatry. You know, just like anything, if we know the history, hopefully we don't make the same mistakes over and over again. And there is a darker side to this, right? And so we want to make sure that we always try to get this right. And, again, the clinician's role often is a leadership role and we really should not abdicate everything about seclusion or restraint to staff. They play such a key role in the moment, but it's important. We have to make sure there's proper training and policies and that we talk about seclusion or restraint. You know, are we talking about events that happen in our morning rounds on the inpatient unit? And I think another thing is just, you know, helping to help the patient understand, you know, what may have happened to them. And I'll talk about that in a moment. And, yeah, again, discussing, like having debriefs, we know that's a very important part of most policies and regulations for the use of seclusion or restraint. All right, next I'm going to, we're going to have a video from one of our other patient safety work group members, Jeff Rado, and he's going to talk about the risks of harm from seclusion or restraint. And that's our consideration number three. Hello, everyone, and greetings from Chicago. It's great to be with you all today in San Francisco, even though I'm coming from the other side of the country. My name is Jeff Ferriero, and I am a psychiatrist and internist at Northwestern in Chicago. And I'm also a member of the APA patient safety work group, along with my colleagues who are here in person. I'm going to be talking today about risks of harm with seclusion and restraint. And this is referred to in the assertion and retreat of the research document, which states that 100% of risks can reduce harm from using seclusion or restraint. And the basic idea here is that you can't reduce risk if you don't know what the harms are that come from harm, restraint, and seclusion. And I think this is very relevant for myself, and hopefully it will be for you, in terms of better understanding what these risks are. So a little bit of background. When you look at studies regarding risks of harm, you find that there's really a lack of systematic reporting, such that you don't really have a consistent database or reliable database on how often these adverse outcomes occur. When you look at epidemiological studies, which we think of as large studies, large populations of patients, you may find incidents of mechanical or restrained seclusion. But you don't always find a report of the adverse events. That's often not described. And finally, it's important to remember that the risks to restraint and seclusion include both psychological and physical, and they include death. So how can we understand risks of harm? Well, there's three types of studies that we can look at. Epidemiological studies, association studies, and case reports and case series. The challenge is to look at these studies and say, OK, there's a lack of uniform reporting. And what do I mean by that? So there's a lack of consistent ways of describing these events, describing the severity of the events. And there's a lack of consistency in including all events. So we end up with really more unviable incomplete data. And we often don't have comparators. We don't know whether the rates that we find in one study, we don't always know how they compare to people who were not restrained or were not in seclusion. So what do we see when we look at epidemiological studies and in psychiatric studies when we look at the physical, in terms of the physical risks of mechanical restraints? So the first two studies were done in psychiatric wards in the United Kingdom. And the first one found a 4% rate of injury among 680 instances of restraints over three years. The second study found a 0.94% rate of injury among 59,000 instances of restraints over a two-year period. Now, the tricky part here is they only say injury. The studies did not describe what that injury actually was. So we don't know. The next study looked at DVT in a psychiatric ward in Japan and found among 181 cases of restraint over a two-year period, there was about 11.6% rate of DVT. Finally, this last study, which was done in a psychiatric county hospital in New Jersey, they looked at 1,400 instances of restraint over a five-year period. And they found no deaths. But in this study, they didn't record any other outcomes or adverse outcomes. So we don't know if there are any other negative outcomes. So what about association studies? So these studies look at exposure to an event in one group compared to a non-exposed group. And so you see here, for instance, in the first study, patients who underwent mechanical restraint had a higher risk of falls compared to non-restrained. Another study found an increased risk of fractures versus non-restrained patients. A third study looked at DVT and did not find a difference in the incidence of DVT in restrained versus non-restrained patients. And then finally, the fourth study looked at DVT and actually did find a higher rate of DVT in patients who were restrained compared to non-restrained. Finally, we have case reports in series. And sometimes these actually give us the richest description of these adverse outcomes. And some of these are, you know, when I read them, I thought they were just incredibly heartbreaking that in the process of providing care, these really severe negative outcomes occurred. So the first is pulmonary embolism. 17 cases of PE and all of them died. Asphyxiation, there were six cases of strangulation by mechanical restraints and bed rails, three cases of death by strangulation in restraint vests, four cases of asphyxia, one case of death by asphyxiation after a restrained patient crawled into a mattress. In terms of cardiac outcomes, there were 34 cases of sudden cardiac death. After patients were struggling against mechanical restraints. And in one case of cardiopulmonary arrest, one case of a restrained patient who was unmonitored and jumped out of a window and died. And then finally, a case of fatal hypovolemic shock following liver injury from mechanical restraint. So this just shows the spectrum of physical harms that we can see with mechanical restraints. So at the top, you see DVT and then falls and fractures and then potentially fatal outcomes such as asphyxiation, pulmonary embolism and sudden cardiac death. What about psychological harms of mechanical restraint? So in general, this has been described as a traumatic and stressful experience by most patients. So you see some of the emotions described by patients, tension, sense of fear, rage, feeling of helplessness, cases of PTSD have been described and really a sense of being controlled in a sense of perceived coercion by staff. When we look at the risk of harm from seclusion, this is even more understudied compared to restraint. First study of 63 secluded patients found that there was a risk of self-injury and physical deterioration, but there was no comparative group. So we don't know how these numbers compare to a non-secluded group. A second study found no risk of DVT in 63 patients who were secluded. And then another study looked at really more of what we would describe as a lived experience. How did patients describe being in seclusion? It was often perceived by patients as punitive or a way that staff was exerting control over them. The descriptions include like being in a jail cell, being destroyed, rejection and deprivation, but also time for meditation. So there was a variety of experiences. And finally, post-traumatic stress disorder has also been described in patients who undergo seclusion, but the risk is probably greater among those who undergo mechanical restraint. So this just shows the broad range of outcomes. On the left you see with regard to mechanical restraint, as we mentioned, things like sudden cardiac death, asphyxia, DVT and PE, events that really can very easily be fatal, also falls and fractures. On the right you see seclusion and you see things like physical deterioration. And in the middle, you see negative outcomes that really occur with both mechanical restraint and seclusion. And these include a feeling of fear, tension and rage, intentional self-injury and PTSD. So in summary, when we think about the risks of harm from seclusion and restraint, it's really important to think that the negative outcomes include psychological and physical and may include death. So these things are really important to keep in mind because if we wanna reduce harm, we can only do that if we understand the risks with these procedures. And finally, it's really important that we get more research done in this area, that we get a better understanding of how frequently these outcomes occur. And it's really important that we have a better and more uniform systematized reporting system. Thank you. Hello everyone and greetings from Chicago. It's great to be with you all today. There we go. Don't wanna have to go through it all over again. So we'll move then to consideration number four, advocating for availability of environmental interventions including seclusion rooms can minimize the need for restraint. I think that, again, going back to the action paper, that was really what the author was trying to get at and his experience of traveling around and seeing all kinds of institutions. He saw the most injury he felt and even death from restraints and so he was a big advocate of seclusion. I think that in our work with the patient safety work group and in doing this resource document, we just felt it was very important to think about having more options in general. Restraints, as you've heard from Jeff, there's the highest morbidity and mortality and we should avoid it as much as possible. The other thing is that plans for new psychiatric facilities or renovations to existing facilities should include calming, sensory, and seclusion rooms to minimize the need for restraint. And I think it's important to know that the APA has a position statement on the importance of involving psychiatrists in facility design and so we have that link there for you as well. I think that one feedback we got when we were creating this is that some members of APA who got to review it, they were like, I'm going to take this to my medical directors or my boss basically and this is how I'm going to help advocate for better care for patients. So the next consideration is the patient experience of seclusion or restraint is important when considering use of these interventions. As you've heard already from Jeff and others, there can be both positive and negative experiences. I would say most of them are more negative, as you'll also hear in a moment, but occasionally patients will have some positive and we want to make sure that we balance everything. So patients have described their seclusion room experiences negatively, that there are feelings of fear, estrangement, hostility, retaliation, guilt, paranoia, and bitterness. On the positive side, they found it at least somewhat necessary and calming and helped to reduce overstimulation. Again, there may be other ways to reduce that overstimulation than using seclusion even. Everything can always depend too on how the staff work with the patient. If they're talking through things, if they're supportive, as much as possible during these events. We all know they can be pretty trying, but as much as possible to support the patient. So here's a pretty, probably famous person living with schizophrenia and Ellen Sachs, author of The Sinner Cannot Hold, and she described in her TED Talk what it was like for her to be physically restrained. So we will hear from her. Extension on the memo assignment. And I began gibbering unintelligibly as I had the night before and he eventually brought me to the emergency room. Once there, someone I'll just call the doctor and his whole team of goons swooped down, lifted me high into the air and slammed me down on a metal bed with such force that I saw stars. Then they strapped my legs and arms to the metal bed with thick leather straps. A sound came out of my mouth that I'd never heard before. Half groan, half scream, barely human and pure terror. Then the sound came again, forced from somewhere deep inside my belly and scraping my throat raw. This incident resulted in my involuntary hospitalization. One of the reasons the doctors gave for hospitalizing me against my will was that I was, quote, gravely disabled. To support this view, they wrote in my chart that I was unable to do my Yale Law School homework. I wondered what that meant about much of the rest of New Haven. During the next year, I would spend five months in a psychiatric hospital. At times, I spent up to 20 hours in mechanical restraints, arms tied, arms and legs tied down, arms and legs tied down with a net tied tightly across my chest. I never struck anyone. I never harmed anyone. I never made any direct threats. If you've never been restrained yourself, you may have a benign image of the experience. There's nothing benign about it. Every week in the United States, it's been estimated that one to three people die in restraints. They strangle, they aspirate their vomit, they suffocate, they have a heart attack. It's unclear whether using mechanical restraints is actually saving lives or costing lives. While I was preparing to write my student note for the Yale Law Journal on mechanical restraints, I consulted an eminent law professor who was also a psychiatrist and said surely he would agree that restraints must be degrading, painful, and frightening. He looked at me in a knowing way and said, Ellen, you don't really understand. These people are psychotic. They're different from me and you. They wouldn't experience restraints as we would. I didn't have the courage to tell him in that moment that no, we're not that different from him. We don't like to be strapped down to a bed and left to suffer for hours any more than he would. In fact, until very recently, and I'm sure some people still hold it as a view that restraints help psychiatric patients feel safe. I've never met a psychiatric patient who agreed with that view. Today, I'd like to say I'm very pro-psychiatry but very anti-force. I don't think force is effective as treatment and I think using force is a terrible thing to do to another person with a terrible illness. All right, so, and I, you know, that's just an excerpt from that talk. And if you haven't watched this or haven't watched it for a while, I think it's a really good one to go back and watch and like, especially like listening to her descriptions, I think it really can help you sort of develop your empathy for what patients, you know, really go through. Extension on the memo assignment. And I'm doing that. All right, and I'm gonna turn it over to Beta. All right. All right, so I'm gonna be talking about consideration number six and number seven of the resource document. So consideration number six is basically, basically states that we should have a culturally competent trauma-informed and patient-centered approach when we are making decisions or when we are considering seclusion or restraint. So just to set the tone about this consideration, we added this question just to have an idea about how prevalent trauma is on patients who are hospitalized in psychiatric facilities. Let's just do this question here kind of the old-fashioned way. If the question is, what's the percentage of psychiatric inpatients that have a history of trauma? Who of the audience thinks that it's 20%? Just raise your hands. How about who thinks it's 40% to 50%? Okay. How about 60% to 70%? Yes, and how about 90% or more? Yeah, so it's actually, yeah, the data show that it's between 60% to 80% of psychiatric inpatients that actually have a history of trauma. So it's very important to understand that because we know that these are very serious interventions when we consider seclusion or restraints and that the patient is placing a very vulnerable position at the time. So this consideration actually has three parts. I'm sorry. That it's a culturally competent patient-centered and trauma-informed consent. And we decided to include these parts because we want to emphasize that we don't want to perpetuate disparities when we consider seclusion or restraints. We know that, as we talked before, we know that historically there are certain populations or ethnic groups that have been disproportionately affected by these interventions. As we talked, we know that the history of trauma is very prevalent in this population. And again, we know that people are in a very vulnerable position when we are considering these interventions. We also want to make sure that the patient is involved in the decision-making process, ideally ahead of time, because we know that in these kind of situations, most of the time the patient lacks capacity to participate in the decision-making process. And again, as we emphasize on the resource document, seclusion and restraints should only be used as a last resort. First, let's start with culturally competent approach. So basically, this is basically culturally competent is a definition that has attracted more attention lately. We're talking more about that. It's basically the care that respects diversity in patient populations and that considers cultural factors when providing mental health care. We need to consider language, communication styles, beliefs, attitudes, and behaviors. And again, this is important because, as we see in the box on the left, there are certain groups that are more likely or that historically have been more likely to be affected by these interventions or that we use these interventions more often. In one of these studies from 2020, we see that males are twice as likely to have these interventions done. People with public insurance or no insurance are more likely. Homeless individuals are six times more likely to be, I mean, to have been secluded or to have been restrained. Patients with substance use, with bipolar or psychotic disorders, and patients at a young age. So this is important because we need to look at the structural factors contributing to disparities. And as Molly was saying, it's also important that healthcare facilities aim to develop systems to monitor institutional data. Because we cannot change if we not acknowledge what is happening on a daily basis in clinical practice. And we have also some strategies that we can use to review that data. I mean, we have like post-incident reviews, meetings, disclosures, all those things that we can review after these episodes have happened to try to learn how we can improve for what we can do better in clinical practice. So then we have the trauma-informed approach that basically involves four components. One is to recognize the high prevalence of trauma in psychiatric patients. Two, that trauma not only affects patients, but also affect healthcare workers. Three, that it's important to always actively assess and treat trauma-related symptoms. And four, that basically the ultimate goal, whenever we consider seclusion or restraint, is to prevent re-traumatization in these particular patients. And finally, we have a patient, I mean, we need to consider a patient-centered approach, specifically where we have the patients involved on these decisions. Because they are the driving force behind this. They are the ones that we are caring for, and they should be involved in these decisions. And we know that patient-centered approach has different aspects, including having a collaborative and coordinated care, that the ultimate goal is to provide physical comfort and emotional well-being as top priorities, that our treatment interventions or treatment goals should be aligned with the patient's values as well, among other kind of aspects when we consider a patient-centered approach. So and this also sets the tone to the consideration number seven, that it's how we can involve the patient a little bit more, especially in those moments when they are in a behavioral crisis, when we're considering seclusion or restraints. And that's where consideration number seven comes into place, that patient preferences and psychiatric advance directives are critical when we consider the use of restraints or seclusion. And this is something, I mean, psychiatric advance directives are something that we've been talking about for the last several years, but it's sometimes there are a lot of challenges to try to implement these in clinical practice. And just to have an idea, I also, I mean, kind of from what you all think about that, or how often this is used in your institutions, I have this question for you. How often do you usually document, I mean, psychiatric advance directives in your institution? Can you raise your hand if it's A, never? How about B, rarely? How about C, sometimes? Okay, how about always? Yes, so it's something that we've been talking about, and that actually it's, I mean, something that we've been talking about lately, but it's not, in clinical practice, there are a lot of challenges and limitations to actually implement that. And I'm gonna talk to you a little bit about what psychiatric advance directives involve, and what are some of the resources that we can use to try to implement it. So psychiatric advance directives, as you might know, it's a legal document that states the patient's preferences for mental health treatment in advance of a behavioral crisis. Given the possibility that the patient may actually lose his or her decision-making capacity at the time of a behavioral crisis. And this has the, I mean, the ultimate goal of these is to protect the patient's autonomy when they are in a behavioral crisis. Why is this important? Because we know that ethically and clinically, it's beneficial for the patient. And the data actually show that when we use psychiatric advance directives, or when we document psychiatric advance directives, we know that it impacts involuntary treatments. It empowers patients to participate on the decision-making process. It helps with minimizing coercion, improving coping strategies, and potentially reduced frequency of inpatient admissions too. And more concretely, what kind of information we should consider to include when we document advance directives. So, what it's being actually discussed, and there is this really interesting website that it's called, it's the National Resource Center for Psychiatric Advance Directives. They have different resources, documents, that can be downloaded when we consider to do this in clinical practice. They actually suggest to include these four main, I mean, these four things on there, or these four questions on the document. One is, what medications have or have not been used, or have or have not been helpful before for this particular patient in a behavioral crisis? What treatments or treatment locations does the patient prefer? And that actually includes seclusion or restraints in the context of a behavioral crisis. We know that maybe some patients might prefer seclusion over restraints. Some patients might be the other way around. So, that's important information to document too. And who should be contacted in case of a behavioral crisis or a mental health crisis? And that can be different, I mean, we know that some of this information might be present on the medical advance directives, but it might be different in the case of a psychiatric emergency or a behavioral crisis. They might want to, I mean, some patients might want to contact other family members. So, and finally, what causes or what helps prevent a behavioral crisis? And finally, in terms of implications and logistics, as I mentioned before, PADs or psychiatric advance directives remain legally in effect when the patient lacks decision-making capacity. We know that psychiatric, I mean, it's important to mention that psychiatric advance directive instructions do not trump safety. Always the priority is patient safety and staff member safety. And then the last question, kind of more concrete questions, as I mentioned before, what should we, what do we need to document in terms of psychiatric advance directives? And I included some of these examples in terms of documents that with the questions that sometimes we can utilize in these kind of cases. It can be as simple as just filling out, I mean, filling out a document, asking the question, what symptoms of problems do you experience during a period of a mental health crisis? Or what medications you tried before that were helpful? Or maybe what are the emergency contacts in that, I mean, case of a behavioral crisis? So, and there are different examples of these documents, and these can vary, I mean, from state, from state to state, because of the laws as well. But the website that I mentioned, the National Resource Center for Psychiatric Advance Directives is a very useful starting point. And finally, as I mentioned, there are limitations and barriers. So some of the limitations and barriers when we think about psychiatric advance directives include the legal ambiguity, laws vary by states, there are some states that might not permit proxy decision makers. Clinician's resistance, because there is always kind of this, I mean, we, a lot of physicians have been used to the more paternalistic approach when taking care of psychiatric patients. Anxiety over liability, lack of awareness of psychiatric advance directives. As I mentioned before, implementation challenges. It's difficult sometimes to implement this in clinical practice. Lack of collaboration between units. We need to think about what's the best way to communicate or to pass on this information between different teams. For example, from the emergency psychiatry team or behavioral crisis team to the inpatient teams. All those things we need to keep in mind when we implement psychiatric advance directives. And finally, competing pressures on resources like time constraints, financial constraints as well. And I'm gonna, I mean, the last part of the presentation, I mean, you can download the presentation from the website. I mean, these are just references. There's this table about references for this presentation and for the resource document as well. And you also can download the resource document from the APA website too. And I am going to stop right here so we leave some time for questions and discussion. Thank you. Hi, my name is Chelsea Atwater. I'm a psychiatrist at a state hospital. And so unfortunately, I do have to use my fair share of seclusion restraint. I try to use chemical restraint first. Unfortunately, with the uptick in patients, we've been running about 40% higher volumes for about a year and a half. That unfortunately, our numbers of seclusion restraints are going up. So I guess a couple of questions. Have there been any, I guess, longitudinal studies about patients who have filled out these advanced directives and how that has actually affected their treatment? And if that has led to them having more positive experiences of psychiatric hospitalization? If we actually see them being more adherent to their medications? Have there been any studies? And then just as a tip that I learned today, I stopped by the SMI advisor booth. And there is an app called My Mental Health Crisis Plan where the patients can download and fill out their psychiatric advanced directive on their phone. So. Thanks for your question. And yes, there are some studies actually. I didn't include the percentages or specific numbers. But on one of the slides that I put, basically, it's been seen most of the studies are basically cross-sectional studies. But it's been seen that the data suggests that it actually, people who have consistent advanced directives documented on the chart actually showed that they are less likely to be involuntary committed to psychiatric facilities. And also kind of some of the other subjective measures like patient's experience, trauma-related metrics are also lower on the patients who actually had psychiatric advanced directives documented. Just to add to that a little bit. Very similar, I think sometimes we think of an advanced directive as this thing you do when you're well, and you're an outpatient, and you're having a nice calm conversation. But you're in a hospital already. There are very similar kind of plans that we looked at where you actually develop them in the hospitals. They're really part of the treatment plan that you say, now what would help you, especially someone who just had an event, wait till the event's over or something. But you're sort of thinking, even in this context, even in this hospital context, what would help you? Is it quiet? Is it dark? Is it lights out? Really engaging them in the steps that would help. So I think this is something we talked a lot about at my hospital. We use the CPI model. And that's part of that de-escalation part, that we should be meeting with the patients after these events happen and say, hey, what happened that set you off? What can we do next time to try to de-escalate you? If we do have to resort to using medications, how would you prefer the medications be delivered? I've really been working with patients to try to offer POPR in medications as I'm noticing that de-escalation. And I think that's helped a lot. But I think, to your point, that's the question for me, is how do we get patients to fill out these directives prior to when they're already in crisis and they're already incapacitated? Yeah, and I think that's one thing that I didn't mention, too. Again, it's kind of hard in the crisis of being in the hospital. I think that as psychiatrists, clinicians, when we are seeing patients, wherever they may be, but in the outpatient setting, again, where you can have these a little more calm conversations, asking a patient, debriefing with them if they've ever had an event. I ask this question of my residents all the time. How often have you ever asked your outpatients if they've had such an event and what it was like for them getting that patient experience? But then you could lead that conversation into getting an advanced directive. So I think those are just some thoughts about it. I see we have some more questions. Thank you. Hi, I'm a psychiatrist. I work in a crisis center in Arizona. We do use chemical restraint as a term, and so does Arizona. And we don't like that, but it hinges on consent. If you're providing medication and it's not considered a restraint, but it's for acute treatment of agitation, but the patient is not agreeing to it, but you're giving it anyway because of their dangerous behavior, if it's not a restraint, how are you justifying that? Or who's consenting to the medication? I just want to understand the different framework. So chemical restraint I don't think falls into any particular regulatory entity, right? That's not something that typically has to be reported. I could see potentially advantages and arguments in favor of going that route as opposed to using mechanical restraint. And there probably are reasonable things to think about there. I think it's more of the framework around what are we trying to accomplish by the administration of the medication? Is the goal to render the patient incapable of moving or incapable of taking care of basic functions, like even going to the toilet, getting up if they need to? Or is the goal something other than that? Is the goal to reach a different point, which is what I was suggesting as the preferred option to determine treatment of agitation, because you ideally are picking an agent that is targeted towards the condition that's leading to the behavior. And that the endpoint is their ability to participate in further treatment planning and engage with the team. But how do you document who consents to that? Or how do you give it without consent? Well, documenting consent, in the case of involuntary medication, there is no consent, right? So the IM is given, intramuscular is given, and it's given only in emergency conditions, and it's given without consent. All the other medication, at least in the state of California, if an antipsychotic is to be given in any other form other than intramuscular for emergency use only, it's all pre-consented as the medication is ordered. So California allows involuntary medication that's not a chemical restraint? It allows involuntary medication. It doesn't term that as a chemical restraint, correct. Florida has some similar things about emergency treatment orders for medications. I work in Philadelphia, and I have two points. One, with regard to involuntary medication, our involuntarily committed patients need to have a second attending opinion, saying that its least restrictive setting is to give meds over objection. And so we have two attendings to that, and then it's medication over objection. That's the consent that's done for our involuntary patients. For our patients who are voluntary, it cannot be given except in an emergency as an emergency exception. I have to tell you that the psychiatric advance directive is bogus. The emperor has no clothes. I realize that I'm among the believers, potentially. But we spent four years trying to draft a bill in Pennsylvania that would be an advance directive. It was more than 100 pages long. And we now, at the time of discharge, need to give every patient a pamphlet describing how it can be done. 51-page pamphlet. It's absurd. And the problem is that there was a great promise that this would be a way of avoiding involuntary treatment, that we would have people consenting when they're well to be able to get treatment when they're ill, and they would be able to say what helps and so on. But it can be abrogated at any time. Until they have their involuntary commitment petition called in, or until someone declares them incapacitated, which almost never happens, they can abrogate their psychiatric advance directive. So really, we've been doing this for 10 years now. I've only seen it twice. And there are both patients who have been discharged from our state hospital system, which as part of their quality control mandate that it be done. But we have to do it every discharge document that we have given them information about psychiatric directives. It's wrongheaded. I don't agree with it. Rethink it. It's not like other advance directives, which are legally binding. Because again, it can be abrogated. Again, because it's been drafted with the involvement of patients' rights groups that really do not want to have anything binding, usually, because they can think of circumstances where they would not want it to happen. I'm sorry, it's been a travesty in Pennsylvania. And thank you so much for your comment. And one of the, I just wanted to also point out that another important challenge is not only the communication within the systems, how that information is communicated between different health care systems, where a patient on a behavioral crisis is usually, for example, transported to different hospitals, depending on the EMS or the ambulance that it's transporting the patient. Yeah, I mean, it's very challenging. Thank you so much. I was also just going to add, I mean, I'm really interested in the experience that you had. Because it sounds like the state tried quite hard. And it didn't, you know, the way that it was implemented was felt to be not helpful. But I'm not sure if the emperor's no clothes, or maybe the emperor's too many outfits. And it's like getting tangled up in all their outfits. I mean, one might say, like, when's the right time to have that conversation? If you're saying it's a discharge, and here's a big fat book to carry home with you, the timing might not be right, and the vehicle might not be right. But you know, a nice one pager that summarized, that was already finished, and summarized, and like, yeah, that's a reflection of what I want. I own this. It's what I want. And it reminds me of sort of safety plans. I don't know, those are supposed to be one page. But it's something that is designed to engage and have a conversation. It's completed, not like a big fat pile of homework for someone to do. But I'm curious about your experience. And I think it's a good cautionary tale, sounds like, about how not to do it. Hi. I'm one of the inpatient psychiatrists. I'm from Melbourne, the state of Victoria in Australia. It was a very interesting presentation for me because I belong to the group where we do a monthly meeting on reducing restrictive intervention. Victoria is driving a huge change in how we view the mental health system. We've recently had a Royal Commission looking into overhauling the system, and we have had this reducing restrictive intervention strategy going on for the past few years now. As I said, we have a monthly meeting, and we are implementing a lot of the things that you have discussed in your talk, and I can say it works. We are collecting the data, including doing the advance directives. We are mandated to do, under our Mental Health Act, for every patient to have an advance directive whenever it is feasible. Being in the acute sector, it's not always feasible, but we do work with the community team to make sure that something is done when they are discharged into the community and when they are reasonably settled. But having said that, even in the acute setting, we have found that after a restrictive intervention, be it seclusion or restraint, patients are able to talk with us and tell us their preferences, and we do make a treatment plan accordingly. What I have found is that if we have that in writing and we put that in our EMR, in our electronic system, when the patient comes in next time, we are able to implement that right at the get-go, so that we don't reach a point where they have to have the restrictive intervention. I've had patients who would say, oh, yes, ECT did work for me last time. They may not have insight and they may not be able to give a fully informed consent, but they do recognise that, yes, ECT did work for me and that has reduced my length of stay. I will go for the ECT this time, and that's there in my directive. I've had patients who we were able to give Acuphase, I don't know whether you call it Acuphase here, Zuclopandixol acetate, which has worked really well for them, or droperidol or whatever, and we have implemented it at the get-go, at the beginning of the intervention, not as a restrictive method. IMI was not used as a restrictive method, but it is with the consent of the patient. We do not even have to use physical restraint to administer the IM, so it does work. I think it is what we struggled with initially is that whole change of culture, change of the mindset, but once that started rolling, we found it was working, and our restrictive interventions have significantly declined, and our goal is, the whole of Victoria's goal is to go towards zero restrictive interventions. I'm not sure whether we will reach there, but going back to the question of chemical restraints, yes, our working body, which is Safer Care Victoria, which is driving the whole process, has said we cannot even use chemical restraint, but they have not really clearly defined what chemical restraint was. What they have loosely stated is that if the medication is used to the point that the patient is not able to be mobile or talk or discuss, so that's what their definition is. I don't know how we are working on it still. What was the other thing? We do have a process, like when you talk about psychiatrists being involved, I can't imagine a situation where a patient is restrained and a psychiatrist is not involved. We have to have review. If a patient is restrained, within the first two hours a psychiatrist has to be involved. That's mandatory. We have a lot of legal forms that we have to sign, and after the first two hours, every four hours the junior medical officer has to review and the psychiatrist has to, and it has to be discussed with the psychiatrist either in person, reviewing the patient, or at least over the telephone. So it's a very rigorous process, and all of the restraint events have to go to the office of the chief psychiatrist, and questions will be asked. If it goes beyond four hours, mechanical restraint, we have to give answers as to why the restraint was done. If the seclusion is beyond 12 hours, we have to again give explanation. So there's a whole rigorous process, and I can say that it works. Sorry I took a long time, but it's been really interesting. »» No, those are great comments. And I should go back and say I didn't mean to say that physicians and psychiatrists are not completely involved. We do have to have some face-to-face review and documentation. It's just that I think that in general a lot of people think, you know, there's a team that's sort of on site there all the time dealing with the patient, and that psychiatrists maybe take like a little less role overall. But yes, we do have to have oversight and see the patient. Go ahead. »» Hi. I'm a medical student. I just wanted to ask if there were recommendations or best practices from the APA on what a seclusion room should look like. I know you mentioned low sensory input, quiet and dark and so on, but if there are other considerations there. »» I'm sorry. I couldn't hear. Let me get a little closer to the... »» Is that better? Yeah. I was wondering if there were recommendations or best practices to what a good seclusion room should look like from the APA. I know there's mention of it being dark and quiet and so on, but beyond that? »» The question is what does a good seclusion room look like? Yeah. To the best of my knowledge that's defined by regulatory standards about the size and access to a bathroom and observation opportunities. And I think beyond that it's the embellishment and this is just from experience of our project of building a new hospital now is can you add features within that room that allow different levels of control of lighting, of the design of graphics on the wall as opposed to start their room? Are you able to bring in any type of furniture if that's safe to do at the time or remove it? So different adaptations that you can do for a space. I think one of the biggest things that I wrestle with in my mind is efficiency of the kind of combined seclusion and restraint room that a lot of folks do. So like if you put the patient in there and you lock the door, it's seclusion. If you tie them to the bed it's restraint. It's hard to, I think that's the argument of a lot of facility designers that say once you put that restraint bed in there, you've got a big imposing threatening entity sitting there lurking and it's hard to get a patient to experience something other than the threat of the restraint bed in there. But I got to tell you, it's very difficult when you're designing a facility to kind of decide if you are going to deliberately go with a seclusion room or put a restraint bed in there. Thank you. Hi everyone. I'm John Corpix. I'm a psychiatrist at VA in Chicago. Just want to thank the work group for your work. I think this was a needed resource document. I think it will be of great service to the field. To comment on the sample algorithm you had, I noticed that it doesn't include medication for agitation. Just wondering, could that be inserted in there? What that would look like? That algorithm didn't include any option for involuntary emergency medication as we've been discussing, chemical restraint. I'd suggest that there is certain patients that will agree to go to the quiet room and then don't stay in the quiet room and are back out in the milieu and will agree to go back, but then they're agitated and they're back out again. That's the kind of person you can medicate without restraining oftentimes because with the medication, then they've got the tool they needed to calm down just enough to stay in the quiet room and then avoid any seclusion or restraint. Sorry. The algorithm itself might have been hard to see it. There is a decision point high up for voluntary medication administration. Then there is another decision point for involuntary medication administration. Again, Ken Serta from Philadelphia. Without being as negative as last time, I thank you for your work with this. Seclusion and restraint is something that we've struggled with in the Quaker City for a very long time. We have some facilities that pride themselves on being restraint free, but they generally tend not to take patients like many of the rest of us take. I can easily change my numbers based on whether or not I accept other people from facilities. I know we're going to end up needing restraint or seclusion at times, but it's really very important work. One thing that wasn't included in the discussion about risk, though, is musculoskeletal injury, which is, of the things that I've seen, it's very disheartening to have a patient who is really agitated, gets restrained. It's usually in the process of being restrained that these things happen. A woman who, unfortunately, had a cervical plexus injury and had to be restrained ended up leaving the restraint room in a sling. It's disheartening. We try not to hurt our patients at all, and when that happens, it's a reminder. I would encourage people to think about the kind of situation that you're talking about with in terms of the bed in the room that has some grommets on the floor to have seclusion. It's worked out pretty well for us, but compared to when I was in training 40 years ago now, we use seclusion almost never. It's really remarkable how much we have improved in the reduction of restraints, and it's mainly a mindset. The one other thing that I would encourage people to consider, though, is part of my job as unit director is to manage the milieu, and we have patients who are, especially being extremely loud, touching other patients, getting to the point where other patients want to sign out because of them, or sexually inappropriate. Those are the times that we tend to use it now. It's not nearly as much as it used to be where people were just loud and wild. Now it's more to try to keep the milieu under a dull roar and to avoid victimization of our other patients. Hi. Thank you for this wonderful talk. Should I wait for you to address his comment, or would you? Can I ask my question? I think it was a comment. Yeah. Yeah, go ahead. Okay. I was very interested in the idea of psychiatrists helping design units. I wonder if there are studies comparing the degree of restraints and seclusions in places that psychiatrists help design versus places that are not maybe as intelligently designed. Thank you. I'm not sure that I'm aware of any specific data about that. Again, I think it's something though that the APA feels very strongly about. Again, I think it just makes sense, right? We have had the kind of training in so many different facilities, and we've had experience with seclusion and restraint. I think that's the important part. I think we'll take that back. I would definitely like to look and see if we can find any data about that. Feel free to contact me. I'm just going to go ahead and put this slide up. If you do want to get any information, to please just email me, and I will make sure that I get that to you. Did you want to say anything? Yeah. I didn't quite hear the question, but I think you were asking about whether is it about psychiatrists being involved at the start of the intervention? You had a very interesting slide about psychiatrists helping create units or design units. I was wondering whether that has showed improved results with people having less seclusion and restraint. I'm not aware. We're building a new hospital. I haven't come across any information about psychiatry specific and facility design, but there's a whole lot of information about facility design regardless, even if it's not led by psychiatrists. That is very valuable from all different aspects, all different disciplines. I just wanted to make a quick comment, but I think our Australian colleague may have left. Again, we're a state hospital. We have very tight regulations. For instance, if I have any type of mechanical restraint, I meet with my administration. If I have a physical hold or a seclusion that goes over 19 minutes, I meet with my administration. I don't know where this idea came from that American psychiatrists aren't, at least at a state hospital level because we're so tightly regulated, aren't checking in on seclusions. We have to have face-to-face every hour with a patient if they're in a seclusion or a restraint in my hospital. Do you find that those things have been effective at limiting restraint? Absolutely. The entire first year of my job being in attending, I didn't have a single mechanical restraint. I do pride myself on being a good verbal de-escalator and liberal use of chemical restraint, both intramuscular and PO, but that has drastically driven down the use of mechanical restraint and seclusion. One other point I wanted to make, I think Dr. Cortina, who was actually one of the writers of the action paper that stemmed this workgroup, he was here earlier, but he left. His big thing was that there are units now that aren't even seclusion rooms. They've just gotten rid of seclusion rooms entirely. To your point, at my hospital, our bed is smack dab in the middle of the seclusion room. It would be helpful if we had some data on length, I don't know if this exists or if it could be studied, length of patient seclusion in a room where it's just a seclusion room versus a seclusion room where they know that the option of going into restraint exists to see if patients who don't have that threat of a mechanical restraint bed present de-escalate faster, or if they have visuals on the wall, music, whatever it might be that help de-escalate them more quickly. I think that data would be really helpful in driving how we pay for changes to psychiatric facilities over time. That's all my comments. Thank you. I think your points are very well taken. I think that physician, psychiatrist involvement in seclusion and restraint is a cultural thing. It depends on where you work, what state you're in, what the laws are. Again, most regulations state, yes, you must do some sort of face-to-face. I think these things, it's delegated to residents. I think that, again, I've been in cultures where it was like the doctor's only role is to go write orders for medications or for the seclusion or restraint. It's a vital role, but again, I think it's just the sense of being involved at a bigger level, just like you are doing. I think that's wonderful, and I think that should be encouraged. We are just about out of time. I will encourage you to evaluate the session. Thank you so much for your attendance and participation. We've really enjoyed this.

APA resource document

seclusion and restraint

psychiatric settings

trauma-informed care

psychiatric advance directives

sensory rooms

culturally competent care

restrictive interventions

data monitoring

facility design

legal ambiguity

patient-centered approaches