Hospital restraint figures (not) revealed

Portland Tribune, November 2008

Hospital restraint figures revealed – State to make public quarterly data about psychiatric units

    The data described in this article is available online.

    Adult Seclusion and Restraint Occurrences Per 1000 Patient Days: 1st Quarter 2008 (PDF)

    (NOTE: DHS has linked to data which DOES NOT provide facility-specific information for adults, as DHS informed Peter Korn of the Portland Tribune they would.)

    Youth Seclusion and Restraint Occurrences Per 1000 Patient Days:1st Quarter 2008 (PDF)

A friend of the family told Elaine Shipman a week ago that hospitals don’t change their practices unless they are sued. Shipman said she didn’t believe it, that suing a hospital was just as likely to make the institution more secretive.

The subject is still a topical one at the Shipman home in Scappoose because in August 2007, Shipman’s son, Glenn Shipman Jr., was involved in one of Oregon’s most controversial hospital deaths.

Shortly after being admitted to the psychiatric unit at Legacy Emanuel Hospital and Health Center in Northeast Portland, Shipman, who suffered from schizophrenia and weighed 400 pounds, began walking away from nurses, was tackled by staff and asphyxiated while being held face down to the floor for at least 10 minutes in a position called prone restraint.

The Shipmans never sued on behalf of their son, despite findings from state and federal officials that a series of mistaken procedures by the hospital may have contributed to his death.

This week, Elaine Shipman said she feels she can tell her family friend that hospitals can change, or be induced to change, without being sued.

Largely as a result of public scrutiny inspired by Glenn Shipman Jr.’s death – and over the objections of the state hospital lobby – this week the Oregon Department of Human Services is making public the frequency with which individual Oregon hospitals restrain and seclude patients in their psychiatric units.

The department released the data to the Portland Tribune last week in response to a public records request, and later decided to post the data on the department’s Web site.

Restraining a patient can involve physical force, as occurred in Shipman’s case, or the use of leather or plastic cuffs that tie a patient to a bed, or with a special device called a Posey vest. Seclusion refers to putting a patient in an isolated, locked room, often for long periods.

But comparison restraint and seclusion data for hospitals treating psychiatric patients has never been available – until now.

“It’s the beginning of transparency,” said Beckie Child, board president of Mental Health America of Oregon, a nonprofit that advocates for people with mental illness.

The data being released covers the first three months of 2008 and shows that restraint and seclusion took place much more frequently at the psychiatric unit of the Portland Veterans Administration Medical Center than at most private hospitals in the Portland area.

Legacy Emanuel had 11 total restraints and seclusions while Legacy’s Good Samaritan Hospital had none, even though it treated more patients.

Some rural Oregon hospitals had much higher rates of restraint and seclusion than Portland area hospitals – Rogue Valley Medical Center in Medford and Bay Area Hospital in Coos Bay, particularly.

Restraint and seclusion are among the most controversial aspects of hospital care. Some mental health experts consider them necessary tools for handling patients who might endanger themselves or staff.

Other experts believe that viewing restraint and seclusion as tools rather than as treatment failures is one of the reasons many hospitals still restrain and seclude patients. Still, some Oregon hospitals, including the Salem Hospital and a few others, have eliminated their use.

But one thing experts agree on is that in the states that seclusion and restraint data has been made public, their use went down.

In fact, Oregon Department of Human Services officials said last week that they will be in touch with the hospitals whose restraint and seclusion data appears higher than the average. For the first time, they know which hospitals bear watching.

Trends worth noting

Hospital officials caution that the initial data is a snapshot, and that trends will be more obvious as more quarterly reports are made public.

For instance, the VA’s restraint and seclusion numbers were high, but the VA deals with a different population than other hospitals, according to Steve Dobscha, the hospital’s chief of psychiatry.

A large number of the veterans who use its 21 psychiatric beds are elderly and suffering dementia. Among the younger veterans, a large percentage is suffering from brain injuries suffered in Iraq and Afghanistan.

Patients with brain injuries and psychiatric illness can be much harder to control with the de-escalation techniques hospitals use as a way of pre-empting restraint and seclusion.

And the data for the VA does not reflect that hospital’s norm, Dobscha said. In 2007, the VA had a much lower rate than for the first quarter of this year. The increase is due to two patients in the psychiatric unit who were in and out of seclusion a number of times, Dobscha said.

Meanwhile, Legacy officials said that they send their most acute psychiatric cases to Legacy Emanuel, which explains the disparity between Emanuel and Good Samaritan.

Herb Ozer, director of Behavioral Health Services for Providence Health and Services, said something as simple as a hospital remodeling also can affect restraint and seclusion rates. St. Vincent’s, he said, has been remodeling its psychiatric unit this year.

“It creates a lot more chaos,” Ozer said, adding patients sometimes react to that chaos higher than usual.

Much to be gleaned from data

Mike Morris, a Department of Human Services manager for the state Addictions and Mental Health Division, said the data might contain all sorts of lessons yet to be learned.

For instance, Tuality Forest Grove Hospital reported a higher than average rate for use of seclusion. But Tuality runs a geriatric psychiatric program for treating the elderly, some of whom might be suffering aggressive dementia, Morris said.

“This is a start for us talking about one way to look at hospitals and the services they provide,” Morris said.

Hospital officials say that if similar numbers were collected just a few years ago they would have shown significantly higher rates of restraint and seclusion.

Robin Henderson, director of behavioral health at St. Charles Medical Center in Bend, said that five years ago her hospital’s seclusion room was always in use. In the last three years, Henderson said, St. Charles has almost completely eliminated the need for restraint and seclusion.

Reporting their seclusion and restraint data has forced hospitals to overcome a long-standing taboo, Henderson said. And it will be helpful, she said.

“We have to go back and really talk among each other about what models are working and what models aren’t,” Henderson said. “This has not been the safest thing to talk about. There are not a lot of venues where we can go out and share high-risk data.”

Child, of the Mental Health America of Oregon, was secluded at the now-closed Woodland Park Hospital in Northeast Portland years ago. She said making psychiatric data public could help mental health patients avoid trauma – the trauma she said that often accompanies the aftermath of a hospital stay.

“What’s happened in the past is people have a bad experience and they complain as individuals, which means hospitals bring in attorneys and risk-management folks, so it makes it feel like it’s very personal,” Child said. “This at least gives you a chance to look at it with a different lens.”

Jason Renaud, another longtime Portland activist on mental health issues, said release of the new data represented a victory of sorts for mental health advocates.

“This required abundant public oversight, but we have had nothing up until this point,” Renaud said of seclusion and restraint. “It’s not part of the happy story of hospitals.”