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Use of Control Interventions in Ontario: Where Are We Now—Where are We Heading?Nawaf Madi

Canadian Institute for Health Information

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Mental Health Services in General Hospitals

Where Are We Now?

Where are We Heading?

Control Interventions--Overview

Mental Health Services in General Hospitals

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4

Hospital Mental Health Services in Canada

1982-1983 1993-1994 2006–2007 2007–2008 2008–2009 2009–20100%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

General Hospitals Psychiatric Hospitals

Sepa

ratio

ns

5

General Hospital Separation Rates 2009-2010

Newfou

ndlan

d & La

brado

r

Prince

Edw

ard Is

land

Nova S

cotia

New B

runsw

ick

Quebe

c

Ontario

Manito

ba

Saska

tchew

an

Alberta

British

Colu

mbiaYuk

on

Northw

est T

errito

ries

Nunav

ut

Canad

a0.0

200.0

400.0

600.0

800.0

1000.0

1200.0

1400.0A

ge S

tand

ardi

zed

Sep

arat

ion

Rat

e\10

0,00

0

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Hospital Mental Health Services in Canada 2009-2010

Org

anic

D

isor

ders

Sub

stan

ce-

Rel

ated

D

isor

ders

Sch

izop

hren

ic

and

Psy

chot

ic

Dis

orde

rs

Moo

d D

isor

ders

Anx

iety

D

isor

ders

Per

sona

lity

Dis

orde

rs

Oth

er

Dis

orde

rs

0

5

10

15

20

25

30

35

40

General Hospitals Psychiatric Hospitals

Diagnosis Category

Perc

enta

ge o

f Sep

arat

ions

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General Hospital Length of Stay 2009-2010

Newfoundlan

d and Lab

rador

Prince

Edward Is

land

Nova Sco

tia

New Brunsw

ick

Quebec

Ontario

†

Manito

ba

Saska

tchew

an

Alberta

British

ColumbiaYuko

n

Northwes

t Terr

itorie

s

Nunavut

Canad

a0.0

5.0

10.0

15.0

20.0

25.0

30.0

AverageMedian

Len

gth

of S

tay

(Day

s)

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Hospital Mental Health Services in Canada 2009-2010    General Hospitals Psychiatric Hospitals

    Non–Mental Illness Mental Illness Mental Illness

Male (%)   41.5 49.5 56.8Mean Age (Years)   52.9 46.3 42.0Age (%) 0–14 7.3 3.1 2.3  15–24 6.9 15.5 16.1  25–44 22.9 31.7 39.0  45–64 23.7 28.4 30.8  65+ 39.1 21.3 11.9Income Quintile (%) 1 (Low) 23.0 28.8 NA  2 20.7 21.2 NA  3 19.8 17.5 NA  4 18.6 15.2 NA  5 (High) 16.6 13.4 NA  Unknown 1.3 4.0 NAAdmitted via the Emergency Department (%) 51.8 76.9 NADeath in Hospital (%)   4.2 1.1 0.7Separations (%)   94.1 5.9 NATotal Length of Stay (%) 86.6 13.4 NAAverage Length of Stay (Days)

  7.4 18.3 80.5

Median Length of Stay (Days)   3 8 22Distribution of Lengths of Stay (%) 1 Day 24.0 14.1 9.1

  2–7 Days 53.7 34.4 18.6  8–30 Days 4.0 15.5 35.3  31–365 Days 18.4 35.8 33.8  366+ Days 0.0 0.1 3.2

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A Look at the Data

Where Are We Now?

Control Interventions Defined

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Acute Control Medication

• Psychotropic (e.g. sedative) medication given as an immediate response to prevent harm to self or others

Mechanical Restraint

• Restrained in bed and unable to ambulate• Wrists restrained but able to ambulate

Physical Restraint

• Holding the person for a brief period to restore calm

Seclusion

• A room that confines and from which the person cannot exit freely

Legislation, Guidelines, Policies & Practice

• Patient Restraint Minimization Act (2001) stipulates use should be limited to prevention of bodily harm

• CNO & RNAO Guidelines emphasize least restrictive approaches• Interventions classified by level of restrictiveness

• Many institutional policies stipulate restraints as a measure of last resort

• It is generally agreed that restraints are to be avoided if possible– Although stigma and negative attitudes remain

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Control Interventions an Issue of Importance

• Adverse outcomes

– Physical injury to patients & staff

– Negative emotional\psychological impacts• Retraumatization

– Not conducive to therapeutic alliance• Time spent on CI’s is time not spent on therapeutic care

– Financial costs

• Ethical Issue– Media interest drawn by question of human rights

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What the Data Tell Us?

• International Estimates Vary– Estimates vary from 0%-35% of admissions (Steinert,

2009)

– Variation in definitions and policies

• Limited Standardized & Comparable Canadian Data– Except in Ontario

– Many gaps, much analyses focus on elderly

• …but interest is growing

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Control Intervention Use in Ontario

FY2006 FY2007 FY2008 FY2009 FY2010 FY2011 FY2006 FY2007 FY2008 FY2009 FY2010 FY20110.0

5.0

10.0

15.0

20.0

25.0

Admission (72 Hrs) Quarterly/Change in Status Discharge Short Stay

Percent

General Hospitals Psychiatric Hospitals

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Acute Control Medication Use in Ontario

FY2006 FY2007 FY2008 FY2009 FY2010 FY2011 FY2006 FY2007 FY2008 FY2009 FY2010 FY20110.0

2.0

4.0

6.0

8.0

10.0

12.0

14.0

Admission (72 Hrs) Quarterly/Change in Status Discharge Short Stay

Percent

General Hospitals Psychiatric Hospitals

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Physical\Mechanical Restraint Use in Ontario

FY2006 FY2007 FY2008 FY2009 FY2010 FY2011 FY2006 FY2007 FY2008 FY2009 FY2010 FY20110.0

0.5

1.0

1.5

2.0

2.5

3.0

3.5

4.0

4.5

5.0

Admission (72 Hrs) Quarterly/Change in Status Discharge Short Stay

Percent

General Hospitals Psychiatric Hospitals

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Seclusion Room Use in Ontario

FY2006 FY2007 FY2008 FY2009 FY2010 FY2011 FY2006 FY2007 FY2008 FY2009 FY2010 FY20110.0

0.5

1.0

1.5

2.0

2.5

3.0

3.5

4.0

4.5

Admission (72 Hrs) Quarterly/Change in Status Discharge Short Stay

Percent

General Hospitals Psychiatric Hospitals

What factors are associated with CI use?

CI Analysis Part I:

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Purpose of Analysis in Brief

• Examining rates within Ontario hospitals

• Profile of individuals experiencing CIs

• Identifying risks factors for CIs with adjustment for socio-demographic, clinical, & other variables

• Examining differences between types of CIs interventions

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Methods

• Used OMHRS data for 2006-2007 to 2009-20010

• Three mutually exclusive groups of control intervention– Acute Control Medication

– Physical\Mechanical Restraint

– Seclusion

– Comparison: Psychiatric hospitalization with no control interventions

• 70 general hospital and specialty mental health facilities

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Individuals who experienced a CI 2006-2009

15%

5%

5%

74%

Acute control medication only

Physical/mechanical restraint

Seclusion

No control intervention

Risk factors:

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Sociodemographic

• Gender - male

• Age - younger • Education • Employment• Neighbourhood Income

Behavioural

• Danger to others• Danger to self• Inability for self-care due to MH• Police Intervention

Clinical

• Depression• Substance Use

• Organic disorders

• Bipolar disorders

• Schizophrenia or Psychosis

Treatment

• >6 lifetime MH admissions

• Medication non adherence

Cognitive/ Communication

• Cognitive impairment

• Unable to consent to treatment

• Difficulty making self understood

Life Stressor

• History of emotional, physical or sexual abuse or assaulte

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      Adjusted Odds Ratios

Domain Potential Predictor ACMMechanical/Physical Restraint

SeclusionAll Control

Interventions

DemographicAge (years)        

  18-24 (reference) 1  1  1 1   25-34 0.90 0.68 0.70 0.81  35-44 0.82 0.63 0.61 0.73  45-54 0.75 0.56 0.53 0.66  55-64 0.65 0.43 0.47 0.57  65-74 0.65 0.45 0.33 0.53  >=75 0.64 0.59 0.22 0.54

Male gender (vs. female)     1.18  More than high school education 1.08 1.14 0.84  Not employed (vs. employed) 1.22 1.13 1.28 1.22Highest SES (vs. lowest)     0.84  

Behavioral Threat/danger to self 1.64 1.33 1.29 1.53Threat/danger to others 1.48 2.14 2.00 1.72Cannot care for self due to mental illness 1.65 1.66 1.37 1.60Recent police intervention (vs. none) 1.35 1.62 1.64 1.51Recent violence to others (vs. none) 1.54 3.11 1.99 1.98

Cognitive/communication

Not capable of consenting 1.19 1.90 1.38 1.39Making self understood        

  Understood 1 1   1  1  Usually/often understood 1.71 1.78 1.41 1.68  Sometimes/rarely understood 1.60 2.92 2.36 2.09

Life stressors

History of abuse 0.84

Risk Factors for Control Interventions

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      Adjusted Odds Ratios

Domain Potential Predictor ACMMechanical/Physical Restraint

Seclusion

All Control Interventio

nsTreatment Number of lifetime psychiatric hospitalizations      

  0 (reference) 1        1 to 3 1.31 1.29 1.42 1.33  4 to 5 1.69 1.58 1.86 1.71  6 or more 1.98 2.00 2.21 2.03

Medication adherence          Always adherent (reference) 1        80% or more 1.45 1.65 1.25 1.43  <80% and fail to buy meds 1.86 2.61 1.82 1.95  No meds prescribed 1.28 1.87 1.40 1.37

Type of facility          Psychiatric/Specialty (reference) 1        General Hospital 1.68 2.61 1.45 1.76

Clinical Primary mental health diagnosis          Depression/other mood disorders 1 1 1 1  Organic disorders 1.42 2.66 1.97 1.69  Substance related disorders 0.88 1.37   0.91  Schizophrenic/other psychotic

disorders 1.28 1.82 1.51 1.40  Bipolar disorders 1.22 2.27 2.09 1.50  Anxiety disorders     0.43  

Concurrent substance abuse/addiction          Yes 1.07      

Concurrent personality disorder          Yes 1.13     1.09

Risk Factors for Control Interventions

Part I:Summary

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Patients admitted to a general hospital more likely to experience restraint use

• Difficulty communicating, violent behavior greatly increase chances of patients experiencing control interventions

Highlights areas for intervention: treatment compliance, communication, training

What are the outcomes of control intervention use?

CI Analysis Part II:

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0 11 22 33 44 55 66 77 88 99 1101211321431541651761871982092202312422532642752862973083193303413523633743850

5

10

15

20

25

30

35

40

First psychiatric readmission following index hospitalization by restraint type

No restraint ACM Physical/Mechanical Seclusion

Time to readmission (Days)

Perc

ent r

eadm

itted

5.4%

9.9%

11.9%

11.4%

22.3%

32.7%

36.0%

36.4%

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Age*

Abuse

Homeless

Control intervention

≥6 Hospitalization (vs. 0)

General facility (vs. Psych)

Bipolar

Anxiety

Substance related

Schizophrenia 

Aggressive Behaviour Scale**

Risk of self-harm†

Self-care difficulties‡

-1

-0.5

0

0.5

1

1.5

Adjusted odds ratios from the logistic model of readmission within 30 days

Odd

s Rati

o

1

0

1.5

2.0

NSNS NS

0.5

*Age: Oldest quintile vs. youngest**Highest risk vs. none (3-12 vs. 0)†Severity of Self-Harm Scale (5-6 vs. 0)‡Self-care Index (high risk vs. none)

Part II Summary

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Preliminary findings--those experiencing CI’s are 60% more likely to be readmitted within 30 days even when adjusted for other factors

• At 1 year, those who experienced CI’s were more likely to be readmitted

Need to understand what is it about control intervention use in previous hospitalizations that is related to readmissions

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Where are We Heading?The Role of Data

“People being locked in tiny rooms they cannot leave, tied

to a bed and injected with chemicals against their will

are clearly traumatic

experiences that taken in any other context

would be seen as devastating”

A patient’s perspective – Jennifer Chambers

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Out of the Shadows at Last

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Larue et al. 2009

Larue et al. 2009

Leadership• Restraint reduction vision• Philosophy of care• Values and Strategies

Data• Evidence based

decisions• Est. baselines• Reduction targets• Peer comparison• Trends• Cost analysis• Resourcing• Etc.

LEGISLATION

In Ontario

• Patient Restraint Minimization Act, (2001) Government of Ontario

• Mental Health Act, (2001) Government of Ontario

• College of Nurses of Ontario Practice Standard: Restraints, (2009)

• Health Care Consent Act, 1996 (2010) Government of Ontario

• Restraint use as a patient safety issue

• Restraint use as a Quality of Care Indicator (HQO)

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Comparative Reporting on CI’s

Fac Peer LHIN Prov0

10

20

30

40

50

60

70

80

90

100Prevalence of physical restraint use

Prevalence of acute control medication use

No physical restraint or acute control medication used

%

Informing Clinical PracticeMental Health Clinical Assessment Protocols (CAPs)

• CI CAP will trigger based on the following RAI-MH components:

– Recent self-injurious attempt

– Intent of any attempt was to kill self

– Violent behaviour/Extreme disturbance to others

– Recent command hallucinations

– ABS score of 6 or higher

– Recent ACM use

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Clinical Assessment Protocol ReportsInforming Management Decisions

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0.010.020.030.040.050.060.070.080.090.0

100.01. Harm to Others 2. Suicidality and

Purposeful Self-Harm3. Self Care

4. SocialRelationships

5. Support Systemsfor Discharge

6. InterpersonalConflict

7. Traumatic LifeEvents

8. Criminal Activity

9. Personal Finances10. Education and

Employment11. ControlInterventions

12. MedicationManagement and…

13. Rehospitalization

14. Smoking

15. Substance Use

16. WeightManagement

17. Exercise

18. SleepDisturbance

19. Pain

20. Falls

Facility, Peers and Province Overall Triggered CAPs Percentage

FACILITY

PEERS

PROVINCE

Informing Communities of Practice

Control Interventions Experienced 2006-2009

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0.0

10.0

20.0

30.0

40.0

50.0

60.0

5.3

51.4

4.4

38.3

OMHRS Facilities

Percent

General Hospitals Psychiatric Hospit-als

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Acute Control Medications 2006-2009

0.0

5.0

10.0

15.0

20.0

25.0

30.0

35.0

40.0

45.0

1.7

39.4

1.2

31.3

OMHRS Facilities

Percent

General Hospitals Psychiatric Hospit-als

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Physical\Mechanical Restraints Experienced 2006-2009

0.0

5.0

10.0

15.0

20.0

25.0

30.0

0.2

26.3

0.0

6.8

OMHRS Facilities

Percent

General Hospitals Psychiatric Hospit-als

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Seclusions Experienced 2006-2009

0.0

5.0

10.0

15.0

20.0

25.0

30.028.2

0.8

27.0

OMHRS Facilities

Percent

General Hospitals Psychiatric Hospit-als

0.0

Evidence Informed Decisions

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Standardized, accurate clinical assessments provide evidence to:

• Identify risks• Guide care planning • Measure treatment effectiveness

Aggregate reporting of comparable clinical information provides evidence to:

• Evaluate quality of care• Guide decision making at all levels from unit, to facility, to

Ministry of Health• Identify areas for improvement

nmadi@cihi.ca

Questions?

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