leb.qxd PSYCHIATRIC SERVICES ♦ http://ps.psychiatryonline.org ♦ September 2005 Vol. 56 No. 9 11110099 National interest in reducing oreliminating the use of seclu-sion and restraint was ignited by the Hartford Courant’s 1998 Pulitzer Prize–winning series on deaths associated with restraint (1) and was fueled by several important ef- forts, including the Children’s Health Act of 2000, the Substance Abuse and Mental Health Services Administra- tion’s (SAMHSA’s) National Call to Ac- tion: Eliminating The Use of Seclusion and Restraint, the National Associa- tion of State Mental Health Program Directors’ (NASMHPD’s) National Executive Training Institutes and curriculum to reduce seclusion and restraint, and successful state seclu- sion and restraint reduction initiatives (2–6). Massachusetts has an established history of stringent statutory and reg- ulatory requirements that govern the use of seclusion and restraint in psy- chiatric facilities. In 1985, the state’s Department of Mental Health (DMH) issued regulations limiting the use of seclusion and restraint among children. An impact analysis at one facility concluded that the new requirements had been successful in reducing rates of restraint (7). In 2001, DMH used its statutory role again to change seclusion and re- straint practices in psychiatric facili- ties that serve children and adoles- cents by developing a statewide initia- tive to reduce or eliminate the use of seclusion and restraint among chil- dren and adolescents (6). This effort was undertaken because rates of seclusion and restraint in child and adolescent psychiatric facilities were The Economic Cost of Using Restraint and the Value Added by Restraint Reduction or Elimination JJaanniiccee LLeeBBeell,, EEdd..DD.. RRoobbeerrtt GGoollddsstteeiinn,, PPhh..DD.. Dr. LeBel is affiliated with the child and adolescent division of the Massachusetts De- partment of Mental Health, 25 Staniford Street, Boston, Massachusetts 02114 (e-mail, janice.lebel@dmh.state.ma.us). When this work was done, Dr. Goldstein was with the clinical and professional services division of the department. He is currently affiliated with Synergy Consulting Associates in Stow, Massachusetts. An earlier version of this pa- per was presented at the annual conference of the National Association of State Mental Health Program Directors National Research Institute, held February 8 to 10, 2004, in Arlington, Virginia, and at the Massachusetts Department of Mental Health Restraint Re- duction/Elimination Grand Rounds, held March 30, 2004, in Natick, Massachusetts. This article is part of a special section on the use of seclusion and restraint in psychiatric treat- ment settings. Objective: The purpose of this study was to calculate the economic cost of using restraint on one adolescent inpatient service and to examine the effect of an initiative to reduce or eliminate the use of restraint af- ter it was implemented. Methods: A detailed process-task analysis of mechanical, physical, and medication-based restraint was conducted in accordance with state and federal restraint requirements. Facility re- straint data were collected, verified, and analyzed. A model was devel- oped to determine the cost and duration of an average episode for each type of restraint. Staff time allocated to restraint activities and med- ication costs were computed. Calculation of the cost of restraint was re- stricted to staff and medication costs. Aggregate costs of restraint use and staff-related costs for one full year before the restraint reduction initiative (FY 2000) and one full year after the initiative (FY 2003) were calculated. Outcome, discharge, and recidivism data were analyzed. Results: A comparison of the FY 2000 data with the FY 2003 data showed that the adolescent inpatient service’s aggregate use of re- straint decreased from 3,991 episodes to 373 episodes (91 percent), which was associated with a reduction in the cost of restraint from $1,446,740 to $117,036 (a 92 percent reduction). In addition, sick time, staff turnover and replacement costs, workers’ compensation, injuries to adolescents and staff, and recidivism decreased. Adolescent Global Assessment of Functioning scores at discharge significantly improved. Conclusions: Implementation of a restraint reduction initiative was as- sociated with a reduction in the use of restraint, staff time devoted to restraint, and staff-related costs. This shift appears to have contributed to better outcomes for adolescents, fewer injuries to adolescents and staff, and lower staff turnover. The initiative may have enhanced ado- lescent treatment and work conditions for staff. (Psychiatric Services 56:1109–1114, 2005) SSppeecciiaall SSeeccttiioonn oonn SSeecclluussiioonn aanndd RReessttrraaiinntt leb.qxd 8/22/2005 9:41 AM Page 1109 five to six times higher than in adult facilities. The initiative began in fiscal year (FY) 2001 and was fully implemented in FY 2002. It included strategic plan- ning, training, and technical assis- tance from DMH; quarterly grand rounds; annual provider forums; monthly facility-specific consultation; data monitoring and comparative re- ports; and continuous review and planning. No new fiscal resources were provided. When statewide child and adoles- cent seclusion and restraint data for FY 2000 and FY 2003 were com- pared, a decrease in the number of episodes of seclusion and restraint (68 percent, from 8,599 to 2,712) and in the number of hours of seclusion and restraint (79 percent, from 14,085 to 2,924) was demonstrated. Reduction was evident, but questions resulted: Were treatment outcomes or inpatient services affected? What did seclusion and restraint cost? What did reducing seclusion and restraint save? What else changed? No research on the explicit costs as- sociated with the use of seclusion and restraint in psychiatric inpatient set- tings was found in the literature. Phillips and colleagues (8) considered cost implications of reducing the use of physical restraint in 276 nursing homes in seven states. After examining the major component of nursing home cost—staff time—and how time was allocated with residents who were re- strained and those who were not, these authors concluded that “residents free of restraints are less costly to care for than restrained residents.” Fraser and associates (9) considered the cost of patient-initiated elimination of re- straint in intensive care settings and noted that the use of restraint repre- sented a “significant consumption of health care resources.” The issue of cost in psychiatric in- patient settings has been researched by others. However, the focus has been on the impact of violence, such as the cost of patient assault (10), the cost of staff injuries from inpatient vi- olence (11,12), and the cost of imple- menting total quality management to reduce violence (13). Although vio- lence and resulting patient and staff injuries often involved the use of seclusion and restraint (11,12,14), none of the analyses included the cost of using seclusion and restraint or the economic impact if seclusion and re- straint were reduced or eliminated. However, the literature articulated the more recent determination that the use of seclusion and restraint was not therapeutic and reflected a failure in the treatment process (15,16). This pronouncement was particularly meaningful when measured against the federal statute that defined the purpose of psychiatric inpatient serv- ice as providing physician-directed diagnostic services and active individ- ualized treatment that must be rea- sonably expected to improve the per- son’s condition (17). The use of seclu- sion and restraint conflicted with the statute, the goals of psychiatric inpa- tient service, and the advancement of standards of care. Moreover, children and adolescents with trauma histories who experienced seclusion and re- straint perceived the hospital as a source of new trauma, not treatment (18–21). Hippocrates’ dictum to physicians—“to help, or at least to do no harm” (22)—underscored the con- tradictory nature of the use of seclu- sion and restraint in contemporary psychiatric practice. We developed a model to analyze the cost of restraint, to answer the question, What else did the initiative achieve besides reducing restraint episodes and hours? Our purpose was to retrospectively calculate the cost of restraint and the impact of the initia- tive on one inpatient facility by com- paring the use of restraint and re- straint-related costs for one full year before the initiative was implement- ed (FY 2000) with those one full year after (FY 2003). A 30-bed, co-ed, adolescent contin- uing care inpatient service for youths aged 13 to 18 years was selected for the study. The service is located at Westborough State Hospital in West- borough, Massachusetts. The service is the only privatized long-term inpa- tient resource for adolescents who re- quire extended postacute inpatient care to stabilize treatment-refractory behavior. All adolescents have experi- enced previous hospitalizations, and their diagnostic profiles are complex. The most frequently occurring admit- ting diagnoses are posttraumatic stress disorder, bipolar disorder, con- duct disorder, major depression, and psychotic disorders. Before admission, adolescents are assessed by trained child and adoles- cent psychiatrists. Admission is rec- ommended only if clinical criteria es- tablished for this service are satisfied. The admission criteria have not changed since the service was created in 1985. Of 81 patients served in FY 2000, 49 (60 percent) were Caucasian, 11 (14 percent) were African American, and six (7 percent) were Hispanic. In FY 2003, of 75 patients, 50 (67 per- cent) were Caucasian, ten (13 per- cent) were Hispanic, and nine (12 percent) were African American. A portion of the population was not racially identified in FY 2000 and FY 2003. No patient-identifying informa- tion was reviewed or used. The data were collected from July 2003 to Feb- ruary 2005, and prior consent was ob- tained from DMH’s institutional re- view board. Methods To analyze the cost of restraint, the principles of time-motion analysis were applied (23,24). Time-motion PSYCHIATRIC SERVICES ♦ http://ps.psychiatryonline.org ♦ September 2005 Vol. 56 No. 911111100 The focus of studies of cost in psychiatric research settings has been on the impact of violence; none of the analyses included the cost of using seclusion and restraint. leb.qxd 8/22/2005 9:41 AM Page 1110 analysis pioneers Frederick Taylor and Frank Gilbreth endorsed study- ing an activity process and analyzing each task in the process to improve outcomes. Thus we conducted a process-task analysis for physical, me- chanical, medication-based, and medication-combination restraint. Seclusion was not used at the service and therefore was not included in the analysis. Process-task analysis A process-task analysis was conduct- ed by examining statutory and regula- tory restraint requirements of DMH, accreditation standards of the Joint Commission on Accreditation of Healthcare Organizations, and certi- fication requirements of the Centers for Medicare and Medicaid Services (25–27,17). This analysis produced a template in which each task of the re- straint process was identified. Next, several meetings were held with service staff. Using the template, staff further delineated restraint tasks, the staff disciplines involved, and the number of staff and time re- quired to perform each task (Table 1). A detailed sequence of restraint activ- ities resulted. The refined restraint process-task analysis indicated three discrete phas- es: prerestraint (initial crisis manage- ment); restraint application, monitor- ing, and release; and postrestraint ac- tivities, as shown in Table 2. The number of tasks, staff, and time re- mained consistent across restraint types in the first and third phases but not in the second phase. This varia- tion affected the cost of each type of restraint. Cost estimation To fully evaluate the cost of restraint and the impact of reducing restraint, a range of costs were considered. De- termining which costs to include in the cost calculation for a restraint episode proved difficult. Costs explic- itly incurred during restraint were clear (staff time and medication). Costs resulting from restraint activi- ty—that is, injuries, lost staff time, and turnover—were calculated but were not factored into the cost calcu- lation for each type of episode. Prerestraint episode costs, such as escalation monitoring and deescala- tion interventions, were considered, but we were unable to quantify them because of variations in staff tech- niques and the inability to define standardized procedures. Staff stated that an important part of their work is good milieu management—anticipat- ing and intervening early to prevent circumstances from escalating to cri- sis proportions. This approach was used by staff “all the time” as part of their job rather than being a discrete task. Similarly, postrestraint episode costs, such as milieu instability, conta- gion, damage to the treatment process, and the traumatic effect of being restrained, could not be ade- quately measured and were not in- cluded (28). To generate conservative cost esti- mates for the use of restraint, the fol- lowing criteria were used: the mini- mum number of staff needed per task, the minimum amount of staff time needed per task, and the low end of the staff salary range per disci- pline. The medication-based and medication-combination restraint calculations were based on these cri- teria and included a fixed medication cost estimate according to FY 2003 PSYCHIATRIC SERVICES ♦ http://ps.psychiatryonline.org ♦ September 2005 Vol. 56 No. 9 11111111 TTaabbllee 11 Total staff hours by discipline per episode of restraint in an adolescent inpatient service, by type of restraint Mechanical or physical with Type of staff Medication Physical Mechanical medication Mental heath counselor 4.57 4.73 4.98 5.98 Nursing 3.33 3.25 3.33 3.83 Psychiatrist .33 .75 .75 .75 Social worker 1.17 1.17 1.17 1.17 Psychologist .5 .5 .5 .5 Program director .5 .5 .5 .5 Secretary .42 .42 .42 .42 Human rights officer .25 .25 .25 .25 Total 11.07 11.57 11.9 13.4 TTaabbllee 22 Costs of an average-duration episode of restraint for various phases of restraint in an adolescent inpatient service, by type of restraint intervention Mechanical or physical with Type of staff Medication Physical Mechanical medication Phase 1 (prerestraint) Number of tasks 8 8 8 8 Number of staff disciplines 4 4 4 4 Staff time (hours) 1.65 1.65 1.65 1.65 Cost $39.35 $39.35 $39.35 $39.35 Phase 2 (restraint application, monitoring, and release) Number of tasks 8 7 7 11 Number of staff disciplines 3 3 3 3 Staff time (hours) 3.58 4.08 4.42 5.92 Medication cost 12.33 — — 12.33 Cost $96.20 $110.94 $118.12 $163.41 Phase 3 (postrestraint activities) Number of tasks 10 10 10 10 Number of staff disciplines 8 8 8 8 Staff time (hours) 5.83 5.83 5.83 5.83 Cost $151.74 $151.74 $151.74 $151.74 Total staff time 11.07 11.57 11.90 13.40 Total cost per episode $287.30 $302.03 $309.21 $354.51 leb.qxd 8/22/2005 9:41 AM Page 1111 costs of the service’s most frequently prescribed medication-based re- straints: haloperidol (5 mg/mL, $4.69 per vial), lorazepam (2 mg/mL, $1.14 per vial), and benztropine (2 mg/mL, $6.50 per vial). Data collection Restraint data were reported to DMH each month by the inpatient service and by Westborough State Hospital. These reports were submit- ted on standard DMH forms with in- structions on the restraint data, initia- tion and termination times, staff sig- natures, and other staff documenta- tion to be reported and then cross- referenced to verify the service’s data. The inpatient service and the hos- pital provided restraint data (episodes and hours) for each type of restraint for one full year preinitiative (FY 2000) and one full year postinitiative (FY 2003). There were 3,991 episodes, or 8,040 hours, in FY 2000 and 373 episodes, or 327 hours, in FY 2003. Restraint episodes varied by type and duration, which determined the number of tasks, staff, and staff time. The service’s average episode duration for each restraint type for FY 2000 and FY 2003 was calculated and applied in phase 2 (Table 3). The exception was medication-based re- straint, for which no duration factor was applied. The inpatient service also provided staff, salary, and staff-related data. The service was state-contracted and level-funded from FY 2000 to FY 2003. Consequently, salary costs and ranges remained constant. There was no change in staffing pattern, envi- ronment of care, benefits, or other staff-related factors that could have contributed to a change in the work or environmental conditions. Cost calculations were performed for restraint, medication, staff, and staff-related costs in FY 2000 and FY 2003. Restraint and nonrestraint time also was calculated. Using this ap- proach, we examined the staff time allocated to restraint as a subset of the total staff time available in FY 2000 and FY 2003 (Table 4). In addition, Global Assessment of Functioning (GAF) scores assigned at admission and discharge for each adolescent by the treating psychia- trists for the pre- and poststudy peri- ods were obtained from the service and the hospital. The data were com- pared by using unpaired two-tailed t tests of statistical significance. Data from the DMH performance- based contracting (PBC) system were also used. Since FY 2002, the inpa- tient service has analyzed and report- ed semiannually on performance in- dicators, including adolescent partici- pation, family and collateral involve- ment, outcomes, postdischarge fol- low-up, and recidivism. Results Restraint cost Restraint costs varied by type and phase (Table 2). The amount of time required for one average episode of any type of restraint was considerable, particularly in the third phase. Costs were driven by the number of tasks and staff, staff time, and the average episode dura- tion. A compilation of these re- straint costs yielded an aggregate restraint cost. A comparison of ag- gregate restraint costs in FY 2000 and FY 2003 indicated a reduction in cost from $1,446,740 to $117,036 (a 92 percent reduction) because of the decrease in episodes from 3,991 to 373 (a 91 percent reduction). Impact on adolescents The admission and discharge GAF scores for FY 2000 and FY 2003 were analyzed and compared. A sig- nificantly more impaired population was admitted in FY 2003 than in FY 2000 (29.64±11.54 and 34.25±10.66, respectively; t=2.05, df=96, p<.05). Despite the increased functional im- pairment of FY 2003 admissions, discharge GAF scores from pre- to postinitiative nevertheless increased significantly (57.79±13.39 compared with 52.70±11.59; t=2.08, df=102, p<.05). Aggregate data from the PBC sys- tem supported this finding. More adolescents were discharged with higher GAF scores in FY 2003 (90 percent, or 46 of 51 discharges) than in FY 2002 (77 percent, or 27 of 35 discharges). The PBC data also revealed de- creased recidivism. At six months postdischarge, 32 percent fewer ado- lescents were rehospitalized in FY 2003 (two of 25 adolescents) than in FY 2002 (three of 12 adolescents). Similarly, at 12 months postdischarge, PSYCHIATRIC SERVICES ♦ http://ps.psychiatryonline.org ♦ September 2005 Vol. 56 No. 911111122 TTaabbllee 33 Mean duration of restraint episodes in an adolescent continuing care inpatient service, by type of restraint Fiscal year 2000 Fiscal year 2003 Type of restraint Mean SD Mean SD Medication only — — — — Physical 0 — .25 .08 Mechanical 2.01 .375 .87 .277 Mechanical or physical with medication 2.01 .375 .85 .272 TTaabbllee 44 Staff time spent in restraint and nonrestraint activities in an adolescent continuing care inpatient service Fiscal year 2000 Fiscal year 2003 Variable N % N % Total staff hours available 105,984 105,984 Staff hours spent in restraint activities 24,690 23 4,285 4 Staff hours spent in nonrestraint activities 81,294 77 101,699 96 leb.qxd 8/22/2005 9:41 AM Page 1112 14 percent fewer adolescents were rehospitalized in FY 2003 (five of 35 adolescents) than in FY 2002 (three of 18 adolescents). Other positive adolescent outcomes were suggested when FY 2000 and FY 2003 data were compared. Aggregate injury data indicated a 60 percent re- duction in restraint-related injuries (from 15 to six injuries). No major in- juries were reported. In addition, the average number of restraints for the cohort of adolescents who were re- strained the most decreased 91 per- cent (from 83 to seven episodes). The average length of stay for this group also decreased by 58 percent (from 556 to 229 days). Impact on staff The initiative was associated with a shift in staff focus. The reduction in the use of restraint decreased the amount of time that staff devoted to restraint activities. In FY 2000, staff spent 23 percent of their work time (24,690 hours) engaged in restraint- related tasks. In FY 2003, staff spent four percent of their time in such ac- tivities (4,285 hours). The initiative was associated with a 19 percent redi- rection of staff time (20,405 hours) into nonrestraint activities (Table 4). Increased staff availability may have contributed to greater adolescent participation in programming (a 15 percent increase, from 58 to 67 ado- lescents), family and collateral partic- ipation in treatment planning (10 per- cent, from 61 to 67 adolescents), and postdischarge follow-up (45 percent, from 29 to 42 adolescents). The change in focus may have also contributed to positive staffing out- comes. A comparison of FY 2000 and FY 2003 data indicated that staff turnover decreased by 80 percent (from 45 to nine staff changes). The use of sick time decreased by 53 per- cent (from 4,825 to 2,289 days). In- juries to staff decreased modestly by seven percent (from 29 to 27 in- juries). However, the severity of staff injuries lessened, resulting in a 98 percent reduction in the number of workdays missed because of restraint- related injury (from 226 to five days). The use of replacement staff de- creased by 78 percent (from 83 to 18 shifts). The cost to fill shifts vacated because restraint-related injury de- creased by 77 percent (from $13,007 to $2,916). Less demand for replace- ment staff reduced the need to adver- tise vacant positions, resulting in low- er advertising costs (65 percent, from $9,800 to $3,400). A comparison of FY 2000 and FY 2003 data indicated a reduction in workers’ compensation costs. The number of workers’ compensation claims decreased by 29 percent (from 31 to 22 claims). However, the amount of compensation paid decreased by 98 percent (from $29,355 to $597), and the amount of medical costs paid decreased by 98 percent (from $6,798 to $157). Decreased staff-related costs were not attributable to staff reduction or change in staffing pattern. Preventing the use of restraint required staff to be in the milieu, anticipate crises, and be available to adolescents before a prob- lem erupted. To operate a more proac- tive program, staff resources became more effective but were not reduced. Impact on the facility The preinitiative cost of restraint was considerable ($1,446,740) because of the high use of restraint. The cost was staggering when measured against the service’s annual budget ($3,998,741), representing a substantial amount of staff time engaged in nontherapeutic activities, which is contrary to the pur- pose of care. No new fiscal resources were pro- vided to Massachusetts child and ado- lescent facilities through the initia- tive. However, the inpatient service modified existing resources to sup- port the effort. For example, staff training was refocused to emphasize building relationships, understanding each adolescent’s needs, precrisis in- tervention planning, and deescalation skill development. Alternative inter- ventions were created by using exist- ing program resources. The role of occupational therapy was expanded. Sensory modulation and integration as well as pet therapy interventions were integrated into crisis prevention plans and activities for adolescents to practice and use as needed. The serv- ice also changed its debriefing prac- tice and added administrative de- briefing after each restraint. Although additional staff supervision was not used, the focus shifted to a preven- tion orientation and how to intervene at the earliest signs of distress. One area of possible increased cost was physical plant repair. The explicit repair cost was not quantifiable and was managed within the operating budget. However, the number of inci- dents of property destruction in- creased by 13 percent (from 86 inci- dents in FY 2000 to 97 incidents in FY 2003), and the number of episodes of purposeful property de- struction by adolescents increased by 17 percent (from 30 to 35 episodes) during this period. As staff developed greater skill in using alternatives to restraint, they also developed toler- ance for minor environmental dam- age. Rather than restraining adoles- cents, staff later enlisted their help with repairing and making restitution to the inpatient community. Discussion and conclusions Several limitations to this study re- strict interpretation and application of the findings. The nonrandomized, nonexperimental, pre-post study de- sign raises the possibility that the re- sults were affected by confounding or extraneous variables or secular trends. Generalizability of the study’s findings to other settings is limited by the small sample, the estimated time per restraint activity, and the limited staffing and outcome data. The lack of comparative data was another limitation. Early efforts to select an adolescent-serving acute care hospital to compare with the in- patient service in this study suggest- ed that little comparable information of this type was routinely or uni- formly collected or available at other facilities. Questions remain that further chal- lenge the interpretation of this ef- fort—for example, are statistically sig- nificant findings clinically significant? Adolescents’ postinitiative discharge functional assessment (GAF) scores were significantly higher and suggest- ed true clinical improvement. How- ever, the most important arbiter of clinical significance is the perspective of the adolescents. Unfortunately, their voice was not a part of the study, which is a limitation of this effort and PSYCHIATRIC SERVICES ♦ http://ps.psychiatryonline.org ♦ September 2005 Vol. 56 No. 9 11111133 leb.qxd 8/22/2005 9:41 AM Page 1113 of all service-related research that at- tempts to interpret or evaluate mean- ing absent the essential perspective of those we serve. The intent of the initiative was to reduce or eliminate the use of re- straint. In addition to reduction in re- straint, other positive changes result- ed that could not be attributed to al- teration of environmental, fiscal, or administrative practices. The number of injuries to adolescents and staff was reduced, and sick time, workers’ compensation, and replacement costs decreased substantially. Recidivism also decreased, and adolescent func- tioning measured at discharge signifi- cantly improved. We expected that the decrease in the number of restraints would drive the reduction in restraint costs. How- ever, the improved adolescent out- comes, positive impact on staff, and decreased staff-related costs were not anticipated. Calculating the econom- ics of the restraint process and seque- lae of restraint reduction also illumi- nated the negative consequences of restraint: adverse treatment and staffing effects and redirected staff time. The value-added component of restraint reduction or elimination was the improvement in these dimensions and a return to the mission of inpa- tient care: treatment. Seclusion and restraint are high- risk, violent interventions whose im- pact extends beyond the immediate task of attempting to manage a volatile situation. Additional study can occur only if leaders from federal agencies, state mental health authori- ties, and psychiatric facilities contin- ue to work toward elimination of seclusion and restraint. National ef- forts implemented by SAMHSA Ad- ministrator Charles Curie and by NASMHPD’s leadership, Robert Glover and Kevin Huckshorn, are critical to advancing this direction. Additional study is needed to assess the impact of reduction and elimina- tion initiatives, particularly the long- term staffing and therapeutic effects, the fiscal implications, and the rela- tionship between redirected staff time and restraint reduction. ♦ References 1. Weiss EM: Deadly restraint: a nationwide pattern of death. The Hartford Courant, Oct 11–15, 1998 2. Children’s Health Act. PL 106-310, (codi- fied at 42 USC 201), 2000 3. National Executive Training Institute Cur- riculum for the Reduction of Seclusion and Restraint. Alexandria, Va, National Associa- tion of State Mental Health Program Di- rectors, National Technical Assistance Cen- ter for State Mental Health Planning, 2003 4. A National Call to Action: Eliminating the Use of Seclusion and Restraint. 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