Eliminating Restraints on a High Acuity Inpatient Behavioral Health Unit Melinda Elliott MSN, RN, NE BC The speaker has no conflicts of interest to disclose. OBJECTIVES Identify the techniques Grady s Behavioral Health Department used to decrease and eventually eliminate the use of mechanical restraints on an inpatient behavioral health unit. Explain the relationship of a therapeutic restraintfree environment and patient improvement. Develop a plan to involve front line staff in the development of a restraint free environment. Elliott 1
HISTORY Restraints have been used to prevent harm to staff, other patients and self harming behavior January 2000, The Joint Commission revised its standards around use of restraints and actively sought to reduce their use for the protection and safety of individuals involved in restraint situations. National average in 2014 was 0.39 hours per thousand patient hours THERE HAS TO BE A BETTER WAY Traumatizing Demoralizing Staff injuries Patient Injuries Ruins a Trusting Relationship Set Back in Therapy 50 to 150 Deaths per Year Increased Healthcare Costs RESTRAINTS ARE NOT THERAPEUTIC A TREND WAS NOTICED 2011: 274:15 hours of mechanical restraints 2012: 163:45 hours of mechanical restraints 2013: 63:15 hours of mechanical restraints 2014: 37:30 hours of mechanical restraints 2015: 17:15 hours of mechanical restraints Decision made January 2015 to work toward eliminating restraints on the Inpatient unit LAST MECHANICAL RESTRAINT WAS APRIL 13, 2015 Elliott 2
WHAT DID WE DO? 1. Changed the culture 2. Formed a workgroup of frontline staff 3. Changed the Policy 4. Increased therapeutic group opportunities to engage individual 5. Removed restraints from room and placed in storage room 6. Developed and implemented PACE CULTURE CHANGE Restraints as a last resort Staff buy in Training, training, training Patient focused care WORKGROUP February 2015 first workgroup meeting Members: Psychiatrists, Nurses, Mental Health Technicians, Licensed Clinicians, Performance Improvement Team Implemented Changes: Orientation brochure for the patients Reviewed each debriefing form Talked to staff about what could have been done differently to prevent a restraint Used a red sticker on the observation forms to alert all staff to a patient who is possibly agitated, angry, or has a history of restraints Elliott 3
CHANGE IN THE POLICY Restraint orders from 4 hours to 2 hours Code Alvin Versus Code Green At 1 hour the Clinical Manager/Charge Nurse must assess the patient GROUP SCHEDULE MORE THAN 30 DIFFERENT GROUPS OFFERED EVERYDAY/ 12 HOURS A DAY DECREASE IN ESCALATION/ DECREASE IN RESTRAINTS MUSIC/MOVEMENT MEDICATION EDUCATION GROUNDING SKILLS MOVIE MANIA LIFE SKILLS SYMPTOM MANAGEMENT COMMUNITY CHECK IN INTRO TO DBT SEEKING SAFETY WOMEN S GROUP SKILL BUILDING SUBSTANCE ABUSE BIPOLAR/SCHIZOPHRENIA DISCHARGE READINESS ARTS AND CRAFTS PATIENT SATISFACTION COPING SKILLS FOR LIFE MINDFULNESS SPIRITUALITY HEALTHY LIFESTYLE KAROKE INTRO TO GRADY AFTERCARE ANGER MANAGEMENT HEALTHY RELATIONSHIPS PATIENT S RIGHTS SUICIDE PREVENTION COPING SKILLS PACE P Pause A Assess C Communicate E Engage Elliott 4
WHAT IS PACE? HOW IS IT DIFFERENT? PACE is a training we developed to help teach staff to focus on recovery and de escalation skills rather than restraints. Modules taught in PACE: Culture Change Recovery and Resiliency Effective Communication Managing Aggression and De escalation Techniques Physical Intervention Techniques Preventing Seclusion and Restraint STAFF FEEDBACK During the PACE training staff are given time to provide feedback on: Environment physical surroundings, policies and rules, resources, unit culture, attitudes, cultural norms Relationships direct care staff relationships to peers, administration and consumers Leadership How does leadership foster growth, learning and improvement GRADY BH INPATIENT RESULTS 15 10 5 0 2013 2014 2015 2016 Elliott 5
EARLY DETECTION Any change in normal behavior Pacing Clenched fists Talking rapidly Cursing Rapid breathing PREVENTING ESCALATION 1. Can I avoid criticizing and finding fault with the angry person? 2. Can I avoid being judgmental? 3. Can I keep myself removed from the conflict? 4. Can I try to see the situation from the angry person s point of view or understand the need s/he is trying to satisfy? 5. Can I remember that my job is to keep the peace and protect the client and staff? 6. What are my patient s preferences for de escalation (i.e. music, talking 1:1, walking, coloring) and is this documented on the chart? LEARNING AND GROWING Debriefing, Debriefing, Debriefing Review videos with staff involved in a restraint episode Have staff identify what could have been done differently Allow a safe environment where staff can talk freely and learn from the incident Elliott 6
STAFF INVOLVEMENT STAFF INVOLVEMENT NEW IDEAS CHANGE IN THE CULTURE GROUNDWORK Track monthly restraint numbers and share with staff Consistent debriefings for staff and patients Focus on de escalation Listen to ideas from frontline staff Celebrate ALL Wins 10 COMMANDMENTS OF DE ESCALATION 1. You shall be respectful (personal space, tone, attitude) 2. You shall not be provocative 3. You shall pay attention to early warning signs 4. You shall be concise and gain understanding 5. You shall identify wants and feelings 6. You shall listen 7. You shall agree or agree to disagree 8. You shall be fair but firm and offer choices 9. You shall provide a safe, therapeutic place to heal. 10. You shall debrief the patient and staff Elliott 7
REFERENCES APNA. (April 2014). APNA position on the use of seclusion and restraint. Retrieved July 13, 2016 from https://www.apna.org/i4a/pages/index.ctm?pageid=3730 Ferguson, D. (March 2016). Patient restraints overuse: expose reveals harmful practice at North Carolina hospital. Retrieved July 13, 2016 from https://www.fiercehealthcare.com/healthcare/patient restraint oversuse expose reveals harmfulpractice at north carolina hospital. Gifford, M.L., Anderson, J.E. (2010). Barriers and motivating factors in reporting incidents of assualt in mental health care. Journal of the American Psychiatric Nurses Association. 16(5). Pp. 288 298. Grizzle, T. (February, 2015). PACE Training. Training presented at Grady Memorial Hospital, Atlanta Georgia. Knox, D.K., Holloman, G.H. (February 2012). 13(1). Use and avoidance of seclusion and restraint: Consensus statement of the American Association for Emergency Psychiatry project BETA seclusion and restraint workshop. Retrieved from https://www.ncbi.nlm.gov/pmc/articles/pmc3298214. Lawlar, J. (June 13, 2014). Restraint, seclusion rates of Maine psych patients run high. Retrieved July 13, 2016 from https://www.pressherald.com/2014/06/13/restraint and seclusion of psychpatients run high in maine hospitals. Mental Health America. (December 5, 2015). Position statement 24: Seclusion and restraints. Retrieved July 13, 2016 from https://www.mentalhealthamerica.net/positions/seclusion restraints. Elliott 8