Reducing Restraint Use with De-Escalation Training in the Emergency Department
Jennifer Scott, BSN, RN; Jillian Nickerson, MSN, RN, CPEN; Lynn Pittsnger, MSN, CPNP, PMHS, CENP, CPHQ
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Session J presented Saturday, September 16, 2017
Purpose: In addition to the annual number of emergency room visits progressively rising over the last couple decades, there has also been an annual increase in patients presenting to emergency rooms for acute care of psychiatric and mental health crises. Care for this patient population comes with the possibility of restraint utilization to prevent patient harm from themselves or to others. Physical restraint use is associated with dangerous risks for the patient and staff, including injury and even the risk of death.
Design: A collaborative quality initiative was begun in 2013/2014 whereby the department's nursing leadership, registered nurses, certified nursing assistants, unit assistants, child life specialists, and family assistants were required to attend a two-day behavioral safety training course to obtain de-escalation training, and subsequently maintain their annual recertification. Additionally, corresponding de-escalation policies were implemented within the department, and the triage process for these patients was updated. Measurements of restraint use and elopement rates were then taken from before and after the applied intervention, and have subsequently been tracked by the department.
Setting: The aforementioned training and protocols were implemented in a pediatric, level 1 trauma center at a teaching hospital in an urban environment.
Participants/Subjects: All ED staff participated in this project. Subjects include all patients within the department who are documented as being restrained or eloping, secondary to a chief complaint or diagnosis of/or pertaining to psychiatric, behavioral, or mental health needs.
Methods: First, all of the department's staff completed a two-day evidence-based, safety and de-escalation training course, and have since been required to maintain annual recertification. Accompanying this education, the need for an updated triage process for behavioral health and psychiatric patients presenting to the ED and recognized and implemented, as it was identified as a source of escalation for this patient population. Furthermore, implementation of standardized de-escalation policies were created for the department to standardize and reinforce the education. Data collection has been annually captured May through February, starting in 2013, with a baseline data captured from pre-intervention year of 2012. No patient identifiers are utilized.
Results/Outcomes: Education, policy and procedure interventions created a 40% decrease in restraint use within the department between 2012 (pre-intervention year), and 2014 (all interventions in place). In subsequent years, despite a significant increase in annual patient volume, our department has been able to continue to demonstrate an annual decrease in restraint use, and also a decrease in patient elopement, as documented via our hospital’s safety event reporting system. Our department has maintained 100% educational compliance among staff.
Implications: These findings support the premise that when staff members are given evidence-based tools and education to assist them in their care of patients with potentially challenging or dangerous behaviors in the acute care setting, staff are more likely to maintain a safe environment with the use of de-escalation techniques and are more likely to advocate for the respect of patient rights. Ultimately, restraint use is often avoided, resulting in safer patient and staff outcomes.
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