developing a multidisciplinary care bundle to reduce the use of behavioral restraints francis x....
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Developing a Multidisciplinary Care Bundle to
Reduce the Use of Behavioral Restraints
Francis X. Holt, PhD, RN, BSN
Presenter Disclosures
The following personal financial relationships with commercial interests relevant to this presentation
existed during the past 12 months:
Francis X. Holt. PhD, RN
No relations to disclose.
Background: In the first 10 months of 2013, this unit typically exceeded state norms for restraints in:
Events per 1000 pt days Patients Restrained per 1000
pt days Average Hours per event Total Hours per 1000 pt days
Why a “Care Bundle?”
• These bundled interventions are evidence-based practices that, when implemented together, provide better outcomes than when used individually.
• Review of literature suggests that nursing care bundles have not been developed for psychiatric nursing.
Evidence based practices to be included
in the Psychiatric Nursing Care Bundle
Use of Data to Inform/Drive Practice
Use of Individual Safety Tool
Trauma Informed CareUse of Sensory Grounding
Techniques (Sensory Based Treatment: SBT)
Enhanced Patient Engagement
Chart Review/Audit
for Mock Survey 9/13/13
Unit restraint rates compare unfavorably with
statewide averages
Conduct Safety Tool Audit shows
7/15 (47%) Safety Tool completion rate. (10/23/13)
Educate Staff regarding Safety Tool requirements and
techniques, distribute staff memo (10/24/13)
Continuous Quality Improvement for Restraint Reduction
Step One
Use of Data to Inform/Drive Care: Restraint and Lack of Individual Crisis Prevention Plan (Safety Tool)
April May June July August September
7
8
6
5
1
3
7 7
4 4
1
2
RestraintsRestraints without Safety Tool Completed
0123456789
RestraintsRestraints with Safety Tool Com-pleted
September 2013: Review of data shows apparent relationship between prevalence of restraints and restraints without Safety Tools completed
47.00
100.00
Perc
en
tag
e o
f S
afe
ty
Tools
com
ple
ted
Change in Percentage of Individual Safety Tools
Completed
October 2013: Decision is made that Safety Tool Completion is a first step towards restraint reduction and PDSA model will be used to guide improvement. Asking staff reveals many are unaware of state regulations regarding Safety Tool Completion, even when a patient is unwilling or unable to participate in the process. A memo with excerpts from the regulations is circulated to all staff and posted in staff lounge. Safety Tools reviewed in monthly staff meeting.
December 2013: Chart audit shows progress, but improvement still needed. Decision is made to place copies of Individual Safety Tools in newly created binders for each Multi-Disciplinary Treatment (MDT) Team; with review expected at each MDT meeting. Safety Tools and PDSA steps in this process so far reviewed in monthly staff meeting.
104 CMR: DEPARTMENT OF MENTAL HEALTH 27.12(3) Individual Crisis Prevention Planning. A facility shall develop an individual crisis prevention plan for each patient. (a) Definition. An individual crisis prevention plan is an age and developmentally appropriate, patient-specific plan that identifies triggers that may signal or lead to agitation or distress in the patient and strategies to help the patient and staff intervene with de-escalation techniques to reduce such agitation and distress and avoid the use of restraint and seclusion. (b) Development of the Individual Crisis Prevention Plan. As soon as possible after ad-mission, facility staff shall collaborate with each patient and his or her legally authorized representative, if any, and, where appropriate, with other sources, such as family members, caregivers, and the patient's health care proxy, to complete and implement an individual crisis prevention plan. If the patient refuses or is unable to participate in the initial development of the plan, staff shall develop a plan using available information and shall make continuing efforts to include the patient's participation in review and revision of the plan. Relevant clinical data, including medical risk factors, physical, learning, or cognitive disability, and the patient's history of trauma shall inform the development of the plan. The plan shall include, at a minimum, the following elements:
Safety
Tools:
Gold Team
January 2014: Chart audit reveal all charts on unit have completed Safety Tools. Plan is to continue to monitor compliance and move on to adding/improving other components of an integrated and comprehensive Behavioral Restraint Reduction Strategy
Internal Education/Public Relations via Academic Poster Highlighting Interim Gains
Patient Time Mapperiod M Tu W Th F
total time
07:30/8:00 Breakfast 30 min
08:00/09:00 Free Time 60 min
0900/0930Community Meeting 30 min
0930/1100 Free Time (2 pts at a time to respective tx teams)
80 min
10:30/11:15 Free time 45 min
11:15/12:00Coping skills
Life skillsSymptom
Mgmt
Commun-ication Skills
Stress Mgmt
45 min
12:00/12:15 Free time 15 min
Growing Clinical Programming: Analysis/Data Development BEFORE
Three hours and twenty minutes of free time every morning
Growing Clinical Programming: Analysis/Data Development AFTER
Forty minutes of free time every morning
Growing Clinical Programming to Increase Patient Engagement
The beneficial cycle of increasing staff time spent with patients (Scanlon, 2009)
Increasing interaction between staff and patients is generally associated with lower rates of seclusions or restraint (Donat, 2003; Huckshorn, 2004; Witte, 2008)Reductions of adverse events
such as seclusion and restraint increases the amount of time that staff have to engage with patients in a more productive way, which may lead to better outcomes (Lebel & Goldstein, 2005)
Groups Attendance as percentage of census and Mechanical
RestraintsMarch – July 2014
AM Mtg PM Mtg Build Safety Tool Open OT restraints0
10
20
30
40
50
60
70
March April May June July
Outcomes:
Patient Complaints
January – September 2013
19 Complaints
January – September 2014
12 Complaints
Outcomes:
Sensory Cart (SBT)training starts August 25, 2014. Continue to monitor Safety Tool Completion Rate, continue emphasis on “Every Patient, Every Shift, Every Day” for Inter-Shift review of Safety Tools, TV’s off during groups, additional exercise group daily
• Safety Tool completion rate of 100% Continues Dec 2013 – August 2014• Several periods of 15 and 20 days and one of 65 days w/o restraint• Data show 6 patients accounting for 16 restraint episodes in Apr –July, with one patient accounting for 8 episodes. • Group attendance increased by an average of 62%
Feedback to staff on success, celebrate!
Initiate chart review to seek any commonalities
among frequently restrained patients. Do
deeper analysis on other factors (day of the week,
e.g.)
Plan for Sensory Cart Training for all unit clinical staff, explore training for an aromatherapy component of sensory grounding, environmental and
programming changes to encourage attendance at group. Plan measure to capture Individual Active Treatment.
Continuous Quality Improvement for Mechanical Restraint Reduction o
Step Five
→
From Boardroom to Group Room
• Positive outcomes lead to presentation to Board ↙
• Board has useful input re: Safety Tool ↙
• Board-suggested changes incorporated into practice (Boardroom to Group Room)↙
• Board engagement increases potential for Board support of Next Steps
Next Steps
• Continue PDSA cycle
Leadership Lesson:
A shared structure for change makes for more stakeholder buy-in and team cohesion
• Enhance Trauma Informed Care training
Next Steps
Next Steps• Collect and Analyze Sensory Based
Treatment Data
Leadership Lesson:
Providing staff with skills, equipment and data needed to improve care enhances both buy-in to new processes and staff satisfaction
• Expand SBT to include aromatherapy
Next Steps
• Tease out common factors shared by those patients still being restrained
Next Steps
Next Steps
• Involve physicians in ED and on unit in assessing and developing medication
protocols
The Business Case for Restraint Reduction• Decreased:
• sick time associated with staff injury
• staff turnover• staff replacement• 1:1 sitter costs • patient injury• workers compensation claims• Litigation• time spent in RCA’s and other
risk mitigation• Increased• Patient Engagement & Safety• “Likelihood to Recommend”
score• Staff moraleVision: To be a safe and effective provider of inpatient psychiatric
services
Next Steps
• Start Writing!
Thank you!