1. Developing a Multidisciplinary Care Bundle to Reduce the Use of Behavioral Restraints Francis X. Holt, PhD, RN, BSN

2. 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.

3. 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

4. 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.

5. 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 Care Use of Sensory Grounding Techniques (Sensory Based Treatment: SBT) Enhanced Patient Engagement

6. 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

7. Use of Data to Inform/Drive Care: Restraint and Lack of Individual Crisis Prevention Plan (Safety Tool)

8. September 2013: Review of data shows apparent relationship between prevalence of restraints and restraints without Safety Tools completed Percentage of Safety Tools completed 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

9. Patient Time Map periodMTuWThF total time 07:30/8:00Breakfast30 min 08:00/09:00 Free Time 60 min 0900/0930 Community Meeting30 min 0930/1100 Free Time (2 pts at a time to respective tx teams) 80 min 10:30/11:15 Free time 45 min 11:15/12:00 Coping skills Life skillsSymptom Mgmt Commun- ication Skills Stress Mgmt 45 min 12:00/12:15Free time15 min Growing Clinical Programming: Analysis/Data Development BEFORE Three hours and twenty minutes of free time every morning

10. Growing Clinical Programming: Analysis/Data Development AFTER Forty minutes of free time every morning

11. 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)

12. Groups Attendance as percentage of census and Mechanical Restraints March – July 2014 Outcomes:

13. Patient Complaints January – September 201319 Complaints January – September 201412 Complaints Outcomes:

14. 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

15. → 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

16. Next Steps Continue PDSA cycle Leadership Lesson: A shared structure for change makes for more stakeholder buy-in and team cohesion

17. Enhance Trauma Informed Care training Next Steps

18. 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

19. Expand SBT to include aromatherapy Next Steps

20. Tease out common factors shared by those patients still being restrained Next Steps

21. Involve physicians in ED and on unit in assessing and developing medication protocols

22. 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 morale Vision: To be a safe and effective provider of inpatient psychiatric services

23. Next Steps Start Writing !

24. Thank you! fxholt@gmail.com