February 29, 2024
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Key takeaways:
- Care team “huddles” led to a reduction in physical restraint events at a children’s hospital.
- Restraint events declined from 14 to 4.1 per 100 days over the study period.
Coordinated “huddles” with care teams reduced physical restraint events in one children’s hospital’s medical behavioral health unit, according to study findings published in Pediatrics.
One of the researchers said the study was prompted by a prior investigation conducted during his residency, in which he worked with children who were hospitalized for mental and behavioral health conditions.
“When I was a resident, one of the things that I experienced was getting called to the bedside when a child who was hospitalized had become agitated,” Evan M. Dalton, MD, MSHP, now a pediatric hospitalist at Texas Children’s Hospital in Houston, told Healio.
“For the first time, I saw children being placed in physical restraints, and it certainly was an uncomfortable situation [to witness] as a third party but also as a pediatrician. It led us to ask, Is this kind of process of physically restraining children something that we can safely avoid, given the trauma that the patients experience and the staff experience in the restraint process?”
Dalton’s experiences led to a quality improvement study published in Pediatrics in 2021, which found that a team-based improvement methodology was associated with a sustained reduction in physical restraint use on children admitted for behavioral health conditions to a children’s hospital. As he continued on to a fellowship, Dalton said he was unsure if he wanted to continue this research, until the AAP and the American Academy of Child and Adolescent Psychiatrists declared a crisis in mental health.
“The summer of 2021 was when we kind of noticed this rise in restraint use in the medical behavioral unit (MBU) that had been really percolating for months previously,” Dalton said. “We were seeing a lot of patients that were agitated, and so I really felt like [conducting] similar work to safely reduce restraints was needed at our hospital and particularly in the MBU, which is where we really focused our study.”
Dalton and colleagues began by examining the root causes of why children were becoming agitated and why staff were using restraints, which they found resulted from some inconsistencies in how to respond to patient agitation.
“It took us about 6 months to go through this process of understanding the kind of underlying reasons for restraint use and designing different interventions to try to address this rising issue in the hospital,” Dalton said.
After 6 months, the team developed a de-escalation protocol that centered on a scoring system for staff to assess a patient’s agitation. Based on the score, staffers would use one of three color zones — either green, yellow or red — to triage and respond to the situation, but 1 month in, the researchers did not see any change. Dalton and colleagues then spoke to the nurses and physicians of the unit.
“What they told us was that they felt like they understood the patient’s level of agitation, but they had a difficult time tailoring the plan to the need of the patient, and so they would get to a point where they felt like they had no other option but to use the restraints,” Dalton said. “That’s when we kind of changed course, so to speak, and came up with this idea of huddles.”
The “huddles” concept was initiated in February 2022, and involved bedside teams for patients in the MBU huddling with the unit’s board-certified behavior analysts and pediatrician each morning to discuss the patient’s behavior and de-escalation plans. The researchers also created a huddle script to standardize this intervention.
Dalton and colleagues studied a cohort of 527 consecutive patients hospitalized in the MBU between January 2021 and January 2023. In that time, a baseline mean of 14 weekly physical restraint events per 100 MBU patient-days in 2021 decreased to 10 per 100 patient-days during the intervention period from January through July 2022, and to a low of 4.1 in August, which was sustained through December.
“I still think that there is a great perception that restraint is safe or safer than other things,” Dalton said. “We’ve now shown that it is possible to reduce restraint use without increasing staff injuries.”
References:
Dalton EM, et al. Pediatrics. 2021;doi:10.1542/peds.2020-003939.
Dalton EM, et al. Pediatrics. 2024;doi:10.1542/peds.2023-062747.
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