Behavioral crisis management is the most high-risk process in the psychiatric care of children and adolescents (Paccione-Dyszlewski, et al, 2012), particularly regarding the use of restraint and seclusion. Paccione-Dyszlewski and colleagues reported in 2012 that 50 to 150 patient deaths occurred each year in the United States due to restraint and seclusion procedures, and a more recent study found that 79 restraint-related fatalities occurred for children 18 years and younger between 1993-2018 (Nunno, et al, 2021). In addition, the use of restraint and seclusion has been linked to adverse outcomes such as increasing patient aggression and injuries to patients and staff. While restraint and seclusion procedures can effectively and therapeutically manage crisis behaviors, it is imperative to develop systems for ensuring patient and staff safety and restrict the use of these procedures until absolutely necessary.
This was recognized by Bradley Hospital in East Providence, RI in the early 2000s. Bradley Hospital is a neuropsychiatric hospital serving 500 children and adolescents on a given day and acts as a teaching hospital for Brown University. In 2008, Bradley Hospital recognized a need to examine its crisis intervention model and improve its crisis management program. The goal was to reduce patient and staff injuries during crisis events, reduce the frequency of restraint and seclusion incidents, and increase patient satisfaction.
The Challenge: Rethinking Crisis Management
A Crisis Prevention & Intervention Work Group was established to examine current approaches to crisis intervention and recommend improvements to the program. The group was tasked with examining the root causes of shortcomings in crisis management and developing a project plan including goals, recommendations, and implementation. The work group selected QBS’s Safety-Care training as its crisis management program and worked with QBS to develop a training curriculum for its specific pediatric population.
The Process: Key Implementation Strategies
The hospital didn’t just adopt a new program—they created a comprehensive cultural shift.
Once the crisis prevention training curriculum was selected, Bradley Hospital added a statement on their philosophy and position on behavioral management and confirmed the training’s alignment with regulatory compliance. Two documents, De-Escalation & Crisis Management and the SafetyCare Behavioral Safety Management program were cornerstones to the hospital philosophy and its commitment to least restrictive approaches to treatment.
Program proficiency was then recommended for various staff roles across the hospital. Several staff were identified to become trainers and all staff who provided direct care to patients were required to complete the full training and annual recertification in the course. Staff with indirect support roles were trained in incident prevention and staff safety, with the goal of reducing risk to staff during crisis events. Additionally, the hospital revised job descriptions for direct care staff to include “fitness for duty requirements” to address physical and psychological demands of the role (i.e. ability to lift, bend, grasp and the ability to remain calm in crisis situations).
Furthermore, mechanical interventions (i.e. restraint beds and chairs) were eliminated from practice and transport of patients was restricted to extreme circumstances and in accordance with Rhode Island legislation. A Crisis Management Subcommittee was formed to address policies, procedures, and protocols as well as issues regarding training, personnel, and regulatory concerns.
Staff training occurred over two months and a total of 734 staff were trained in the new program. Coaching teams were formed to provide ongoing support, enforce skill acquisition, and ensure compliance across the program. Staff evaluated the training upon completion, with ratings of 97% for clarity and organization of the presentation and 96% for effectiveness of trainers and perceived knowledge gained, respectively.
The Results: System-wide Improvement
Data were collected and analyzed pre- and post-implementation on the following:
- Number of patient hours in restraint and seclusion (R&S)
- Frequency of patient injury resulting from restraint or seclusion procedures
- Ratio of staff hours lost to staff injury when implementing R&S to staff hours worked was assessed
- Patient satisfaction (using select items from the Press-Ganey Inpatient Behavioral Health Report)
- Frequency of parent complaints concerning child restraint or seclusion
# of Patient Hours in R&S
Data were available for 21 months prior to the project and 24 months following implementation. Patient hours in restraint and seclusion fell 28.8%, from 1.11 hours to 0.91 at the 1-year follow up. A second follow-up 2 years post-project indicated a further reduction to 0.79 hours.
Frequency of Patient Injury
Data on patient injuries was also available for 21 months prior and 24 months following the project. Patient injuries dropped by 78% at the 1-year mark, from 1 injury per 180 interventions pre-project to 1 in 803 one-year post-project.
Staff Injury Data
Staff injury data was available for 12 months prior to implementation and 24 months following. Pre-project, the ratio of staff hours lost to staff hours worked was 12,528 : 1,049,896, falling to 13,008 : 2,167,113, a 49.5% reduction in work lost. Bradley Hospital estimates that the reduction correlates to approximately $470,000 in savings across the 2-year post-project period.
Patient Satisfaction
Patient satisfaction data were recorded for 1 year prior and 2 years following the project. Patient satisfaction scores for safety felt on the unit improved from 87.4 pre-project to 90.8 following implementation.
Parental Complaints
Parent complaints were documented and available for 10 years, with 2 years following implementation. Complaints received pre-project averaged 4 per year and post-project there were 0 complaints made by parents regarding restraint and seclusion.
The Human Element: Beyond the Data
Perhaps most importantly, the program shifted organizational culture. Staff moved from viewing physical management as a primary skill to prioritizing de-escalation and individualized patient care. Secondly, Bradley Hospital was able to successfully implement a hospital-wide crisis management improvement project, from task force development, curriculum vetting and customization, to training and implementation for over 700 employees in under two years, proving that systemwide change is possible for large organizations without costing significant time resources. Finally, all goals for reduced use of restrictive practices, injuries to patients and staff, and patient and caregiver satisfaction showed favorable and significant results.
This initiative demonstrates that with thoughtful design, commitment, and a focus on human dignity, healthcare institutions can transform crisis management from a potentially traumatic experience to a therapeutic intervention.
Safety-Care is proven effective across many settings, including schools, clinics, residential services, and hospitals. Safety-Care is designed to be effective with all ages and a variety of diagnoses. Learn more about how our training curriculum can reduce behavioral incidents and injuries through an emphasis on prevention and de-escalation.
Resources
Nunno, M.A., McCabe, L.A., Izzo, C.V., Smith, E.G., Sellers, D.E., & Holden, M.J. (2021). A 26-year study of restraint fatalities among children and adolescents in the United States: a failure of organizational structures and processes. Child & Youth Care Forum, 51, 661-680.
Paccione-Dyszlewski, M., Conelea, C.A., Heisler, W.C., Vilardi, J.C., & Sachs, H.T. (2012). A crisis management quality improvement initiative in a children’s psychiatric hospital: design, implementation, and outcome. Journal of Psychiatric Practice, 18, 304-311.