Health care providers have been working to reduce the use of restraint for years, and risk managers have looked to the possibility of fewer injuries and lawsuits as a result. A behavioral health care center in Mississippi is proving that a concentrated effort to reduce restraint can yield great improvements not only for the patients but also for the bottom line of the health care facility.
Millcreek Behavioral Health Services in Magee has reduced its use of restraints by more than 99%, from 1,025 episodes in 1999 to only four episodes in 2003. The organization credits this clinical and cultural change to increased physician and leadership involvement and a treatment planning process that facilitates a response to each child’s unique needs. Millcreek’s efforts made it a 2003 winner of the Ernest A. Codman Award from the Joint Commission on Accreditation of Healthcare Organizations.
Restraint use has been almost eliminated at Millcreek, says Margaret F. Tedford, MEd, administrator and CEO. Mechanical restraints are a thing of the past and other restraint is used sparingly. The facility removed all its restraint beds from the premises. In 1999, Tedford had just joined Millcreek, a psychiatric residential treatment facility and an intermediate care facility for the mentally retarded that provides services to approximately 300 children each year through its residential programs, group homes, community-based programs, and special education schools. Millcreek Behavioral Health Services is owned and operated by Youth and Family-Centered Services, an Austin, TX-based corporation that provides health care and educational services exclusively for children and adolescents.
In 1999, Youth and Family-Centered Services mandated a systemwide culture change to reduce the use of restraint. As a result, a performance improvement initiative was started with the Millcreek facility and reduction of restraint was deemed a resource priority. "When you reduce restraint and seclusion, you totally change the environment you’re working in. You change the attitude toward the children," she says. "You have less injury to staff and a less stressful working environment."
To get the ball rolling, the leaders at Millcreek gathered data to measure performance related to the use of "special procedures," such a physical restraints and seclusion, and staffing effectiveness. After studying the data, the administration determined that the current method of crisis intervention was inadequate and a new plan was needed. Not only was the old approach harmful to the children, but it also exposed Millcreek to great liability, Tedford says. "We were motivated, partly, by our fears about risk," she says. "Every restraint increases your risk."
The new plan focused on enhanced communication of treatment needs through the interdisciplinary treatment planning process. Policies and procedures were changed across the board and were revised as the effort went on and the viability of the new strategies was tested. "We always reviewed our experiences not only to see what went right, but what went wrong," Tedford says. "We talked to staff and looked for what could have been done better, what might have prevented the use of restraint in this case."
Millcreek adopted a new model for responding to potentially violent patients, the Therapeutic Crisis Intervention strategy developed at Cornell University in Ithaca, NY. That strategy emphasizes verbal de-escalation of the situation, but allows for seclusion if necessary. Physically restraining the patient is a last resort, but even then it is done without mechanical means. Also, each patient now has a specific behavior management plan that staff can consult whenever necessary. As opposed to broad recommendations for how to deal with disruptive or violent behavior, the staff now have guidelines drawn up for each individual.
The results have been significant. In the first year, there was an 89% reduction in restraint, from 1,025 episodes to 112. In the second year, there was a 96% reduction to 41 episodes; and in the third year, there was a 98% reduction to 18 episodes. In 2003, the fourth year, the cumulative reduction in restraint use rose past 99%, amounting to only four episodes in the entire year.
The primary benefits have been to the patients, but Millcreek also is reaping financial rewards from the improvement. Workers’ compensation claims related to patient/staff interactions decreased from 109 claims in 2000 to 45 claims in 2002, a reduction of 45%.
That adds up to a significant savings at Millcreek, Tedford says. The reduction in workers’ compensation claims comes not just from reducing restraint but also from the bigger goal of minimizing the power struggles between patients and staff, she adds. "We have injuries from children hitting the staff, or biting, or throwing a chair at someone because they got in a power struggle," she says. "Reducing those injuries clearly is a part of the therapeutic approach we’re taking and teaching the staff to stay out of a power struggle."
Similarly, employee turnover has fallen sharply in the same period. Physically restraining children was a terribly stressful and sometimes dangerous job for staff and Millcreek, and they weren’t willing to stay on the job when they had to do it more than 1,000 times a year. With the sharp reduction in restraint, job satisfaction has soared, Tedford says.
Millcreek had 44% employee turnover in 1999, but that figure fell to 17% in 2000 when the new strategies were introduced. That figure has held steady ever since. "That drop has let us go to 50% fewer orientations of new staff, and an orientation here takes two weeks," Tedford reports. "Plus there is on-the-job training. So all of that, and the workers’ comp, adds up to a real financial benefit. It’s substantial."
More physician, nurse involvement
Millcreek took the approach that physical restraint and other special procedures had to be the absolute last resort for dealing with behavior problems. But that philosophy is the easy part. So how did Millcreek do it? The basic answer is that it took a collaborative, interdisciplinary approach to resolving the issues that previously would have prompted restraint, seeking to identify the individual patient’s needs before they reach a crisis point. These were some of the strategies Millcreek employed:
- The physicians initiated more in-depth questioning and discussion with the nurses related to interventions attempted prior to the initiation of restraint, ultimately enhancing nursing accountability and the number of intervention attempts. Tedford and physicians are on call 24 hours a day for help with disruptive patients. But when they are called, they expect the nurses to know not just what is going on with the patient at that moment but what happened all day long, so that they can determine what might be prompting the behavior and what might stop it.
- Physician involvement in the use of restraints and other special procedures has increased significantly, primarily by helping to guide each patient’s treatment plan in such a way that restraints are unnecessary.
- Millcreek sent senior administrators to education and training seminars and observe procedures at similar facilities.
- Compliance was monitored at all levels of patient intervention, resulting in stricter compliance with all policies and procedures.
Compliance nurse’ monitors restraint
- New staff positions were added, including the "compliance monitoring nurse" and "special procedures nurses" to provide additional support and oversight of restraint and other special procedures by well-trained, licensed staff.
- The compliance monitoring nurse distributes aggregated data on a weekly basis that summarize the previous week’s episodes of restraint and other special procedures, including an analysis by patient, shift, living unit, duration, and day of the week. Those data allow for early intervention related to potential problem areas.
- The hospital increased knowledge and attention to restraint and other special procedures through discussion in regular meetings at all staff levels. The senior administration stressed to staff that reducing restraint was a major priority.
- A new daily facility report was implemented to record the use of all special procedures in the past 24 hours.
- Debriefing was emphasized as a key process, and its method was continually redesigned. A complete debriefing and written analysis of all patient-related staff injuries also became mandatory. The debriefing process focuses on staff’s reactions to the episode, which can prompt greater stress in the child having a behavior problem. Debriefing sessions emphasize depersonalization and a positive child-focused perspective. Millcreek provides ongoing training about how to deal with power struggles and negative feedback from patients.
- Millcreek enhanced the treatment planning process to include the analysis of aggregated data related to target problem behaviors identified on individual behavior management plans.
- Performance improvement indicators were reviewed and revised at least monthly to assist in determining the success and sustainability of improvement actions.
- The admissions committee focused on close screening of referrals and admissions in an effort to match admissions to existing populations. The committee also paid special attention to those patients for whom more historical information was needed before admission.