Focus on Staff Education and New Practices Reduce ED Escalations in Behavioral Health Patients

Focus on Staff Education and New Practices Reduce ED Escalations in Behavioral Health Patients

How one hospital used trauma-informed care principles to improve staff awareness and reduce escalations and use of restraints in the ED.

Shortly after the shooting at Sandy Hook Elementary School in Newtown, Connecticut, in 2012, Children's National Hospital in Washington, D.C., started having more of a conversation around behavioral health and tracking those patients in their emergency department (ED). Children's National noticed what every other children's hospital is noticing—a growing trend in patients presenting to the ED with a behavioral health concern.

"Why was the burden of care falling in our arms?" says Linda Talley, M.S., RN, NE-BC, FAAN, vice president and chief nursing officer at Children's National. "Where are the opportunities to partner in a more meaningful way across the community?"

At the 2020 Behavioral Health Summit, Talley and Theresa Schultz, MBA, M.S.N., RN, NEA-BC, director of Nursing, Emergency Medicine and Trauma Center at Children's National, discussed their charge to create a task force specifically focused on creating safer environments for encounters with patients. The task force, established in 2015, was dubbed The Disruptive Patients Task Force to look at facilities, care delivery and staff education around behavioral health in the ED. "Without a doubt, it is very clear that what we were looking to do is reduce disruptive events with front line staff," Talley says.

Staff education was crucial. Children's National partnered with the local police department and offered a town hall to learn about what's going on in the community and where the hospital could better offer support. New positions were added in the hospital's care delivery model, as were alerts in the electronic health record.

Then BERT was created. BERT is the Behavioral Emergency Response Team and, under the leadership of Schultz, focused on emergency room de-escalation. She outlined six principles of trauma-informed care:

  • Safety
  • Trustworthiness and transparency
  • Peer support
  • Collaboration and mutuality
  • Empowerment, voice and choice
  • Cultural, historical and gender issues

Educating staff on trauma-informed care became fundamental to improvements in ED behavioral health care. Interventions included:

  • A color-coded dashboard that identified ED patients who are at high, medium and low risk of aggressive behavior.
  • Locking up the belongings of parents and visitors.
  • Using handheld metal detector wands on patients twice. Patients are first scanned clothed, then again after disrobing and wearing only a hospital gown. They are then given their undergarments back. Schultz noted giving pieces of their clothing back was essential to the trauma-informed care principle of psychological safety.
  • Staff gained identification holders on their wrists, removing grabbable lanyards from around their necks.
  • Kevlar sleeves for staff reduce potential harm from biting or scratching.
  • ED signage shows exactly what is not allowed: alcohol, drugs, weapons, certain behavior. "While a poster will not stop the behavior, it gives our staff language to reference and feel confident about," Schultz says.
  • Weighted blankets are available for children in the ED with autism.

These interventions are proven effective. More awareness has increased the number of patients who receive behavioral health evaluations in the ED, but there's been a 36% decrease in the rate of disruptive events. Additionally, there's been a 16% decrease in physical restraints, 26% decrease in chemical restraints and 38% decrease in attempted elopements.

"We changed our mantra from ‘This is really hard, we don't know what to do,' to ‘This is really complex, what can we do?'" Schultz says.

Next, the team at Children's National is taking these strategies to areas outside of the ED. Schultz and Talley say it's important to educate all areas of the hospital, since violence doesn't just come from patients. It could come from places you wouldn't expect violence, like the NICU, PICU or other high-stress areas. "It's not a matter of if they'll have that encounter—they will have that encounter," Talley says.

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