The national crisis in children’s mental and behavioral health has caused a rise in admissions at Children’s Mercy Kansas City in those patient populations, leading to increased escalations and more frequent and severe staff injuries. In response, the hospital created an improvement team and launched a 90-day sprint to address the growing problems. The initiative achieved substantial reductions in staff injuries, patient self-harm, and the use of restraints with behavioral health patients.
The initiative was based on the Rapid Results framework, a method for getting results in under 100 days. Children’s Mercy set three goals:
- Reduce the total use of pharmacological and physical restraints by 25%.
- Reduce the risk for self-harm in patients with suicidal or homicidal ideation by 20%.
- Reduce reported physical staff injuries related to behavioral health patients by 30%.
The goals were executed by three workgroups within the behavioral health rapid improvement team (BHRIT) focused on specific areas: patient cohorting and unit staffing, staff education and training, and staff support. The workgroups were led by a doctor/nurse dyad leadership structure and supported by an administrative sponsor. BHRIT overall was also supported by an executive sponsor, a coach and a communications and marketing specialist. The team represented a variety of disciplines and levels of staff, including nursing, social work, regulatory, child life, psychology, psychiatry, local leaders and frontline staff.
Patient cohorting and unit staffing
The patient cohorting and unit staffing workgroup focused on environmental modifications to improve the care of patients and decrease patient escalations. They sought to group behavioral health patients on one unit to require less staff, but regulations prohibited it. Instead, the team implemented facility room modifications, adapted a patient room risk-mitigation checklist, and built confirmations into Tracers with AMP, a Joint Commission resource, for ease of collection.
These changes resulted in safer rooms by removing items and equipment that could pose a risk for patient self-harm, such as sharp objects, choking hazards and ligature points. Additionally, the workgroup initiated remote monitoring of patients with eating disorders. This allowed more one-on-one observers to stay with the more aggressive patients while still preventing self-harm in the patients with eating disorders.
Education and training
The education and training workgroup focused on preparing staff to meet the needs of patients and provide interventions to reduce patient escalations. The group implemented three pilots: increase The Mandt System training, provide foundational behavioral health education to all clinical staff, and produce soothing stations for patients.
The Mandt System training. Adopted by Children’s Mercy Kansas City in 2019, The Mandt System is a behavioral health crisis interaction training program that promotes prevention, de-escalation and intervention approaches to decrease workplace violence. During BHRIT, over 600 staff were trained. The training primarily focused on caring for patients in continuous observations and responding to Code Strongs, the behavioral health escalation response team, to prevent staff and patient injuries.
Education. The workgroup launched foundational behavioral health education for all clinical staff. This education was mandatory for clinical staff during the BHRIT sprint and is now embedded into the hospital’s annual mandatory education.
Soothing stations. The workgroup created stations filled with items designed to help patients self-regulate. Some items targeted the senses with a variety of textures and smells, and others provided distraction with sounds or visual effects.
Staff support
The staff support group identified staff safety concerns. They also created several new documentation tools to identify risks and improve processes and strategies to reduce violent situations:
Escalation assessment and prevention tool. This is completed upon admission with the patient and family to identify risk factors for escalation and strategies to de-escalate the patient.
Observer handoff tool. Used by the observer sitting in the room with the patients, this provides a structured way to document any information on the patient that may better serve the observer.
Behavioral health observation tool. This breaks down behaviors into green, yellow and red zones and provides staff ideas on how to de-escalate the patient based on observed behaviors.
Behavior information note. A note tracks staff injuries in the electronic medical record. This ensures staff can see historic trends and be better prepared in the care of a particular patient regardless of where the patient presents for care.
Lastly, the workgroup helped make available to staff behavioral personal protective equipment. This equipment helps prevent injuries to the hands, arms and head, and includes head coverings, cut-resistant gloves, padded forearm sleeves and Kevlar sleeves.
The entire behavioral health rapid improvement team sprint resulted in a 33% reduction in the frequency of staff injuries in the inpatient areas, a 78% reduction in the use of violent physical restraints, a 14% reduction in the use of intramuscular pharmacological restraints, and an 11% reduction in the risk for patient self-harm in the inpatient setting. Overall, it also reduced the severity of staff injuries.
