Reducing Physical Restraint Use in the Medical Behavioral Unit

Our institution is a 603-bed free-standing children’s hospital in the mid-Atlantic region of the United States. The MBU is a 10-bed inpatient medical unit that provides specialized behavioral supports through enhanced staffing and environmental design.⁶ The MBU’s multidisciplinary team includes: (1) an attending pediatrician and pediatric APPs; (2) an attending psychiatrist, a psychologist, and a psychiatric APP; (3) board-certified behavior analysts (BCBAs); (4) a social worker; (5) bedside nurses, nurse supervisors, and a nursing manager; (6) certified child life specialists; and (7) behavioral health clinicians (BHCs). BHCs are bedside safety observers, also called psychiatric technicians, who have college or graduate-level education and receive additional training on deescalation support for hospitalized children. MBU staffing includes a 3:1 patient to nurse ratio and a 1:1 patient to BHC ratio. An in-house pediatric APP provides overnight MBU coverage with an attending pediatrician and psychiatrist on home call. MBU nurses and BHCs participated in a recent qualitative study where they predominately self-reported their gender as female, their race as White or Black, and their highest educational level as a college or professional degree.²¹ 

The MBU was designed to care for children hospitalized for primary medical conditions with concurrent behavioral needs, yet many of the children admitted to the MBU are medically cleared and awaiting psychiatric disposition.⁶ When a MBU bed becomes available, the children with the highest behavioral acuity on other units are prioritized for transfer. MBU patients have significant behavioral acuity, which led to increasingly frequent physical restraint use. The proportion of MBU patient-days with a physical restraint event was 10.1% between 2017 and 2019, which increased to 14.0% in 2021,⁶ exceeding previously documented proportions of patient-days with physical restraint for children with behavioral health conditions in a pediatric emergency department (6.8%)²² and general medical units at a children’s hospital (2.6%).¹⁶ 

In August 2021, a multidisciplinary team including a pediatrician, the MBU medical director (who is a child and adolescent psychiatrist), the MBU nursing manager, and the BHC manager met to discuss the rising frequency of MBU physical restraint events. With institutional support, a QI team was formed with the global aim of improving the prevention, early recognition, and assessment of MBU patient agitation, as well as safe deescalation without physical restraint.

Our QI team mapped the existing MBU deescalation process (Supplemental Fig 6) and analyzed the root causes of physical restraint events. The first root cause was inconsistency in the method and timing of communication between frontline MBU employees during deescalation. The second root cause was variability in the MBU’s deescalation model, with inconsistent use of nonpharmacologic and pharmacologic interventions before physical restraint. The third root cause was difficulty in revising ineffective behavior and deescalation plans for MBU patients. The final root cause was the unavailability of toys and activities tailored to patients’ interests. This analysis informed a key driver diagram outlining the primary drivers toward our aim of reducing physical restraint and proposed interventions (Fig 1).

In January 2022, we recruited MBU nurses, BHCs, APPs, child life specialists, and BCBAs to join our team. This team met monthly throughout the initiative to share MBU physical restraint and employee injury data and discuss Plan-Do-Study-Act cycles. All children hospitalized in the MBU between January 4, 2021, and January 1, 2023, were included in our analysis. 2021 was our baseline period, January through July 2022 was our intervention period, and August through December 2022 was our sustainment period. Physical restraint and patient data were collected from automated dashboards linked to our electronic health record (EHR). Physical restraint orders were tracked via a dashboard and confirmed through manual chart review weekly. Patient behavioral events (PBEs) that resulted in days away, restricted, or transferred (DART) for MBU employees were monitored monthly, which is our institution’s metric for employee injuries secondary to patient behaviors.²³ 

Our primary outcome measure was the weekly rate of physical restraint events per 100 MBU patient-days. Our operational definition of a physical restraint event included the application of mechanical restraint devices for a patient exhibiting agitated, combative, or aggressive behavior. The physical restraint devices used in the MBU are 4-point neoprene limb restraints (Twice as Tough Cuffs).²⁴ Physical restraint events began with device application and ended when all 4 of the patients’ limbs were released from the devices. Per policy, renewal of physical restraint orders was a continuation of the original physical restraint event rather than a separate event. Manual physical holds performed without the application of a mechanical device were excluded from our operational definition. Weekly MBU patient-days were calculated as the sum of the MBU’s midnight patient censuses over 1 week. Our secondary outcome was the weekly average duration of MBU physical restraint events, measured in minutes. The duration of a physical restraint event was calculated as the number of minutes that elapsed between application of restraint devices and their removal from all 4 of the patient’s limbs, as was entered in the EHR by the patient’s nurse. We manually verified these timepoints with the placement and discontinuation times of the physical restraint order, which replaced nursing documentation in cases of significant discrepancy. Our balancing measure was the number of days between PBEs with DART involving MBU employees.

Statistical process control charts were used to monitor the impact of our interventions. Special cause variation was identified in accordance with standard rules for statistical process control charts. Eight consecutive points above or below the centerline demonstrated a centerline shift.²⁵ We used a u-chart to measure the weekly rate of physical restraint events per 100 MBU patient-days. An x-bar and s-chart was used to analyze the weekly average duration of MBU physical restraint events. A g-chart was used for days between PBEs with DART involving MBU employees because these events occur rarely.

Race and ethnicity are social constructs rather than genetic or biological categories. We stratified our analyses by patient and family-reported race, ethnicity, and language to investigate disparities in physical restraint and ensure that our interventions did not exacerbate existing disparities. However, there were only enough patients to stratify our analyses by Black and White race. This project was undertaken as a QI Initiative and does not constitute human subjects research.²⁶ This manuscript was prepared using the Revised Standards for Quality Improvement Reporting Excellence (2.0) Guidelines.²⁷ 

During our 2-year study period, 527 consecutive patients were hospitalized in the MBU with a 14-day median length of admission. This cohort included 282 patients during the 2021 baseline period, of which 64 (23%) were physically restrained for a total of 473 physical restraint events. During our 2022 intervention and sustainment periods, 245 patients were hospitalized and 61 (25%) were physically restrained for a total of 276 physical restraint events.

In January 2022, our QI team developed a deescalation protocol using a standardized agitation assessment based on the Brøset Violence Checklist (Brøset),²⁸ which had previously shown efficacy in the inpatient children’s hospital setting.¹⁶ Before implementation, Brøset scoring was performed by a pediatrician, psychiatrist, and psychologist. This deescalation protocol was tested throughout January with bedside BHCs and nurses, and their feedback was incorporated into iterative revisions. The final MBU deescalation protocol comprised an agitation scoring system based on a modified Brøset corresponding to deescalation interventions (Supplemental Fig 7).

In February 2022, our team discontinued use of this protocol, noting a lack of physical restraint reduction during its implementation. MBU nurses and BHCs reported that they were comfortable assessing patients’ level of agitation but were uncomfortable using deescalation interventions without physical restraint.

Based on this feedback, our team piloted a novel daily deescalation huddle in February 2022. The deescalation huddle leveraged a multidisciplinary team for individualized deescalation planning, using standardized scripts and behavioral acuity assessment tools per the Six Core Strategies for Reducing Seclusion and Restraint Use.²⁹ The bedside teams for the MBU patients with the highest behavioral acuity huddled with the BCBAs and pediatrician each morning to discuss the patient’s behavior and deescalation plans. Assessment of patients’ behavioral acuity was based on the patient meeting one of the following criteria: (1) physical restraint event in the past 48 hours; (2) PRN medication in the past 24 hours; or (3) an upcoming event with agitation risk (eg, family meeting, behavior plan change, anticipated transfer or discharge). The deescalation huddle script was iteratively improved and standardized in March 2022.

Although our team noted an initial association between the deescalation huddles and a reduction in physical restraint events, inconsistency in huddle implementation was noted in April 2022, particularly on nights and weekends. Our team then conceptualized and implemented the role of a charge BHC, which elevated a tenured BHC to a new role responsible for leading both the daily deescalation huddles and subsequent patient deescalations. The charge BHC role was piloted with 2 BHCs in May 2022. We incorporated iterative qualitative feedback obtained from MBU employees through semistructured interviews to improve this role until its standardization in July 2022.²¹ 

In August 2022, the daily deescalation huddle was expanded into a series of 3 huddles led by the charge BHC, now with expanded staffing to provide full-time MBU coverage (Supplemental Fig 8). The first huddle occurred at 8:30 am, bringing together the charge BHC, charge nurse, and BCBAs in the MBU conference room. The aim of this huddle was to identify the most behaviorally acute patients and propose changes to their behavior and deescalation plans (Supplemental Fig 9). The charge BHC updated patient plans on a huddle grid (Supplemental Fig 10), which was documented in BCBAs’ EHR notes. Next, the charge BHC and BCBAs traveled to these patients’ rooms and huddled with the bedside BHC and nurse about the patients’ individualized plans (Supplemental Fig 11). The third huddle occurred in the MBU conference room at 9:20 am and included the charge BHC, charge nurse, child life specialist, BCBAs, and the pediatrics and psychiatry teams. The goal of this huddle was to review the previous huddles for the most behaviorally acute patients and finalize changes to their deescalation plans. The standardized script for this huddle included (1) reviewing deescalation plan changes, (2) discussing needed toys and activities, and (3) identifying and ordering changes to PRN medications (Supplemental Fig 12).

The frequency of weekly physical restraint events per 100 MBU patient-days improved from our 1-year baseline of 14.0 to 10.0 after the implementation of the daily deescalation huddle resulted in special cause variation in February 2022 (Fig 2). Additional special cause variation was noted in May and June 2022 during a period of high patient acuity and in August 2022 after the implementation of the charge BHC and deescalation huddle series, which resulted in a shift in the centerline to a new mean of 4.1. This reduction was sustained for 5 months, despite brief special cause variation in November 2022, which was associated with a staffing change that left the MBU without a charge BHC. When the charge BHC was restored in December 2022, our primary outcome returned to its new baseline.

In addition, we observed a racial disparity in the MBU’s baseline physical restraint rate with Black patients experiencing physical restraint nearly twice as often as White patients (Fig 3). This primary outcome was reduced for both Black patients (17.9 to 6.1) and White patients (10.9 to 4.3), exhibited by special cause variation for both groups in August 2022. Although this disparity was narrowed by our interventions, Black patients remained more likely to be physically restrained in the MBU.

Before our interventions, the average weekly duration per MBU physical restraint event was 112 minutes. MBU physical restraint event duration began trending below our baseline mean in December 2021. Special cause variation occurred during our intervention period, resulting in a centerline shift to 77 minutes per physical restraint event with further reduction to 66 minutes during our sustainment period (Fig 4). This reduction in our secondary outcome was seen among Black patients, but not White patients, in our stratified analysis (Supplemental Figs 13 and 14).

During the baseline period, the mean number of days between PBEs with DART involving MBU employees was 42, which did not significantly change during our intervention period (Fig 5). However, there were 6 PBEs with DART involving MBU employees that occurred during a period of high patient behavioral acuity between May and June 2022, corresponding with special cause variation when the physical restraint rate rose above our upper control limit.

Our QI team implemented multidisciplinary interventions that reduced the weekly rate of physical restraint events from our baseline mean of 14.0 per 100 MBU patient-days to 4.1, which was sustained for 5 months. Our interventions also decreased the duration of weekly physical restraint events from 112 to 66 minutes without significantly increasing MBU employee injuries.

Our interventions individualized daily deescalation planning for the most behaviorally acute MBU patients and established a shared mental model for deescalation among MBU employees. Our most successful intervention was a series of charge BHC-led multidisciplinary huddles, which were based in principles that facilitated restraint reduction in pediatric psychiatric hospitals.^29,30 The charge BHC role elevated BHCs to become MBU leaders, allowing for deference to their expertise in agitation prevention and deescalation, establishing a standardized method of communication with bedside teams, and facilitating a culture change surrounding physical restraint (Supplemental Table 1).

Our study is the first to report physical restraint reduction on a specialized medical behavioral unit at a children’s hospital. Unlike previous studies describing successful restraint reduction interventions in children’s hospital medical units,^16,31 our deescalation protocol did not reduce physical restraint use. We hypothesize that this intervention was ineffective because of MBU employees’ existing expertise in patient agitation assessment. Instead, the charge BHC role elevated the voices of BHCs through multidisciplinary huddles, resulting in successful deescalations without physical restraint use.

Our findings also depict a racial disparity in physical restraint use in the MBU because Black patients were more likely to be physically restrained than White patients. Racial inequity in physical and pharmacologic restraint use in emergency departments has previously been documented, likely reflecting the effects of systemic racism.^13,15 Although our interventions did not directly focus on reducing race-based differences, they did narrow the racial inequity in MBU physical restraint use. We hypothesize that by reducing variability in our deescalation practices, our standardized interventions mollified the impact of bias on physical restraint use. However, racial disparities in physical restraint use remain, providing a target for future equity-focused quality improvement efforts.³² 

This study was performed on a specialized medical behavioral unit at a quaternary care children’s hospital, which is unique and may limit its generalizability. Our baseline physical restraint rate was higher than rates documented from other children’s hospitals; however, published pediatric physical restraint data are scarce and lack a standardized reporting process. This elevated physical restraint rate provided an opportunity for improvement and a barrier to culture change. Second, our primary outcome measure of physical restraint events was not independent, which may have led to autocorrelation because the likelihood of a patient being physically restrained depended on their physical restraint in preceding days. There also may have been variability in the reporting of our balancing measure, PBEs with DART, as employee injuries on inpatient psychiatric units are often not reported.^33,34 Still, employee safety remains a critical balancing metric that requires monitoring during restraint reduction efforts. Finally, our study did not monitor the concurrent use of pharmacologic restraints, nor did we track economic implications, although economic benefits to restraint reduction have been previously shown.³⁵ 

The interventions implemented in our study resulted in a safe reduction in the rate and duration of MBU physical restraint events, which was sustained for 5 months. Future investigation of physical restraint reduction at children’s hospitals can be pursued through multicenter implementation of multidisciplinary interventions tailored to the unique needs of each hospital.

The authors thank Daniel Hyman, Kristen Czech, Kevin Blackshear Jr, Angela Luciani, Barathi Chinnappan, and Dawn DeBrocco for their support of this project. The authors also thank Capri Burnett and David Lemisch for leading the development of the BHC charge role and Kristi McNaughton for assistance with editing the manuscript. Finally, we thank the entire MBU staff for their daily efforts to provide the best possible care for children in the MBU.

APP

advanced practice provider

BCBA

board-certified behavior analyst

BHC

behavioral health clinician

DART

days away, restricted, or transferred

EHR

electronic health record

MBU

medical behavioral unit

PBE

patient behavioral event

PRN

as needed

QI

quality improvement