Improving Care of Pediatric Behavioral Health Patients and Employee Safety through Quality Collaborative Participation

Background:

With limited behavioral health placements, our hospital houses behavioral health patients for extended periods of time. Without a dedicated behavioral health unit and full-time behavioral health staff members, there was no consistent process for the management and care of pediatric behavioral health patients in our facility, a children’s hospital within an adult hospital, within a larger system. This led to patient and employee harm. A review of employee injury reports and days away restricted/transferred (DART) events related to behavioral patients found 5 total reports, 2 DART events, 64 lost days, and 146 restricted days (210 DART days total) between June 2017 and June 2018 (Fig. 1).

Methods:

Our interdisciplinary behavioral health team created a standardized room safety/preparation checklist, established a template and process for daily individualized safety plans based on the patient’s assigned safety classification, and developed a formalized process for the management of these patients. The facility also supported de-escalation training for all pediatric staff members, providing additional behavioral health education and resources for pediatric nurses and providers. Simultaneously, our facility joined the SPS Employee/Staff Safety: Patient Behavioral Events group. This provided a venue to share our progress and learn from other organizations.

Results:

After the process rollout in June 2018, 91% of behavioral health patients had individualized safety plans created, ensuring continuity between caregivers and as patients transfer units, and no serious patient harm has been reported. Postintervention employee injury report and DART results between June 2018 and June 2019 were 11 reports received, 1 DART event, 3 lost days, and 28 restricted days (31 DART days total) (Fig. 1). The interdisciplinary team has implemented a process to review pediatric behavioral health cases twice monthly to monitor progress and address opportunities. Our campus adult and system partners have adopted some of these best practices and we continue to share information to spread best practices across both the pediatric and adult population.

Fig. 1.: Children's Memorial Hermann Hospital Employee Safety Reported Events and Days Away Restricted/Transferred (DART) Days, June 2017-September 2019/. Graph shows number of events reported per month and number of staff days from work or restricted per month related to violence caused by a behavioral health patient. Preintervention (June 2017 and June 2018), staff reported 5 events, 3 of which were OSHA recordable (TRIR) and 2 of which sustained injuries, resulting in 64 total lost days (days away) and 146 restricted days (210 DART days total). Postintervention between June 2018 and June 2019, 11 event reports were received (a 120% increase). One event was OSHA recordable (a 66% decrease) with the employee reporting sustaining injuries, which resulted in 3 lost days (a 95% decrease), and 28 restricted days (an 80% decrease), for a total of 31 DART days reported (an 80% decrease). CMHH, Children's Memorial Hermann Hospital; DART, days away restricted/transferred; OSHA, Occupational Safety and Health Administration; TRIR, Total Recordable Incident Rate.

Conclusions/Implications:

Through our safety classification and daily safety plans, we have improved the standardization of care for our behavioral health patients. These interventions have reduced variability in care among caregivers and nursing units and provided a process for providers and nursing staff members to communicate and coordinate care for these patients. Decreased variability and improved coordination of care has led to improved competency in caring for this patient population as evidenced by decreased patient and staff member harm. We learned that data collection and regular retrospective chart audits help ensure compliance and timely course correction, stakeholder buy-in is crucial for a project of this magnitude, and the project must be scoped appropriately to continue moving toward goals.