R E V I E W S & A N A LY S E S Aligning Behavioral Health Management of Patient Aggression with State and National Initiatives Lea Anne Gardner, PhD, RN INTRODUCTION Senior Patient Safety Analyst It is 3 p.m. on the adult behavioral health unit when inpatient Joe starts to appear agitated Mary C. Magee, MSN, RN, CPHQ, CPPS Senior Patient Safety/Quality Analyst about another patient, Bob. Suddenly, Joe punches a wall. A peer tells Joe to make a good choice Pennsylvania Patient Safety Authority and please stop hitting the wall and encourages him to ask staff for help.* Katherine G. Calder, MSN, RN Patient aggression is an anticipated behavior in acute care inpatient behavioral health- Patient Safety and Quality Coordinator care settings. Aggressive patients can direct their aggression toward themselves, staff, or Children’s Hospital of Philadelphia other patients. In Pennsylvania, patient-to-patient aggression in behavioral health hos- pitals and acute care inpatient behavioral health units was the leading type of inpatient ABSTRACT aggression event reported through the Pennsylvania Patient Safety Reporting System In 1997, Pennsylvania introduced a (PA-PSRS).1 Coercive interventions, such as restraint and seclusion, were the most program to reduce the use of restraints frequently described responses to patient-to-patient aggression events for pediatric and and seclusion in state behavioral adult patients when interventions were identified. In the geriatric population, coercive health hospitals. Restraint or seclusion interventions and interventions that were not specifically identified in the literature may only be used when less restrictive as noncoercive or coercive (e.g., patient distracted or redirected) were described with interventions have been determined equal frequency. See the Figure. to be ineffective to protect the patient Based on the Pennsylvania Patient Safety Authority’s findings that coercive interven- or others from harm. Between January tions were most frequently reported, the analysts were interested to learn more about 1, 2012, and August 31, 2013, coer- how behavioral health hospitals within Pennsylvania address patient aggression; cive interventions (i.e., restraints and approaches from two facilities are presented. For a description of the data query and seclusion) were the most frequently analysis of interventions, see “Patient Aggression Management Strategy Analyses.” identified interventions used to manage Patient-to-patient aggression can present as a verbal confrontation between patients patient-to-patient aggression in behav- that escalates to a physical confrontation or can begin, without warning, as a physical ioral health patient aggression-related confrontation between patients. event reports submitted through the Pennsylvania Patient Safety Reporting Staff who engage with patients involved in aggression-related altercations often have System. Analysts, interested by this opportunities to diffuse the situation, calm the patients down, and help the patients deal finding, explored how patient aggres- with their anger or frustration in a nonviolent way. The following PA-PSRS event narra- sion is managed in two behavioral tive† illustrates this issue: health hospitals that have incorporated A patient grabbed another patient’s [neck] and started punching that patient [in the face]. the philosophy and principles of the Staff immediately responded and separated the patients. Pennsylvania Recovery and Resiliency Patient aggression is a complex issue that arises from a mix of patient risk factors, such program to inform the management as history of violence, and environmental risk factors, such as lack of structured activity of patient aggression using nonco- or frequent use of temporary staff.2 Interventions—classified as noncoercive or coercive— ercive techniques. The Recovery and have the potential to defuse patient aggression. Use of noncoercive interventions, Resiliency program promotes trauma- such as de-escalation techniques, is the preferred method to manage patient aggression informed care and the Sanctuary Model whenever possible because it promotes patient engagement and preserves dignity.2-8 to address patient issues and build a Coercive measures (i.e., restraints and seclusion) may only be used when less restrictive restraint-free environment. (Pa Patient interventions have been determined to be ineffective to protect the patient or others Saf Advis 2015 Jun;12[2]:49-53.) from harm.4,9,10 Corresponding Author In 1997, a program was introduced by Charles Curie, then Pennsylvania deputy secre- Lea Anne Gardner tary of mental health and substance abuse services, to reduce seclusion and restraint use in state behavioral health hospitals. The basis of the program was tied to his phi- losophy that “most [state hospital] patients are already the victims of trauma. There is no need to reinforce that trauma.”11 * Patient names and circumstances are fictitious and used for example purposes only. † The details of the PA-PSRS event narratives in this article have been modified to preserve confidentiality. None of these event narratives came from Philhaven or Southwood Psychiatric Hospital. Vol. 12, No. 2—June 2015 Pennsylvania Patient Safety Advisory Page 49 ©2015 Pennsylvania Patient Safety Authority R E V I E W S & A N A LY S E S In the following year, the Hartford Courant Figure. Patient-to-Patient Aggression Interventions Reported through the published a series of reports about patient Pennsylvania Patient Safety Reporting System January 2012 through August 2013 deaths associated with the use of restraints in patients needing psychiatric care12 In PERCENTAGE OF EVENT REPORTS the initial Hartford Courant report, where 90 ages could be identified, “more than 80 Pediatric (n = 270) 78.6 80.0 26 percent of [deaths involved] children— 76.3 nearly twice the proportion they constitute Adult (n = 238) in mental health institutions.”12 A follow- 70 Geriatric (n = 30) up review conducted six years later showed patient deaths caused by restraints were 60 still occurring.13 In 2006, the Pennsylvania Department 50 of Human Services, formerly the Department of Public Welfare, urged 40 providers of child residential care to move toward reducing or eliminating the use 30 of restraints. A kickoff event, Alternatives 20 18.1 to Coercive Techniques, and 12 other 13.4 forums were held across the state, address- 10.0 10.0 ing organizational change, leadership, 10 7.6 5.9 4.8 3.3 3.0 de-escalation, incident debriefing, data collection, and youth and family involve- 0 Noncoercive Coercive Other Details not ment. The forums were designed to help reported MS15297 providers understand the vision for build- ing a restraint-free system and gain their TYPE OF AGGRESSION MANAGEMENT STRATEGY support for creating organizational change by introducing the trauma-informed care Philhaven is a multisite behavioral health Organizational Culture (TIC) philosophy using the Sanctuary organization serving patients of all ages Both organizations have a culture that fos- Model.14,15 in the Lancaster, Lebanon, York, and ters a proactive approach to prevent and As a result of the forums and recommen- Harrisburg areas. Analysts met with Heidi address patient aggression while helping dations, the Sanctuary Model was brought McMullan, RN, MSN, chief nursing offi- patients learn more effective ways to man- to Pennsylvania. “Preliminary data cer; Brent Swope, director of milieu and age their emotional challenges. Philhaven from implementation of the Sanctuary behavior management training program; attributes the adoption and maintenance Model in other states showed positive and others at the Mt. Gretna facility and of its proactive approach to a stable long- results, including a decrease in the use of were given a tour of the facility. term commitment in senior leadership, restraints, less staff turnover, and better Southwood Psychiatric Hospital, located including a medical director who began outcomes for children and youth.”15 in the southwest region of Pennsylvania, working at Philhaven as a psychiatrist in is a private for-profit children’s behavioral the 1980s, succession planning for future TWO BEHAVIORAL HEALTH hospital that is part of Acadia Healthcare, a leadership personnel, education and train- FACILITY APPROACHES national behavioral healthcare corporation. ing of staff, and board support. Two behavioral health organizations, The director of nursing at Southwood Leadership commitment to proactively Philhaven and Southwood Psychiatric Psychiatric Hospital, Kim Owens, DrPH, address one of the potential consequences Hospital, discussed their organizational RN, and the analysts held a conference of patient aggression, property damage, philosophies and approaches to managing call to discuss her organization’s philoso- is evident in an example provided by Ms. patient aggression with the analysts. phy and approach to managing patient McMullan, who said, “Leadership recog- aggression. Analysts found similarities in nizes that patient aggression is a potential the facilities’ philosophies and programs. aspect of a psychiatric patient’s mental Page 50 Pennsylvania Patient Safety Advisory Vol. 12, No. 2—June 2015 ©2015 Pennsylvania Patient Safety Authority Philhaven’s and Southwood Psychiatric PATIENT AGGRESSION MANAGEMENT STRATEGY ANALYSES Hospital’s overall rates of physical restraint use per 1,000 patient-hours were 0.086917 Analysts used the 538 Pennsylvania Patient Safety Reporting System patient-to-patient and 0.0923,18 respectively, compared with aggression event reports identified in a previous Pennsylvania Patient Safety Advisory the national average rate of 0.5226 and article.1 Analysts also used the previously identified age categories—pediatric (i.e., age 18 or younger), adult (i.e., age 19 to 64), and geriatric (i.e., age 65 or older)— state average rate of 0.3303.17,18 to analyze the type of strategies used to manage patient-to-patient aggression. The categorization of aggression-related management strategies was based on a taxon- Theoretical Foundation: omy identified by Davison: noncoercive, coercive, and strategies not clearly explained Trauma-Informed Care in the event reports (e.g., separated, pulled apart, staff intervened).2 TIC is a nationwide movement and A detailed analysis of intervention strategies used by behavioral healthcare providers part of a larger statewide initiative, the was performed to identify trends in the event reports. Analysts discovered that the Pennsylvania Recovery and Resiliency pro- majority (more than 75%) of the event reports did not identify specific intervention gram, managed by the Pennsylvania Office strategies used to manage patient-to-patient aggression. In the event reports in which of Mental Health and Substance Abuse intervention strategies were identified, coercive interventions (i.e., restraints and Services.15 Dr. Owens stated that the recov- seclusion) were the most frequently reported. Several population-specific analyses ery and resiliency movement in behavioral were performed: harm score and intervention type by patient population, aggressor health started “years ago [2006]” and rep- or victim status by patient population, and combination of intervention strategies used during an event (e.g., coercive alone, coercive and noncoercive) by patient resents a change from what mental health population. These analyses, however, resulted in extremely small numbers that limited services did “to you [the behavioral health conclusions about the patient aggression management strategies behavioral health patient]” to what they do “with you” and hospitals implement and were subsequently excluded from further study. involves the patients’ families.15,19 Notes TIC is a theoretical framework that is 1. Gardner LA, Magee MC. Patient-to-patient aggression in the inpatient behavioral health identified as “a program, organization, or setting. Pa Patient Saf Advis [online] 2014 Sep [cited 2015 Apr 30]. http://patientsafety system that is trauma-informed [and]: authority.org/ADVISORIES/AdvisoryLibrary/2014/Sep;11(3)/Pages/115.aspx 1. Realizes the widespread impact of 2. Davison SE. The management of violence in general psychiatry. Adv Psychiatr Treat trauma and understands potential 2005;11:362-70. paths for recovery; 2. Recognizes the signs and symptoms of trauma in clients, families, staff, illness and when designing the facility aggression. Staff are put through a rigor- and others involved with the system; for safety, takes into account the poten- ous orientation prior to working with the 3. Responds by fully integrating knowl- tial for property damage.”16 Philhaven’s patients.” Anticipating the potential for edge about trauma into policies, organization-wide effort to change its phi- aggressive situations and planning for them procedures, and practices; and losophy to reduce restraint use, initiated proactively provides leadership, physicians, 4. Seeks to actively resist by leadership in the early 2000s, is now and frontline staff with the necessary tools re-traumatization.”20 a fundamental part of its organizational to reduce the occurrence and mitigate the Philhaven and Southwood Psychiatric culture and day-to-day operations. consequences of patient aggression. Hospital have adopted these principles to Southwood Psychiatric Hospital’s organiza- Southwood Psychiatric Hospital, like transform their cultures of restraint use. tional philosophy uses a similar proactive Philhaven, is data-driven in using key The American Psychiatric Nurses approach to preventing and addressing performance indicators and participating Association position statement identifies patient aggression. Southwood Psychiatric in national benchmarking. For example, the “growing awareness that inpatient Hospital attributes the adoption and both organizations participate in the Joint treatment must be shaped by the prin- maintenance of its proactive approach Commission’s Hospital-Based Inpatient ciples of trauma-informed care and the to recruitment and retention of the right Psychiatric Services measure set. The recovery movement and that these phi- staff, beginning with a robust orienta- physical restraint use rates for June 2013 losophies will create a collaborative spirit tion program. Dr. Owens stated, “New through July 2014 for these two organiza- that is essential to restrain reduction and hires, including myself, are screened for tions are lower than national and state elimination efforts.”21 their approach toward managing patient average rates for the same time period. Vol. 12, No. 2—June 2015 Pennsylvania Patient Safety Advisory Page 51 ©2015 Pennsylvania Patient Safety Authority R E V I E W S & A N A LY S E S Sanctuary Model in Therapeutic Crisis Intervention that such as unit routines. Dr. Owens related The Sanctuary Model, introduced in 2006 focuses on de-escalation and attend that staff “gauge activities that are appro- as part of the implementation of the TIC a four-hour refresher course annually.19 priate for the patients. Keeping children philosophy in Pennsylvania, represents a This training also includes role-play in smaller groups and reducing stimuli “theory-based, trauma-informed, evidence- and simulation. and clutter can help manage agitation and supported, whole culture approach . . . to aggression. For example, some children teach individuals and organizations the The Importance of Milieu need help with brushing their teeth, get- necessary skills for creating and sustaining Both organizations stressed the impor- ting a shower, or making their bed; clear nonviolent lives and nonviolent systems tance of milieu in the management of prompts are provided by staff about com- and to keep believing in the unexplored aggression. The “milieu” includes the sur- pleting these activities, and these prompts possibilities of peace.”14 The Sanctuary roundings and environment of patients help address impulsive issues.”24 Model, a part of the Pennsylvania and staff.25 As depicted in the scenario in Southwood Psychiatric Hospital employs Recovery and Resiliency program, focuses the introduction, unit culture in the form the principles of normalizing the environ- on training staff consistently to build rela- of positive peer interaction and proactive ment. This concept supports physical tionships with patients and among staff.14 staff response to aggression is an impor- healthcare delivery by focusing on holistic Philhaven’s residential program is a certi- tant aspect of the milieus both facilities try design and promoting socialization by fied sanctuary program.22 to foster. integrating public and private spaces At Philhaven, the milieu includes the phys- in a secure manner.26 When caring for Therapeutic Crisis Intervention ical structure, patient and unit routines, children, both organizations provide infor- Philhaven and Southwood Psychiatric and patient relationships with staff. The mation and education for parents. Hospital have adopted the Therapeutic physical building at Philhaven has a lot Crisis Intervention program, originally of natural light, wide hallways, and many CONCLUSION developed for child and youth popula- private rooms. Every patient is assigned State and national trends emphasizing non- tions, to educate staff on how to prevent a staff member who is their primary coercive strategies in the management of and manage a crisis23 and to align with the contact for purposes of encouragement, patient aggression in the behavioral health TIC model. Philhaven adapted and imple- goals review, and general support. Staff setting began two decades ago with the mented this program for all inpatient are constantly reminded about tailoring intention of reducing the use of restraints units, regardless of patient age. According de-escalation techniques to fit the client’s and seclusion. Operationalizing organiza- to Mr. Swope, “Staff are trained on the needs or character, as illustrated in the tional changes to effect noncoercive patient Therapeutic Crisis Intervention model to following PA-PSRS event narrative: care strategies requires a long-term commit- reduce behavioral crises, support patients ment that starts with leadership. Patient was punched in the face and staff in the day-to-day management when arguing with a female peer on In Pennsylvania, Philhaven and South- of patients, and help patients learn new the unit. No injury apparent. Patient wood Psychiatric Hospital have aligned behavioral health management skills.” 24 followed verbal redirection and went their philosophical and operational Upon hire, new employees are required to to [her] room to calm down. approaches to noncoercive management of attend and successfully complete an initial 24 hours of training in Therapeutic Crisis At Southwood Psychiatric Hospital, patient aggression with state and national Intervention. Training is then provided milieu management includes the follow- initiatives. Both facilities continually evalu- on a quarterly basis, during which staff ing: (1) creating and maintaining a calm ate the effectiveness of their approaches are exposed to additional role-play and and safe environment, (2) encouraging and adapt as circumstances dictate, achiev- simulations of behavioral events. positive interactions between staff and ing overall restraint use rates that are lower patients, and (3) addressing the environ- than state and national averages. At Southwood Psychiatric Hospital, staff mental elements outside of group therapy, receive a two-and-a-half day initial training Page 52 Pennsylvania Patient Safety Advisory Vol. 12, No. 2—June 2015 ©2015 Pennsylvania Patient Safety Authority NOTES 1. Gardner LA, Magee MC. Patient-to- 11. Pennsylvania Department of Public Welfare. 19. Owens, Kim (Director of Nursing, South- patient aggression in the inpatient Pennsylvania seclusion and restraints reduc- wood Psychiatric Hospital). Interview behavioral health setting. Pa Patient Saf tion initiative [online]. 2000 [cited 2015 with: Lea Anne Gardner and Mary C. Advis [online] 2014 Sep [cited 2015 Mar Mar 11]. http://www.power2u.org/down Magee. 2015 Feb 27. 5]. http://patientsafetyauthority.org/ loads/Pennsylvania_S&R_Initiative.pdf 20. Substance Abuse and Mental Health Ser- ADVISORIES/AdvisoryLibrary/2014/ 12. Module 1: the personal experience of vices Administration. Trauma-informed Sep;11(3)/Pages/115.aspx seclusion and restraint [online]. In: care and alternatives to seclusion and 2. Davison SE. The management of violence Center for Mental Health Services. Sub- restraint [online]. [cited 2015 Mar 9]. in general psychiatry. Adv Psychiatr Treat stance Abuse and Mental Health Services http://www.samhsa.gov/nctic/ 2005;11:362-70. Administration. Roadmap to seclusion trauma-interventions 3. Macpherson R, Dix R, Morgan S. A and restraint free mental health services. 21. American Psychiatric Nurses Associa- growing evidence base for management 2005 [cited 2015 Mar 9]. http://store. tion. APNA position statement on the guidelines: revisiting . . . guidelines for samhsa.gov/shin/content//SMA06- use of seclusion and restraint [online]. the management of acutely disturbed 4055/SMA06-4055-B.pdf Revised 2014 [cited 2015 April 28]. psychiatric patients. Adv Psychiatr Treat 13. Altimari D. Many restraint deaths http://www.apna.org/i4a/pages/index. 2005;11:404-15. unreported [online]. Hartford Courant cfm?pageid=3728 4. Centers for Medicare and Medicaid. 2006 Oct 14 [cited 2015 Mar 9]. http:// 22. Sanctuary network: programs that are Medicare and Medicaid programs; hospi- articles.courant.com/2006-10-14/ adopting the Sanctuary Model [online]. tal Conditions of Participation: patients’ news/0610140661_1_inspector-general- [cited 2015 Mar 12]. http://www.sanc rights [final rule]. Fed Regist 2006 Dec psychiatric-hospitals-deaths tuaryweb.com/TheSanctuaryModel/ 8;71(236):71378-428. 14. An integrated theory: what is the Sanctu- ComponentsoftheSanctuaryModel/ 5. Dean AJ, Duke SG, George M, et al. ary Model? [online]. [cited 2015 Mar 12]. SanctuaryNetwork.aspx Behavioral management leads to reduction http://www.sanctuaryweb.com/ 23. Cornell University Residential Child in aggression in a child and adolescent TheSanctuaryModel.aspx Care Project. Therapeutic crisis interven- psychiatric inpatient unit. J Am Acad Child 15. Pennsylvania Recovery and Resiliency. tion system: information bulletin [online]. Adolesc Psychiatry 2007 Jun;46(6):711-20. Trauma-informed care for children 2010 [cited 2015 Mar 9]. http://rccp. 6. Richmond JS, Berlin JS, Fishkind AB, [online]. [cited 2015 Mar 13]. http:// cornell.edu/assets/TCI6_SYSTEM_ et al. Verbal de-escalation of the agitated parecovery.org/services_trauma_ BULLETIN.pdf patient: consensus statement of the Amer- informed_care.shtml 24. Swope, Brent (Director of Milieu and ican Association for Emergency Psychiatry 16. McMullan, Heidi (Chief Nursing Officer, Behavior Management Training Program, Project BETA de-escalation workgroup. Philhaven). Interview with: Lea Anne Philhaven). Interview with: Lea Anne Gard- West J Emerg Med 2012 Feb;13(1):17-25. Gardner and Mary C. Magee. 2015 Feb 24. ner and Mary C. Magee. 2015 Mar 12. 7. Price O, Baker J. Key components of 17. Joint Commission. Quality report— 25. Dorland’s Illustrated Medical Dictionary. de-escalation techniques: a thematic hospital: Philhaven. National quality 30th ed. Philadelphia: Saunders; 2003, synthesis. Int J Ment Health Nurs 2012 improvement goals: hospital-based psychi- s.v. “milieu.” Aug;21(4):310-9. atric services—reporting period: July 2013 26. Muirhead K, Treece MA. Normalizing 8. Center for Mental Health Services. – June 2014 [online]. [cited 2015 Mar 31]. the patient environment [online]. Behav Substance Abuse and Mental Health http://www.qualitycheck.org/Quality Healthc 2006 Feb 1 [cited 2015 Mar Services Administration. Roadmap to Report.aspx?hcoid=3112&x=nqigQtr&pro 12]. http://www.behavioral.net/article/ seclusion and restraint free mental gram=Hospital&mst=Hospital-Based Inpa normalizing-patient-environment health services [online]. DHHS Pub. No. tient Psychiatric Services&msrId=66 (SMA) 05-4055. 2005 [cited 2015 Mar 5]. 18. Joint Commission. Quality report—hospital: http://www.asca.net/system/assets/ Southwood Psychiatric Hospital. National attachments/2661/Roadmap_Seclusion. quality improvement goals: hospital-based pdf?1301083296 psychiatric services—reporting period: 9. 55 Pa. Code §§ 13.1-13.9. Also available July 2013 – June 2014 [online]. [cited at http://www.pacode.com/secure/ 2015 Mar 31]. http://www.qualitycheck. data/055/chapter13/chap13toc.html org/QualityReport.aspx?hcoid=1048 &x=nqigQtr&program=Hospital&ms 10. Pennsylvania Department of Public Wel- t=Hospital-Based Inpatient Psychiatric fare. The use of seclusion and restraint Services&msrId=66 in mental health facilities and programs [online]. 2002 Apr 8 [cited 2015 Mar 05]. http://www.pccyfs.org/dpw_ocyfs/ Seclusion-Restraint/2006/OMHSAS_ Bulletin_02-01(Apr2002).pdf Vol. 12, No. 2—June 2015 Pennsylvania Patient Safety Advisory Page 53 ©2015 Pennsylvania Patient Safety Authority PENNSYLVANIA PATIENT SAFETY ADVISORY This article is reprinted from the Pennsylvania Patient Safety Advisory, Vol. 12, No. 2—June 2015. The Advisory is a publication of the Pennsylvania Patient Safety Authority, produced by ECRI Institute and ISMP under contract to the Authority. Copyright 2015 by the Pennsylvania Patient Safety Authority. 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