Few issues raise as many concerns
in acute behavioral health treatment settings as patient restraint (i.e.,
limiting patient access to or movement of his/her body). Major regulatory
agencies such as the Joint Commission and the Centers for Medicare & Medicaid
Services (CMS) have identified seclusion and restraint as core quality measures
in hospital-based psychiatric treatment.
In the spring of 2005, Acadia Hospital, a provider of behavioral health and addictions treatment, launched a performance improvement initiative designed to reduce the incidence of mechanical restraints. Borrowing principles from the Network for the Improvement of Addictions Treatment (www.niatx.net) and from the Institute of Healthcare Improvement (www.ihi.org), the hospital implemented rapid response teams which met within 24 hours of each restraint episode, seven days per week. These teams included both attending and "consulting" physicians, nurse managers, and social workers or psychologists. The response team's purpose was to identify interventions which would reduce the likelihood of an additional restraint episode in the same patient. Using a rapid cycle change model, the hospital implemented the response teams for three weeks and then studied the results to determine whether or not the intervention should be continued.
The results were dramatic. Over a three-week period the mechanical restraint rate decreased from 21 restraints per 1,000 patient bed days baseline (calculated over previous 12 months) to 14 restraints per 1,000 patient bed days. The rapid response teams continued over the next 6 months with the restraint rate holding at or below 14 per 1000 bed days.
Implementation of the rapid response teams involved a significant work redesign in terms of organizing a meeting of 6 busy providers within a limited time frame, and encouraging consulting physicians to actively intervene with a patient in lieu of the attending physician. The response teams also provided a unique forum for timely changes in treatment that were driven by patient behavior rather than fixed treatment plan review schedules.