Some of the key players in this project, from left to right: Gail Perry-Estime, clinical nurse; Francesca Jean, clinical nurse; Robin Kahn, clinical nurse; MaryJoy Adverderada, MSN, RN-C, nurse manager (now retired); and Kenneth Larock, nurse practitioner.
“Vision Zero” is New York City Mayor Bill de Blasio’s campaign to reduce pedestrian deaths to zero by improving traffic safety. Kenneth Hung, MD, Assistant Clinical Professor and Director of the Psychiatric Emergency Department at Mount Sinai Hospital, decided to create his own vision zero based on the mayor’s model. The goal? To completely eliminate the use of four-point restraints in the Psychiatric Emergency Department.
Background
As the hospital’s main access point for patients with psychiatric emergencies, the Psychiatric Emergency Department team treats a disproportionate number of our most highly agitated or violent patients. For the patient’s safety and the safety of hospital staff, four point restraints (securing wrists and ankles to the bedframe) have historically been used to manage very agitated patients. This is extremely traumatizing for both the hospital staff and the patient and can also lead to injury due to thrashing.
Leaders of the New Standard
To mitigate this situation, regulatory bodies such as the Joint Commission are pushing for a drastic decrease in the use of these restraints—and Mount Sinai Hospital has met these goals before any other psychiatric emergency departments in New York City. The department went from an average of 22 restraints per year between 2006 and 2012 to 7 in 2013, and an average of 1 per year thereafter (with zero in 2016). At the American Psychiatric Association’s annual meeting in May, Dr. Hung presented the multi-year process his department underwent to achieve this.
Data presented at the American Psychiatric Association’s annual meeting in May.
Transforming the Culture
To incorporate a culture of safety, four main changes were implemented:
- Regular Crisis Prevention Institute training for all staff.
- Modifying the clinical environment; specifically, redesigning the room to a layout conducive to walking off anger.
- Constructing a padded seclusion room for extreme cases so the patients can’t hurt themselves.
- Emphasizing early intervention including verbal de-escalation techniques and medication.
“The few cases of restraint use in the past five years have been for truly extreme circumstances and only as a last resort,” said Dr. Hung. “The success of this new ‘vision zero’ goal has really improved team morale, and we are continually looking for new ways to improve our processes.”