Best Practices: Safety Guidelines for Injury-Free Management of Psychiatric Inpatients in Precrisis and Crisis Situations

TVBH benchmarks the quality of its services with national standards and the other four regional, state-operated, psychiatric ODMH hospitals. In the fall of 2003, TVBH determined that its direct care staff was experiencing a disproportionately higher rate of lost workdays as a result of staff injuries; 90% of the injuries were related to staff-patient physical-contact interventions, and 50% were specifically related to use of the patient restraint process. To reduce staff injuries, TVBH developed the Safety Guidelines for Injury-Free Management of Patients in Precrisis and Crisis Situations. The guidelines' safety rules were implemented in 2004 with multimedia training sessions and incorporated into TVBH policies with an agency logo: "Working Smart=Working Safe." This logo was incorporated into all TVBH orientation, educational, and training documents and serves as the initial sign-on wallpaper for all staff desktop computer workstations. [A graphic of the logo is available in an online supplement to this column at ps.psychiatryonline.org. ]

Each year TVBH staff are interviewed and surveyed to obtain input for effectiveness to update the guidelines. During the period 2004–2008, the number of staff injuries, incidents defined as recordable by the Occupational Safety and Health Administration (OSHA), and the number of individuals with lost workdays were recorded and analyzed.

The TVBH quality assurance office aggregates and analyzes all incidents. The quality assurance patient safety coordinator monitors all reports for any incidents related to patient or staff injuries and ensures that all incident reports are accurate, complete, and comprehensive. The safety and health inspector and personnel from the Human Resources Department manage the records and procedures for individuals with lost workdays. Other productivity outcomes measured were reduction of restraints and seclusions, use of emergency medications, and use of precrisis interventions to de-escalate events.

TVBH staff safety performance outcomes showed that the number of staff injuries decreased 90%— from 91 injuries in 2004 to nine injuries in 2008. Incidents defined as OSHA recordable declined by 77%—from 40 to nine. The number of individuals with lost workdays decreased 77%—from 22 to five. In addition, there was a significant positive impact on patient care: episodes of restraint and seclusion were reduced by 36% (from 301 to 191) during this period. The number of patient complaints fell by 37% (from 291 to 181), and the need for codes for staff to assist in a psychiatric emergency (announced over the public-address system) was reduced by 25% (from 346 to 259).

Safety guidelines can be implemented effectively for the injury-free management of patients both before and during a crisis. The implementation of TVBH's safety guidelines helped staff members to stop saying, "Getting hurt is part of the job." Instead, they now say, "No, getting hurt is not part of the job." TVBH continues to foster a culture of safety and a culture of learning actualized by a team approach to staff and patient safety. If our observations are borne out in controlled research studies, then these safety guidelines will become a "best practice."

The authors are affiliated with Twin Valley Behavioral Healthcare (TVBH), an inpatient facility of the Ohio Department of Mental Health (ODMH), 2200 W. Broad St., Columbus, OH 43223 (e-mail: [email protected]). Mr. Short is chief executive officer, Dr. Raia is psychology director, Ms. Bumgardner is clinical nurse specialist and director of staff training and education, Mr. Chambers is safety and health inspector, and Ms. Lofton is quality assurance and performance improvement director, all at TVBH. Dr. Sherman is medical director of ODMH. William M. Glazer, M.D. is editor of this column.