Physical restraint for children who have behavioural health related issues

Abstract

The Archivist has never supported physically restraining angry or violent and emotionally charged children in the emergency department or on the ward. Unfortunately there may be situations where it is felt the only option. Many units will have a physical or chemical restraint guidelines which always causes controversy and most clinicians and nurses, when discussing options with the parents and trying to engage the child, do not find it easy to instigate. Dalton E M et al (Pediatrics 2021;148:e2020003939) have tackled this issue and provide some excellent advice and suggestions on how to prevent the need for restraint. Children with primary behavioural health conditions are presenting to children’s hospitals with increasing frequency and can be a major challenge in the inpatient environment. There may well be no immediate child psychiatric bed available so they are admitted to a paediatric ward while awaiting psychiatric assessment and admission to the psychiatric unit. The ward staff has to balance the safety of the children and the hospital staff while trying to deescalate the situation. If there is a high risk of selfharm or injury to staff members or other children and families then the child or young adult can be placed in physical restraints to reduce the risk of violence to themselves and others. This group used quality improvement methodology to decrease physical restraint use on children admitted to their children’s hospital for behavioural health conditions They included all children over 3 years of age who had been admitted to their hospital medicine service with a primary behavioural health diagnosis from 1 July 2016, to 1 February 1 2020. The cohort included 3962 consecutive behavioural health patient encounters, encompassing a total of 9758 patient days. They formed a multidisciplinary team, in July 2018, tested interventions based on key drivers targeted toward their aim. A 2 year baseline revealed physical restraint orders placed on 2.6% of behavioural health patient days, which was decreased to 0.9% after interventions and has been sustained over 19 months without any change in staff injuries. Their driver diagram illustrates the six core strategies in this bundle. They used a standardised deescalation protocol based on the Brøset Violence Checklist (Brøset) which is a 6item checklist used to assess the presence of 6 independent behaviours to help predict the risk of imminent violent behaviour over the following 24 hours. This was one of the Six Core Strategies of restraint reduction which was their overall strategy; an improved deescalation protocol using the Brøset scoring, introduction of a behavioural health admission policy, the creation of a multidisciplinary behavioural team and they restructured the behavioural health team staff meetings, they created individualised health treatment plans and an updated their toy and activity reward system. So using this teambased quality improvement methodology there was a sustained reduction in physical restraint use on children admitted for behavioural health conditions. Physical restraint use can be safely reduced. Is it a potential problem on your wards?