1. Transforming a Culture of Patient Safety: Reducing Restraint and Seclusion Jennifer M. Brown, M.S., CTRS and Jane Le Vieux, PhD, LPC-S, RN-BC Children’s Medical Center – Dallas Center for Pediatric Psychiatry Background Children with both medical and psychiatric diagnoses represent a vulnerable population, at risk for being misunderstood and mismanaged in medical settings. Chart audits revealed an increase in the number of behavioral restraint events and a decrease in meeting documentation standards. The management and documentation of behavioral restraint and seclusion events requires specific steps and documentation by both the provider and the nurse. There are over 56 specific standards to be met. Initiative and project design In 2010, the results of a convenience/opportunistic sampling of the healthcare professionals at Children's Health using the Attitudes toward Mental Illness in Pediatric Patients Scale resulted in the formation of the High Risk Behaviors Clinical Practice Workgroup. The workgroup consists of direct care staff, operational leaders and clinical educators and nurse specialists from Acute Care Services (ACS), Emergency Services (ES) and psychiatry services. Interventions were created to increase the knowledge base, training and comfort level of the staff caring for pediatric patients with mental illness. The complexity of the documentation standards was also identified as a problem and interventions were designed at simplifying the process, increasing expert support, and providing tools to support compliance. Data was captured for a three year period that tracked restraint and seclusion events in all areas of the hospital and compliance with management and documentation standards. Problem areas noted prior to 2011:  Physician compliance of face to face evaluation within 60 minutes of initiation of a restraint or seclusion event  Nursing compliance of the q 15 minutes documentation  Physician order within one hour of a restraint or seclusion Innovation  Understanding the attitudes and perceptions of clinical staff and providers towards children with mental illness prior to developing interventions.  Providing the support of 24/7 Restraint and Seclusion Resource Specialists (RSRS) to support staff and providers in real time for these low volume high risk events throughout the hospital. Countermeasures were developed to address the following: Knowledge Base  High Risk Behavior (HRB) Badge Buddy for Psychiatry Fellows  Behavioral Restraint Checklist Job Aids  HRB Standards of Care for Acute Care Services Job Aid  HRB Resource Guide  Monthly restraint/seclusion compliance graphs distributed to the ES, ACS and Psychiatry operational leadership Training  Psychiatry Consult Service Rounds with Medical/Nursing Team  Created Emergency Services “super-users”  Optimization of the EMR to prompt appropriate order writing and documentation  Increased volume of staff attending PPMAB annual instruction  Increased education on de-escalation techniques Comfort Level  HRB Documentation tip sheet  Promotion of restraint training for all clinical staff within the ACS and ES  24 /7 telephone consultation availability with a restraint/seclusion resource specialist (RSRS)  Auto-paging to a RSRS when an Emergency Department restraint order is entered in the EMR Lessons Learned Creating an organizational culture to reduce the number of restraints, along with compliance with regulatory requirements and hospital policy encompassed changing attitudes. In 2014, we had 112 events which yielded a 99.1 per cent compliance rate. Recruiting the members of the High Risk Behavior Clinical Practice Workgroup to become champions within their own units gave credibility to the initiatives. Staff education, role modeling, training, and reducing the stigma of mental health contributed to the decrease in the number of behavioral restraint events Training, tip sheets, availability of 24/7 access to a restraint specialist, and optimization of the EMR contributed to the increase in adherence to policy and documentation standards for restraint events. Future of Initiative/Next Steps Future steps include continuing to find ways to effectively utilize the EMR to provide de-escalation strategies that are unique to individual patients in order to avoid restraint and seclusion events, and to prompt providers in the management and documentation standards. Establishing an effective debriefing process for providers and staff will serve to evaluate the event and serves to reinforce training regarding the standards.