Improving the Standard of Care in the Management of Agitation in the Acute Psychiatric Setting

INTRODUCTION: In 2016-2017, assault and restraint rates on the involuntary inpatient psychiatric unit in an academic medical center in northeast United States were highest for the seven behavioral health hospital networks. Organizational assessment identified inconsistent implementation of Best Practices in Evaluating and Treating Agitation (BETA) guidelines, adopted in 2014. Contributing factors: 50% of nurses hired in 2016-2017 had 5 years or less nursing experience. Newer nurses might lack confidence managing escalating agitation until more restrictive containment is necessary. AIMS: The aims of this 8-week quality improvement project were (1) to determine if Brøset Violence Checklist (BVC) education improved documentation of BETA interventions from pre- to post-project, (2) to reduce restraint rates by 5% or greater, and (3) to improve registered nurses’ attitudes regarding the use of violence risk assessment tools. METHODS: Retrospective restraint documentation was audited 8 weeks prior to project. Patients were assessed using the BVC twice daily for first 72 hours of admission. BVC checklists and electronic health record documentation were audited for BVC scores above 2. The author and nurses involved in each restraint reviewed documentation improvement opportunities. Pre- and post-BVC intervention surveys assessed nurse attitudes regarding violence risk tools. RESULTS: Outcome measurement included electronic health record documentation showed improvement reflecting BETA interventions; 6.5% reduction in restraint rates during the intervention; and improvement in attitudes regarding violence risk assessments. CONCLUSIONS: BVC agitation assessment in conjunction with BETA guidelines supports proactive management of violence risk, improving the standard of documentation and care.