Novel Program Cuts Aggression in Psychiatric Inpatients

Pauline Anderson

May 23, 2017

SAN DIEGO, California – After nurses and other staff were trained in trauma-informed care, the number of aggressive events by inpatients in an acute care academic psychiatric hospital was dramatically reduced, researchers report.

Reducing aggressive events and resulting seclusions may contribute to a safer and more therapeutic environment for recovery.

Although it is not clear why, violence in healthcare settings is on the rise, and psychiatric hospitals are looking for ways to optimize and maintain safety on their units, Luke Misquitta, MD, Department of Psychiatry and Behavioral Health, the Ohio State University, Columbus, told Medscape Medical News.

Dr Luke Misquitta

The findings were presented here at the American Psychiatric Association (APA) 2017 Annual Meeting.

Dramatic Decrease

It is increasingly recognized that patients with schizophrenia or bipolar disorder have experienced some sort of trauma in their life. Causes of such trauma are numerous and may include the theft of belongings or a physical assault while living on the streets.

Use of seclusion and restraint for violent patients in psychiatric hospitals incurs substantial risk but may be necessary to maintain safety during behavioral health emergencies. Training in trauma-informed care may improve the handling of a violent event.

Starting in 2013-2014, clinical staff at a 73-bed psychiatric hospital participated in the National Center for Trauma-Informed Care (NCTIC) and Alternatives to Seclusions and Restraint, recommended by the Substance Abuse and Mental Health Services Administration (SAMHSA).

According to the SAMHSA website, trauma-informed approaches are designed to address the consequences of trauma in the individual and to facilitate healing. The NCTIC supports approaches that eliminate the use of seclusion, restraints, and other "coercive practices."

The study included patients aged 6 to 88 years who were admitted to the adolescent and adult units. The hospital admits some 3000 patients every year; among those admitted, the number of aggressive episodes ranges from five to 47 in any given month.

The analysis showed that trauma-informed care was associated with an 80% reduction in the number of physical assaults and a 72% reduction in the number of aggressive incidents.

The greatest reduction in aggressive events occurred on the adolescent unit, said Dr Misquitta.

"Putting both the child and adult units together, we had a decrease from about 42 aggressive events per 1000 patient days down to six events per 1000 patient days," he said.

The researchers also assessed episodes of adolescent seclusion, in which violent patients are put in a locked room that contains nothing with which they can harm themselves.

Following a "big spike" in episodes around the time the training started in October 2013, seclusions "went down markedly" as the training continued, said Dr Misquitta.

Overall, the number of episodes and hours of seclusion among patients has been reduced by 68% since implementation of trauma-informed care.

Dr Misquitta said the training changed the overall tone on the hospital's units.

"Our staff members are better able to connect with patients. With patients who have a history of trauma, they are able to take that into consideration and connect with them better. And in patients who are at higher risk of violence, they're better able to recognize those signs early."

As well, as a matter of course, staff members review each episode of aggression to learn how to improve their approach in future.

Although the training likely contributed to the reduction in aggressive episodes, some of the success may be due to the recent redesign of the units, said Dr Misquitta. Staff have incorporated such things as "comfort plans" and "comfort boxes" to help minimize the triggering of violent behavior.

A Step in the Right Direction

Commenting on the new research, Col. (retired) Elspeth Cameron Ritchie, MD, a clinical and forensic psychiatrist with experience in caring for violent patients, said that "overall, the trend is in a positive direction."

Trauma-based care "is a bit of a buzz word" these days, said Dr Ritchie. "There has been a lot of discussion about trauma-informed care, so not just treating patients with medications but also understanding the role that trauma may play for them."

Recently there has been an emphasis "across the board" on avoiding the use restraints, said Dr Ritchie, who at one time was chief medical officer of the Department of Behavioral Health in Washington DC.

What is not clear to Dr Ritchie is how training in trauma-informed care changes the way nurses and others deal with violent patients.

"You can be sensitive that someone may have been assaulted before and therefore not want to recreate the assault, and restraints especially can be perceived as being very assaultive, but the challenge becomes deciding what to do instead."

She pointed out that even without special training, nurses learn on the job how to deescalate a situation, how to calm down a patient in a dignified and respectful way, and how to give them the "space" they need.

No relevant financial relationships have been disclosed.

American Psychiatric Association (APA) 2017 Annual Meeting. Abstract P3-143, presented Sunday May 21, 2017.


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