Code De-Escalation: Effectiveness and Feasibility Pilot Study of Intervention to Decrease Restraint Use and Health Inequities in Agitation Management in a Community Hospital Emergency Department

ABSTRACT

Study Objectives: Restraint use in the emergency department (ED) has been shown to pose significant physical, psychological, and medicolegal risk to both patients and health care workers. Recent studies have demonstrated racial disparities in restraint application in the ED setting. This study aimed to evaluate the effectiveness of Code De-escalation, a standardized team-based approach for agitation management and assessment of perception of threatening behaviors, in reducing restraint use and racial disparities in restraint application in a community hospital emergency department. Study Design/Methods: We performed a retrospective observational study of the effect of introduction of the Code De-escalation pathway on violent restraint use among ED patients who had been placed on an involuntary psychiatric hold in a community emergency department. This new pathway includes a built-in step for the team members to systematically assess the perception of threat related to the patient behavior and the threat perceived by the patient. We used a Chi-squared test to compare incidence of restraints per ED encounter during the eight- month period after the intervention (May 2021-Dec 2021) with an eight-month period pre-intervention. We used a Cochran-Mantel- Haenszel test to look for differences in restraint use among racial and ethnic groups. To avoid confounding by the dramatic changes in patient volume and type during the peak of the COVID pandemic, we chose a pre-intervention period that pre-dated this (May 2019-Dec 2019). We compared our results to rates at neighboring community hospitals within the same hospital network during the same period. Results/Findings: Our sample size included 434 ED encounters pre intervention and 535 ED encounters post intervention. Over the study period, we observed a significant decrease in the violent restraint use among patients on an involuntary psychiatric hold from a rate of 7.4% to 3.7% (p=0.02). This was despite an overall increase in the number of patients requiring an involuntary psychiatric hold over the same period. This decrease was observed across all racial and ethnic groups. The same decrease in violent restraint use was not observed at the two other community hospitals within our hospital network and in the same metro area. Conclusion(s) A standardized de-escalation algorithm may be an effective tool in helping EDs decrease their use of restraints and may be one tool to help close the racial gap in restraint use among patients experiencing agitation. * Note Dana Im and Alice Bukhman contributed equally to conception and writing of this No, authors do not have interests to disclose Copyright © 2022