Reducing Injury During Restraint by Crisis Intervention in Psychiatric Wards in Singapore

The application of restraints during psychiatric crises is a serious adverse event. We aimed to reduce the number of injuries sustained by patients during the application of restraints.

Structured interviews were conducted with 10 staff to determine six root causes of patient injury during restraint. Three plan-do-study-act cycles were implemented: (1) reorganising shift rosters to pair trained staff with inexperienced staff, (2) holding monthly session for practising de-escalation and restraint techniques as a team in a supervised setting, and (3) rotating the responsibility for leading the de-escalation in real crises.

Pre-intervention period was from January 2014 to December 2014 (28 251 inpatient bed days). Intervention period was from January 2015 to March 2015 (7121 inpatient bed days). Post-intervention period was from April 2015 to December 2016 (51 735 inpatient bed days). Data extracted included the dates and numbers of crises, activation of the crisis team, use of restraints, and injuries. During pre-intervention and intervention periods, only two minor and three moderate injuries were recorded. During post-intervention period, no injury was recorded and the number of restraints decreased gradually although the number of crisis team activations increased in the early phase. Eventually restraints were used only upon arrival of the crisis team.

Our quality improvement project identified six root causes and implemented three plan-do-study-act cycles to successfully eliminated patient injuries during the use of restraints.