Restraints and Seclusion: A Multimodal Approach to Improving Face-to-Face Documentation Compliance in the Emergency...

Regulatory bodies require the use of restraints and seclusion in health care settings to be strictly monitored and carefully documented. In our emergency department (ED), an internal audit uncovered low compliance with required patient safety documentation, the so-called "face-to-face (FTF)" assessment, within 1 hour of restraint or seclusion initiation. The primary objective of this quality improvement (QI) study is to evaluate a series of interventions as a mechanism to improve FTF documentation compliance.

This project was conducted in a single-site academic ED. Patients requiring restraints and seclusion application from November 2021 to June 2024 were included. We implemented 3 plan-do-study-act (PDSA) cycles: (1) development of FTF documentation flowsheet with delayed best practice alert (BPA) trigger, (2) direct audit and clinician feedback via email, and (3) modification to immediate BPA trigger. Our primary outcome was a change in the rate of FTF documentation completion within 60 minutes of restraint or seclusion application. We used descriptive analysis to evaluate adherence rates.

There were 856 qualifying instances during the study period. Our intervention bundle was associated with an increase in documentation adherence from a preintervention baseline of 10.96% to a final performance of 81.28%, an absolute increase of 70.32% ( P <0.001).

Our series of interventions, including direct feedback and technical solutions, was effective in increasing clinician FTF documentation adherence. By deploying these interventions iteratively, our approach supported practice change and behavioral modification among ED clinicians, highlighting the importance of an incremental process in changing practice and culture.