The first thing that greets a visitor to the Child Inpatient Unit at Sheppard Pratt Hospital is the silence. Considering that among 16 patients, there are generally at least 11 children present with some form of disruptive behavior disorder, the lack of noise is positively astonishing. But it is no accident. Staff on the unit, under the direction of Service Chief Michael Bogrov, M.D. and Unit Manager Marty Spence, R.N., LCSW-C, have been making major changes in the milieu.
Sheppard Pratt Health System has been in operation since 1891, and its child inpatient units in operation since 1978. Sheppard Pratt now operates two campuses and hospitals, one in Towson and one in Ellicott City, Maryland. The Child Inpatient Unit in Towson serves children ages three through 11. The most commonly diagnosed disorders are Bipolar Disorder, Attention Deficit Disorder, Reactive Attachment Disorder, and Posttraumatic Stress Disorder. Last year, the Child Unit had 437 admissions and provided 5,206 inpatient days. Some 41 percent of all child inpatient psychiatric admissions in Central Maryland are served by this unit. The Child Unit also serves as a training site for two child psychiatry fellows who are among the 90 residents within the joint Sheppard Pratt and University of Maryland residency program. Sheppard Pratt is in the process of applying for magnet status to certify the leadership position it holds.
When Dr. Bogrov first came onto the childunit, he found that a variety of systemic pressures had compromised the provision of treatment. Reimbursement pressures and shortened lengths of stay had minimized staffing ratios and allowed less time to build relationships with patients and families. More stringent admission criteria and reduced outpatient support systems had resulted in higher levels of distress and aggression and disorganization among the admitted patients. More than 35 percent of the youngsters served by Sheppard Pratt’s inpatient child units come from the most disadvantaged areas of inner city Baltimore, and 60 percent of the care is funded through the public mental health system (Medical Assistance). Several years ago, it became clear that the milieu on the unit demanded improvement. Instances of seclusion were very high. Staff were reluctant to select employment on the unit and family members and custodial agencies were vocal about their concerns. Consequently, Dr. Bogrov and Ms. Spence set to work to implement strategies that would result in an improved milieu. They chose two statistical areas to measure success: a reduction in the rates of seclusion and restraint, and a reduction in the rates of staff injury. But also considered were the anecdotal analysis of staff satisfaction and morale. There were several areas on which staff focused to achieve their goals: (1) modification of the physical space; (2) deployment of staff to maximize therapeutic effort; (3) staff development and training in aggression management; and (4) implementation of a child centered, behavioral philosophy.
An immediate issue was that of boundaries. As more acutely ill children were admitted, their illnesses and behaviors produced a contagion effect of disruption. A high number of staff was needed to manage this phenomenon. One very successful intervention, based on the need for boundaries and manageable space, was to divide the unit by means of a safety-glass door. Acute and subacute areas were immediately created and the contagion effect was greatly diminished. A more generalized effect of the door was the diminished ambient sound of the unit. This decrease in sound enhanced the overall sense of calm for both the children and the staff. In the acute unit, chairs and tables were removed for safety, while in the subacute unit, heavy sand bag chairs were set up. The weight of these chairs, and the fact that they were always to be found by children in the same location and arrangement, created a sense of permanence.
Other physical plant changes included the construction of cabinetry for books and shoes to which the children had access, a step for the children to use to reach the nurse’s window during the administration of medications, and an extension of the nurse’s station to create a clearer limit for the children. Staff set out to make the unit one which the children could identify as their own. Thus, paintings, drawings, and sculptures that children produced adorn the walls of the unit and also the space opposite the elevators when coming onto the ward. Certain works of art were made into notecards which are for sale by the Hospital Auxiliary (firstname.lastname@example.org). Staff quickly found that the peacefulness or turmoil on the ward could be measured by the degree to which the art work remained respected and untouched.
Another intervention was the use of electronic equipment to enhance safety and communication on the unit. Dr. Bogrov acquired handheld walkie-talkies and a video and audio monitoring system to provide coverage of key areas. These devices promptly abolished yelling when it came time to summon clinicians. And the availability of staff improved a sense of cohesiveness and morale. Attention was also paid to staffing assignments. For example, a “floater” clinician, rather than the therapist himself, would engage in any needed intervention with a child in group therapy so that the treatment with other children could continue.
It was apparent that the children had difficulty around the change of shift and the evening activities. While specific programming was developed to address these critical times, the children did not respond as well as was hoped. Therefore, a different effort involved staggering the hours over which the staff changed, so that more staff were available over critical times and the children were not exposed to wholesale shift changes. A chief priority for staff training was aggression management. Participants in this training included all clinicians, including physicians. The number of staff who became certified as aggression management trainers increased sevenfold.
Consumer feedback was utilized as part of continuous quality improvement. For example, the patient courtyard and playground were added as a result of parent input. This secure facility, visible from the windows of the unit, is a lovely grass and gravel space with a large, mature tree in the center. The courtyard allows for recreation of staff and families. Visiting hours were modified in response to family sentiments. In addition, families now participate in family therapy three times weekly.
Positivism became a watchword in creating a therapeutic milieu and behavioral program. Instead of indicating to children what they should not do, staff became skilled in saying what was expected; i.e., “It’s good you could wait your turn to speak.” A child yelling at a staff member would be told, “I really like it when you speak to me nicely.” An effort was made to communicate with children. An orientation handbook was rewritten from the child’s perspective. It has a word search puzzle in it for all the names of staff, and expectations of behavior spelled out instead of prohibitions.
Dealing with an upset child is always a crisis point, and Dr. Bogrov and staff have tried to make sure that critical moments are diffused not by the staff asserting control, but by the staff assisting the child in his or her efforts at controlling emotions. Now, when a child becomes agitated, staff acknowledge the child’s feelings but clarify that it is up to the child to resolve his or her own distress. For instance, “calming boxes” were created. A distressed child can ask for such a box which contains such items as a CD player or art materials. Using some behavioral techniques, children are given stickers which comment on positive things they have done such as “I kept my hands to myself today.”
In the arena of seclusion, locked door seclusion was replaced with an unlocked “quiet room” in which children are given large options over their release. Over the last three year period, instances of seclusion among patients were reduced from .232 per patient day or 1,136 events (based on 4,903 patient days) to .038 or 186 events, a reduction of 84 percent. Instances of assault on staff decreased from 24 reported assaults on staff per quarter, to three reported assaults per quarter, a reduction of 87.5 percent. Staff injuries decreased from 12 resultant staff injuries per quarter to one staff injury. Staff morale increased dramatically, while staff turnover almost ceased. Presently, there exists a rich complement of staff for the 16 bed unit. In addition to psychiatrists, nurses, and mental health workers, there are designated social workers, a discharge planner, a diagnostic and prescriptive teacher, an occupational therapist, and a part-time substance abuse counselor.
All members of the team, including housekeeping, are asked to join in staff meetings and these meetings are held on the unit in view of children. Dr. Bogrov knows and greets every member of his staff as they come onto the unit. He knows and greets the children as well. Opening the door to the kitchen, he says good morning to the assembled children. They are all eating quietly. One could not guess the extent of the marked emotional difficulties for which they are presently hospitalized.