Evaluating adolescent outcomes and staff member injuries following treatment on a general psychiatric inpatient unit

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Romani, Ava Anjom, Tyler Anderson, Merlin Ariefdjohan This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-3617156/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Brief psychiatric hospitalization represents an intervention used to manage acute crisis behaviors (e.g., out-of-control behavior; suicidal ideation) exhibited by children and adolescents. To date, few studies have presented their clinical model of care in addition to key outcome metrics, such as patient outcome and staff injury. Studies sharing this type of information could provide descriptions of desperately needed clinical models to ensure that standards of care for both patients and staff are met on psychiatric inpatient units. The purpose of the current study was to describe one unit’s clinical model emphasizing group therapy grounded in the principles of dialectical behavior therapy within a brief psychiatric inpatient admission (mean length of stay = 8 days). We provide outcome data on patient symptoms of depression, anxiety, and anger upon discharge from the hospital, patient satisfaction with the hospitalization, and staff member safety on the unit. This programming produced statistically significant changes in adolescent symptoms of depression, anxiety, and anger at the time of discharge from their brief psychiatric hospitalization. Patients also reported a high level of satisfaction with the services received. While these outcomes were promising, we recorded a high rate of staff member injury while delivering care. We were unable to identify a patient profile that contributed to staff member injury but did identify relations between staffing ratios, time of day, and staff member injury. We hope to share this information in an attempt to provide additional evidence regarding the effectiveness of these brief inpatient programs as well as to draw awareness to variables that may influence staff member experience on these units. Dialectical Behavior Therapy psychiatric inpatient unit psychological assessment and staff member injury Introduction There is a high prevalence of psychiatric disorders among children and adolescents globally, with an estimated number of cases reaching approximately 7.7 million in 2016 in the United States alone 1 . For some of these individuals, emergent psychiatric services will be necessary. Psychiatric hospitalization is essential for establishing safety and stability when these individuals experience an acute episode of psychiatric crisis. Psychiatric crises might include suicidal ideation, homicidal tendencies, and out-of-control behavior 2-6 . Over the past 20 years, research documented increased use of psychiatric hospitalization, with depressive disorders accounting for almost half of all psychiatric admissions 3,7 . In sum, psychiatric hospitalization is an essential and highly utilized mode of treatment for youth experiencing a psychiatric crisis. While necessary, treatment on psychiatric inpatient units (PIU) is costly, which contributes to the large economic burden associated with treatment of mental health disorders 3,8-10 . In trying to find a compromise between the cost of hospitalization and its benefits towards patients’ recovery, the average length of stay in an inpatient unit has been reduced from an estimated 12.8 days to approximately 7-9.6 days between 2006 and 2012 11-12 . Thus, PIU providers are tasked with managing the most challenging mental health problems in a short amount of time. In addition to treatment constraints, there is a paucity of research on effective treatment modalities to use on PIUs. The arguably most researched modality of group-based treatment delivered on PIUs is grounded in the principles of dialectical behavior therapy (DBT) 13-14 . DBT is an evidence-based treatment for youth suicidal ideation, aggression, and personality disorders 15-16 . Patients receiving DBT learn strategies related to emotional regulation, distress tolerance, mindfulness, and interpersonal effectiveness via individual or group therapy. Given the short lengths of stay in PIUs, most units incorporate aspects of DBT into their group-based treatments. To evaluate the impact of integrating DBT onto a PIU, one research group compared a “treatment as usual” group to a DBT treatment group 13 . These researchers showed significantly lower self-reported symptoms of depression following inpatient treatment with DBT. Other researchers have documented similar findings 14 . Thus, it seems that group-based treatment that incorporates aspects of DBT reduces self-reported symptoms of depression, anxiety, or anger on PIUs. While patient symptoms gradually improved over their PIU admission, direct-care staff providing the majority of treatment need to sometimes manage assaultive behaviors, like aggression or self-injury 17 . Managing these assaultive behaviors may involve risky procedures like restraint and seclusion, which have been shown to significantly relate to staff member injury occurrence 18-19 . Staff member injuries represent a complex problem for hospital settings 20 . Injuries affect staff morale, staff retention, and can be quite expensive 21-22 . For example, one study showed that staff injuries accounted for 2% of one hospital’s budget 17 . A growing evidence-base of research shows staffing patterns 23 , use of behavior management programs 19,24 comprehensive staff training programs 25 , use of protective equipment 26 , and being mindful of patient diagnosis 27 relates to staff member safety. However, most of this research comes from adult PIUs. There needs to be more research understanding the prevalence and potential causes of injuries on pediatric PIUs. In summary, it seems that implementation of group therapy grounded in the principles of DBT on a PIU results in positive patient outcomes. Despite this important finding, PIU staff injuries are still reported to occur at unacceptable rates. Limited research exists on the occurrence and conditions under which injuries occur on pediatric PIUs. Thus, the purpose of this study was two-fold. First, we describe one PIUs treatment programming model and the resulting outcomes on patient self-reported symptoms of depression, anxiety, and anger. Second, we evaluated the conditions leading to staff member injury over a 1-year period. We hope that these two pieces of data will support continued description of PIU models of care as well as an understanding of expected patient outcomes and variables related to staff member injury. Methods Participants and Setting The PIU operated within an urban academic medical center providing specialized psychiatric care for adolescents experiencing psychiatric crises (e.g., following a suicide attempt). Clinical procedures took place on an 18-bed inpatient unit. The unit afforded each patient their own bedroom. Common programming areas included three classrooms (approximately 20 to 30 m 2 in size housing two tables and at least 10 chairs per classroom) and a cafeteria. Unit staff divided the classrooms by the age of the patients (i.e., tweens between 12 and 14 years of age; adolescents between the ages of 15 and 17 years). Patients averaged 15.4 years of age. Please refer to Tables 1 and 2 for additional demographic information about the patient population served on this PIU. The PIU was staffed by university faculty and hospital staff. The university faculty consisted of three psychiatrists and a psychologist. The hospital staff consisted of 45 direct-care staff (holders of bachelor’s or master’s degree in psychology or related field), 10 nurses (holders of bachelor’s degree in nursing), and three licensed behavioral health clinicians (master’s degree in professional counseling or social work). Dependent Variables Patient Outcomes. Patients receiving treatment on the PIU during the study period were asked to complete the Anger, Depression, and Anxiety Scales from the Patient-Reported Outcomes Measurement Information System (PROMIS). Patients responded to questions structured according to a 5-point ordinal scale about whether the item was never, rarely, sometimes, often, or always true in the past 7 days 28 . The anger scale measured angry moods, verbal aggression, and physical aggression 29 . The depression scale measured symptoms of depression, such as feeling sad 28 . Finally, the anxiety scale measured fear, anxious misery, hyperarousal, and somatic symptoms related to arousal 30 . A previous study indicated alpha-coefficient values of 0.90, 0.95, and 0.93 for the anger, depression, and anxiety scales, respectively, which collectively reflects a high degree of assessment reliability 31 . An additional study by the same author 32 indicated a strong convergent validity of the PROMIS anger, depression, and anxiety measures with other established measures of these domains of emotions 31-32 . These outcome measures were administered upon admission to the PIU and at discharge (either the night before or the morning of patients’ departure from the unit). Patients completed the Patient Satisfaction Inventory at the conclusion of their admission. The authors created this inventory to measure patient satisfaction with medication management, therapy services received as well as whether they felt that the skills learned during their admission would be helpful outside of the hospital. This inventory consisted of a 1 – 7 likert-type scale in which scores of 1 represented low satisfaction and scores of 7 indicated high satisfaction. Patients completed these questionnaires using a tablet computer as overseen by the unit psychologist or a psychology trainee. Assistance was provided if the patient struggled to read or reported being unable to understand the question. Staff Member Injury. The research team extracted pertinent data from the daily records collected by the Occupational Health Services department of the study site and from the clinic registry. These data included the number of staff and patients working on the unit throughout each day, frequency of restraint or seclusion usage, the number of staff member injuries, and the time each staff member injury occurred. Additional demographic information about the patients who injured the staff were gathered from the electronic medical record at the study site. Considering the complexity of the data extraction process, data entry integrity was ensured by having a second, independent observer auditing the work of the primary data coder. This second observer input data on each of the variables described above for 30% of days across each month of the study period. We defined exact agreement as when the primary data coder reported the same value for the dependent variables described above (e.g., number of restraints used each day) as the secondary data coder. A disagreement was defined as when the primary data coder reported a different value than the secondary data coder for the variables described above. The research team calculated agreement by dividing the number of agreements by the number of agreements plus disagreements and multiplying this quotient by 100 to produce a percentage. Agreement between the two observers was 100%. Procedures The PIU delivered interdisciplinary treatment by a child and adolescent psychiatrist, social worker, and psychologist. The psychiatrist evaluated each patient’s medication regimen as well as assisted with diagnostic conceptualization. The social worker provided family therapy and assisted with identifying after-care services for the families. The psychologist organized the DBT treatment each patient received on the Unit. The social worker and psychologist closely collaborated to ensure that the DBT material contacted by the patients could be integrated into the family therapy services. Prior to starting data collection on patient outcomes, the unit’s psychologist and social workers trained PIU staff to deliver the DBT groups. The training lasted 2 hrs and consisted of didactic presentation and role-play with coaching and feedback. The didactic presentation began by describing the history of DBT along with a description of the groups the unit would be conducting with patients (30 minutes). After this, the psychologist and social workers modeled one of the therapeutic groups (15 minutes). The trainers then provided all staff with a protocol of one of the DBT groups and divided them into groups of four. PIU staff took turns implementing the group according to the protocol, while either the psychologist or social workers provided feedback and support (60 minutes). At the end of the coaching period, the psychologist or social workers encouraged PIU staff to ask additional questions (15 minutes). DBT can have a lengthy course of implementation, which is not feasible for short-term PIU admissions. Thus, DBT programming at the study site was modified to selectively focus on learning about mindfulness skills, distress tolerance, and emotional regulation. The unit schedule incorporated one DBT group, a group led by an occupational therapist, and snack/meals during the morning. After lunch, patients visited with their families and then participated in a DBT and social skills group. Free time and snacks/meals occurred during the afternoon programing period too. During the evening, patients ate meals, visited with their families, and engaged in a wrap-up group that reviewed programming topics for the day. The Tween and Adolescent groups participated in the same activities but with their own groups. That is, patients assigned to the Tween group did not program with the Adolescent group. Patients began each group session by participating in a mindfulness activity (e.g., mindful eating, mindful exercise, and mindful coloring) as led by PIU staff. Afterwards, PIU staff conducted the assigned DBT group. The unit conducted DBT groups according to a weekly schedule. On Mondays, groups focused on introducing mindfulness and DBT to patients. Tuesdays and Fridays involved discussion of distress, identification of personally distressing situations, and formulation of coping strategies to manage distress using the six senses or other distraction strategies. On Wednesdays and Sundays, staff facilitated discussions on emotion regulation, including distinguishing negative emotions and antecedents to these emotions, recognizing positive attributes or experiences, and identifying and preparing to use various coping strategies. Finally, on Thursdays and Saturdays PIU staff reviewed dialectics to discern the existence of multiple truths to a situation as a way to reinforce positive behaviors and decrease maladaptive behaviors. Given the abbreviated nature of the PIUs DBT treatment, we collaborated with an outpatient team trained to deliver extended DBT programming to offer a step-down care approach to continue patient therapy following their discharge. Data Analyses Descriptive and inferential statistical approaches (e.g., count, percent frequency, mean ± standard deviation, paired t-test, MANOVA, Spearman correlation) were applied to summarize trends and determine significant differences in staffing, cases of restraint and seclusion, incidence of injury, and patient psychological scores, at admission to the PIU and at discharge from the PIU. All statistical analyses were completed using IBM SPSS Statistics for Windows (Version 26.0). Non-parametric approaches were applied when data did not show normal distribution. Significance level was set at p<0.05. All data analyses were performed on de-identified data and key findings were presented based on aggregate data. Results Patients Demographic and Clinical Profile Table 1 describes the patient population treated at the PIU during the study period (N=190). Briefly, majority of patients identified as female (56.3%), followed by male, transgender, and those preferring not to answer (at 33.2%, 4.7%, and 5.8%, respectively). These patients were mostly White/Caucasian (63.2%), identified as biracial/multi-racial (16.8%), or Black/African American (8.9%). Most of these patients also identified as not Hispanic or Latino (72.1%). The top three psychiatric diagnoses of these patients were Depression (68.4%), followed by Trauma and Stressor Related Disorders (9.5%), and Disruptive Behavior Disorders (7.9%). These patients were grouped as tweens (10 to 13 years old; 48.4%) and adolescents (14 to 17 years old; 51.6%). Further, approximately half of the patient population (56.8%) indicated that this was their first inpatient mental health admission (Table 2). Hospitalization for most of these cases lasted between 6 to 9 days (39.0%), or approximately 0 to 5 days (37.0%) (Table 2). Notably, there were fewer than 5% of cases who were hospitalized for an extended length of time (i.e., defined as longer than 20 days) (Table 2). Patient Psychological Outcomes (PROMIS Scores) Depressive scores at discharge were observed to be significantly lower than those at admission (59.3 ± 10.5 vs. 65.7 ± 10.0; t(148) = 8.2, p<0.001, d = 0.68). A similar trend was also observed for anxiety scores (56.2 ± 11.7 at discharge vs. 60.1 ± 12.2 at admissions; t(149) = 4.5, p<0.001, d = 0.37) and anger scores (51.8 ± 12.0 at discharge vs. 55.7 ± 11.9 at admission; t(148) = 4.2, p<0.001, d = 0.34). Interestingly, the clinical significance cut-off value for these domains is set at 60 (Kroenke et al., 2020). Thus, our data indicate that while the average scores for depression, anxiety, and anger were clinically elevated at admission (> 60), these dipped below the clinical threshold at discharge. Collectively, these trends indicated a marked improvement in depression, anxiety, and anger symptoms among patients resulting from their admission to the PIU at the study site. However, our analysis did not show any significant association between PROMIS scores and length of hospitalization ( F (12,320) = 1.12, p = 0.34; Wilk's Λ = 0.89, partial η 2 = 0.04). This suggests that length of stay at the PIU may not necessarily influence the extent of symptom change or benefit that the patient received from the program. Patients provided positive feedback towards their treatment at the PIU, whereby majority indicated receiving “excellent” or “good” care (39.6% and 45.8%, respectively), and that they “generally” (44.8%) or “definitely” (40.1%) received the type of help they needed. Trends of Staff Injury at the PIU During the study period, there were 129 instances of staff injuries caused by 41 patients (52.8% identified as male patients and 47.2% female). On average, these patients were 13.5 years old, 158.6 cm in height, 73.4 kg in weight, and had a BMI of 26.7. Our analyses indicated that incidences of staff injury were not significantly correlated to patients’ age (r = 0.47; p = 0.20), height (r = 0.03; p = 0.95), weight (r = -0.16; p = 0.71) or BMI (r = 0.06; p = 0.70). Further, we observed that staff member injury tended to occur the most during the mid-afternoon (75.0% of reported total injuries) than other shifts. However, our data did not indicate significant differences in daily staff-to-patient ratio during this particular shift (1500 - 2300; all p-values above 0.05). In contrast, data reflecting the evening shift (19:00 to 07:00) noted higher incidences of staff injury on days when there were fewer staff managing patients. Over the course of this study, we showed that usage of restraint and seclusion decreased slightly (13.8 hrs at the beginning of the year to 11.1 hours at the end of the year). This difference was not statistically significant (p = 0.24). However, the use of restraint and seclusion was significantly associated with occurrence of staff injury (c 2 = 17.4; p<0.001). There were fewer number of extensive staff injuries requiring reporting to the Occupation Safety and Health Administration (OSHA) when restraint and seclusion was not used to manage aggressive patient behavior than when it was used (12 incidences of staff injury vs. 14 incidences, respectively); but the difference was not statistically significant. Discussion The current study evaluated the effect of interdisciplinary PIU programming involving therapeutic groups that incorporated DBT material, medication management, and family therapy for adolescents between the ages of 12-17 years. We tracked patient outcomes via self-report measures of depression, anxiety, and anger at the beginning and end of their PIU admissions. Statistically significant decreases in patient reported symptoms occurred at the end of the hospitalization. Next, we looked at specific contributors to staff member injury and found that specific periods of the day were associated with a higher likelihood of staff injury and that injuries occurred more so when restraint or seclusion were used. The care received on this short-term PIU resulted in positive patient outcomes. Patients self-reported symptoms of depression, anxiety, and anger significantly reduced at the end of treatment. This PIU delivered DBT-based group therapy along with individualized family therapy and medication management. Previous research teams have documented the benefit of this type of therapy 13 . Our study matches their outcome data. However, a lack of a comparison group before the implementation of this model of care represents a limitation of the current study. The current research team began conducting standard outcome measures upon admission and discharge from the unit to permit evaluation of treatment outcomes 33 . Outcome measurement was not a standard part of practice on this inpatient unit beforehand. We advocate for more inpatient programs to integrate outcome measurement into psychiatric inpatient care to permit outcome studies to be conducted. We believe this will help with establishing best practices 34 . While our PIU produced positive patient outcomes, we did not observe a change in staff member injury over the study period. Previous research documents a direct correlation between use of restraint and seclusion and staff member injury 19 . We showed a significant relationship between use of restraint and seclusion and the combination of minor and major staff member injuries. That is, injuries occurred more often when restraint and seclusion were used. Interestingly, though, major injuries (i.e., OSHA reportable) alone did not seem related to restraint or seclusion use. These major injuries occurred equally when managing aggressive behaviors with or without use of restraint and seclusion. We did, however, document more injury occurrence during the overnight hours when less staff were present to manage patients. In these hours, there are often not structured programming tasks as patients visit with their families, engage in leisure activities, and go to sleep. For patients that do not sleep or struggle with leisure time, PIUs might consider having more structured activities for staff to implement with them. Additionally, when aggressive patients exhibit a pattern of not sleeping through the night, unit leadership might consider additional staff to ensure staff member safety. Another way to address staff member injury by targeting reduced use of restraint and seclusion could be by having and following structured behavioral treatment plans 19,35 . This unit’s schedule generally alternated between less- and more-preferred activities to encourage safe behavior and participation. However, it could be the case that individualized treatment programs may be needed for patients at risk of injuring others. For example, one research team showed a program that conducted individualized behavioral assessment to inform individualized behavioral treatment programs led to positive youth outcome as well as decreased staff injury 17,19 . Future research should evaluate if the addition of a program to design individualized behavior plans further suppresses use of restraint and seclusion and staff member injury on PIUs. The current study is not without its limitations. Outcome measures were not obtained prior to the implementation of new DBT programming. These data could have been helpful to track and compare symptomatology before and after the PIU admission. Given the retrospective nature of our analyses, it was not clear what the relative impact of DBT programming compared to medication management, being in a structured hospital environment, and family therapy was on patient outcomes. Future research should attempt to clarify these issues when conducting prospective research to understand how PIUs are helpful to adolescents and their families. Second, we were unable to administer these outcome measures after discharge from the PIU to evaluate maintenance of treatment effects. Third, due to the acute nature of the inpatient unit, the primary method of implementing DBT was in a group setting and skills-focused. Additional components of DBT (e.g., individual therapy) were not a standardized part of programming and could have provided further benefit. Implications for Behavioral Health Patients in need of psychiatric inpatient care represent a highly challenging population that demand considerable resources to effectively treat. Despite recognition of this challenge, there continues to be a paucity of research providing information regarding ways to work with this population as well as expected patient outcomes. The current study provides patient outcome data that showed the effectiveness of a model of care including DBT and other services from healthcare professionals. Additionally, this study provides descriptive information about the conditions under which staff member injuries occur. This PIU documented more injuries during restraint and seclusion usage as well as during evening and overnight hours. Other researchers and practitioners, alike, could replicate these analyses to determine when and how staff member injuries occur to develop matched interventions. Declarations Compliance with Ethical Standards All authors do not have conflicts of interest to disclose. This research was funded by the Clinical and Operational Effectiveness and Patient Safety (COEPS) grant from Children’s Hospital Colorado. All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. IRB approval was granted by the Colorado Multiple Institutional Review Board. This article does not contain studies with animals performed by any of the authors. Data Availability Statement The data that support the findings from this study are available from the authors, but restrictions apply to the availability of these data and so are not publicly available. The data are, however, available from the authors upon reasonable request and with permission from the healthcare organization in which the data were collected. References Whitney DG, Peterson MD. US National and State-Level Prevalence of Mental Health Disorders and Disparities of Mental Health Care Use in Children. 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Journal of Clinical Epidemiology . 2016;73:119-127. doi:https://doi.org/10.1016/j.jclinepi.2015.08.036 Pilkonis PA, Choi SW, Reise SP, et al. Item Banks for Measuring Emotional Distress From the Patient-Reported Outcomes Measurement Information System (PROMIS®): Depression, Anxiety, and Anger. Assessment . 2011;18(3):263-283. doi:https://doi.org/10.1177/1073191111411667 Pilkonis PA, Yu L, Dodds NE, et al. Validation of the depression item bank from the Patient-Reported Outcomes Measurement Information System (PROMIS®) in a three-month observational study. Journal of Psychiatric Research . 2014;56:112-119. doi:https://doi.org/10.1016/j.jpsychires.2014.05.010 Glick ID, Sharfstein SS, Schwartz HI. Inpatient Psychiatric Care in the 21st Century: The Need for Reform. Psychiatric Services . 2011;62(2):206-209. doi:https://doi.org/10.1176/ps.62.2.pss6202_0206 Leffler JM, D’Angelo EJ. Implementing Evidence-Based Treatments for Youth in Acute and Intensive Treatment Settings. Journal of Cognitive Psychotherapy . 2020;34(3):185-199. doi:https://doi.org/10.1891/jcpsy-d-20-00018 Carlson GA, Chua J, Pan K, et al. Behavior Modification Is Associated With Reduced Psychotropic Medication Use in Children With Aggression in Inpatient Treatment: A Retrospective Cohort Study. Journal of the American Academy of Child & Adolescent Psychiatry . 2020;59(5):632-641.e4. doi:https://doi.org/10.1016/j.jaac.2019.07.940 Tables Table 1. Demographic Characteristics of Sample Patient Population Characteristic n % Primary Admission Dx Depression 130 68.42 Anxiety 13 6.84 Disruptive Behavior Disorder 15 7.89 Bipolar and Related Disorder 8 4.21 Trauma and Stressor Related Disorders 18 9.47 Schizophrenia Spectrum Disorders 3 1.58 Eating Disorders 1 0.53 Other Dx 2 1.05 Total 190 100 Gender Identity Female 107 56.3 Male 63 33.2 Transgender 9 4.7 Prefer Not to Answer 11 5.8 Total 190 100 Race American Indian or Alaska Native 6 3.2 Asian 3 1.6 Black or African American 17 8.9 White 120 63.2 More Than One Race 32 16.8 Prefer Not to Answer 12 6.3 Total 190 100 Ethnicity Hispanic or Latino 37 19.5 Not Hispanic or Latino 137 72.1 Prefer Not to Answer 16 8.4 Total 190 100 Age Group TPU (10-13 Years) 91 48.43 APU (14-17 Years) 97 51.6 Total 188 100 Table 2 Admission Characteristics of Sample Patient Population Characteristic n % Admission Number 1 108 56.8 2 27 14.2 3 11 5.8 4 15 7.9 5 14 7.4 6 2 1.1 7 5 2.6 8 2 1.1 9 3 1.6 10+ 3 1.6 Total 190 100 Length of Stay (Days) 0-5 57 37.01 6-9 60 38.96 10-14 18 11.69 15-19 12 7.79 20+ 7 4.55 Total 154 100 Additional Declarations No competing interests reported. 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Romani","email":"data:image/png;base64,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","orcid":"","institution":"University of Colorado School of Medicine","correspondingAuthor":true,"prefix":"","firstName":"Patrick","middleName":"W.","lastName":"Romani","suffix":""},{"id":266681612,"identity":"58ba0a44-8feb-4140-ab48-0ff3775014a2","order_by":1,"name":"Ava Anjom","email":"","orcid":"","institution":"University of Colorado School of Medicine","correspondingAuthor":false,"prefix":"","firstName":"Ava","middleName":"","lastName":"Anjom","suffix":""},{"id":266681613,"identity":"89f90445-4cdc-4b59-a45d-7a51acf862a3","order_by":2,"name":"Tyler Anderson","email":"","orcid":"","institution":"University of Northern Colorado","correspondingAuthor":false,"prefix":"","firstName":"Tyler","middleName":"","lastName":"Anderson","suffix":""},{"id":266681614,"identity":"97f7ba14-1cba-4eda-8bd5-3d54b64c3b49","order_by":3,"name":"Merlin Ariefdjohan","email":"","orcid":"","institution":"University of Colorado School of Medicine","correspondingAuthor":false,"prefix":"","firstName":"Merlin","middleName":"","lastName":"Ariefdjohan","suffix":""}],"badges":[],"createdAt":"2023-11-15 21:59:15","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-3617156/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-3617156/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":58655441,"identity":"d5e90cd2-1356-4785-808b-fb57c605341f","added_by":"auto","created_at":"2024-06-19 11:19:57","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":429032,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-3617156/v1/1b50f86f-a95d-462e-96ec-f5bfc1f6d11d.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Evaluating adolescent outcomes and staff member injuries following treatment on a general psychiatric inpatient unit","fulltext":[{"header":"Introduction","content":"\u003cp\u003eThere is a high prevalence of psychiatric disorders among children and adolescents globally, with an estimated number of cases reaching approximately 7.7 million in 2016 in the United States alone\u003csup\u003e1\u003c/sup\u003e. For some of these individuals, emergent psychiatric services will be necessary. Psychiatric hospitalization is essential for establishing safety and stability when these individuals experience an acute episode of psychiatric crisis. Psychiatric crises might include suicidal ideation, homicidal tendencies, and out-of-control behavior\u003csup\u003e2-6\u003c/sup\u003e. Over the past 20 years, research documented increased use of psychiatric hospitalization, with depressive disorders accounting for almost half of all psychiatric admissions\u003csup\u003e3,7\u003c/sup\u003e. In sum, psychiatric hospitalization is an essential and highly utilized mode of treatment for youth experiencing a psychiatric crisis.\u003c/p\u003e\n\u003cp\u003eWhile necessary, treatment on psychiatric inpatient units (PIU) is costly, which contributes to the large economic burden associated with treatment of mental health disorders\u003csup\u003e3,8-10\u003c/sup\u003e. In trying to find a compromise between the cost of hospitalization and its benefits towards patients\u0026rsquo; recovery, the average length of stay in an inpatient unit has been reduced from an estimated 12.8 days to approximately 7-9.6 days between 2006 and 2012\u003csup\u003e11-12\u003c/sup\u003e. Thus, PIU providers are tasked with managing the most challenging mental health problems in a short amount of time. In addition to treatment constraints, there is a paucity of research on effective treatment modalities to use on PIUs. The arguably most researched modality of group-based treatment delivered on PIUs is grounded in the principles of dialectical behavior therapy (DBT)\u003csup\u003e13-14\u003c/sup\u003e. DBT is an evidence-based treatment for youth suicidal ideation, aggression, and personality disorders\u003csup\u003e15-16\u003c/sup\u003e. Patients receiving DBT learn strategies related to emotional regulation, distress tolerance, mindfulness, and interpersonal effectiveness via individual or group therapy. Given the short lengths of stay in PIUs, most units incorporate aspects of DBT into their group-based treatments. To evaluate the impact of integrating DBT onto a PIU, one research group compared a \u0026ldquo;treatment as usual\u0026rdquo; group to a DBT treatment group\u003csup\u003e13\u003c/sup\u003e. These researchers showed significantly lower self-reported symptoms of depression following inpatient treatment with DBT. Other researchers have documented similar findings\u003csup\u003e14\u003c/sup\u003e. Thus, it seems that group-based treatment that incorporates aspects of DBT reduces self-reported symptoms of depression, anxiety, or anger on PIUs.\u003c/p\u003e\n\u003cp\u003eWhile patient symptoms gradually improved over their PIU admission, direct-care staff providing the majority of treatment need to sometimes manage assaultive behaviors, like aggression or self-injury\u003csup\u003e17\u003c/sup\u003e. Managing these assaultive behaviors may involve risky procedures like restraint and seclusion, which have been shown to significantly relate to staff member injury occurrence\u003csup\u003e18-19\u003c/sup\u003e. Staff member injuries represent a complex problem for hospital settings\u003csup\u003e20\u003c/sup\u003e. Injuries affect staff morale, staff retention, and can be quite expensive\u003csup\u003e21-22\u003c/sup\u003e. For example, one study showed that staff injuries accounted for 2% of one hospital\u0026rsquo;s budget\u003csup\u003e17\u003c/sup\u003e. A growing evidence-base of research shows staffing patterns\u003csup\u003e23\u003c/sup\u003e, use of behavior management programs\u003csup\u003e19,24\u003c/sup\u003e comprehensive staff training programs\u003csup\u003e25\u003c/sup\u003e, use of protective equipment\u003csup\u003e26\u003c/sup\u003e, and being mindful of patient diagnosis\u003csup\u003e27\u003c/sup\u003e relates to staff member safety. However, most of this research comes from adult PIUs. There needs to be more research understanding the prevalence and potential causes of injuries on pediatric PIUs.\u003c/p\u003e\n\u003cp\u003eIn summary, it seems that implementation of group therapy grounded in the principles of DBT on a PIU results in positive patient outcomes. Despite this important finding, PIU staff injuries are still reported to occur at unacceptable rates. Limited research exists on the occurrence and conditions under which injuries occur on pediatric PIUs. Thus, the purpose of this study was two-fold. First, we describe one PIUs treatment programming model and the resulting outcomes on patient self-reported symptoms of depression, anxiety, and anger. Second, we evaluated the conditions leading to staff member injury over a 1-year period. We hope that these two pieces of data will support continued description of PIU models of care as well as an understanding of expected patient outcomes and variables related to staff member injury.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003e\u003cstrong\u003eParticipants and Setting\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe PIU operated\u0026nbsp;within an urban academic medical center providing specialized psychiatric care for adolescents experiencing psychiatric crises (e.g., following a suicide attempt). Clinical procedures took place on an 18-bed inpatient unit. The unit afforded each patient their own bedroom. Common programming areas included three classrooms (approximately 20 to 30 m\u003csup\u003e2\u003c/sup\u003e in size housing two tables and at least 10 chairs per classroom) and a cafeteria. Unit staff divided the classrooms by the age of the patients (i.e., tweens between 12 and 14 years of age; adolescents between the ages of 15 and 17 years). Patients averaged 15.4 years of age. Please refer to Tables 1 and 2 for additional demographic information about the patient population served on this PIU.\u0026nbsp;The PIU was staffed by university faculty and hospital staff. The university faculty consisted of three psychiatrists and a psychologist. The hospital staff consisted of 45 direct-care staff (holders of bachelor\u0026rsquo;s or master\u0026rsquo;s degree in psychology or related field), 10 nurses (holders of bachelor\u0026rsquo;s degree in nursing), and three licensed behavioral health clinicians (master\u0026rsquo;s degree in professional counseling or social work). \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDependent Variables\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePatient Outcomes.\u0026nbsp;\u003c/strong\u003ePatients receiving treatment on the PIU during the study period were asked to complete the Anger, Depression, and Anxiety Scales from the Patient-Reported Outcomes Measurement Information System (PROMIS). Patients responded to questions structured according to a 5-point ordinal scale about whether the item was never, rarely, sometimes, often, or always true in the past 7 days\u003csup\u003e28\u003c/sup\u003e. The anger scale measured angry moods, verbal aggression, and physical aggression\u003csup\u003e29\u003c/sup\u003e. The depression scale measured symptoms of depression, such as feeling sad\u003csup\u003e28\u003c/sup\u003e. Finally, the anxiety scale measured fear, anxious misery, hyperarousal, and somatic symptoms related to arousal\u003csup\u003e30\u003c/sup\u003e. A previous study indicated alpha-coefficient values of 0.90, 0.95, and 0.93 for the anger, depression, and anxiety scales, respectively, which collectively reflects a high degree of assessment reliability\u003csup\u003e31\u003c/sup\u003e. An additional study by the same author\u003csup\u003e32\u003c/sup\u003e indicated a strong convergent validity of the PROMIS anger, depression, and anxiety measures with other established measures of these domains of emotions\u003csup\u003e31-32\u003c/sup\u003e. These outcome measures were administered upon admission to the PIU and at discharge (either the night before or the morning of patients\u0026rsquo; departure from the unit). Patients completed the Patient Satisfaction Inventory at the conclusion of their admission. The authors created this inventory to measure patient satisfaction with medication management, therapy services received as well as whether they felt that the skills learned during their admission would be helpful outside of the hospital. This inventory consisted of a 1 \u0026ndash; 7 likert-type scale in which scores of 1 represented low satisfaction and scores of 7 indicated high satisfaction. Patients completed these questionnaires using a tablet computer as overseen by the unit psychologist or a psychology trainee. Assistance was provided if the patient struggled to read or reported being unable to understand the question.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStaff Member Injury.\u003c/strong\u003e The research team extracted pertinent data from the daily records collected by the Occupational Health Services department of the study site and from the clinic registry. These data included the number of staff and patients working on the unit throughout each day, frequency of restraint or seclusion usage, the number of staff member injuries, and the time each staff member injury occurred. Additional demographic information about the patients who injured the staff were gathered from the electronic medical record at the study site. Considering the complexity of the data extraction process, data entry integrity was ensured by having a second, independent observer auditing the work of the primary data coder. This second observer input data on each of the variables described above for 30% of days across each month of the study period. We defined exact agreement as when the primary data coder reported the same value for the dependent variables described above (e.g., number of restraints used each day) as the secondary data coder. A disagreement was defined as when the primary data coder reported a different value than the secondary data coder for the variables described above. The research team calculated agreement by dividing the number of agreements by the number of agreements plus disagreements and multiplying this quotient by 100 to produce a percentage. Agreement between the two observers was 100%. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eProcedures\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe PIU delivered interdisciplinary treatment by a child and adolescent psychiatrist, social worker, and psychologist. The psychiatrist evaluated each patient\u0026rsquo;s medication regimen as well as assisted with diagnostic conceptualization. The social worker provided family therapy and assisted with identifying after-care services for the families. The psychologist organized the DBT treatment each patient received on the Unit. The social worker and psychologist closely collaborated to ensure that the DBT material contacted by the patients could be integrated into the family therapy services.\u003c/p\u003e\n\u003cp\u003ePrior to starting data collection on patient outcomes, the unit\u0026rsquo;s psychologist and social workers trained PIU staff to deliver the DBT groups. The training lasted 2 hrs and consisted of didactic presentation and role-play with coaching and feedback. The didactic presentation began by describing the history of DBT along with a description of the groups the unit would be conducting with patients (30 minutes). After this, the psychologist and social workers modeled one of the therapeutic groups (15 minutes). The trainers then provided all staff with a protocol of one of the DBT groups and divided them into groups of four. PIU staff took turns implementing the group according to the protocol, while either the psychologist or social workers provided feedback and support (60 minutes). At the end of the coaching period, the psychologist or social workers encouraged PIU staff to ask additional questions (15 minutes).\u003c/p\u003e\n\u003cp\u003eDBT can have a lengthy course of implementation, which is not feasible for short-term PIU admissions. Thus, DBT programming at the study site was modified to selectively focus on learning about mindfulness skills, distress tolerance, and emotional regulation. The unit schedule incorporated one DBT group, a group led by an occupational therapist, and snack/meals during the morning. After lunch, patients visited with their families and then participated in a DBT and social skills group. Free time and snacks/meals occurred during the afternoon programing period too. During the evening, patients ate meals, visited with their families, and engaged in a wrap-up group that reviewed programming topics for the day. The Tween and Adolescent groups participated in the same activities but with their own groups. That is, patients assigned to the Tween group did not program with the Adolescent group.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003ePatients began each group session by participating in a mindfulness activity (e.g., mindful eating, mindful exercise, and mindful coloring) as led by PIU staff. Afterwards, PIU staff conducted the assigned DBT group. The unit conducted DBT groups according to a weekly schedule. On Mondays, groups focused on introducing mindfulness and DBT to patients. Tuesdays and Fridays involved discussion of distress, identification of personally distressing situations, and formulation of coping strategies to manage distress using the six senses or other distraction strategies. On Wednesdays and Sundays, staff facilitated discussions on emotion regulation, including distinguishing negative emotions and antecedents to these emotions, recognizing positive attributes or experiences, and identifying and preparing to use various coping strategies. Finally, on Thursdays and Saturdays PIU staff reviewed dialectics to discern the existence of multiple truths to a situation as a way to reinforce positive behaviors and decrease maladaptive behaviors. Given the abbreviated nature of the PIUs DBT treatment, we collaborated with an outpatient team trained to deliver extended DBT programming to offer a step-down care approach to continue patient therapy following their discharge.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData Analyses\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eDescriptive and inferential statistical approaches (e.g., count, percent frequency, mean \u0026plusmn; standard deviation, paired t-test, MANOVA, Spearman correlation) were applied to summarize trends and determine significant differences in staffing, cases of restraint and seclusion, incidence of injury, and patient psychological scores, at admission to the PIU and at discharge from the PIU. All statistical analyses were completed using IBM SPSS Statistics for Windows (Version 26.0). Non-parametric approaches were applied when data did not show normal distribution. Significance level was set at p\u0026lt;0.05. All data analyses were performed on de-identified data and key findings were presented based on aggregate data.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003e\u003cstrong\u003ePatients Demographic and Clinical Profile\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eTable 1 describes the patient population treated at the PIU during the study period (N=190). Briefly, majority of patients identified as female (56.3%), followed by male, transgender, and those preferring not to answer (at 33.2%, 4.7%, and 5.8%, respectively). These patients were mostly White/Caucasian (63.2%), identified as biracial/multi-racial (16.8%), or Black/African American (8.9%). Most of these patients also identified as not Hispanic or Latino (72.1%). The top three psychiatric diagnoses of these patients were Depression (68.4%), followed by Trauma and Stressor Related Disorders (9.5%), and Disruptive Behavior Disorders (7.9%). These patients were grouped as tweens (10 to 13 years old; 48.4%) and adolescents (14 to 17 years old; 51.6%). Further, approximately half of the patient population (56.8%) indicated that this was their first inpatient mental health admission (Table 2). Hospitalization for most of these cases lasted between 6 to 9 days (39.0%), or approximately 0 to 5 days (37.0%) (Table 2). Notably, there were fewer than 5% of cases who were hospitalized for an extended length of time (i.e., defined as longer than 20 days) (Table 2).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePatient Psychological Outcomes (PROMIS Scores)\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eDepressive scores at discharge were observed to be significantly lower than those at admission (59.3\u0026nbsp;\u0026plusmn;\u0026nbsp;10.5 vs. 65.7\u0026nbsp;\u0026plusmn;\u0026nbsp;10.0; t(148) = 8.2, p\u0026lt;0.001, \u003cem\u003ed\u003c/em\u003e = 0.68). A similar trend was also observed for anxiety scores (56.2\u0026nbsp;\u0026plusmn;\u0026nbsp;11.7 at discharge vs. 60.1\u0026nbsp;\u0026plusmn;\u0026nbsp;12.2 at admissions; t(149) = 4.5, p\u0026lt;0.001, \u003cem\u003ed\u0026nbsp;\u003c/em\u003e\u003csub\u003e=\u0026nbsp;\u003c/sub\u003e0.37) and anger scores (51.8\u0026nbsp;\u0026plusmn;\u0026nbsp;12.0 at discharge vs. 55.7\u0026nbsp;\u0026plusmn;\u0026nbsp;11.9 at admission; t(148) = 4.2, p\u0026lt;0.001, \u003cem\u003ed\u003c/em\u003e = 0.34). Interestingly, the clinical significance cut-off value for these domains is set at 60 (Kroenke et al., 2020). Thus, our data indicate that while the average scores for depression, anxiety, and anger were clinically elevated at admission (\u0026gt; 60), these dipped below the clinical threshold at discharge. Collectively, these trends indicated a marked improvement in depression, anxiety, and anger symptoms among patients resulting from their admission to the PIU at the study site. However, our analysis did not show any significant association between PROMIS scores and length of hospitalization (\u003cem\u003eF\u003c/em\u003e (12,320) = 1.12, p = 0.34; Wilk\u0026apos;s \u0026Lambda; = 0.89, partial \u0026eta;\u003csup\u003e2\u003c/sup\u003e = 0.04). This suggests that length of stay at the PIU may not necessarily influence the extent of symptom change or benefit that the patient received from the program. Patients provided positive feedback towards their treatment at the PIU, whereby majority indicated receiving \u0026ldquo;excellent\u0026rdquo; or \u0026ldquo;good\u0026rdquo; care (39.6% and 45.8%, respectively), and that they \u0026ldquo;generally\u0026rdquo; (44.8%) or \u0026ldquo;definitely\u0026rdquo; (40.1%) received the type of help they needed.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTrends of Staff Injury at the PIU\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eDuring the study period, there were 129 instances of staff injuries caused by 41 patients (52.8% identified as male patients and 47.2% female). On average, these patients were 13.5 years old, 158.6 cm in height, 73.4 kg in weight, and had a BMI of 26.7. Our analyses indicated that incidences of staff injury were not significantly correlated to patients\u0026rsquo; age (r = 0.47; p = 0.20), height (r = 0.03; p = 0.95), weight (r = -0.16; p = 0.71) or BMI (r = 0.06; p = 0.70). Further, we observed that staff member injury tended to occur the most during the mid-afternoon (75.0% of reported total injuries) than other shifts. However, our data did not indicate significant differences in daily staff-to-patient ratio during this particular shift (1500 - 2300; all p-values above 0.05). In contrast, data reflecting the evening shift (19:00 to 07:00) noted higher incidences of staff injury on days when there were fewer staff managing patients. Over the course of this study, we showed that usage of restraint and seclusion decreased slightly (13.8 hrs at the beginning of the year to 11.1 hours at the end of the year). This difference was not statistically significant (p = 0.24). However, the use of restraint and seclusion was significantly associated with occurrence of staff injury (c\u003csup\u003e2\u003c/sup\u003e = 17.4; p\u0026lt;0.001). There were fewer number of extensive staff injuries requiring reporting to the Occupation Safety and Health Administration (OSHA) when restraint and seclusion was not used to manage aggressive patient behavior than when it was used (12 incidences of staff injury vs. 14 incidences, respectively); but the difference was not statistically significant.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe current study evaluated the effect of interdisciplinary PIU programming involving therapeutic groups that incorporated DBT material, medication management, and family therapy for adolescents between the ages of 12-17 years. We tracked patient outcomes via self-report measures of depression, anxiety, and anger at the beginning and end of their PIU admissions. Statistically significant decreases in patient reported symptoms occurred at the end of the hospitalization. Next, we looked at specific contributors to staff member injury and found that specific periods of the day were associated with a higher likelihood of staff injury and that injuries occurred more so when restraint or seclusion were used.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe care received on this short-term PIU resulted in positive patient outcomes. Patients self-reported symptoms of depression, anxiety, and anger significantly reduced at the end of treatment. This PIU delivered DBT-based group therapy along with individualized family therapy and medication management. Previous research teams have documented the benefit of this type of therapy\u003csup\u003e13\u003c/sup\u003e. Our study matches their outcome data. However, a lack of a comparison group before the implementation of this model of care represents a limitation of the current study. The current research team began conducting standard outcome measures upon admission and discharge from the unit to permit evaluation of treatment outcomes\u003csup\u003e33\u003c/sup\u003e. Outcome measurement was not a standard part of practice on this inpatient unit beforehand. We advocate for more inpatient programs to integrate outcome measurement into psychiatric inpatient care to permit outcome studies to be conducted. We believe this will help with establishing best practices\u003csup\u003e34\u003c/sup\u003e.\u003c/p\u003e\n\u003cp\u003eWhile our PIU produced positive patient outcomes, we did not observe a change in staff member injury over the study period. Previous research documents a direct correlation between use of restraint and seclusion and staff member injury\u003csup\u003e19\u003c/sup\u003e. We showed a significant relationship between use of restraint and seclusion and the combination of minor and major staff member injuries. That is, injuries occurred more often when restraint and seclusion were used. Interestingly, though, major injuries (i.e., OSHA reportable) alone did not seem related to restraint or seclusion use. These major injuries occurred equally when managing aggressive behaviors with or without use of restraint and seclusion. We did, however, document more injury occurrence during the overnight hours when less staff were present to manage patients. In these hours, there are often not structured programming tasks as patients visit with their families, engage in leisure activities, and go to sleep. For patients that do not sleep or struggle with leisure time, PIUs might consider having more structured activities for staff to implement with them. Additionally, when aggressive patients exhibit a pattern of not sleeping through the night, unit leadership might consider additional staff to ensure staff member safety.\u003c/p\u003e\n\u003cp\u003eAnother way to address staff member injury by targeting reduced use of restraint and seclusion could be by having and following structured behavioral treatment plans\u003csup\u003e19,35\u003c/sup\u003e. This unit\u0026rsquo;s schedule generally alternated between less- and more-preferred activities to encourage safe behavior and participation. However, it could be the case that individualized treatment programs may be needed for patients at risk of injuring others. For example, one research team showed a program that conducted individualized behavioral assessment to inform individualized behavioral treatment programs led to positive youth outcome as well as decreased staff injury\u003csup\u003e17,19\u003c/sup\u003e. Future research should evaluate if the addition of a program to design individualized behavior plans further suppresses use of restraint and seclusion and staff member injury on PIUs.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe current study is not without its limitations. Outcome measures were not obtained prior to the implementation of new DBT programming. These data could have been helpful to track and compare symptomatology before and after the PIU admission. Given the retrospective nature of our analyses, it was not clear what the relative impact of DBT programming compared to medication management, being in a structured hospital environment, and family therapy was on patient outcomes. Future research should attempt to clarify these issues when conducting prospective research to understand how PIUs are helpful to adolescents and their families. Second, we were unable to administer these outcome measures after discharge from the PIU to evaluate maintenance of treatment effects. Third, due to the acute nature of the inpatient unit, the primary method of implementing DBT was in a group setting and skills-focused. Additional components of DBT (e.g., individual therapy) were not a standardized part of programming and could have provided further benefit.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eImplications for Behavioral Health\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003ePatients in need of psychiatric inpatient care represent a highly challenging population that demand considerable resources to effectively treat. Despite recognition of this challenge, there continues to be a paucity of research providing information regarding ways to work with this population as well as expected patient outcomes. The current study provides patient outcome data that showed the effectiveness of a model of care including DBT and other services from healthcare professionals. Additionally, this study provides descriptive information about the conditions under which staff member injuries occur. This PIU documented more injuries during restraint and seclusion usage as well as during evening and overnight hours. Other researchers and practitioners, alike, could replicate these analyses to determine when and how staff member injuries occur to develop matched interventions. \u0026nbsp;\u0026nbsp;\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cu\u003eCompliance with Ethical Standards\u003c/u\u003e\u003c/p\u003e\n\u003cp\u003eAll authors do not have conflicts of interest to disclose. This research was funded by the Clinical and Operational Effectiveness and Patient Safety (COEPS) grant from Children\u0026rsquo;s Hospital Colorado. All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. IRB approval was granted by the Colorado Multiple Institutional Review Board. This article does not contain studies with animals performed by any of the authors.\u003c/p\u003e\n\u003cp\u003e\u003cu\u003eData Availability Statement\u003c/u\u003e\u003c/p\u003e\n\u003cp\u003eThe data that support the findings from this study are available from the authors, but restrictions apply to the availability of these data and so are not publicly available. The data are, however, available from the authors upon reasonable request and with permission from the healthcare organization in which the data were collected.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eWhitney DG, Peterson MD. 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Characteristics of American Assaultive Psychiatric Patients: Review of Published Findings, 2000\u0026ndash;2012. \u003cem\u003ePsychiatric Quarterly\u003c/em\u003e. 2014;85(3):319-328. doi:https://doi.org/10.1007/s11126-014-9294-6\u003c/li\u003e\n\u003cli\u003eKroenke K, Stump TE, Chen CX, et al. Responsiveness of PROMIS and Patient Health Questionnaire (PHQ) Depression Scales in three clinical trials. \u003cem\u003eHealth and Quality of Life Outcomes.\u003c/em\u003e 2021;19(1). doi:https://doi.org/10.1186/s12955-021-01674-3\u003c/li\u003e\n\u003cli\u003eIrwin DE, Stucky BD, Langer MM, et al. PROMIS Pediatric Anger Scale: an item response theory analysis. \u003cem\u003eQuality of Life Research\u003c/em\u003e. 2011;21(4):697-706. doi:https://doi.org/10.1007/s11136-011-9969-5\u003c/li\u003e\n\u003cli\u003eSchalet BD, Pilkonis PA, Yu L, et al. Clinical validity of PROMIS Depression, Anxiety, and Anger across diverse clinical samples. \u003cem\u003eJournal of Clinical Epidemiology\u003c/em\u003e. 2016;73:119-127. doi:https://doi.org/10.1016/j.jclinepi.2015.08.036\u003c/li\u003e\n\u003cli\u003ePilkonis PA, Choi SW, Reise SP, et al. Item Banks for Measuring Emotional Distress From the Patient-Reported Outcomes Measurement Information System (PROMIS\u0026reg;): Depression, Anxiety, and Anger. \u003cem\u003eAssessment\u003c/em\u003e. 2011;18(3):263-283. doi:https://doi.org/10.1177/1073191111411667\u003c/li\u003e\n\u003cli\u003ePilkonis PA, Yu L, Dodds NE, et al. Validation of the depression item bank from the Patient-Reported Outcomes Measurement Information System (PROMIS\u0026reg;) in a three-month observational study. \u003cem\u003eJournal of Psychiatric Research\u003c/em\u003e. 2014;56:112-119. doi:https://doi.org/10.1016/j.jpsychires.2014.05.010\u003c/li\u003e\n\u003cli\u003eGlick ID, Sharfstein SS, Schwartz HI. Inpatient Psychiatric Care in the 21st Century: The Need for Reform. \u003cem\u003ePsychiatric Services\u003c/em\u003e. 2011;62(2):206-209. doi:https://doi.org/10.1176/ps.62.2.pss6202_0206\u003c/li\u003e\n\u003cli\u003eLeffler JM, D\u0026rsquo;Angelo EJ. Implementing Evidence-Based Treatments for Youth in Acute and Intensive Treatment Settings. \u003cem\u003eJournal of Cognitive Psychotherapy\u003c/em\u003e. 2020;34(3):185-199. doi:https://doi.org/10.1891/jcpsy-d-20-00018\u003c/li\u003e\n\u003cli\u003eCarlson GA, Chua J, Pan K, et al. Behavior Modification Is Associated With Reduced Psychotropic Medication Use in Children With Aggression in Inpatient Treatment: A Retrospective Cohort Study. \u003cem\u003eJournal of the American Academy of Child \u0026amp; Adolescent Psychiatry\u003c/em\u003e. 2020;59(5):632-641.e4. doi:https://doi.org/10.1016/j.jaac.2019.07.940\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003eTable 1.\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" align=\"\" width=\"416\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"100%\" colspan=\"3\" valign=\"bottom\"\u003e\n \u003cp\u003eDemographic Characteristics of Sample Patient Population\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"73.79807692307692%\" valign=\"bottom\"\u003e\n \u003cp\u003eCharacteristic\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.221153846153847%\" valign=\"bottom\"\u003e\n \u003cp\u003en\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.98076923076923%\" valign=\"bottom\"\u003e\n \u003cp\u003e%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"73.79807692307692%\" valign=\"bottom\"\u003e\n \u003cp\u003ePrimary Admission Dx\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.221153846153847%\" valign=\"bottom\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"12.98076923076923%\" valign=\"bottom\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"73.79807692307692%\" valign=\"bottom\"\u003e\n \u003cp\u003e\u003cem\u003eDepression\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.221153846153847%\" valign=\"bottom\"\u003e\n \u003cp\u003e130\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.98076923076923%\" valign=\"bottom\"\u003e\n \u003cp\u003e68.42\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"73.79807692307692%\" valign=\"bottom\"\u003e\n \u003cp\u003e\u003cem\u003eAnxiety\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.221153846153847%\" valign=\"bottom\"\u003e\n \u003cp\u003e13\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.98076923076923%\" valign=\"bottom\"\u003e\n \u003cp\u003e6.84\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"73.79807692307692%\" valign=\"bottom\"\u003e\n \u003cp\u003e\u003cem\u003eDisruptive Behavior Disorder\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.221153846153847%\" valign=\"bottom\"\u003e\n \u003cp\u003e15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.98076923076923%\" valign=\"bottom\"\u003e\n \u003cp\u003e7.89\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"73.79807692307692%\" valign=\"bottom\"\u003e\n \u003cp\u003e\u003cem\u003eBipolar and Related Disorder\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.221153846153847%\" valign=\"bottom\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.98076923076923%\" valign=\"bottom\"\u003e\n \u003cp\u003e4.21\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"73.79807692307692%\" valign=\"bottom\"\u003e\n \u003cp\u003e\u003cem\u003eTrauma and Stressor Related Disorders\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.221153846153847%\" valign=\"bottom\"\u003e\n \u003cp\u003e18\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.98076923076923%\" valign=\"bottom\"\u003e\n \u003cp\u003e9.47\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"73.79807692307692%\" valign=\"bottom\"\u003e\n \u003cp\u003e\u003cem\u003eSchizophrenia Spectrum Disorders\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.221153846153847%\" valign=\"bottom\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.98076923076923%\" valign=\"bottom\"\u003e\n \u003cp\u003e1.58\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"73.79807692307692%\" valign=\"bottom\"\u003e\n \u003cp\u003e\u003cem\u003eEating Disorders\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.221153846153847%\" valign=\"bottom\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.98076923076923%\" valign=\"bottom\"\u003e\n \u003cp\u003e0.53\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"73.79807692307692%\" valign=\"bottom\"\u003e\n \u003cp\u003e\u003cem\u003eOther Dx\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.221153846153847%\" valign=\"bottom\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.98076923076923%\" valign=\"bottom\"\u003e\n \u003cp\u003e1.05\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"73.79807692307692%\" valign=\"bottom\"\u003e\n \u003cp\u003e\u003cem\u003eTotal\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.221153846153847%\" valign=\"bottom\"\u003e\n \u003cp\u003e190\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.98076923076923%\" valign=\"bottom\"\u003e\n \u003cp\u003e100\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"73.79807692307692%\" valign=\"bottom\"\u003e\n \u003cp\u003eGender Identity\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.221153846153847%\" valign=\"bottom\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"12.98076923076923%\" valign=\"bottom\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"73.79807692307692%\"\u003e\n \u003cp\u003e\u003cem\u003eFemale\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.221153846153847%\"\u003e\n \u003cp\u003e107\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.98076923076923%\"\u003e\n \u003cp\u003e56.3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"73.79807692307692%\"\u003e\n \u003cp\u003e\u003cem\u003eMale\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.221153846153847%\"\u003e\n \u003cp\u003e63\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.98076923076923%\"\u003e\n \u003cp\u003e33.2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"73.79807692307692%\"\u003e\n \u003cp\u003e\u003cem\u003eTransgender\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.221153846153847%\"\u003e\n \u003cp\u003e9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.98076923076923%\"\u003e\n \u003cp\u003e4.7\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"73.79807692307692%\"\u003e\n \u003cp\u003e\u003cem\u003ePrefer Not to Answer\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.221153846153847%\"\u003e\n \u003cp\u003e11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.98076923076923%\"\u003e\n \u003cp\u003e5.8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"73.79807692307692%\"\u003e\n \u003cp\u003e\u003cem\u003eTotal\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.221153846153847%\"\u003e\n \u003cp\u003e190\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.98076923076923%\"\u003e\n \u003cp\u003e100\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"73.79807692307692%\"\u003e\n \u003cp\u003eRace\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.221153846153847%\" valign=\"bottom\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"12.98076923076923%\" valign=\"bottom\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"73.79807692307692%\"\u003e\n \u003cp\u003e\u003cem\u003eAmerican Indian or Alaska Native\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.221153846153847%\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.98076923076923%\"\u003e\n \u003cp\u003e3.2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"73.79807692307692%\"\u003e\n \u003cp\u003e\u003cem\u003eAsian\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.221153846153847%\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.98076923076923%\"\u003e\n \u003cp\u003e1.6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"73.79807692307692%\"\u003e\n \u003cp\u003e\u003cem\u003eBlack or African American\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.221153846153847%\"\u003e\n \u003cp\u003e17\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.98076923076923%\"\u003e\n \u003cp\u003e8.9\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"73.79807692307692%\"\u003e\n \u003cp\u003e\u003cem\u003eWhite\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.221153846153847%\"\u003e\n \u003cp\u003e120\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.98076923076923%\"\u003e\n \u003cp\u003e63.2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"73.79807692307692%\"\u003e\n \u003cp\u003e\u003cem\u003eMore Than One Race\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.221153846153847%\"\u003e\n \u003cp\u003e32\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.98076923076923%\"\u003e\n \u003cp\u003e16.8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"73.79807692307692%\"\u003e\n \u003cp\u003e\u003cem\u003ePrefer Not to Answer\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.221153846153847%\"\u003e\n \u003cp\u003e12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.98076923076923%\"\u003e\n \u003cp\u003e6.3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"73.79807692307692%\"\u003e\n \u003cp\u003e\u003cem\u003eTotal\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.221153846153847%\"\u003e\n \u003cp\u003e190\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.98076923076923%\"\u003e\n \u003cp\u003e100\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"73.79807692307692%\"\u003e\n \u003cp\u003eEthnicity\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.221153846153847%\" valign=\"bottom\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"12.98076923076923%\" valign=\"bottom\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"73.79807692307692%\"\u003e\n \u003cp\u003e\u003cem\u003eHispanic or Latino\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.221153846153847%\"\u003e\n \u003cp\u003e37\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.98076923076923%\"\u003e\n \u003cp\u003e19.5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"73.79807692307692%\"\u003e\n \u003cp\u003e\u003cem\u003eNot Hispanic or Latino\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.221153846153847%\"\u003e\n \u003cp\u003e137\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.98076923076923%\"\u003e\n \u003cp\u003e72.1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"73.79807692307692%\"\u003e\n \u003cp\u003e\u003cem\u003ePrefer Not to Answer\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.221153846153847%\"\u003e\n \u003cp\u003e16\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.98076923076923%\"\u003e\n \u003cp\u003e8.4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"73.79807692307692%\"\u003e\n \u003cp\u003e\u003cem\u003eTotal\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.221153846153847%\"\u003e\n \u003cp\u003e190\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.98076923076923%\"\u003e\n \u003cp\u003e100\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"73.79807692307692%\"\u003e\n \u003cp\u003eAge Group\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.221153846153847%\" valign=\"bottom\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"12.98076923076923%\" valign=\"bottom\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"73.79807692307692%\"\u003e\n \u003cp\u003e\u003cem\u003eTPU (10-13 Years)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.221153846153847%\"\u003e\n \u003cp\u003e91\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.98076923076923%\"\u003e\n \u003cp\u003e48.43\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"73.79807692307692%\"\u003e\n \u003cp\u003e\u003cem\u003eAPU (14-17 Years)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.221153846153847%\"\u003e\n \u003cp\u003e97\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.98076923076923%\"\u003e\n \u003cp\u003e51.6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"73.79807692307692%\"\u003e\n \u003cp\u003e\u003cem\u003eTotal\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.221153846153847%\"\u003e\n \u003cp\u003e188\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.98076923076923%\"\u003e\n \u003cp\u003e100\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eTable 2\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"444\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"85.58558558558559%\" colspan=\"2\" valign=\"bottom\"\u003e\n \u003cp\u003eAdmission Characteristics of Sample Patient Population\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.414414414414415%\" valign=\"bottom\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"72.52252252252252%\" valign=\"bottom\"\u003e\n \u003cp\u003eCharacteristic\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.063063063063064%\" valign=\"bottom\"\u003e\n \u003cp\u003en\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.414414414414415%\" valign=\"bottom\"\u003e\n \u003cp\u003e%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"72.52252252252252%\" valign=\"bottom\"\u003e\n \u003cp\u003eAdmission Number\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.063063063063064%\" valign=\"bottom\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"14.414414414414415%\" valign=\"bottom\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"72.52252252252252%\" valign=\"bottom\"\u003e\n \u003cp\u003e\u003cem\u003e1\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.063063063063064%\" valign=\"bottom\"\u003e\n \u003cp\u003e108\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.414414414414415%\" valign=\"bottom\"\u003e\n \u003cp\u003e56.8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"72.52252252252252%\" valign=\"bottom\"\u003e\n \u003cp\u003e\u003cem\u003e2\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.063063063063064%\" valign=\"bottom\"\u003e\n \u003cp\u003e27\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.414414414414415%\" valign=\"bottom\"\u003e\n \u003cp\u003e14.2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"72.52252252252252%\" valign=\"bottom\"\u003e\n \u003cp\u003e\u003cem\u003e3\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.063063063063064%\" valign=\"bottom\"\u003e\n \u003cp\u003e11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.414414414414415%\" valign=\"bottom\"\u003e\n \u003cp\u003e5.8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"72.52252252252252%\" valign=\"bottom\"\u003e\n \u003cp\u003e\u003cem\u003e4\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.063063063063064%\" valign=\"bottom\"\u003e\n \u003cp\u003e15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.414414414414415%\" valign=\"bottom\"\u003e\n \u003cp\u003e7.9\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"72.52252252252252%\" valign=\"bottom\"\u003e\n \u003cp\u003e\u003cem\u003e5\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.063063063063064%\" valign=\"bottom\"\u003e\n \u003cp\u003e14\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.414414414414415%\" valign=\"bottom\"\u003e\n \u003cp\u003e7.4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"72.52252252252252%\" valign=\"bottom\"\u003e\n \u003cp\u003e\u003cem\u003e6\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.063063063063064%\" valign=\"bottom\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.414414414414415%\" valign=\"bottom\"\u003e\n \u003cp\u003e1.1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"72.52252252252252%\" valign=\"bottom\"\u003e\n \u003cp\u003e\u003cem\u003e7\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.063063063063064%\" valign=\"bottom\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.414414414414415%\" valign=\"bottom\"\u003e\n \u003cp\u003e2.6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"72.52252252252252%\" valign=\"bottom\"\u003e\n \u003cp\u003e\u003cem\u003e8\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.063063063063064%\" valign=\"bottom\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.414414414414415%\" valign=\"bottom\"\u003e\n \u003cp\u003e1.1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"72.52252252252252%\" valign=\"bottom\"\u003e\n \u003cp\u003e\u003cem\u003e9\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.063063063063064%\" valign=\"bottom\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.414414414414415%\" valign=\"bottom\"\u003e\n \u003cp\u003e1.6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"72.52252252252252%\" valign=\"bottom\"\u003e\n \u003cp\u003e\u003cem\u003e10+\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.063063063063064%\" valign=\"bottom\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.414414414414415%\" valign=\"bottom\"\u003e\n \u003cp\u003e1.6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"72.52252252252252%\" valign=\"bottom\"\u003e\n \u003cp\u003e\u003cem\u003eTotal\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.063063063063064%\" valign=\"bottom\"\u003e\n \u003cp\u003e190\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.414414414414415%\" valign=\"bottom\"\u003e\n \u003cp\u003e100\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"72.52252252252252%\" valign=\"bottom\"\u003e\n \u003cp\u003eLength of Stay (Days)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.063063063063064%\" valign=\"bottom\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"14.414414414414415%\" valign=\"bottom\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"72.52252252252252%\" valign=\"bottom\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026nbsp;0-5\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.063063063063064%\" valign=\"bottom\"\u003e\n \u003cp\u003e57\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.414414414414415%\" valign=\"bottom\"\u003e\n \u003cp\u003e37.01\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"72.52252252252252%\" valign=\"bottom\"\u003e\n \u003cp\u003e\u003cem\u003e6-9\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.063063063063064%\" valign=\"bottom\"\u003e\n \u003cp\u003e60\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.414414414414415%\" valign=\"bottom\"\u003e\n \u003cp\u003e38.96\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"72.52252252252252%\" valign=\"bottom\"\u003e\n \u003cp\u003e\u003cem\u003e10-14\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.063063063063064%\" valign=\"bottom\"\u003e\n \u003cp\u003e18\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.414414414414415%\" valign=\"bottom\"\u003e\n \u003cp\u003e11.69\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"72.52252252252252%\" valign=\"bottom\"\u003e\n \u003cp\u003e\u003cem\u003e15-19\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.063063063063064%\" valign=\"bottom\"\u003e\n \u003cp\u003e12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.414414414414415%\" valign=\"bottom\"\u003e\n \u003cp\u003e7.79\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"72.52252252252252%\" valign=\"bottom\"\u003e\n \u003cp\u003e\u003cem\u003e20+\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.063063063063064%\" valign=\"bottom\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.414414414414415%\" valign=\"bottom\"\u003e\n \u003cp\u003e4.55\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"72.52252252252252%\" valign=\"bottom\"\u003e\n \u003cp\u003e\u003cem\u003eTotal\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.063063063063064%\" valign=\"bottom\"\u003e\n \u003cp\u003e154\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.414414414414415%\" valign=\"bottom\"\u003e\n \u003cp\u003e100\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Dialectical Behavior Therapy, psychiatric inpatient unit, psychological assessment, and staff member injury","lastPublishedDoi":"10.21203/rs.3.rs-3617156/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-3617156/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eBrief psychiatric hospitalization represents an intervention used to manage acute crisis behaviors (e.g., out-of-control behavior; suicidal ideation) exhibited by children and adolescents. To date, few studies have presented their clinical model of care in addition to key outcome metrics, such as patient outcome and staff injury. Studies sharing this type of information could provide descriptions of desperately needed clinical models to ensure that standards of care for both patients and staff are met on psychiatric inpatient units. The purpose of the current study was to describe one unit\u0026rsquo;s clinical model emphasizing group therapy grounded in the principles of dialectical behavior therapy within a brief psychiatric inpatient admission (mean length of stay\u0026thinsp;=\u0026thinsp;8 days). We provide outcome data on patient symptoms of depression, anxiety, and anger upon discharge from the hospital, patient satisfaction with the hospitalization, and staff member safety on the unit. This programming produced statistically significant changes in adolescent symptoms of depression, anxiety, and anger at the time of discharge from their brief psychiatric hospitalization. Patients also reported a high level of satisfaction with the services received. While these outcomes were promising, we recorded a high rate of staff member injury while delivering care. We were unable to identify a patient profile that contributed to staff member injury but did identify relations between staffing ratios, time of day, and staff member injury. We hope to share this information in an attempt to provide additional evidence regarding the effectiveness of these brief inpatient programs as well as to draw awareness to variables that may influence staff member experience on these units.\u003c/p\u003e","manuscriptTitle":"Evaluating adolescent outcomes and staff member injuries following treatment on a general psychiatric inpatient unit","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-01-15 09:38:31","doi":"10.21203/rs.3.rs-3617156/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"13a3293e-f539-41ce-a71a-32f9093a430e","owner":[],"postedDate":"January 15th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2024-06-19T11:11:50+00:00","versionOfRecord":[],"versionCreatedAt":"2024-01-15 09:38:31","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-3617156","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-3617156","identity":"rs-3617156","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}