PM2087: Security and Safe Behavior Contracts: What Have We Learned and Where Are We Going?

Background: Although most children’s hospitals have internal policies and processes regarding unsafe behavior of patients and visitors, there is a distinct lack of shared data in this area. In 2018, Ann & Robert H. Lurie Children’s Hospital of Chicago initiated a new system to promote a culture of safety: the Security Safe Behavior Contract. Our objective was to examine patient characteristics and circumstances surrounding the implementation of Security Safe Behavior Contracts between 2018 and 2020.

Methods: We conducted a retrospective review of all Security Safe Behavior Contracts at Lurie Children’s Hospital between January 01, 2018 and December 31, 2020. Data extraction was performed from the original contracts and the electronic medical record. Collected data include patient age, gender, primary language, race, ethnicity, relation to the patient of individuals signing the contract, and service of record caring for the patient at the time of contract implementation. This study was deemed exempt by IRB.

Results: A total of 62 contracts were executed: 37 contracts (60%) were with a Black/African American patient (Table 1). Most contracts (97%) were for patients with English as their primary language. Of the contracts completed, 27 (44%) were implemented while the patient was admitted to an intensive care service, whereas only 24 (39%) were implemented while the related patient was on a regular floor service. The two services with the highest incidence of behavior contract implementation were the PICU (14 contracts) and the CICU (9 contracts). At the time of chart review, 12 of the 62 patients with associated contracts were deceased- a total of 19% of our study population.

Conclusion: Over half of patients with behavior contracts identified as Black/African American and many patients with behavior contracts were admitted to an intensive care service. These findings highlight concerns that inequitable utilization of these behavior contracts is occurring among a diverse patient population. The percentage of behavior contracts with parent/caregivers, who identified as Black/African American, seemed greater than the yearly proportion of patients identified as Black/African American admitted to the hospital (19%). Further, the proportion of patients admitted to an intensive care service and the proportion of deceased patients associated with a behavior contract suggest that there is likely immense stress experienced by families during the use of behavior contracts. Limitations of this study include not being able to make any comparative inferences given the small sample size. Overall, the findings suggest that improvements are required for the current system of Security Safe Behavior Contracts. Knowing that families are often experiencing distress at the time of behavior contracts, critical next steps include recentering and reconstructing the current process. Finally, health systems should consider examination of their data surrounding these types of policies as a part of equity initiatives.