A data-driven approach to workplace safety and behavioral de-escalation in pediatric care

Workplace violence and behavioral escalation in pediatric settings remain persistent challenges for health systems nationwide. In response, children’s hospitals are developing structured, multidisciplinary approaches to strengthen safety while maintaining family-centered care.

In this Q&A, Meghan Drastal, MSN, MBA, RN, CPN, PCS, Behavioral Health Manager at Children’s Hospital Los Angeles (CHLA), discusses her institution’s experience implementing proactive behavioral safety strategies informed by internal data, standardized response protocols, and cross-departmental coordination.

Drastal outlines how CHLA identifies early warning signs of aggression among pediatric patients and families, operationalizes multidisciplinary response teams that include child life, behavioral health, and security, and integrates safety tools into routine clinical workflows. She also describes transferable elements of CHLA’s framework that may be adapted in community and non–children’s hospital settings, with the goal of supporting clinician safety while preserving therapeutic, high-quality patient care.

Contemporary Pediatrics®: From your institution’s experience, what early warning signs of patient or family aggression are most predictive in pediatric settings, and how are clinicians trained to recognize them in real-time?

Meghan Drastal, MSN, MBA, RN, CPN, PCS: At Children’s Hospital Los Angeles (CHLA), we take a proactive, data-driven approach to behavioral safety. We use a behavioral escalation dashboard that helps us identify patterns. We found in families, predictive behaviors include increasing emotional volatility and communication breakdown—like raised voices, profanity, or difficulty engaging in conversation. For pediatric patients, the early signs can be communication breakdown, and also tend to be more physical: restlessness, refusal to cooperate, or attempts to elope.

Recognizing these signs requires training, so we have built this into our onboarding for all new Patient Care Services staff. Everyone goes through learning modules on pediatric behavioral health and crisis response basics. We also offer a crisis prevention and de-escalation curriculum that teaches clinicians not just what to look for, but how to understand what's driving the distress and what interventions work. To bridge the gap between content and application, we utilize our simulation lab where staff practice responding to realistic scenarios in a controlled environment.

Contemporary Pediatrics: How do you operationalize coordination across child life, behavioral health, and security when a situation begins to escalate, and what has been most critical to making those responses effective rather than disruptive to care?

Drastal: In 2019, our data showed that 44% of staff were being affected by high-acuity behavioral events. It became clear we needed a standardized, proactive response system. We created the Behavioral Escalation Response Team (BERT), a multidisciplinary team that includes the house supervisor, social work, security, and the primary care team, with child life and psychiatric providers joining as needed.

We activate BERTs the moment verbal de-escalation is not successful. What makes this effective is that we have designed it to prioritize both safety and dignity. Security stays out of direct sight but remains immediately available if needed. This prevents a uniform from inadvertently escalating someone’s stress response. The goal is to make sure our intervention supports family-centered care rather than disrupting it.

Contemporary Pediatrics: Can you share a specific case or data point that changed how your organization approaches de-escalation or staff safety in pediatric care environments?

Drastal: Over the past 2 years, we have seen a significant increase in verbal threats directed at staff. We strive to make sure our staff feel empowered to voice concerns in the moment, with total confidence that their perspective is valued and that the organization will respond with appreciation and the resources to keep everyone safe.

One of the key pieces we have implemented in response is what we call "House Rules," paired with a "Visitor Alert" banner in the electronic medical record. This alert ensures the entire care team is aware of established contingency plans for visitors with a history of disruption, allowing for a unified and proactive approach to interactions.

Contemporary Pediatrics: How do you balance the need for rapid safety interventions with maintaining a therapeutic, family-centered care experience, especially in high-stress clinical scenarios?

Drastal: Our philosophy is to build safety infrastructure that’s high-impact but low-friction. We recognize that a therapeutic environment cannot exist without a foundation of safety. We have over 1,000 security cameras, smart camera systems, validate visitors through a credentialing system, and keep security support out of sight until they are needed. This maintains vigilance without creating an intimidating atmosphere that can be triggering for those in crisis. When discrete, rapid intervention is needed, staff activate their personal duress button programmed by Canopy, the connected safety platform we have incorporated to keep our staff safe. We average 30 activations per month with a security response time of 30 seconds. By integrating Canopy’s technology and personnel, we can manage risks in the background while the clinical team stays focused on the patient and family during high-stress moments.

Contemporary Pediatrics: For pediatric clinicians working in community or non–children’s hospitals, what elements of your safety framework are most transferable and realistic to implement?

Drastal: The most transferable piece is moving from a reactive to a proactive mindset. This starts with picking up on early signs of distress during routine interactions like family conversations, handoffs, and rounds. When you can spot these progressions early, you can intervene while the situation is still manageable.

One effective way we implemented is that each nurse and worker wears a discreet safety button they can choose to press at any given moment. The button is used as a proactive and preventive measure, intervening at the earliest signs of distress or potential violence before a situation escalates. Discreet buttons, like the ones we use by Canopy, integrate seamlessly with our safety framework and training, giving staff peace of mind while they work.

Another highly effective, no-cost tool is the behavioral safety huddle. When someone identifies a high-risk situation, a multidisciplinary team comes together to discuss the plan, identify triggers, coping strategies, and environmental hazards that need to be modified.

Hospitals can also standardize their approach through order sets, Multidisciplinary Action Plans (MAPs), and safety protocols. At CHLA, we have developed MAPs for acute suicidality and opioid withdrawal, and are currently working on others for acute agitation and benzo/alcohol Withdrawal. These MAPs have standardized the care plan and safety practices, resulting in 100% decrease in critical patient safety incidents and decreased workplace violence.