prevention of violence in minnesota health care settings november 18, 2014 1

Prevention of Violence in Minnesota Health Care Settings

November 18, 2014

1

Overview

• Welcome• Background/Context• St. Luke’s – Erin Metzger & Michael Mock• St. Cloud – Ann Seppelt, Chris Walker, & Joy

Plamann• Mayo Clinic – Della Derscheid• Questions

Use chat box for questions, all phones are on mute. This presentation is being recorded.

Violence Prevention

Violence prevention is a multi-faceted, multidisciplinary approach that includes being trained to be aware of circumstances, physical infrastructure, continual training and constant communication.

St. Luke’s is a health care system based in Duluth, Minnesota. Our two hospitals, 14 primary care clinics, 24 specialty clinics and

two pharmacies serve the people of Northeastern Minnesota, Northwestern Wisconsin and the Upper Peninsula of Michigan.

About St. Luke’s

Incidents of Violence

• Behavioral incidents for St. Luke’s• 2011 - 274 behavioral events

• 2012 - 257 behavioral events

• In 2011 we had 16 employee injuries, leading to 165 lost work days and 666 restricted work days

Acts of Violence in the Healthcare Setting

• A patient had been admitted to Behavioral Health involuntarily. The patient was upset that he was being held in the hospital. He became extremely upset that the physician would not prescribe a controlled substance for his use while in the hospital. The patient began to slam and pull a door off the hinges and managed to dislodge half of the steel door frame from the wall. The patient attempted to come after staff and had to be restrained by 12 staff members. Later during the hospital stay the patient tried to elope from the locked inpatient unit and choked a nurse during the attempt.

• Another patient admitted to Behavioral Health became agitated and began to destroy his hospital room. The patient pulled the toilet completely out of the wall and threw it across the room. The patient then picked up large pieces of the broken toilet and attempted to cut staff with them.

Violence Awareness

How do we keep staff and other patients safe? Ensuring staff are educated on violence prevention

Providing infrastructure and tools to keep staff and patients safe

Do we have the ability to track patients with a history of violence?

– We were relying on staff to remember incidents and take precautions

– How do we ensure that risk for violence is communicated to all staff who may come into contact with that patient?

MOAB

• Management of Aggressive Behavior

• Trains for pre-event, in-event and post-event scenario

• Teaches proper verbal and non-verbal response for wide range of observed behaviors

• Teaches skills and response:– Anxiety: Support

– Verbal or non-verbal aggression: Assertive

– Physically aggressive: Defensive

Training

• All security, nursing, facility assistants and other sensitive departments attend 8-hour MOAB training on hire

• There is refresher training annually or bi-annually depending on department– We have the ability to tailor the class to the specific audience

• There are videos available on the internal intranet to review skills

• There is a mandatory education assignment regarding safety and security

• All Lead Security Officers are certified as MOAB instructors (this ensures an expert is on duty 24/7)

Circumstances

• Type of complaint (drug-seeking behaviors, homicidal ideation, etc.)

• Past behaviors (documented incidents of threat or assault, etc.)

• Verbal keywords (“you’ll be sorry”, “there will be hell to pay if…”, “you’d better hurry or else…”, etc.)

• Non-verbals (signs of anxiety or aggression)

Infrastructure

• Secured Emergency Department, Mental Health and ICU

• Panic buttons at sensitive locations

• Duress alarms worn by staff in sensitive units

• Security post within the ED serves as dispatch, campus monitoring and emergent ED responder

• A Facility Assistant (a branch of security services) serves as the receptionist to the ED/Urgent Care

Communication

Radio communications exist among sensitive areas: Facility Assistants

Security Officers

ED Staff

Mental Health Staff

PBX (operators)

Maternal Child Health

This ensures the capability to immediately relay to any other individual or department an emergent event or suspicious activity

Communication

• All patients with risk have a plan coordinated by staff whom have direct access via phone, radio, email or emergency alert infrastructure

• Plans are passed shift-to-shift on nursing units and through reports

• A Violence Prevention Team plans for and reviews incidents on campus

Use of EMR to Flag Violent Patients

• Have been able to flag patients in the system that have had a significant episode of violence within the health care system.

• This intervention will generate a flag on the status board to alert staff to the potential danger the patient may pose. This flag is meant to help staff better prepare for patient interaction.

• The flag will roll over from visit to visit.

• It is an RN assessment, and clearly defined as significant violence towards staff.

Violent Patient Flag

Outcomes

Due to all the increased early intervention, tools from the security department, and initiating a mechanism for tracking in 2012, we saw a decrease in behavioral events in the inpatient setting. 2011 274 behavioral events

2012 257 behavioral events



Outcomes cont.

We also saw a decrease in employee injury, loss work days (LWD) and restricted work days (RWD) 2011 16 injuries, 165 LWD and 666 RWD

2012 5 injuries, 2 LWD and 11 RWD

2013 8 injuries, 3 LWD and 126 RWD

2014 5 injuries to date, 2 LWD and 48 RWD

Moving Forward

• Goals are to:

• Look for an assessment tool that can help staff predict a patient’s risk for violence in the inpatient setting

• Educate staff at outlying clinics

• Continually audit for patients who are flagged and communicate with patient admissions

• Encourage reporting of incidents and staff feedback

• Strengthen working relationships with local law enforcement on incidents of violence and difficult patients

Erin Metzger, Nurse Manager

Mental Health, General Surgery/Urology, Diabetes Education/Clinical Nutrition

Michael Mock, Manager

Security Services

Implementing a Violence Risk Assessment Tool at St.

Cloud Hospital

Ann Seppelt, RN, CNP, DNPClinical Consultant, St. Cloud Hospital

Chris Walker, MSN, RN, MHADirector, Inpatient Mental Health Unit, SCH

Screen Shot in EPIC

Combination of:1. screening tool--list of seven risk factors based on research--2 or more is considered high risk, tool cascades out

2. Broset Violence Checklist--six item checklist of behavioral signs of increased violence risk

3. Nursing judgment

Violence Risk Assessment Tool

Every 12 hours while a patient is awake

Screening tool (risk factors) screen out many low risk patients

Documentation by RNs

Screening question in EpicTwo or more risk factors= high riskScreens out low risk patients

Risk Factors:Verbal Aggression in past 24 hrsPast episode of violence/aggressionAlcohol or drug influenceDementia or deliriumPsychotic symptomsHostilityImpulsivity

Risk Factors for Violence

Broset Violence ChecklistHeart of assessment tool in Epic

Violence Risk Assesment

Created by Roger Almvik, RN, PhD

One of only 2 out of over 300 violence prediction tools tested by RCT

(According to Dr. Singh, international expert in violence prediction, Fall

2012)

Broset Violence Checklist

Confused

Irritable

Boisterous

Physically threatening

Verbally threatening

Attacking objects


The key is structured clinical judgmentInvolves using:

actuarial tool (i.e, BVC) AND

nursing judgment

Repeated assessments over time

Violence Risk Assesment

Successfully identifies patients at high risk for violence

High risk: estimated 1 out of 3 becomes violent

Shown to decrease violence in RCT when combined with preventive interventions

(Abderhalden et al., 2008)


Score: 2 or less => low risk

> 3 => high risk

Indicates risk of violence for next 24 hours--about $6,000 license fee for St. Cloud hospital for one year


In audits of over 45 incidents of aggressive patients in the two fiscal quarters since implementation, nurses had documented patients as high risk in over 90% of them (frequently before the incident, sometimes after the incident)◦ --Broset predicted about 2/3 of the incidents in

the first quarter after implementation◦ --Benefit is that often, those scoring high risk have

the assessment carried forward for future shifts ◦ --Now have an Epic report identifying all patients

in the hospital scoring high risk at some point in their stay --used by charge nurses and security

After review of the literature:

For violence prevention:Aggression Caution Magnet **Charge Nurse informed **PRN oral medicationsBehavioral health case manager consultedSecurity informedClear escape route maintainedUnique Treatment Plan (UTP)Excess stimulation removed1:1 sitter observationCare Team ConferenceEnvironmental checklist completedOther (comments)

Interventions in Epic

After review of the literature:

For escalating patient:PRN oral medications De-escalation techniquesShow of Support Physical holdInjection of psychotropic drugs Mechanical restraints

Interventions in Epic

Screen Shot in EPIC

For further information on the violence risk assessment tool for Epic, please contact:

Ann Seppelt, RN, CNP, [email protected]. Behavioral Health Clinical ConsultantSt. Cloud Hospital

And/or

Chris Walker, MSN, RN, MHA [email protected] of Inpatient Mental Health Units and Behavioral Access NursesSt. Cloud Hospital

Contact Information

Abderhalden, C., Needham, I., Dassen, T., Halfens, R., Haug, H., & Fischer, J. (2008). Structured risk assessment and violence in acute psychiatric wards: Randomised controlled trial. British Journal of Psychiatry, 193, 45-50.

Hahn, S., Müller, M., Needham, I., Dassen, T., Kok, G., & Halfens, R. J. (2010). Factors associated with patient and visitor violence experienced by nurses in general hospitals in switzerland: A cross-sectional survey. Journal of Clinical Nursing, 19(23), 3535-3546. doi:10.1111/j.1365-2702.2010.03361.x

Hahn, S., Zeller, A., Needham, I., Kok, G., Dassen, T., & Halfens, R. (2008). Patient and visitor violence in general hospitals: A systematic review of the literature. Aggression & Violent Behavior, 13(6), 431-441. Retrieved from http://search.ebscohost.com/login.aspx?direct=true&db=rzh&AN=2010094241&site=ehost-live

Kindy, D., Petersen, S., & Parkhurst, D. (2005). Perilous work: Nurses' experiences in psychiatric units with high risks of assault. Archives of Psychiatric Nursing, 19(4), 169-175. Retrieved from http://search.ebscohost.com/login.aspx?direct=true&db=rzh&AN=2009023108&site=ehost-live

Roche, M., Diers, D., Duffield, C., & Catling-Paull, C. (2010). Violence toward nurses, the work environment, and patient outcomes. Journal of Nursing Scholarship, 42(1), 13-22. doi:10.1111/j.1547-5069.2009.01321.x

Wells, J., & Bowers, L. (2002). How prevalent is violence towards nurses working in general hospitals in the UK? Journal of Advanced Nursing, 39(3), 230-240. doi:10.1046/j.1365-2648.2002.02269.x

World Health Organization (WHO). (2002). New research shows workplace violence threatens health services. Retrieved 8/20, 2013, from http://www.who.int/mediacentre/news/releases/release37/en/

Yarovitsky, Y., & Tabak, N. (2009). Patient violence towards nursing staff in closed psychiatric wards: It's long-term effects on mental state and behavior. Medicine and Law, 28, 705-724.

References

©2014 MFMER | slide-38

Leadership Response to Patient Aggression

Della Derscheid, MS, RN, PhD, CNS

MN Department of HealthNovember 18, 2014


Objectives

Participants will:

1. Describe situations that the Leadership Response may address

2. Identify three process points of developing a Leadership Response to patient aggression

3. Identify two immediate and two delayed staff support options


Background

Nursing Workgroup

• Sue Ellenbecker – Clinical Nurse Specialist

• Cathy Shea – Nurse Manager

• Rose Netzer – Clinical Nurse Specialist

• Linda Smith – Nurse Manager

• Ann McKay – Nurse Administrator

• Deb Cox – Nurse Administrator

• Della Derscheid – Clinical Nurse Specialist


Background

• Nursing Workgroup was from Psychiatry

• For staff following seclusion and restraint incidents, staff injury

• Original purpose to standardize leadership response and staff options

• History: Institutional policy addressing employee initiated violence but not patient

• Culture Change


Process

• Define Aggression • Actual harm or threat of harm

• Literature review, past 10 years • Focus on staff trauma• Interventions following trauma• Similar hospital response plans


Process

• External Consultation• National expert violence with nurses• Personnel who developed similar plans

• Internal Consultation• Institutional security• Employee Assistance Program (EAP)

personnel• Ethics coordinator• Human resources


Process

• Employee’s feedback• Hear staff experiences• One staff per unit

• Psychiatric Nursing Division Leadership

• Psychiatric Nursing Practice Committee

• Institutional Practice Committee


Debriefing

• Traditional • Debriefing for staff• Debriefing for the patient

• Medical Setting Nuances• Physical contributors• Environmental Contributors


Immediate Staff Support Options

• Debriefing with individuals involved with the incident

• Take a break

• Change of patient assignment

• Escort to the emergency department for injury assessment

• Time off from work

• Family notification

• Buddy assignment for safety, if not already in place


Delayed Staff Support Options

• Provide a one or two week check-in

• A scheduled more formal debriefing with individuals involved in the incident

• Consideration of return to work arrangements

• Referral to the Employee Assistance Program for counseling

• Staff education needs


Approval Process-Rochester

• Nursing practice committees

• Hospital practice committee

• Re-review prior to dissemination at nursing practice committee


Future Implementation

• Inclusion in violence program guideline

• Quick reference

• Required education


Questions ?


Contact Information

• Erin Metzger [email protected]

• Michael Mock [email protected]

• Ann Seppelt [email protected]

• Chris Walker [email protected]

• Joy Plamann [email protected]

• Della Derscheid [email protected]

• MN Department of Health resources

• http://www.health.state.mn.us/patientsafety/preventionofviolence/

mailto:[email protected]






http://www.health.state.mn.us/patientsafety/preventionofviolence/




Managing Challenging Patient Behavior Tuesday February 17, 2015

7:00 AM - 2:30 PMSiebens Building: Room 4-05

Rochester, MN Goal: • Managing Challenging Patient Behavior examines the contributing factors to

challenging patient behaviors and how the nurse can contribute to the care of patient's exhibiting these behaviors.

Target Audience:• RN & LPNs interested in expanding their knowledge & skills in managing

challenging behaviors of patients.

Continuing Education Credit: • Participants can earn 7.2 nursing contact hours for attending the entire session.

Registration: • Registration fee of $100.00 for external participants. • Please contact: Jennifer Thompson, Administrative Assistant [email protected] 507-255-1811


prevention of violence in minnesota health care settings november 18, 2014 1

Documents

prevention of violence

lukes slide

acts of violence

history of violence

violence awareness

defensive slide

behavioral health

staff members