APNA 29th Annual Conference Session 4011: October 31, 2015 Camille Kennedy MSN RNBC Director Behavioral Health Service Concord Hospital, Concord NH August 2015 * The speaker has no conflicts of interest to disclose. * Concord Hospital approves the use of the “CH logo” in this presentation. * Any reproductions of material is at your own risk as tools are not evidenced ‐ based and are in trial format. 2 Learning Objectives 1. Describe how an alert system is generated to support patient/staff safety. 2. Identify predicting factors that may contribute to a likelihood of violence. 3. Explain how utilizing a violence risk assessment can support pro ‐ active interventions to mitigate harm. 3 Kennedy 1
APNA 29th Annual Conference Session 4011: October 31, 2015 The Journey… 2010: NH State cuts beds and services for patients, resulting in increased wait times at Emergency Departments to >24h. 2011: Yellow Pod (YP) Lean Committee established to develop processes: Management of Aggressive Behavior training, Security searches, Depression screening tool, risks, & interventions, 15” behavior checks, staffing 16h/day, mental health identification for tracking board, order sets, “hold” up to 24h ED; “admit” > 24h –Hospitalist, education in SIM lab. Violence: 4 assaults result in staff injuries. 2012: Increase wait times result in increased violence toward self or others. 8 incidents of assault w/ staff injuries. Inadequate staffing 1:6 high acuity, increased Security stand ‐ by. Incident at local hosp w/significant outcome causes increased anxiety, fear, reactivity. How do we predict violence? What do we know? 4 Establishing a Staff/Security Alert (SSA) 2013: Identified a list of patients from the past 18 months that were violent in our ED (self ‐ harm, assault, property damage). Worked with Information Technology (IT) to establish a process for an alert to be generated upon registration to the ED. Algorithm ‐ what: process of identification of patients, when: upon registration, who: notification to stakeholders, how: pager, beeper or email SSA Alert: Last name: Location:Room: MRN:incident 5 Staff / Security Alerts (SSA) –List (who) NAME MR# ALERT CPS Assault Yes Self ‐ Harm, Property Destruction, Threats Yes Assault Yes Self ‐ harm, combative Yes Assaultive, biting, Restraints Yes Assault, Self Harm Yes Assault, Self Harm, Restraints Yes Assaultive Behavior, Self Harm, Verbal Threats to staff Yes Assault, Verbal threats, elopement Yes Assaultive, Self ‐ Harm, Elopement, Restraints Yes Assault, Elopement, Self Harm, Restraints Yes Assault, Threats Yes Assault, Threats Yes Assault, Property Destruction, Restraints Yes Assault, Elopement Yes Assault, Restraints Yes Assault, Threats Yes Assault, Elopement, Restraints Yes Property destruction, threats Yes Property destruction, threats Yes Assault, Elopement Yes Property destruction Yes Assault, Threats, Yes Assault, Restraints Yes Assault, Restraints Yes Assault, Threats Yes Assault /Restraints Yes Assault Yes 6 Kennedy 2
APNA 29th Annual Conference Session 4011: October 31, 2015 Staff /Security Alert (SSA) Notification Algorithm 7 SSA Monthly Alerts (2013 ‐ 2015) 8 Predicting Violence *History of violence *Under influence of substances *Brought in by Law Enforcement w/ disorderly *Express hostile or violent conduct ideas/actions *Belief of persecution ‐ threats * Aggressive: Verbal threats to harm or elope *Belief thoughts/actions are controlled *Angry & overtly hostile: shouting, slamming door *Command AH to hurt self or others * Application of force directed at another: throw, *Uncooperative, unable to punch, kick, spit, smash redirect *Poor impulse control 9 Kennedy 3
APNA 29th Annual Conference Session 4011: October 31, 2015 Communicate, Communicate!! Collaborate with law enforcement Collaborate with community mental health (CMH) clinicians Collaborate with security Collaborate with patient/family, SO, and/or friends Assess patient’s current state Review care plan, behavior past admissions Share all relevant information!!! 10 Violence Risk Assessment 2013: Research on Violence assessment tools: Broset Violence Checklist (BVC), Dynamic Appraisal of Situational Aggression (DASA), Columbia Suicide Severity Rating Scale (C ‐ SSRS), Violence/Aggression Assessment Checklist (VAAC). Granite Health Network (5 hospitals networking: Concord, LRGH, SNHMC, CMC, Wentworth Douglass) recommended the VAAC. 2014: Adopted VAAC and did a rapid trial approach x48h with nursing & security Staff dissatisfaction, multiple concerns from feedback 11 Re ‐ Design of Violence Risk Assessment 2014: Task force created a new tool and incorporated a Plan of Care (POC) for interventions to correspond with assessment. Rapid trial x 48h. Positive staff feedback, liked the Violence Risk Assessment (VRA) tool better, minor changes needed. Presented at Security meeting. Agreement on plan for implementation with Security and Nursing together to do initial assessment, include CMH or LE Re ‐ assessment every 8h w/ Security ‐ Agreement to change risk to higher level if indicated. Establish visual cues: meetings with stakeholders. 12 Kennedy 4
APNA 29th Annual Conference Session 4011: October 31, 2015 Visual Cues 13 Violence Risk Assessment Tool 14 Plan of Care 15 Kennedy 5
APNA 29th Annual Conference Session 4011: October 31, 2015 Plan of Care ‐ Revised 16 Safe Interventions Security presence; gather resources Review past plan of care if a known patient Huddle to determine safe entrance if patient enraged Lower voice, maintain eye contact, angle body, LISTEN to concerns, offer comfort measures, medication, fulfill requests as reasonable Re ‐ direct, use 1 ‐ 4 word directions “I need you to…” Yes rather than “no” Environment; Decrease stimulation EMPATHY 17 Survey Monkey ‐ Collaboration 18 Kennedy 6
APNA 29th Annual Conference Session 4011: October 31, 2015 RN Communication Hand Off 19 Interdisciplinary Rounding Daily rounding at 8:30am CMH Clinician presents case RN update; mental status, behaviors, vitals, labs, medications/med rec, sleep, appetite, any restraint or seclusion Behavioral Health Leadership (Manager or Director) support flow, staffing, acuity Quality Assurance nurse ‐ medical issues, past hosp, Psych providers Other when indicated: Emergency Department (ED) Provider, Hospitalist, Pedi Manager, ED RP, Security, Administration 20 References Chu, C. M., Daffern, M., & Ogloff, J. (2013). Predicting aggression in acute inpatient psychiatric setting using Broset Violence Checklist (BVC), Dynamic Appraisal of Situational Aggression (DASA) and HCR ‐ 20 Clinical Scale . Journal of Forensic Psychiatry and Psychology , 4 (24), 269 ‐ 285. Griffith, J. J., Daffern, M., & Gober, T. (2013). Examination of the predictive validity of the Dynamic Appraisal of Situational Aggression on two mental health units. International Journal of Mental Health Nursing, 12 (22)6, 485 ‐ 92. Weeks, S., Barron, B., Horne, M., Sams, G., Monnich, A., & Alverson, L. (2014) Responding to an active shooter and other threats of violence. Nursing Management(6 ), 42 ‐ 46. Posner, K., et al (2010). Columbia ‐ Suicide Severity Rating Scale (C ‐ SSRS). New York State Psychiatric Institute, New York, NY. Public Services Health & Safety Association (2010) . Completing the Violence/Aggression Assessment Checklist (VAAC) for Emergency Departments (ED) or Emergency Medical Services (EMS). Adapted from the Broset Violence Checklist ( Almvik, R & Woods, P. I., 2000), Alert System Risk Indicators (King, R., et al, 2006) and Correlates of accuracy in the assessment of psychiatric inpatients risk of violence (D. McNeil, & R. Binder, 1995). Sabella, D. (2014). Mental Illness and Violence: How can nurses identify and address signs of potential violence in their patients? American Journal of Nursing, 114 (1), 49 ‐ 53. 21 Kennedy 7
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