• Agitation Assessment and Management in the Emergency Department

      Legambi, Tabitha; Michael, Kathleen (2019-05)
      Background: Agitation is common in the emergency department. When agitation is not detected early, patients can become aggressive and violent. This can lead to increased restraint use. When restraints are used, patients and staff are more likely to become injured. Local Problem: An urban emergency department reported a lack of an objective tool for assessing patient agitation. The staff of the ED desired resources to better care for behavioral health patients. Intervention: The aim of the study was to implement the Behavioral Activity Rating Scale (BARS) in the electronic medical record of an urban ED during a 14-week quality improvement project. The goals of the project were early detection and management of patient agitation, reduction of restraint use in the emergency department, and to determine the usability of the BARS using the System Usability Scale (SUS). Results: The results of retrospective chart reviews revealed that BARS was documented frequently (n=4,867 documentations) by ED RN’s to assess patient’s with behavioral health and medical complaints (n=780). Though restraint use decreased in the first two months of the project, overall restraint use was increased in 2018 (µ=5.25; SD=3.10) compared to the previous year (µ=4.75; SD=2.99; p=0.71). However, patients who were placed in restraints, remained in restraints for fewer days in 2018 (µ=1.14; SD=0.69) compared to the previous year (µ=1.68; SD=01.20; p=0.04). The results of the SUS indicated that ED nurses found BARS to be usable. Conclusion: The BARS is a quick and easy tool to assess for patient agitation. With the incorporation of agitation management interventions, the ED team can potentially manage agitation before violence occurs. Further studies are needed on the use of BARS towards managing patient agitation and reducing staff violence in the ED.
    • Development and evaluation of a surveillance instrument for monitoring and cataloging staff injuries in a state mental hospital

      Perdue, Georgia L. (2010)
      This quality improvement study was designed to: 1) review staff injury documentation instruments of public and private mental health facilities and other hospitals in different geographic areas, 2) develop an instrument to document staff injuries and their context, and 3) test the usability/acceptability and the ability to reliably capture relevant data elements.
    • Implementation of De-Escalation Training to Medical-Surgical Nurses

      Ferrara, Kimberly (2015)
      Problem: The American Nurses Association reports only 20% of nurses’ feel safe in their area of practice with patient violence towards nurses happening more frequently on medical-surgical units (Cahill, 2008; OSHA, 2004). Purpose: To determine the effectiveness of de-escalation training on medical-surgical nurses’ confidence levels in handling agitated patients. Methods: This quality improvement project employs a non-experimental, single group, pre- and post-test design. Thackrey’s (1987) Confidence in Coping with Patient Aggression Instrument (CCPAI), a 10-item questionnaire, evaluates nursing confidence levels in dealing with agitated patients before and after implementing Richmond’s et al. (2012) Ten Domains of De-escalation. Outcomes: A one-sample t test comparing the pre- and post-test confidence scores showed the mean as significantly different from 55, a hypothetically neutral score. The post-test mean significantly increased (68.82, 95% CI [6.84 to 20.81]) from the pre-test, t(33) = 4.03, p = <.001 and showed a moderate to large effect size d = .72 (Pilot, 2010). A paired-sample two-tailed t test significantly increased from Time 1 pre-test (M = 49.82, SD = 10.11) to Time 2 post-test (M = 72.82, SD = 14.41), t(10) = 4.46, p < .001. The mean increase was 23.00 [95% CI, 11.51 – 34.49]; d = 1.84 indicating a large effect size (Pilot, 2010). A sensitivity analysis (Wilcoxon Signed Rank Test) showed a median difference amongst the matched pairs with a significant increase in confidence levels post-training, z =-2.847, p < .004. The median score increased from the pre-test (Md =51) to the post-test scores (Md = 71) (Pallant, 2013). Implications: This pilot project demonstrates improved medical-surgical nursing confidence in dealing with agitated patients. Further research using a larger sample size in several nursing units would add validity to the results.
    • Mitigating Workplace Violence Utilizing the Broset Violence Checklist

      Doyle, Karen E.; Jones-Parker, Hazel (2020-05)
      Problem & Purpose: Workplace violence impacts all health care workers especially those working in behavioral health, emergency departments (EDs), and trauma centers. The Broset Violence Checklist (BVC) is an evidence-based, valid and reliable tool demonstrating high sensitivity and specificity with predicting potentially violent patients within a 24-hour period of assessment. The tool is available to nurses in the ED but is not widely used within the system due to a lack of procedure, education and monitoring of compliance. Methods: A quality improvement project developed a procedure to increase the use of the BVC. ED nurses and security personnel were trained and compliance with utilization of the tool was measured. A pre/post implementation survey was conducted to determine perceptions of workplace violence. A daily report detailing the use compliance and the BVC scores of each patient was automatically distributed to the emergency department and security leadership. The outcome measures are: (a) 90% of adult patients > 18 years old seeking treatment in the ED will be assessed for potential violence using the BVC during the intake and triage process and (b) overall incidences of workplace violence are reduced. Data were analyzed using descriptive statistics. Results: A convenience sample of 6,944 adults > 18 years old entered the ED in an academic acute care setting for evaluation and treatment in a 14-week period. Compliance with completion of the BVC pre-implementation was a mean of 74% and implementation of 67% (u = 1355, p = 0.014); 18 patients scored > 3 on the BVC (u = 188, p = 0.68). Conclusion: This quality improvement project illustrates it is difficult to improve compliance based on education alone. Enforcement of compliance with the procedure and assessment tool needs to be hard wired into the workflow of nursing and security personnel. It remains essential that hospitals incorporate violence assessment tools and strategies in the ED setting. As part of routine care, ED staff can use screening tools such as the BVC to identify people at high risk of violence. These tools can offer appropriate behavioral interventions to those who screen high on the assessment tool.