• Emergency Department Psychiatric Patient Violence: Diminishing the Risk

      Burnham, Jamie (2015)
      Problem: Research supports that emergency department (ED) workplace violence (WPV) involving psychiatric patients is a serious problem. While information on successful prevention strategies is limited, a first step in the process is to identify contributing factors. Objective: The Haddon Matrix, a framework that has been shown to be effective in identifying factors related to WPV in the ED, was used to conduct an observational analysis of a local ED to evaluate WPV related to psychiatric patients. Design: The principal investigator used the Haddon Matrix to obtain descriptive observation and analysis of events in a local community ED observational unit. The observation and data collection process involved psychiatric patients, health care providers, and the environment. Sample methods: Patients included those placed in the observational unit for ED psychiatric evaluation who were between 18 and 65 years old. The health care team providing direct patient care was also observed. Results: In this local community ED, 20% of psychiatric patients were involved in WPV during the 8-week observation period. Management included chemical restraints, physical restraints, security involvement, and a combination of the above. The most frequently used management was security participation, relied upon 81.8% of the time. Chemical restraints were used 63.6% of the time. Physical restraints were relied upon 9.1% of the time. Specific factors such as deescalation techniques contributed to the absence of violence. Factors such as ignoring patients, long wait times, and inconsistent processes were associated with WPV. Other concerns observed included distractions related to the use of personal cell devices and Internet that can lead to a delay in responding to escalating patients. Technology has been shown to enhance patient care, though its proper use is imperative for safety.Recommendations: Ensuring that staff has a consistent process and that all are following the protocol will help decrease the risk of WPV. Maintaining a security presence and the early use of de-escalation techniques were also associated with a lower level of WPV. It is recommended that technology be used with caution to enhance patient care but not delay response time or treatment of patients.
    • Implementation of a Violence Checklist to Reduce Seclusion/Restraint on Inpatient Psychiatry

      Newton, Nakeia D.; Bode, Claire (2020-05)
      Problem & Purpose: The effective management of patient aggression and violence presents a significant challenge to inpatient psychiatry units, with seclusion and restraint (S&R) commonly utilized to manage these crisis situations. The purpose of this quality improvement (QI) project is to implement an aggression/violence screening tool on an adult acute psychiatry unit to promote the early identification and management of potential for patient aggression/violence. Methods: The Brøset Violence Checklist (BVC) is an aggression/violence screening tool that assesses for six objective risk factors to establish the potential risk for patient aggression/violence. Aggression is defined as behavior carried out with the intent to harm another person, while violence is an extreme form of aggression that has severe harm (i.e. physical injury or death) as the end goal (Allen & Anderson, 2017). Staff nurses on a 15-bed high acuity inpatient psychiatry unit were trained on the use of the BVC and the least restrictive interventions to implement when a patient has been identified as at risk for aggression/violence. The BVC was to be completed on each patient admission on the unit over a 10-week period. Pre and post implementation surveys were conducted to assess the perception of staff nurses on their knowledge and skill set in the effective management of aggression/violence. Results: During the implementation period, the project leader provided training to 100% of staff nurses (n=43) under the adult inpatient psychiatry service on the use of the BVC to assess for early manifestations of risk for aggression/violence. Staff nurses screened 43% (n=38) of new patient admissions during the project implementation period. Staff nurses reported feeling that a screening tool would be useful in assessing for patient aggression/violence both pre and post implementation. Conclusion: Aggression/violence screening tools are an essential component in the effective management of patient aggression/violence and reducing S&R on inpatient psychiatry. While this QI project was successful in implementing the BVC to aid in the early assessment of patients at risk for aggression/violence, future QI projects should assess the role that least restrictive interventions play in reducing patient aggression and S&R events.
    • Implementing Behavioral Screening Protocols to Reduce Violence in the Emergency Department

      Mangana, William; Bundy, Elaine Y. (2020-05)
      Problem and Purpose: The opioid crisis and lack of mental health resources for patients are two leading causes of elevated levels of violence in the emergency department. As a result, a rise in patient aggressive behavior including verbal and/or physical attacks against emergency department staff has occurred. This increase in violence led to a new restraint protocol and a subsequent increase in restraint orders, though restraint use is not recommended evidence-based practice. The purpose of this quality improvement project was to implement a behavioral assessment protocol for identifying aggressive patient behaviors and reduce physical restraint use in the emergency department at a community hospital. Methods: The protocol was implemented through a quality improvement project using two behavior identification tools to reduce possible violent incidences against staff thus reducing restraint orders. A modified Dynamic Appraisal Situational Aggression was given to every patient in the emergency to self-identify potential aggressive behavior. The Violence Assessment Tool was completed by the nurse on patients when their score on the modified Dynamic Appraisal Situational Aggression was greater than three. Anytime the Violence Assessment Tool has to be completed, the nurse was required to evaluate the combined tool scores for level of risk. Risk reduction and de-escalation strategies were implemented based on the identified risk level. Results: The data reflects a successful implementation of the protocol with 95% of the emergency department nurses completing the protocol when required, along with patients completing the modified Dynamic Appraisal Situational Aggression at a rate of 98% upon intake. Analysis of the data’s clinical component reflects successful reduction of restraint orders from 27.5% to 1.5% percent. Conclusions: The project can be replicated across all departments in the hospital, specifically acute settings and mental health. Educating all new staff regarding the implementation protocol and the de-escalation methods is recommended. In addition, adding a flag to the electronic medical record to alert nurses that a patient completing the modified Dynamic Appraisal Situational Aggression has met the threshold and the completion of the Violence Assessment Tool is necessary. Both recommendations will allow for the results of the project to be sustained and replicated.
    • Improving Safety in the Pediatric Emergency Department through Early Violence/Aggression Assessment

      Mancl, Margo E.; Rawlett, Kristen (2020-05)
      Problem & Purpose: The Pediatric Emergency Department (PED) setting is not exempt from workplace violence (WPV). Frontline staff in the PED have identified concerns around a rise in WPV incidents over the last few years. From January 1, 2018 through March 5, 2019, this PED saw 2,058 mental/behavioral health visits. Of mental/behavioral health focused visits, 79 visits (3.8%) resulted in coercion in the form of intramuscular antipsychotic or anxiolytic medication administration related to aggressive or violent behavior. The purpose of this project was to implement and evaluate the effectiveness of a violence risk assessment tool in a PED setting. Methods: This quality improvement (QI) project involved training PED Psychiatric RNs in an urban, academic PED on the use of the Pediatric Violence/Aggression Assessment Tool (PVAAT) to screen patients aged 8 years-17 years presenting with a chief complaint related to acute mental/behavioral health concerns. The P-VAAT score assisted the RNs to determine preventive or early intervention measures to implement in the interest of patient and staff safety. Results: Of 297 eligible patients, 152 were screened resulting in a 51.1% tool completion rate. One hundred twenty eight patients scored as ‘Low’ risk, 12 scored as ‘High’ risk, and 12 as ‘Moderate’ risk. Of those that scored ‘High,’ five exhibited violent/aggressive behavior during their encounter. Of these five, four required a short-term physical hold with intramuscular anxiolytic/antipsychotic medication administration and one was placed in seclusion. Another patient in the ‘High’ group was de-escalated and cooperative taking oral anxiolytic/antipsychotic medication. Conclusion: Observed and reported feedback through personal interactions with RNs support the ease of use and effectiveness of the Pediatric Violence/Aggression Assessment Tool (PVAAT). RNs report early identification of risk for violence allows for better preparation and safety in potential outbursts. Opportunity exists to expand this QI project with a focus on the use of this tool to include medical patient as well as building the P-VAAT into the electronic medical record system.