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Implementing a Patient Acuity Tool During Admission on a Behavioral Health Unit

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2025-05
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DNP Project
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ADMISSION ACUITY TOOL FOR ENHANCED SAFETY
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Abstract

Problem: A behavioral health unit (BHU) in a government-operated hospital saw a 30% increase in violent incidences (Code Orange) between 2022 and 2023. Purpose: This quality improvement project aimed to implement a Psychiatric Acuity Tool (PAT) on a BHU to reduce violent episodes by integrating the tool into the admission process. Method: During the 15-week implementation period, approximately 120 patients were impacted. Nurse training compliance was tracked using the Nurse Education Attestation Tool, PAT usage was monitored through admission data from charge nurses, and Code Orange incidents were analyzed using reports from the Disruptive Behavior Reporting System. Results: PAT completion rates increased throughout the implementation period, starting at 33% in week 1 and reaching 100% by weeks 13 and 14, with a median completion rate of 60%. A direct analysis of the collected Code Orange data was insufficient to determine whether the project's outcome goal of a 30% reduction in Code Orange incidents following the 15-week implementation phase was achieved. Conclusion: The PAT was successfully integrated into the admission process to guide risk-based care planning and reduce violent episodes. While nurse champions played a crucial role in the PAT implementation, their limited numbers affected support and oversight. To ensure long-term sustainability, BHU leadership supports sustainability by agreeing to incorporating the PAT training into mandatory new hire orientation. It is also recommended to recruit additional nurse champions and establish a feedback loop to evaluate the tool’s effectiveness and address staff concerns. Due to limitations in collecting Code Orange data, there was insufficient data to draw a valid conclusion about the PAT’s impact on Code Orange incidents. Future projects should focus on identifying gaps in data collection, as improved data accuracy and consistency will be essential for evaluating intervention effectiveness.

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