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Kim SC, Kaiser J, Hosford T, Sadate‐Akhavi C, Nurski A, Bos T, Ciampa C. A workplace violence prevention program targeting high-risk patients in emergency departments. J Am Coll Emerg Physicians Open 2024; 5:e13206. [PMID: 39056086 PMCID: PMC11269763 DOI: 10.1002/emp2.13206] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2024] [Revised: 04/22/2024] [Accepted: 05/15/2024] [Indexed: 07/28/2024] Open
Abstract
Objective Patient violence in emergency departments (EDs) may be prevented with proactive mitigation measures targeting potentially violent patients. We aimed to evaluate the effects of two interventions guided by a validated risk-assessment tool. Methods A prospective interventional study was conducted among patients ≥10 years who visited two EDs in Michigan, USA, from October 2022 to August 2023. During triage, the ED nurses completed the Aggressive Behavior Risk Assessment Tool for EDs (ABRAT-ED) to identify high-risk patients. Following the baseline observational period, interventions were implemented stepwise for the high-risk patients: phase 1 period with signage posting and phase 2 period with a proactive Behavioral Emergency Response Team (BERT) huddle added to the signage posting. Before ED disposition, any violent events and their severities were documented. The data were retrieved retrospectively after the study was completed. Results Of 77,424 evaluable patients, 546 had ≥1 violent event. The violent event rates were 0.93%, 0.68%, and 0.62% for baseline, phase 1, and phase 2, respectively. The relative risk of violent events for phase 1 compared to the baseline was 0.73 (95% confidence interval [CI]: 0.59‒0.90; p = 0.003). The relative risk for phase 2 compared to phase 1 was 0.92 (95% CI: 0.76‒1.12; p = 0.418). Conclusion The use of signage posting as a persistent visual cue for high-risk patients identified by ABRAT-ED appears to be effective in reducing the overall violent event rates. However, adding proactive BERT huddle to signage posting showed no significant reduction in the violent event rates compared to signage posting alone.
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Affiliation(s)
- Son Chae Kim
- School of NursingPoint Loma Nazarene UniversitySan DiegoCaliforniaUSA
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2
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Bass GA, Chang CWJ, Winkle JM, Cecconi M, Kudchadkar SR, Akuamoah-Boateng K, Einav S, Duffy CC, Hidalgo J, Rodriquez-Vega GM, Gandra-d'Almeida AJ, Barletta JF, Kaplan LJ. In-Hospital Violence and Its Impact on Critical Care Practitioners. Crit Care Med 2024; 52:1113-1126. [PMID: 38236075 DOI: 10.1097/ccm.0000000000006189] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2024]
Abstract
OBJECTIVES To provide a narrative review of hospital violence (HV) and its impact on critical care clinicians. DATA SOURCES Detailed search strategy using PubMed and OVID Medline for English language articles describing HV, risk factors, precipitating events, consequences, and mitigation strategies. STUDY SELECTION Studies that specifically addressed HV involving critical care medicine clinicians or their practice settings were selected. The time frame was limited to the last 15 years to enhance relevance to current practice. DATA EXTRACTION Relevant descriptions or studies were reviewed, and abstracted data were parsed by setting, clinician type, location, social media events, impact, outcomes, and responses (agency, facility, health system, individual). DATA SYNTHESIS HV is globally prevalent, especially in complex care environments, and correlates with a variety of factors including ICU stay duration, conflict, and has recently expanded to out-of-hospital occurrences; online violence as well as stalking is increasingly prevalent. An overlap with violent extremism and terrorism that impacts healthcare facilities and clinicians is similarly relevant. A number of approaches can reduce HV occurrence including, most notably, conflict management training, communication initiatives, and visitor flow and access management practices. Rescue training for HV occurrences seems prudent. CONCLUSIONS HV is a global problem that impacts clinicians and imperils patient care. Specific initiatives to reduce HV drivers include individual training and system-wide adaptations. Future methods to identify potential perpetrators may leverage machine learning/augmented intelligence approaches.
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Affiliation(s)
- Gary A Bass
- Division of Trauma, Surgical Critical Care and Emergency Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | | | - Julie M Winkle
- Emergency Medicine, UC Health, University of Colorado Hospital, Aurora, CO
| | - Maurizio Cecconi
- Department of Biomedical Sciences, Humanitas University, Milan, Italy
| | - Sapna R Kudchadkar
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins Medicine, Baltimore, MD
| | - Kwame Akuamoah-Boateng
- Department of Surgery Acute Care Surgical Services, Mary Baldwin University and Virginia Commonwealth University Health Richmond, Richmond, VA
| | - Sharon Einav
- General Intensive Care Unit of the Shaare Zedek Medical Center, Faculty of Medicine, Hebrew University School of Medicine, Jerusalem, Israel
| | - Caoimhe C Duffy
- Department of Anesthesiology and Critical Care Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Jorge Hidalgo
- Division of Critical Care, Karl Heusner Memorial Hospital, Belize City, Belize
| | - Gloria M Rodriquez-Vega
- Department of Critical Care Medicine - HIMA-San Pablo, Caguas Puerto Rico
- University of Puerto Rico, School of Medicine, Caguas, Puerto Rico
| | | | - Jeffrey F Barletta
- Pharmacy Practice, Midwestern University, College of Pharmacy-Glendale Campus, Glendale, AZ
| | - Lewis J Kaplan
- Division of Trauma, Surgical Critical Care and Emergency Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
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3
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Kay C, Miller M, Buckingham B. Implementing Behavioral Optimization and Outcomes Support Team in a Medical/Surgical Telemetry Unit. J Healthc Qual 2024; 46:e40-e48. [PMID: 38697091 DOI: 10.1097/jhq.0000000000000436] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/04/2024]
Abstract
BACKGROUND A community hospital reported 21 staff assaults with injuries and 242 emergency response code green (CG) calls for violent behaviors, resulting in a loss of time in the 2022 fiscal year. Evidence has shown that exposure to violent behavior can compromise effective patient care and lead to job dissatisfaction, high turnover, and higher healthcare costs. PURPOSE This quality improvement project aims to develop and implement behavioral optimization and outcome support team (BOOST) in a medical-surgical telemetry unit to reduce patient-to-staff assaults/injuries. METHODS BOOST was piloted for 15 weeks; process data included staff knowledge and satisfaction with BOOST; outcome data included the number of BOOST and CG calls and staff assaults/injuries. The team members included registered psychiatric nurses, nursing supervisors, and security officers. Data were collected and analyzed weekly using a run chart. RESULTS The survey data demonstrated increased staff knowledge of the behavioral response team and staff satisfaction with the BOOST implementation. No staff injuries or assaults were reported during the BOOST implementation. CONCLUSIONS Behavioral optimization and outcome support team was effective in de-escalating patients and the team provided support to nursing staff. BOOST utilization can effectively reduce assaults and injuries in the workplace.
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Hoffmann JA, Corboy JB, Liu L, Cieslak K, Pergjika A, Patel TR, Bardach NS, Alpern ER. Use of Electronic Health Record-Based Measures to Assess Quality of Care for Pediatric Agitation. Hosp Pediatr 2024; 14:319-327. [PMID: 38618654 PMCID: PMC11265604 DOI: 10.1542/hpeds.2023-007532] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/16/2024]
Abstract
OBJECTIVES Acute agitation during pediatric mental health emergency department (ED) visits presents safety risks to patients and staff. We previously convened multidisciplinary stakeholders who prioritized 20 proposed quality measures for pediatric acute agitation management. Our objectives were to assess feasibility of evaluating performance on these quality measures using electronic health record (EHR) data and to examine performance variation across 3 EDs. METHODS At a children's hospital and 2 nonchildren's hospitals, we assessed feasibility of evaluating quality measures for pediatric acute agitation management using structured EHR data elements. We retrospectively evaluated measure performance during ED visits by children 5 to 17 years old who presented for a mental health condition, received medication for agitation, or received physical restraints from July 2020 to June 2021. Bivariate and multivariable regression were used to examine measure performance by patient characteristics and hospital. RESULTS We identified 2785 mental health ED visits, 275 visits with medication given for agitation, and 35 visits with physical restraints. Performance was feasible to measure using EHR data for 10 measures. Nine measures varied by patient characteristics, including 4.87 times higher adjusted odds (95% confidence interval 1.28-18.54) of physical restraint use among children with versus without autism spectrum disorder. Four measures varied by hospital, with physical restraint use varying from 0.5% to 3.3% of mental health ED visits across hospitals. CONCLUSIONS Quality of care for pediatric acute agitation management was feasible to evaluate using EHR-derived quality measures. Variation in performance across patient characteristics and hospitals highlights opportunities to improve care quality.
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Affiliation(s)
- Jennifer A. Hoffmann
- Division of Emergency Medicine, Ann & Robert H. Lurie Children’s Hospital of Chicago
- Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Jacqueline B. Corboy
- Division of Emergency Medicine, Ann & Robert H. Lurie Children’s Hospital of Chicago
- Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Lynn Liu
- Data Analytics and Reporting, Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago
| | - Kristine Cieslak
- Division of Emergency Medicine, Ann & Robert H. Lurie Children’s Hospital of Chicago
- Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Alba Pergjika
- Pritzker Department of Psychiatry and Behavioral Health, Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, IL
| | - Tulsi R. Patel
- Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Naomi S. Bardach
- Department of Pediatrics, Philip R. Lee Institute for Health Policy Studies, University of California San Francisco, San Francisco, CA
| | - Elizabeth R. Alpern
- Division of Emergency Medicine, Ann & Robert H. Lurie Children’s Hospital of Chicago
- Northwestern University Feinberg School of Medicine, Chicago, IL
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5
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Malpass AG, Carroll K. The Neuman Systems Model: A Framework for Aggression and Violence Prevention. Nurs Sci Q 2024; 37:118-124. [PMID: 38491890 DOI: 10.1177/08943184231224436] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/18/2024]
Abstract
Aggression and violence influence nurse-client relationships and the quality of care provided, and just as important, they also influence the nurses' physical and emotional well-being. The Neuman systems model is utilized to define and understand factors that contribute to aggressive and violent behavior and for the purposes of providing a systematic approach to the prevention and management of stressors leading to aggression and violence.
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Affiliation(s)
| | - Karen Carroll
- Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
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6
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Hoffmann JA, Kshetrapal A, Pergjika A, Foster AA, Wnorowska JH, Johnson JK. A Qualitative Assessment of Barriers and Proposed Interventions to Improve Acute Agitation Management for Children With Mental and Behavioral Health Conditions in the Emergency Department. J Acad Consult Liaison Psychiatry 2024; 65:167-177. [PMID: 38070778 PMCID: PMC11032221 DOI: 10.1016/j.jaclp.2023.12.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2023] [Revised: 08/11/2023] [Accepted: 12/04/2023] [Indexed: 01/06/2024]
Abstract
BACKGROUND Mental health visits to the emergency department (ED) by children are rising in the United States, and acute agitation during these visits presents safety risks to patients and staff. OBJECTIVE We sought to assess barriers and strategies for providing high-quality care to children who experience acute agitation in the ED. METHODS We conducted semistructured interviews with 6 ED physicians, 6 ED nurses, 6 parents, and 6 adolescents at high risk for developing agitation. We asked participants about their experiences with acute agitation care in the ED, barriers and facilitators to providing high-quality care, and proposed interventions. Interviews were coded and analyzed thematically. RESULTS Participants discussed identifying risk factors for acute agitation, worrying about safety and the risk of injury, feeling moral distress, and shifting the culture toward patient-centered, trauma-informed care. Barriers and facilitators included using a standardized care pathway, identifying environmental barriers and allocating resources, partnering with the family and child, and communicating among team members. Nine interventions were proposed: opening a behavioral observation unit with dedicated staff and space, asking screening questions to identify risk of agitation, creating personalized care plans in the electronic health record, using a standardized agitation severity scale, implementing a behavioral response team, providing safe activities and environmental modifications, improving the handoff process, educating staff, and addressing bias and inequities. CONCLUSIONS Understanding barriers can inform solutions to improve care for children who experience acute agitation in the ED. The perspectives of families and patients should be considered when designing interventions to improve care.
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Affiliation(s)
- Jennifer A Hoffmann
- Division of Emergency Medicine, Department of Pediatrics, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, IL.
| | - Anisha Kshetrapal
- Division of Emergency Medicine, Department of Pediatrics, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Alba Pergjika
- Prtizker Department of Psychiatry and Behavioral Health, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Ashley A Foster
- Department of Emergency Medicine, University of California San Francisco, UCSF Benioff Children's Hospital, San Francisco, CA
| | | | - Julie K Johnson
- Department of Surgery, Northwestern Quality Improvement Research and Education in Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL
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7
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Hoffmann JA, Pergjika A, Liu L, Janssen AC, Walkup JT, Johnson JK, Alpern ER, Corboy JB. Standardizing and Improving Care for Pediatric Agitation Management in the Emergency Department. Pediatrics 2023; 152:e2022059586. [PMID: 37317809 PMCID: PMC10312235 DOI: 10.1542/peds.2022-059586] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/13/2023] [Indexed: 06/16/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Pediatric mental health emergency department (ED) visits are rising in the United States, with more visits involving medication for acute agitation. Timely, standardized implementation of behavioral strategies and medications may reduce the need for physical restraint. Our objective was to standardize agitation management in a pediatric ED and reduce time in physical restraints. METHODS A multidisciplinary team conducted a quality improvement initiative from September 2020 to August 2021, followed by a 6-month maintenance period. A barrier assessment revealed that agitation triggers were inadequately recognized, few activities were offered during long ED visits, staff lacked confidence in verbal deescalation techniques, medication choices were inconsistent, and medications were slow to take effect. Sequential interventions included development of an agitation care pathway and order set, optimization of child life and psychiatry workflows, implementation of personalized deescalation plans, and adding droperidol to the formulary. Measures include standardization of medication choice for severe agitation and time in physical restraints. RESULTS During the intervention and maintenance periods, there were 129 ED visits with medication given for severe agitation and 10 ED visits with physical restraint use. Among ED visits with medication given for severe agitation, standardized medication choice (olanzapine or droperidol) increased from 8% to 88%. Mean minutes in physical restraints decreased from 173 to 71. CONCLUSIONS Implementing an agitation care pathway standardized and improved care for a vulnerable and high-priority population. Future studies are needed to translate interventions to community ED settings and to evaluate optimal management strategies for pediatric acute agitation.
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Affiliation(s)
| | - Alba Pergjika
- Pritzker Department of Psychiatry and Behavioral Sciences
| | - Lynn Liu
- Data Analytics and Reporting, Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, Illinois
| | | | - John T. Walkup
- Pritzker Department of Psychiatry and Behavioral Sciences
| | - Julie K. Johnson
- Surgical Outcomes and Quality Improvement Center, Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois
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8
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Abstract
ABSTRACT The emergency department can be a particularly challenging environment for the care of pediatric patients presenting with acute agitation. Agitation is a behavioral emergency requiring prompt intervention. Timely recognition of agitation and proactive implementation of de-escalation strategies are critical for safe and effective management of agitation, as well as prevention of recurrent episodes. This article reviews the definition of agitation, explores the domains of verbal de-escalation, and considers multidisciplinary management strategies for children with acute agitation.
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Affiliation(s)
| | - Carl R Baum
- Professor, Section of Pediatric Emergency Medicine, Departments of Pediatrics and of Emergency Medicine, Yale School of Medicine, New Haven, CT
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9
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Shannon MT, Green M, Pires-Serisser AM, King EA. Building a Nurse-Led Collaborative Care Delivery Model for Behavioral Health Patients Boarding on a Pediatric Medical Unit. J Nurs Adm 2023; 53:378-384. [PMID: 37449815 DOI: 10.1097/nna.0000000000001303] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/18/2023]
Abstract
With the current global mental health crisis, hospitals have experienced an exponential increase in behavioral health patients boarding on medical and surgical units. Nursing leaders are challenged with adapting existing infrastructure to deliver safe high-quality care to this patient population. This article describes 1 medical center's nurse-led effort to improve safety and quality care experiences for pediatric behavioral health patients boarding on a medical unit and for the staff providing care.
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Affiliation(s)
- M Teresa Shannon
- Author Affiliations: Education Coordinator (Shannon), Clinical Coordinator (Green and Pires-Serisser), and Nursing Director (Dr King), Inpatient Medicine Department, Boston Children's Hospital, Massachusetts
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10
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Buchholz T, Barzola M, Tayban Y, Halpern NA. A Rapid Response Team (RRT) System at a Cancer Center: Innovative Approaches to System Organization and Clinical RRT Pathways. Crit Care Nurs Q 2023; 46:116-125. [PMID: 36823738 PMCID: PMC10351879 DOI: 10.1097/cnq.0000000000000444] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/25/2023]
Abstract
The Rapid Response Team (RRT) system at Memorial Sloan Kettering Cancer Center led by critical care medicine (CCM) advanced practice providers (APPs) expanded exponentially between 2009 and 2021. CCM-APPs are trained for care of critically ill patients as well as to oversee rapid response calls. The RRT is composed of a CCM-based RRT-APP, respiratory therapist, RRT-RN, and nursing supervisor. Since program inception, 11 RRT pathways and interventions have been developed and adjusted to improve multidisciplinary patient management. Pathways vary in complexity and require multidisciplinary collaboration. In some circumstances, the RRT patient may require transfer to outside facilities for services not provided at our oncology-based facility. RRT data are tracked across the hospital continuum with on-line reporting through RRT website dashboards. 2021 RRT data on electronic sepsis alerts, behavioral RRT and stroke alerts are presented. The RRT program is monitored through robust quality assurance. The APP-led RRT system's scope of care has been continuously expanded through the creation of RRT pathways to meet the increasingly complex medical needs of our patients.
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Affiliation(s)
- Tara Buchholz
- Memorial Sloan Kettering Cancer Center, New York, New York
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11
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Tosswill H, Cabilan CJ, Learmont B, Taurima K. A descriptive study on the use of restrictive interventions for potentially or actually violent patients in the emergency department. Australas Emerg Care 2023; 26:7-12. [PMID: 35882619 DOI: 10.1016/j.auec.2022.07.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2022] [Revised: 07/03/2022] [Accepted: 07/03/2022] [Indexed: 11/28/2022]
Abstract
BACKGROUND Restrictive interventions (chemical, physical, or mechanical restraints) to manage patients who are potentially or actually violent in the emergency department (ED) can be harmful and costly. Non-restrictive interventions are advocated; but this must be preceded with an understanding of patient characteristics that influence their use. A study was conducted to describe the use of restrictive interventions and ascribe it with patient characteristics in the ED. METHODS Records from October 2020 to March 2021 in the occupational violence database were used to analyse patient characteristics and restrictive interventions. Logistic regression was used to establish influencing factors of restrictive interventions adjusting for clinically relevant confounders. RESULTS Of the N = 1276 potentially or actually violent patients, 70 % received restrictive interventions. Chemical restraint was common, with 1 in 2 patients receiving either oral medication or intramuscular injection. Probability of restrictive interventions were higher in patients who were intoxicated [(adjusted odds ratio (aOR) 3.48, 95 % confidence interval (CI) 1.675-7.21)], had high triage score (aOR 2.084, 95 % CI 1.094-3.96), and were in the ED involuntarily (aOR 1.494, 95 % CI 1.105-2.020). CONCLUSION The results reveal the need for multifaceted approaches that limit the presentations of, and minimise restrictive interventions among, potentially or actually violent patients.
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Affiliation(s)
- Hayden Tosswill
- The University of Queensland, Faculty of Medicine, Brisbane, Australia
| | - C J Cabilan
- Princess Alexandra Hospital Emergency Department, Brisbane, Australia.
| | - Ben Learmont
- Princess Alexandra Hospital Emergency Department, Brisbane, Australia
| | - Karen Taurima
- Princess Alexandra Hospital Emergency Department, Brisbane, Australia
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12
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Hoffmann JA, Johnson JK, Pergjika A, Alpern ER, Corboy JB. Development of Quality Measures for Pediatric Agitation Management in the Emergency Department. J Healthc Qual 2022; 44:218-229. [PMID: 35067536 PMCID: PMC9246821 DOI: 10.1097/jhq.0000000000000339] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
OBJECTIVE Pediatric mental health emergency department (ED) visits that involve restraints for agitation are increasing. Quality measures are used to assess and improve healthcare quality. Our objective was to develop quality measures for pediatric ED agitation management informed by multidisciplinary perspectives. METHODS A multidisciplinary panel developed quality measures for pediatric ED agitation management through the modified Delphi method. Panelists ranked measures in importance and feasibility on a 9-point scale during 2 survey rounds, with a teleconference discussion between surveys. Consensus was defined by >75% of panelists ranking a quality measure highly (≥7) in importance and a median feasibility score of ≥4. RESULTS Panelists included 36 physicians, nurses, social workers, security, child life specialists, hospital data analysts, and parents. The panel reached consensus on 20 quality measures. Measures with the highest percentage of scores with importance ≥7 were related to adverse medication events, patients restrained, staff/patient injuries, reescalation plans, presence of an algorithm to standardize care, formal staff training on deescalation techniques, time to medication administration, and room safety. CONCLUSIONS Twenty quality measures that incorporate multidisciplinary perspectives were developed for pediatric ED agitation management. Once operationalized and field tested, these measures may be used to assess and improve healthcare quality for pediatric agitation.
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Affiliation(s)
- Jennifer A. Hoffmann
- Division of Emergency Medicine, Ann & Robert H. Lurie Children’s Hospital of Chicago, IL
| | - Julie K. Johnson
- Surgical Outcomes and Quality Improvement Center, Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Alba Pergjika
- Prtizker Department of Psychiatry and Behavioral Health, Ann & Robert H. Lurie Children’s Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Elizabeth R. Alpern
- Division of Emergency Medicine, Ann & Robert H. Lurie Children’s Hospital of Chicago, IL
| | - Jacqueline B. Corboy
- Division of Emergency Medicine, Ann & Robert H. Lurie Children’s Hospital of Chicago, IL
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13
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Manuel MM, Feng S, Yen K, Patel F. The agitated pediatric patient located in the emergency department: The APPLIED observational study. J Am Coll Emerg Physicians Open 2022; 3:e12766. [PMID: 35769845 PMCID: PMC9208717 DOI: 10.1002/emp2.12766] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2022] [Revised: 05/14/2022] [Accepted: 05/26/2022] [Indexed: 02/05/2023] Open
Abstract
Objectives Focused research on pediatric agitation is lacking despite being a common mental and behavioral health (MBH) emergency. Prevalence of pediatric agitation remains unknown, and prior reports may have underestimated the rate of restraint use for pediatric agitation. This is the largest study to provide a focused evaluation of the prevalence and predictors of pediatric agitation and restraint use as well as the emergency department (ED) length of stay (LOS) and admission rates for agitated patients. Methods We reviewed records of patients aged ≤18 years with MBH needs who visited the pediatric ED of a tertiary care hospital during a 3-year-period. We identified and ascertained agitated/aggressive patients using documented signs/symptoms, International Classification of Diseases, Tenth Revision codes, and Behavioral Activity Rating Scale scores. We performed descriptive and multivariable analyses using SAS 9.4 (SAS Institute). Results Of 10,172 patients with MBH needs, 1408 (13.8%) were agitated/aggressive. Of these (n = 1408), 63.7% were boys, and the mean age was 11.9 years. Among agitated patients, the prevalence of restraint use was 28.7%, with a predominance of pharmacologic restraint with atypical antipsychotics. Non-Hispanic Blacks were more likely to be agitated (adjusted odd ratio [aOR], 1.8; 95% CI, 1.2-2.7), but not restrained (aOR, 0.8; 95% CI, 0.3-1.8). Predictors of restraint use include history of attention deficit hyperactivity disorder (aOR, 2.2; 95% CI, 1.5-3.3), autism (aOR, 2.9; 95% CI, 1.9-4.5), conduct disorder (aOR, 1.7; 95% CI, 1.2-2.5), psychosis (aOR, 14.3; 95% CI, 2.5-271.8), and substance use/overdose states (aOR, 1.9; CI, 1.2-3.2). Restrained agitated patients had longer ED LOS (8.4 vs 5.0 hours; P < 0.0001) and higher admission rates (aOR, 2.6; 95% CI, 2.0-3.5). Depression (aOR, 0.4; 95% CI, 0.3-0.5) and suicidality (aOR, 0.2; 95% CI, 0.1-0.3) were protective against agitation and restraint use. Conclusion Prevalence of acute agitation and restraint use in pediatric EDs may be much higher than previously reported. Predictors of acute agitation and restraint use among MBH patients were consistent with prior reports. Restrained agitated patients had longer ED LOS and higher admission rates.
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Affiliation(s)
- Matthias M. Manuel
- Division of Emergency MedicineDepartment of PediatricsUniversity of Texas Southwestern Medical Center/Children's HealthDallasTexasUSA
| | - Sing‐Yi Feng
- Division of Emergency MedicineDepartment of PediatricsUniversity of Texas Southwestern Medical Center/Children's HealthDallasTexasUSA
- North Texas Poison CenterParkland Health and Hospital SystemDallasTexasUSA
| | - Kenneth Yen
- Division of Emergency MedicineDepartment of PediatricsUniversity of Texas Southwestern Medical Center/Children's HealthDallasTexasUSA
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14
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Wong AH, Ray JM, Cramer LD, Brashear T, Eixenberger C, McVaney C, Haggan J, Sevilla M, Costa DS, Parwani V, Ulrich A, Dziura JD, Bernstein SL, Venkatesh AK. Design and Implementation of an Agitation Code Response Team in the Emergency Department. Ann Emerg Med 2022; 79:453-464. [PMID: 34863528 PMCID: PMC9038629 DOI: 10.1016/j.annemergmed.2021.10.013] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Revised: 10/12/2021] [Accepted: 10/19/2021] [Indexed: 11/01/2022]
Abstract
STUDY OBJECTIVE Agitation, defined as excessive psychomotor activity leading to violent and aggressive behavior, is becoming more prevalent in the emergency department (ED) amidst a strained behavioral health system. Team-based interventions have demonstrated promise in promoting de-escalation, with the hope of minimizing the need for invasive techniques, like physical restraints. This study aimed to evaluate an interprofessional code response team intervention to manage agitation in the ED with the goal of decreasing physical restraint use. METHODS This quality improvement study occurred over 3 phases, representing stepwise rollout of the intervention: (1) preimplementation (phase I) to establish baseline outcome rates; (2) design and administrative support (phase II) to conduct training and protocol design; and (3) implementation (phase III) of the code response team. An interrupted time-series analysis was used to compare trends between phases to evaluate the primary outcome of physical restraint orders occurring during the study period. RESULTS Within the 634,578 ED visits over a 5-year period, restraint use significantly declined sequentially over the 3 phases (1.1%, 0.9%, and 0.8%, absolute change -0.3% between phases I and III, 95% confidence interval [CI] -0.4% to 0.3%), which corresponded to a 27.3% proportionate decrease in restraint rates between phases I and III. For the interrupted time-series analysis, there was a significantly decreasing slope in biweekly restraints in phase II compared to phase I (slope, -0.05 restraints per 1,000 ED visits per 2-week period, 95% CI -0.07 to -0.03), which was sustained in an incremental fashion in phase III (slope, -0.05, 95% CI -0.07 to -0.02). CONCLUSION With the implementation of a structured agitation code response team intervention combined with design and administrative support, a decreased rate of physical restraint use occurred over a 5-year period. Results suggest that investment in organizational change, along with interprofessional collaboration during the management of agitated patients in the ED, can lead to sustained reductions in the use of an invasive and potentially harmful measure on patients.
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Affiliation(s)
- Ambrose H. Wong
- Department of Emergency Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Jessica M. Ray
- Department of Emergency Medicine, Yale School of Medicine, New Haven, CT, USA
| | | | - Taylor Brashear
- Department of Emergency Medicine, Yale School of Medicine, New Haven, CT, USA
| | | | - Caitlin McVaney
- Department of Emergency Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Jeanie Haggan
- Adult Emergency Services, Yale-New Haven Hospital, New Haven, CT, USA
| | - Mark Sevilla
- Adult Emergency Services, Yale-New Haven Hospital, New Haven, CT, USA
| | - Donald S. Costa
- Department of Protective Services, Yale-New Haven Hospital, New Haven, CT, USA
| | - Vivek Parwani
- Department of Emergency Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Andrew Ulrich
- Department of Emergency Medicine, Yale School of Medicine, New Haven, CT, USA
| | - James D. Dziura
- Department of Emergency Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Steven L. Bernstein
- Department of Emergency Medicine, Yale School of Medicine, New Haven, CT, USA,Geisel School of Medicine at Dartmouth, Hanover, NH, USA
| | - Arjun K. Venkatesh
- Department of Emergency Medicine, Yale School of Medicine, New Haven, CT, USA
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15
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Ford-Jones PC, Daly T. Filling the gap: Mental health and psychosocial paramedicine programming in Ontario, Canada. HEALTH & SOCIAL CARE IN THE COMMUNITY 2022; 30:744-752. [PMID: 33034116 DOI: 10.1111/hsc.13189] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/26/2020] [Revised: 09/07/2020] [Accepted: 09/16/2020] [Indexed: 06/11/2023]
Abstract
Paramedics respond to acute medical and trauma emergencies in the community and transport patients to emergency departments (ED). In some cases, paramedics are not only attending calls for mental health and psychosocial care but are also connecting individuals with more appropriate services to address their needs. This study qualitatively explores to what extent there are promising practices to be learned from paramedic services that are connecting patients to mental health and psychosocial programming. The study is organised as follows. In terms of the methods, we conducted a critical ethnographic case study of mental health and psychosocial care within paramedic services in Ontario, Canada. Interviews were conducted with frontline paramedics (n = 31), paramedic services management (n = 5), educators at paramedic college programmes (n = 5) and Base Hospital physicians/directors (n = 5). Work observations were also performed in three paramedic services, with multiple crews across different shifts (n ~90 hr). The study findings outline three promising practices: diversion programmes that transfer patients to a destination other than the ED; crisis response teams that attend calls identified as involving mental health and community paramedicine programmes including referral programmes. We outline the social, political and economic conditions in which these programmes were established and are provided. We also describe the conditions required to enable connecting patients to non-ED supports. The benefits of implementing specific programming for mental health-related calls within paramedic services are discussed, as well as the importance of reaching beyond the prehospital and mental healthcare system to comprehensively and preventatively address mental health needs. Tensions are explored related to running programmatic interventions for mental health by paramedic services. We conclude by noting some public policy-level challenges including the need to focus more broadly on prevention and address the social determinants of health to aid the de-escalation of distress.
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Affiliation(s)
- Polly Christine Ford-Jones
- Faculty of Health Science and Wellness, Humber Institute of Technology & Advanced Learning, Toronto, Canada
| | - Tamara Daly
- School of Health Policy and Management, York University Centre for Aging Research and Education, York University, Toronto, ON, Canada
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16
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Janzen S, Arnetz J, Radcliffe S, Fitzpatrick L, Eden J, Wright MC. Preventing patient violence in hospitals: Applying critical decision method interviews to understand how skilled staff think and act differently. Appl Nurs Res 2022; 63:151544. [PMID: 35034701 DOI: 10.1016/j.apnr.2021.151544] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2021] [Revised: 09/23/2021] [Accepted: 11/15/2021] [Indexed: 01/10/2023]
Abstract
AIMS Our aims were to understand how hospital staff who are skilled at managing aggressive patients recognize and respond to patient aggression and to compare the approaches of skilled staff to the experiences of staff who were recently involved in incidents of patient violence. BACKGROUND Violence from patients toward staff is prevalent and increasing. There is a need for greater understanding of effective approaches to managing patient aggression in a wide variety of hospital settings. METHODS We conducted grounded theory qualitative research applying Critical Decision Method interviews at two hospitals. Skilled staff and incident-involved staff were asked to describe experiences involving aggressive patients and the data were analyzed qualitatively. RESULTS Our interviews (N = 23) identified positive approaches and challenges to managing aggressive patients. Positive approaches included: maintaining empathy for the patient, allowing the patient time and space, exhibiting a calm demeanor, not taking things personally, and implementing strategies to build trust. Challenges included: inadequate psychiatric resources, balancing priorities between patients with urgent physical needs and those exhibiting difficult behaviors, and perceiving pressure to de-escalate situations quickly. Incident-involved staff were more likely to describe the challenges listed above and a limited tolerance for patients whose behavior they perceived as unjustified or detracting from other patients' care. CONCLUSION The Critical Decision Method proved valuable for highlighting nuanced understandings of skilled staff that sometimes contrasted with perceptions of incident-involved staff. Our findings support investigation of novel approaches to training such as peer coaching and improving empathy through increased understanding of mental illnesses and addiction.
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Affiliation(s)
- Suzanne Janzen
- Saint Alphonsus Regional Medical Center, United States of America
| | | | - Sydney Radcliffe
- Saint Alphonsus Regional Medical Center, United States of America
| | | | - Joyce Eden
- Saint Agnes Medical Center, United States of America
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17
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Salvatore GL, Simmons CA, Tremoulet PD. Physician Perspectives on Severe Behavior and Restraint Use in a Hospital Setting for Patients with Autism Spectrum Disorder. J Autism Dev Disord 2021; 52:4412-4425. [PMID: 34657221 PMCID: PMC8520455 DOI: 10.1007/s10803-021-05327-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/07/2021] [Indexed: 12/28/2022]
Abstract
Hospitals, with many features that can evoke severe behavior in patients with autism spectrum disorder (ASD), often use restraint as a behavior management strategy. Prior research on restraint in patients with ASD has primarily focused on children or specific departments. Twenty-five physicians and medical trainees from an urban teaching hospital participated in discussions about experiences managing severe behavior in patients with ASD across the lifespan. Twenty themes emerged from thematic analysis of participant transcripts. The five most salient themes included: lack of procedural knowledge with restraint implemented by other hospital professionals; alternative strategies to manage severe behavior; negative perceptions of restraint; helpful role of caregivers; and limited experience treating patients with ASD, and critical need for training in function-based management.
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Affiliation(s)
- Giovanna L. Salvatore
- Department of Psychology, Rowan University, 201 Mullica Hill Road, Robinson Hall Suite 117, Glassboro, NJ 08028 USA
| | - Christina A. Simmons
- Department of Psychology, Rowan University, 201 Mullica Hill Road, Robinson Hall Suite 117, Glassboro, NJ 08028 USA
| | - Patrice D. Tremoulet
- Department of Psychology, Rowan University, 201 Mullica Hill Road, Robinson Hall Suite 117, Glassboro, NJ 08028 USA
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18
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Summers J, Busch L, Kako M, Lau C. The role of the behavior analyst on interprofessional mental health teams: opportunities for collaboration and enhancing patient care. J Interprof Care 2021; 36:434-440. [PMID: 34514941 DOI: 10.1080/13561820.2021.1969345] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Patients living with mental illness have needs that span a range of professional disciplines, settings, and service systems. These needs are best addressed through interprofessional collaboration. Behavior analysts can play a valuable role in enhancing patient care as part of the interprofessional mental health team. We provide information about the field of applied behavior analysis and its contribution to the assessment and treatment of patients living with mental health and substance use challenges. We outline how behavior analysts are trained and touch upon the practice of behavior analysis in North America and beyond. We describe collaborative relationships with other mental health professionals and, as an example, review the role of the behavior analyst on interprofessional teams in our mental health and addiction teaching hospital in Canada. We highlight some of the challenges faced by behavior analysts working in the mental health field and offer suggestions to increase their profile and opportunities for collaboration in clinical programs.
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Affiliation(s)
- Jane Summers
- Department of Psychiatry, Hospital for Sick Children and University of Toronto, Toronto, ON, Canada
| | - Louis Busch
- Centre for Addiction and Mental Health, Toronto, ON, Canada
| | - Milena Kako
- Launch Behavioural Health, Centre for Health Sciences, George Brown College, Toronto, ON, Canada
| | - Catherine Lau
- Centre for Addiction and Mental Health, Toronto, ON, Canada
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19
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Hoffmann JA, Pergjika A, Konicek CE, Reynolds SL. Pharmacologic Management of Acute Agitation in Youth in the Emergency Department. Pediatr Emerg Care 2021; 37:417-422. [PMID: 34397677 PMCID: PMC8383287 DOI: 10.1097/pec.0000000000002510] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
ABSTRACT When youth in the emergency department become acutely agitated, it can be dangerous and distressing to patients, families, and clinicians. Timely, effective, and patient-centered management is key to reducing the potential for patient and staff injury while preserving patient dignity. We review the definition of agitation and pharmacologic management for youth with acute agitation, including common classes of medications, indications for use, and adverse effects. We also discuss the need to integrate the use of medications into a comprehensive strategy for agitation management that begins with proactive prevention of aggressive behavior, creation of a therapeutic treatment environment, and verbal de-escalation strategies.
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Affiliation(s)
- Jennifer A Hoffmann
- From the Attending Physician, Division of Emergency Medicine, Department of Pediatrics
| | - Alba Pergjika
- Attending Physician, Pritzker Department of Psychiatry and Behavioral Health
| | - Claire E Konicek
- Clinical Pharmacist, Department of Pharmacy, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL
| | - Sally L Reynolds
- From the Attending Physician, Division of Emergency Medicine, Department of Pediatrics
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