Project Timeframe: February, 2011 – ongoing
Problem: With the closing of the State Hospital and the loss of valued inpatient psychiatric beds, BMH has experienced an increasing number of patients admitted for medical care with significant behavior management issues. Additionally, BMH physicians are increasingly admitting individuals in need of medical treatment who are referred from a neighboring psychiatric hospital. These medical/ psychiatric patients have often experienced a suicide attempt, are impaired by an alcohol or drug overdose, or are experiencing debilitating psychiatric symptoms such as hallucinations and delusions. Their violent behavior towards themselves, others or their physical environment often places the patient and our staff at risk. We know that our medical and nursing staff has had training in appropriate behavioral and psychiatric management. However, as an acute care medical facility, staff it has been difficult for staff to maintain confidence in their approach and competency in management techniques. To increase safety for our patients and staff several changers have been made.
Goal: To develop a standard approach to the evaluation and treatment of patients with behavioral management issues, based on standardized, evidence based assessment tools.
Interventions: In February, 2011 we asked our Patient/Employee Safety Committee to address this issue. This committee developed an “order set” — a packet of documents for use by physicians and nursing staff to support their clinical decision making and provide for increased patient safety. This set includes:
- Standardized interview/patient history gathering tools to assess the level of risk for assault/violence and suicide/self harm. Scores on these tools assist the team in making decisions about which unit is most appropriate for the patient and the optimum level of supervision/observation for the patient.
- A de-escalation algorithm to assist nursing staff in monitoring patient behavior and making appropriate small interventions (conversation, phone call to friend, music, etc.) to assist in de-escalation of the patient’s behavior. This inventory includes consideration of limiting visitors, not allowing visitors to bring items into the patient room, and removal of patient personal items to a secure location.
- A room inventory checklist, to assist nursing staff in assessing physical risks present in a standard med-surge patient room and interventions to reduce those risks for suicidal patients.
- A revised Interdisciplinary Collaborative Plan of Care that includes consideration of needed consultations; appropriate tests and treatments; medication; diet, elimination and activity needs; patient education regarding restrictions on visitors and access to personal items; consideration of the patient’s social, cultural, and spiritual background and needs.
- A Patient Watch Information from informing nursing or security staff doing a one-on-one safety watch of the patient of patient risks, needs and restrictions.
- A detailed Observation Record to document periodic assessments of patient behavior and interventions done
Measures: 100% of all instances of use of this protocol are being audited for appropriate use and documentation. We have noted a significant reduction in instances of violent behavior by patients, and staff demonstrates an increasing confidence in their ability to manage behavior appropriately to maintain patient and staff safety while providing needed medical care.
Results: We will continue to monitor utilization of this protocol and instances of violence over the coming month to provide data for analysis. Based on that analysis we will plan either continuation o modification of this protocol for increased patient safety.
Michele Rowland, RN, LICSW
Executive Director, Quality, Utilization and Care Management
Brattleboro Memorial Hospital
17 Belmont Avenue, Brattleboro, VT 05301