Acadia Touch Points Blog

Kim Alexander, RNC, Administrator for Adult Outpatient Services

Jeanne Wypyski, LCSW, CCS, Administrator for Adult Inpatient Services

In our role as administrators, we have been tasked to support the creation of the safest work environment for all Acadia employees.  Despite psychiatric care being a statistically high employee risk profession, Acadia’s leadership is committed to making our hospital an injury free work site.  We are excited about this work and want to share some of what we are doing to make this happen.

In August 2010, the hospital established the Behavioral Response Committee. The charge of this committee is to assess, review and recommend education and processes to promote safety throughout the hospital.

The intent of the Behavioral Response Committee is to focus on maintaining and promoting safety.  The multidisciplinary team, which includes direct care staff, evaluates training/education sessions as they relate to the management of safety for patients and staff and makes recommendations for future training as indicated.  The mission of this committee is to focus on staff and patient injuries/trends/patterns and make recommendations to improve processes that will provide a safe environment (therapeutic, as well as restraint and coercion free) for patients and staff. Accomplishments in the past five months have been:

• Defined role of Nurse Preceptor as one that provides staff with opportunities to move from competent to confident in their abilities to work with patients;
• Evaluated current training modules and made recommendations for more efficient process;
• Provided examples with adult focused CPS training vignettes;
• Ensured safety training included safety maneuvers as well as therapeutic techniques;
• Re-instituted Violence Risk Assessment for early identification and intervention;
• Support and collaboration with the CARE Team;
• Identification of staff injury trends.

The multidisciplinary CARE (Collaborating to Achieve a Respectful Environment) Team was developed out of the Behavioral Response Committee to provide direct support to patient care areas/units to help prevent escalation during a time when the environment has the potential to be volatile. 

The CARE team is intended to assist a patient care area/unit in early intervention whenever possible, to prevent a situation from escalating.  The CARE team is made up of clinical leaders and front line staff throughout the hospital that have demonstrated the skills to be proactive in assisting to de-escalate situations before they reach the crisis level.  The goal of the CARE team is to help provide support to staff before, during or after a (potential) crisis. Early intervention reduces not only the risk of restraints, but also staff and patient injuries.

• Committee reviews occurrence reports related to any injuries to patients and/or staff for patterns, trends and root cause analysis and make any necessary policy recommendations to ensure ongoing safety;
• Committee provides ongoing training and education to staff related to Safety Maneuvers and Collaborative Problem Solving.

Impact:

Reduction in patient restraints and injuries, and reduction in staff injuries.

• The average duration of restraint episodes in December, 2010 was 8.5 minutes, which was a 23% reduction compared to November, 2010 (average duration = 11.1 minutes). Average duration of restraints has continued to decrease in each of the last three months;
• The rate of restraint per 1000 care hours in December, 2010 was 0.23, which was which was an increase compared to November, 2010 (rate = 0.13).  (Again, note that October and November had the lowest restraint rates observed since July, 2009.) December’s rate meets the 60% reduction target and is among the four lowest for 2010;
• The most recent national normative restraint data available is for November.  Acadia Hospital’s rate is again considerably below the national rate (0.46) for the most recently available month;
• In December, three patients accounted for 44% of all restraint episodes; 
• Adolescent and child patients (under age 18) have higher restraint rates than adults.  Hospital efforts to reduce the use of restraint have focused on this age group;
• Improvement efforts implemented last quarter included increased use of CARE teams (early intervention for potential restraints) and gathering/reporting patient ratings of therapeutic alliance with staff;
• Inpatient program revision with target date 1/24/11. This will synchronize treatment groups across units so treatment teams along with patients will be able to pick from a variety of offerings daily that fit their needs. Programs will be balanced across all disciplines with one Recreational Therapist embedded on each unit consistently to assist with programming and to embellish Recreational Therapy services and considerations in patient care plans;
• Alliance ratings are designed as a restraint reduction measure as well, to the extent that they place accountability on providers for the perception of quality or relationship by the patient and provide impetus for a “crucial conversation” between patient and provider for scores under 8. This was implemented in October 2010;
• Over the past 12 months, the rate of lost work time injury cases has decreased compared to 2009;
• The majority of the days where staff are unable to work their regular job due to injury, are days where injured staff members are placed in a different job or are given restricted duty. This represents a commitment to keeping staff members who are injured, working at the hospital in some role;
• The primary strategy for reducing staff injuries is to reduce episodes of behavioral dyscontrol by patients, which are often associated with attempted assault of staff and restraint of the patient.  Previously described efforts to strengthen therapeutic alliance and identify patient self-comfort measures have been implemented/strengthened over the last quarter.

Daniel Johnson, Ph.D.
Director of Education, The Acadia Hospital

The recent mass shooting in Arizona was heart wrenching and evoked powerful feelings and reactions in many of us. It can make us all wonder how we might make sense out of situation such as this. Such events tax us on many levels. We may find ourselves emotionally enraged at the loss of innocent lives and outraged that the attack occurred toward a member of congress or a nine year-old girl or a 79 year-old grandmother. We also may re-experience previous losses we had thought were resolved that have been suddenly unearthed and once again tear at our hearts.

All of these reactions are normal and part of our natural stress reactions but nonetheless can be daunting to manage and sort through. Our children, however, are even more vulnerable. Children deal with these events without the benefit of a full range of adult experiences or the advantage of a fully developed brain. Children look to their parents and caregivers to help them process difficult information. We are their templates and we model behaviors and speech that they will adopt, whether that is our intention or not.

Many times I have worked with children and families who were experiencing a crisis and a child was exhibiting an odd behavior or communicating an unusual belief. When this was explored, the child would often refer to a comment or behavior they had observed from a parent as a critical factor. Frequently the child had misinterpreted the parent’s comment or behavior. Here is a key point: children are terrific at observing but are not so good at interpreting what they observe.

If we don’t explain to our children in developmentally appropriate terms what is going on, they will interpret this on their own as best they can; it is all they can do. We need to be very mindful of what we say. This means not only being very careful of what we say and do; but also monitoring what we allow children to be exposed to on TV. Allowing children to see the scenes of a crisis, especially a crisis created by man-made violence, can be damaging and harmful. We need to explain what occurred in terms they can understand and answer their questions honestly but within a framework that contains compassion and respect.

Powerful events such as this become the template for other powerful events. For example, the little girl who was killed in Arizona last Saturday was born on 9-11-01, THE 9-11. Most of us can close our eyes and still see those planes crashing into the towers because those scenes were continuously looped over and over again on the TV. On that day almost 10 years ago, I visited all of the children’s programs in the hospital and we talked about what they would be seeing that evening when they got home or might hear when they were visited by family. We talked about how their parents would probably be watching and talking about these events a lot. I encouraged them to ask questions and let their parents know if they needed to watch something else that was not so upsetting.
We sent a letter home explaining how the parents should try to be careful and to monitor how much of the violent scenes their children were exposed to and how to check in with their children and ask them what they understood in order to clarify misunderstandings and misinterpretations. Several parents said they appreciated some guidance around discussing this topic. I thought I’d share this advice again for those looking for such guidance. Here are my suggestions:

1. Pay attention to what your children are watching, hearing, and learning from the media as well as from your conversations and your behaviors. Ask yourself, “what do I want them to learn from this?’
2. Check their level of understanding and see if they have the basic facts or if there are misinterpretations and correct them immediately. Be as honest as you can but avoid gruesome details that don’t enhance understanding but contribute to their confusion and fear. The level of detail increases with age and developmental level.
3. Ask them to tell you what they understand to have happened. Reassure them that these tragic events are rare and that they are safe. Remind them of locks on doors, the local police force, and other safety practices you have taught them. Restore their confidence in the world.
4. Don’t dodge the “why” questions but answer them as honestly as you can; dependent on your family’s belief system or religious teachings. It is not only okay to say “I don’t know why this man did this” but perhaps the most important thing you can say. There are not many good answers to such questions and better to say this than guess.
5. Be careful about placing stigma against those with mental illness. The vast majority of those with a mental health disorder are not violent and not everyone who is violent has a mental disorder. Remember, you are setting a template that may last a lifetime. I still remember my parents’ reactions when President Kennedy was shot 47 years ago!
6. Only give your children as much information as they need. This means explain a little and then ask for questions. Sometimes they don’t need or want much information and it will depend on their age and developmental level. If they want or need more details, you can tell by how they react or what they say.
7. If your child has experienced previous trauma or significant loss, you can expect them to often regress to a younger developmental level. Don’t be harsh if you see this as it means they are struggling and need your empathy, support, and patience. If they seem to be significantly affected by the old issues, seek some professional help.
8. Be prepared for questions down the road. If you have had an open dialogue and invited your children to come back if they have any more questions or concerns, they will take you up on it and come back again and sometimes many times. That is a good thing! Be patient and answer them as many times as necessary. An 8 year old sees the world differently than a 12 year old so when the 8 year-old turns 12, be prepared to answer the questions that come from a different perspective.

When President Reagan was shot in 1980, I was working as a new kindergarten teacher in California. On the day following the shooting, some kids were talking about it with varying degrees of concern. But one poor child was very silent and visibly upset. When I checked in with him he said “the world’s going to be split in half!” I was dumbfounded. It took some time but I eventually learned that he had overheard his parents say “Reagan had been shot” but he heard a “ray gun had been shot off” and he filled in the rest with his 5 year-old imagination.

Children can and do misinterpret what they see and hear. Our job is to recognize and correct those misunderstanding and lay a foundation for ongoing discussions of these difficult and sometimes unfortunately tragic events. It is not easy but this task remains such an important responsibility of all parents and guardians of children. 
 

Brent Scobie, LCSW, CCS

Vice President of Clinical Operations

On Monday, January 3, 2010 the Bangor Daily News published a front-page story concerning a recent report from the Substance Abuse and Mental Health Services Administration (SAMHSA) that shows Maine has the highest percentage in the nation of residents seeking treatment for addiction to prescription narcotics (opioids). 

As the story correctly illustrates, this is not exactly news to those involved in law enforcement, healthcare, or public policy. In the late 1990’s the majority of individuals admitted for substance abuse treatment at Acadia were suffering from alcohol dependency, rarely did individuals present with addictions to prescription medications. By 2005, that ratio had completely reversed and we were treating more than 800 patients at a given time for opioid addiction. Today, while there are more treatment resources in our area, we continue to experience daily requests for treatment across all of our programs.

Again, as the article highlights, arriving at this point has many causes - from an over-prescription of narcotic painkillers to the lack of an easily accessible drug return system in Maine. Others also point to the variety of issues around poverty and a lack of education regarding how dangerous these prescription drugs are if used incorrectly.

Prescription pain killers have advanced significantly in the past decade and with shorter hospital stays, many providers and patients have relied on them heavily despite relatively poor treatment outcomes in the context of chronic pain management. Researchers have found that the addictive potential of prescription pain killers is significantly greater as compared to substances like alcohol, even cocaine.

A dynamic and pervasive problem like this demands an equally dynamic response that includes easily accessible treatment options from abstinence-based to those utilizing replacement therapies. Additionally, all healthcare providers, law enforcement, employers, schools, and families must be engaged, educated and activated to address this problem. Acadia remains committed to providing community preventive education and a full continuum of evidence-based addiction treatment services for those who are actively abusing these drugs.

On a larger scale, several initiatives are worth noting as we consider our community-wide response to this problem. The Penquis Public Health District Substance Abuse Workgroup and Eastern Maine Healthcare Systems’ (EMHS) identification of a strategic goal to use the system’s resources to address this issue head-on will have a positive impact in our area. As a member of EMHS, Acadia is involved with both of these efforts.  Because our clinicians are in regular contact with so many people whose lives have been affected by opiate addiction, Acadia is able to provide unique expertise and a valuable perspective to this effort.

We encourage you to visit this site frequently. We will post updates to the Blog periodically and we are most interested in your comments.