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.