PATIENT AGGRESSION & VIOLENCE BEST PRACTICES NCQC PSO Safe Table July 2015

Transcription

1 PATIENT AGGRESSION & VIOLENCE BEST PRACTICES NCQC PSO Safe Table July 2015 Minimize the impact of patient aggression and violence by focusing on various phases of the care process. RECOGNITION Understand Potential Causes of Violence & Aggression Internal factors association between aggression and illness, such as diagnosis, history of aggression or violence and other risk factors such as substance abuse may increase likelihood of aggression. External factors environmental factors (i.e., privacy, space, location, type of treatment regime, unit design, denial of services/liberty) may contribute to aggression Situational/interactional factors interactions with staff, including conflicts regarding limit setting, opportunity for negotiation, ineffective listening skills and poor communication, can trigger aggression. Incongruent organization systems and actions such as hospital or unit policies, unit rules, overarching behavioral health policy and societal views or attitudes toward patients may also impact patient s behavior. Incorporate Risk Prediction into the Care Model Utilize a screening for risk of violence and aggressive behaviors as the first step in designing a treatment or intervention plan that recognizes person s unique condition, triggers and care needs Combine both clinical observation and quantitative risk assessment: o Clinical Observation includes consultation and communication between care team members and other people familiar with patient s status or history. Consider the experience of the care staff in preventing risk, specific care environment, and the rapid changes that may occur once treatment is implemented o Quantitative Risk Assessment for violence and aggressive behavior is a multi- dimensional aggression assessment tool designed to predict a person s risk of expressing violent or aggressive behavior and can be used for initial screening and ongoing monitoring of the patient Safe Tables: Managing Patient Violence & Aggression July 2015 Page 1 of 6

2 Define which factors to assess, when to perform the assessment and which assessment scale to use o Consider implementing an assessment bundle that utilizes multiple assessment scales at various points during the care, for example on arrival to facility (emergency crisis center, emergency department), prior to transport or upon arrival to inpatient setting, whenever a change in patient s condition Do not label the patient. Avoid equating risk of violence or aggressive behavior as a personal feature; rather it should be clear that it is a feature of the condition Communicate and Document; Document and Communicate Document ongoing risk assessment process, including: o Overall level of risk of harm to others and factors contributing to the risk o Evidence of an escalation in nature, frequency and intensity of behaviors o Similarity of patients current circumstances to those surrounding previous expressions of violent or aggressive behavior o History of violence or aggressive behavior among family or friends, including types of behaviors, intended target or behaviors and consequences Communicate with care team about risk, especially during transitions in care where risk of violence or aggressive behavior may be increased due to instability in observation, introduction of new triggers or changes in daily structure Develop a process to ensure risk is communicated to necessary stakeholders o Translate potential risk in to care plan o Use flags (cautiously) that alert clinical team that person may be or has recently displayed violence or aggressive behavior (Flags should be used with caution to avoid potential for stigma. If using flags, develop clear criteria for when the flag should be removed from the chart). PREVENTION Patient- Centered Considerations Incorporate structured short- term risk assessment in to routine care planning Include the patient in the prevention process. o Be transparent with plan to address patient s potential aggressive or violent behavior. o Identify education needs and ascertain what works best for patient during agitated states (listening to music, exercising, crafts, etc). o Assure appropriate transparency with patients about the process of incorporating behavior plan or contract (if applicable) o Assure patient is informed of the result of their behavior; for example, Did you know that what you did made that nurse feel Conduct frequent observations or rounding (example every 15 minutes) to identify potential changes in patient s behavior Safe Tables: Managing Patient Violence & Aggression July 2015 Page 2 of 6

3 Staffing- Centered Considerations Establish a positive initial alliance between staff and patient as strategy to limit aggression. Foster this positive patient- staff alliance thru: o Getting to know the patient o Being open, honest, and having genuine concern for patient o Utilizing good communication techniques, o Assuring staff are available to patients o Providing patient education Ensure that staff is harmonious and have a shared mental model of the care plan. Include the following prevention goals for healthcare team members: o Maintain awareness and identify of risk factors o Identify and implement most efficient intervention, avoiding restraints, to manage current harmful incidents o Communicate with empathy to the person to facilitate better understanding of current needs and distress o Implement therapeutic interventions specific to the person to address their unique risk factors o Develop strategies with the person to reduce the risk of harm to others in the future o Increase perceived sense of safety, predictability, control and choice o Decrease sense of fear and vulnerability Maintain self- awareness, as this can be beneficial when caring for and communicating with patients. o Watch body language - communication begins with non- verbal cues. Tone of the voice or inflection used can be more influential than the words spoken. Body language (i.e., presenting a closed posture, or not making eye contact) could have a negative impact and/or change the message received by the patient. o Incorporate an approach that is respectful, non- controlling, un- provocative, and non- coercive. Environmental- Centered Considerations Minimize environmental factors that may impact behavior, such as: o Structure or layout of unit o Personal space needs o Color and ambiance of unit o Locked doors o Noise level/overstimulation o Degree of privacy Ensure availability of diversionary activities for the patient Apply and communicate unit rules in a consistent manner Safe Tables: Managing Patient Violence & Aggression July 2015 Page 3 of 6

4 DE- ESCALATION Take Immediate Precautions Ensure safety. Minimize risks to the patient and others involved in or around the incident Move patient involved in incident to a quieter room or an open space; keep patient in this space until incident de- escalates o If environment change can not occur, attempt to remove any objects that could cause harm to person or potential victims (chairs, tables, glass, pens or pencils, syringes, etc) Attempt to De- escalate the Situation Identify lead staff member to attempt to de- escalate o Utilize staff who has received formal training and experience with behavior emergencies o Include clinician with best relationship with patient as he/she may be better able to de- escalate situation. Encourage other staff to remain in proximity of the event until advised otherwise in case the incident escalates further Attempt de- escalation techniques o Listen to the patient; avoid giving opinions on issues and grievances beyond your control o Ascertain what the patient actually wants and the level of urgency o Use empathetic non- confrontational approach Use talk- down interventions to make the patient feel understood in terms of his/her emotions and feelings. Acknowledge patient s distress and remind patient that staff is there to help. Express sympathy and understanding to shift patient s attention away from anger and distress, making the motor component of the violent/aggressive behavior less severe Avoid excessive stimulation, aggressive postures and prolonged eye contact. Use non- coercive behavioral approaches to emphasize calm and non- threatening speech and body language (i.e., keeping distance, talking with calm voice, avoiding crossing arms or putting hands on hips) o Address medical issues, especially pain and discomfort o Recruit family, friends, care managers to help Safe Tables: Managing Patient Violence & Aggression July 2015 Page 4 of 6

5 RESPONSE & ACTION Implement a Behavior Response Team Implement behavior response team or code white team composed of clinicians and security personnel. Behavior response team members should be trained and certified in: o Procedures for early detection of violence and aggressive behavior o Identification of potential environmental hazards (objects that could be used as weapons) o Techniques for de- escalation o Processes for calling an emergency code white o Physical response techniques (e.g. hand placement stance); and o How the care team can support each other and maintain awareness of their own need for support (e.g. how can team members manage stress) Optimize methods to facilitate rapid communication o Implement process for paging code over loudspeaker system in facility to summon security staff and personnel form adjacent services o Consider various mobile technologies (i.e., pagers, group paging, zone phones, voice- activated phones, cell phones/smartphones) and consider best methods for 24/7 communication to interdisciplinary team members Activate Rapid Response Systems Activate behavior response team. Identify leader of the behavior response team. Team leader may vary from facility to facility and may depend on circumstances, knowledge of person or organizational policy. The Team leader role is to: o Gather as much information as possible including event triggers and background information on patient o Work with team to develop plan for managing situation including assignment of roles to the team Develop and execute a plan o Consider if continued de- escalation attempts are warranted o Implement acute control processes if necessary and agreed upon by team; this may include chemical restraints/acute control medication, physical restraint, or seclusion (Only use these if de- escalation strategies have been attempted and failed) Document, Report and Review the Incident Develop standardized report forms and reporting mechanism for violence and aggressive behavior incidents to learn from other events Conduct review within 72 hours of incident Incorporate key review steps in evaluation of each act of violence or aggression o Determine type and nature of violence or aggressive behavior o Talk to victim, if any, to identify specific triggers that precipitated the event o Talk to patient about what may have triggered the behavior Safe Tables: Managing Patient Violence & Aggression July 2015 Page 5 of 6

6 o Talk to witnesses for objective observations of events leading to behavior o Review if behavior was related to symptoms of mental or physical illness o Review behavior response process, including actions taken to assure safety, de- escalation, management, and stopping the behavior o Assure all policies and procedure were followed o Consider all actions were taken in light of assuring safety, rights and dignity of the patient and others involved o Provide staff support as necessary Conduct Ongoing Quality Improvement Learn from other patient violence & aggression events o What happened? o Why did it happen (systems lens)? o What could you do to reduce the risk? o How do you know risk was reduced? o How will you share the learnings? Evaluate if staff are adequately trained to recognize and intervene early to prevent escalation of aggressive or violence behavior. Incorporate lessons learned from previous events in to treatment plans to improve outcomes and safety for those continuing to treat patients. Examine how policies address risk assessment for violence or aggressive behavior (nature and timing of assessment), care for persons at risk, and procedures for management of violence or aggressive behavior Incorporate lessons learned from reviews into treatment plans to improve outcomes and safety for those continuing to treat patients Develop measurement strategies to evaluate the incidence and improvement rates of violence and aggressive behavior Identify patterns that can be used to develop targeted quality improvement initiatives Safe Tables: Managing Patient Violence & Aggression July 2015 Page 6 of 6