What We Don t Know CAN Hurt Us! A Comprehensive Model for Managing Violence & Aggression on Psychiatric Inpatient Units Diane E. Allen, MN, RN-BC, NEA-BC Alexander denesnera, MD Lisa A. Mistler, MD, MS Lieutenant Frank N. Harris, NH State Police PRESENTERS HAVE NO CONLFICTS OF INTEREST TO DISCLOSE Objectives Discuss key elements of a comprehensive model to manage violence and aggression Describe strategies used to change culture, promote research, train staff, develop polices and collaborate with other professionals. Identify positive outcomes attributed to the comprehensive model for managing violence and aggression. Alexander denesnera, MD; Frank N. Harris, Lt. 1
Hospital Challenges Increased demand for services Decreased bed capacity Complex patient care needs Challenging patient behaviors Increased Demand Dramatic increase in admissions 1990: 850 admissions 2015: 2400 admissions Hospital daily census at 100% Community mental health centers serving more clients (51,000 in 2015) NH state population increasing 1.1 million in 1990 1.32 million in 2014 Decreased Capacity Decreased NHH beds: 222-1997 to 168-2016 Decreased Designated Receiving Facility (DRF) beds in NH communities: Androscoggin Valley Hospital in Berlin, only North Country DRF closed psychiatric unit in 2007 Only 3 other DRF s in NH: Elliot Hospital (8 beds) Franklin Regional Hospital (10 beds) Portsmouth Pavilion (10 beds) Only 1 Acute Psychiatric Residential Treatment Center available: Cypress Center (16 beds) Alexander denesnera, MD; Frank N. Harris, Lt. 2
Decreased Capacity Fewer inpatient psychiatric beds and community psychiatric services 526 beds in 2005 to 384 beds in 2013 Catholic Medical Center closed 19 bed psychiatric unit in 2008 SNHRMC decreased psychiatric bed capacity from 30 to 10 in 2011 Charter Brookside Hospital and Lakeshore Hospital closed Acute Psychiatric Residential Treatment Centers in Concord, Nashua and Dover closed Ability to transfer patients to the Secure Psychiatric Unit of the DOC increasingly challenging Complex Patients Substance abuse issues increasingly common (alcohol, marijuana) Co-occurring mental illness/substance abuse diagnoses estimated to be 66% Increasingly complex medical conditions (cardiovascular, metabolic, endocrine, GI, infections) Complex Patients Increasing numbers forensic patients, sent from Department of Corrections Secure Psychiatric Unit (SPU) and county jails NHH serves as step-down facility for SPU, treating patients Not Guilty by Reason of Insanity, Incompetent to Stand Trial County jails send individuals on Personal Recognizance bail for treatment of their mental illness Forensic patients need more comprehensive oversight with multiple systems coordinating care Alexander denesnera, MD; Frank N. Harris, Lt. 3
Challenging Patient Needs Homelessness and fewer community housing options (17% of patients in 2011 were considered homeless on admission) Legal issues prohibiting patients from living in certain areas (ex. registered sex offenders can t stay in shelters) Wait times for medication management and substance abuse treatment Patients waiting in emergency departments for involuntary hospitalization admission NEW HAMPSHIRE HOSPITAL Admissions-Average Daily Census Fiscal Years 1988-2014 Decreasing census reflects fewer Hospital beds. 2500 2400 2300 2200 2100 2000 1900 1800 1700 1600 1500 1400 1300 1200 1100 1000 900 800 700 600 500 2 2 1 1 1 1 Census does not include patients on leave status whose beds are held. Room assignment must also accommodate, gender, diagnosis, the need fo Available beds have now been reduced, lowering the census. Average Normal Bed Capacity Consequences Hospital always at maximum capacity Increasing number of violent patients triaged from ED s for admission to NHH Increasing admissions from forensic settings Increasing potential for patient/patient and patient/staff assaults Alexander denesnera, MD; Frank N. Harris, Lt. 4
Administrative Efforts Developed daily review meeting with administrative, nursing, clinical staff Meetings focused on reviewing violent episodes that occurred night (or weekend) before Result: Focus on problem solving, sharing of ideas leading to strategies to decreasing aggression, avoiding use of seclusion/restraint Administrative Efforts Meet with Judges to educate them about violent acts linked to mental illness vs. antisocial behavior Develop ability of NHH physician and/or administrator available to testify at bail hearing Result: Greater understanding/ collaboration between judges and NHH Administrative Efforts Meet regularly with Department of Corrections (DOC) to review forensic patients Develop a memorandum of understanding between DOC and NHH clarifying steps needed for emergency transfers from DOC to NHH Result: Greater collaboration between two agencies (DHHS and DOC) Alexander denesnera, MD; Frank N. Harris, Lt. 5
Administrative Efforts Implemented Administrative Review Committee (ARC), a risk management review team providing guidance to clinicians treating high-risk, high profile patients Result: ARC seen as supporting clinicians, not as a group of administrators making clinical decisions Administrative Efforts Developed hospital policies dealing with emergency measures and role expectations for clinical staff and campus police Result: Increased collaboration and communication between police and clinical staff during situations involving aggression and violence Administrative Efforts Developed regularly scheduled Northern New England medical director s meeting with other state hospitals (Vermont, Maine) to discuss/problem solve around difficult clinical/forensic issues Result: Administrative/clinical expertise shared interstate Alexander denesnera, MD; Frank N. Harris, Lt. 6
Summary Increasing numbers of patients with diverse, complex needs that need mental health treatment Many challenges in maintaining hospital integrity and addressing demand for appropriate services for an increasingly violent patient population Summary Administrators need broad knowledge of multiple systems working (sometimes together, sometimes not) on various aspects of mental health care for individuals Start with low hanging fruit to begin addressing systems issues that impede appropriate treatment of mentally ill patients Managing Violence & Aggression: Nursing s Role Diane E. Allen, MN, RN-BC, NEA-BC Assistant Director of Nursing Director New Hampshire Hospital Alexander denesnera, MD; Frank N. Harris, Lt. 7
Nursing Perspective Seclusion & Restraint Reduction Injury Prevention Recruitment & Retention Key Elements of a Comprehensive Program to Manage Aggression & Violence Leadership Commitment Staff Training and Support Feedback From Direct Care Staff Collaboration Between Professionals Routine Data Collection Relevant Research Questions Alexander denesnera, MD; Frank N. Harris, Lt. 8
New Hampshire Hospital 2005 Contributing Factors January - September 2006 How to Prevent Injuries to Staff? Better Training? Increased Physical Capacity? Develop Special Response Teams? Alexander denesnera, MD; Frank N. Harris, Lt. 9
We Reviewed the Literature Short, R., Sherman, M., Raia, J., Bumgardner, C., Chambers, A. & Lofton, V. (2008). Safety Guidelines for Injury-Free Management of Psychiatric Inpatients in Precrisis and Crisis Situations. Psychiatric Services, 59(12), 1376-78. Talk to the People Who Do the Work Make it safe to talk Let them know they re important and you are interested Listen to what people say Change things that don t make sense We Shared Data Alexander denesnera, MD; Frank N. Harris, Lt. 10
(Recent Data) Inverse relationship 41% of assaults resulted in injury (Staggs, 2013) 60% of psychiatric mental health nurses experienced violence or aggression in past year (Bowers et al., 2011) 76% of all staff had experienced an attack (Yarovitsky & Tabak, 2009) Nurses attacked 10X more often than psychiatrists (Amoo & Fatoye, 2010) Workers Started Talking We Shared More Data Alexander denesnera, MD; Frank N. Harris, Lt. 11
Workers Started Talking More Which of the following are included in your job description? A. Bodyguard B. Amateur wrestler C. Superhero New Directions Getting hurt is NOT part of the job Get Help and Have a Plan before Physically Intervening Alexander denesnera, MD; Frank N. Harris, Lt. 12
Make Improvements Share Critical Information Plan for Bad News Evaluate Unit Rules Avoid Power Struggles Know When to Ask for Help Policies & Procedures Expectations for clinical staff response to violence Clear request for assistance from law enforcement Clear expectations for response from law enforcement Formal process for review of emergency measures Alexander denesnera, MD; Frank N. Harris, Lt. 13
Managing Violence & Aggression Law Enforcement Role Lieutenant Frank N. Harris Unit Commander Division of State Police New Hampshire Department of Safety Initial Obstacles Personal lack of clinical knowledge Staff distrust Clinicians negative interaction history with law enforcement Security- Break glass if needed philosophy Egos Us vs. Them Consequences Officers not allowed to trip units( frightens patients ) Officers unfamiliar with patients and staff Reports/incidents went unchecked High staff assault rate Difficulty communicating with patients when needed ( high risk response), leading to injury due to lack of team work Patient criminal backgrounds unknown, leading to difficult or inappropriate discharges Alexander denesnera, MD; Frank N. Harris, Lt. 14
Things had to change. The Integration Scheduled monthly Nurse / Police Coalition meetings to discuss issues / problem solve Involved in CPI staff training Agreed to start tripping units Stayed after emergencies for debriefings / after- action reports Worked on legal issues Collaborative results Alexander denesnera, MD; Frank N. Harris, Lt. 15
Current Law Enforcement Role CPI training Unit rounding Respond to Code Grays Seclusion/restraint review meetings Discuss legal issues, violence management, discharge plans Policy development Present Joint Trainings Provide unit tours to law enforcement officers Contribute to Orientation NHH staff Nursing students NH State Police Managing Violence and Aggression: The Role of Research Lisa A. Mistler MD MS New Hampshire Hospital Assistant Professor of Psychiatry Dartmouth s Geisel School of Medicine Alexander denesnera, MD; Frank N. Harris, Lt. 16
Outline History of research at NHH Rationale for focus Problems with existing data Addressing the gaps Definitions Measures Patient involvement The history of research at NHH Mono-disciplinary Quality improvement Naturalistic No infrastructure A perfect storm Leadership support Assigned mentor Hired research coordinator Staff interest Alexander denesnera, MD; Frank N. Harris, Lt. 17
Rationale for focus on aggression and violence Problem in the hospital Aligns with regulatory priorities Public health problem Costs increased Injury Absenteeism Staff turnover Coercion Trauma Readmission decreased Morale Engagement Satisfaction with care Arnetz et al 2001; Hahn et al 2010 Alexander denesnera, MD; Frank N. Harris, Lt. 18
Prevalence Outpatient 2.3-13% Acute care 10-36% Involuntary 20-44% 20% inpatients commit violence (Iazzino et al 2015) The tip of the iceberg 50% physical assault and 80% verbal abuse unreported (Campbell et al 2015) No events involving verbal abuse were captured. (Pompeii et al 2013) Alexander denesnera, MD; Frank N. Harris, Lt. 19
Without accurate frequency and prevalence data Cannot make useful policy changes Cannot develop effective and targeted interventions Cannot evaluate changes made What s missing from current research? Consistent definitions Measures All stakeholder input Definition of violence The intentional use of physical force or power, threatened or actual, against oneself, another person, or against a group or community, that either results in or has a high likelihood of resulting in injury, death, psychological harm, maldevelopment or deprivation (WHO 2002) Alexander denesnera, MD; Frank N. Harris, Lt. 20
Measures Built on work already done Looked at our own data Literature review Consulted with experts Piloted a few measures Developed our own measure Did some troubleshooting Involving all stakeholders Projects MoMINT and PAUSE MoMINT Usability Therapeutic Barriers to use Adaptations Endorsement Project PAUSE Temporal relationship between delusions and: Violent ideation Property damage Physical aggression Alexander denesnera, MD; Frank N. Harris, Lt. 21
Project PAUSE Relationship between SI and Violent ideation Physical aggression ETOH and tobacco cravings associated with Violent ideation Damaging property Threatening others Physical aggression Project PAUSE Variability in physical activity Noise on unit Violent ideation Future plans Analyze our standardized data Standardize MOAS Create consortium to share data Collect data from all stakeholders Create and test interventions Alexander denesnera, MD; Frank N. Harris, Lt. 22