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(1)

Situational Awareness:

Developing a reliable system for

patient and clinical staff safety

Natalie A. Elsbrock, MSN,

RN-BC

(2)

Objectives

1. Improvement Science Principles

a. “SMART” Goal setting and Key Driver Diagrams

b. Run Charts/ Control Charts

c. Plan, Do, Study, Act cycles (PDSA)

d. Reliability principles

2. Clinical Concepts

a. “Aggression Bundle”

b. “Psych Safe Hand-Off”

c. Critical failure review

d. Whiteboards

(3)

CCHMC Department of Psychiatry

Total capacity at 4 campuses

-92 In-patient beds

(Length of Stay – 7 days)

-33 Residential beds

(Length of Stay – 120 days)

-35 Partial/Day Treatment

-Outpatient/School Based services

-450 Nursing staff

(4)

4

I’m sure glad the

hole is not in our

end!

People

unclear on the

concept of a

(5)

What is Situational

Awareness?

(6)

SA Categories

Aggressor

Watch Hot

Watch Cold

Self Threat

Medical Concern

Flight Risk

Family Concern

(7)

IHI Principles of

IHI’s Model of Applying

Reliability Principles

A. Prevent Failure

(a breakdown in operations or functions)

B. Identify and Mitigate Failure

(intercede before

harm is caused, or mitigate the harm caused by failures that are not

detected and intercepted)

C. Redesign the process

(based on the critical failures

(8)

Key Improvement Science

Principles

a. Key driver diagram

b. Run charts/ control charts

c. Plan, do, study, act cycles

d. Reliability principles

(9)

KEY DRIVER DIAGRAM

Project Name: Psychiatry Situational Awareness Project Leader: Natalie Elsbrock and Dr. Dan Vogel

SMART AIM

KEY DRIVERS

INTERVENTIONS (LOR)

To increase % of

aggression bundle

compliance from 0% to

95% by December 31,

2014

Reliable Escalation

Identify process for communicating escalation

plans (LOR1)

Identify strategies for managing escalating patient behaviors (LOR1)

Reliable Mitigation Planning

Revision Date: 05/15/14

GLOBAL AIM

2003 - 2009 © Cincinnati Children's Hospital Medical Center. All rights reserved.

Develop system for Staff to easily identify patients with positive OAS and BRACHA scores (LOR 1)

Reliable Prediction of

Patients at Risk

Reliable Communication

Identify Code Violet resources for A4C2 (LOR2)

Real Time Failure Review

Develop process for identify Watchers within the SA patients using definable criteria (LOR 2)

Eliminate patient

incidents of harm Level 6

or above related to SA

failures and to Eliminate

staff incidents of harm

related to SA failures that

result in loss work time ,

work restrictions or

treatment greater than

first aid.

Improve code violet process for College Hill and main Campus (LOR2)

Define a process for reviewing staff injuries related to patient interaction/aggression and Patient Seclusion and Restraints (LOR2)

Improve process for daily huddles on the unit

(LOR1)

Improve process of rounds to increase staff awareness of robust mitigation plans and appropriate support (LOR1)

Explore Option of implementing a Psychiatric Response Team

Clear defined roles for staff responding to a Psychiatry response Code

(10)

PDSA WORKSHEET

PLAN:

Briefly describe the test:

How will you know that the change is an improvement?

What driver does the change impact?

What do you predict will happen? PLAN

List the tasks necessary to complete this test (what)

Person responsible

(who) When Where 1. 2. 3. 4. 5. 6.

Plan for collection of data:

DO: Test the changes.

Was the cycle carried out as planned?  Yes  No

Record data and observations.

What did you observe that was not part of our plan?

STUDY:

Did the results match your predictions?  Yes  No

Compare the result of your test to your previous performance:

What did you learn?

ACT: Decide to Adopt, Adapt, or Abandon.

Adapt: Improve the change and continue testing plan. Plans/changes for next test:

Adopt: Select changes to implement on a larger scale and develop an implementation plan and plan for sustainability

Abandon: Discard this change idea and try a different one

Do Study Act

(11)
(12)

 8/4 All CH IP SA respread- SA Algorithm  8/11 A4C2/LCOH SA respread- SA Algorithm 8/11 Residential SA respread- SA Algorithm   8/28 SA Topics Video #1 8/29 SA education module launched for all IP staff  9/29 Elevation added to SA doc flowsheet & Psych Safe

Handoff (job aid 10/3) 10/3 ICMP Epic report and updates to SA doc flowsheet video during TCI Refresher Epic ICMP quickshot Go Live w/ job aid  10/9 ICMP process map & 4-prong message  10/14 Critical Failure Review TOC1  10/22 Critical Failure Review TOC2  11/6 Held Frontline Focus Group  11/12 Critical Failure Review TOC3  11/25 Critical Failure Review TOC4 11/26 Critical Failure Review TOC5  12/3 Critical Failure Review TOC6  12/19 Critical Failure Review TOC7 Low Census and Unit Closed  12/31 Critical Failure Review TOC8 0 10 20 30 40 50 60 70 80 90 100 0 8 /1 0 /1 4 (n = 6 2 ) 0 8 /1 7 /1 4 (n = 4 7 ) 0 8 /2 4 /1 4 (n = 5 2 ) 0 8 /3 1 /1 4 (n = 5 7 ) 0 9 /0 7 /1 4 (n = 4 6 ) 0 9 /1 4 /1 4 (n = 7 0 ) 0 9 /2 1 /1 4 (n = 4 9 ) 0 9 /2 8 /1 4 (n = 7 0 ) 1 0 /0 5 /1 4 (n = 7 7 ) 1 0 /1 2 /1 4 (n = 3 8 ) 1 0 /1 9 /1 4 (n = 7 3 ) 1 0 /2 6 /1 4 (n = 6 1 ) 1 1 /0 2 /1 4 (n = 7 0 ) 1 1 /0 9 /1 4 (n = 5 2 ) 1 1 /1 6 /1 4 (n = 5 7 ) 1 1 /2 3 /1 4 (n = 4 3 ) 1 1 /3 0 /1 4 (n = 6 2 ) 1 2 /0 7 /1 4 (n = 6 1 ) 1 2 /1 4 /1 4 (n = 4 4 ) 1 2 /2 1 /1 4 (n = 5 1 ) 1 2 /2 8 /1 4 (n = 3 7 ) 0 1 /0 4 /1 5 (n = 4 6 ) 0 1 /1 1 /1 5 (n = 3 6 ) 0 1 /1 8 /1 5 (n = 4 7 ) 0 1 /2 5 /1 5 (n = 4 0 ) 0 2 /0 1 /1 5 (n = 3 3 ) 0 2 /0 8 /1 5 (n = 5 3 ) 0 2 /1 5 /1 5 (n = 5 1 ) 0 2 /2 2 /1 5 (n = 3 5 ) 0 3 /0 1 /1 5 (n = 8 0 ) 0 3 /0 8 /1 5 (n = 7 2 ) 0 3 /1 5 /1 5 (n = 4 5 ) 0 3 /2 2 /1 5 (n = 4 3 ) 0 3 /2 9 /1 5 (n = 5 2 ) 0 4 /0 5 /1 5 (n = 5 4 ) 0 4 /1 2 /1 5 (n = 5 5 ) 0 4 /1 9 /1 5 (n = 5 1 ) 0 4 /2 6 /1 5 (n = 4 3 ) 0 5 /0 3 /1 5 (n = 4 6 ) 0 5 /1 0 /1 5 (n = 5 1 ) 0 5 /1 7 /1 5 (n = 6 9 ) 0 5 /2 4 /1 5 (n = 5 4 ) 0 5 /3 1 /1 5 (n = 3 7 ) 0 6 /0 7 /1 5 (n = 4 6 ) 0 6 /1 4 /1 5 (n = 4 7 ) 0 6 /2 1 /1 5 (n = 1 6 ) 0 6 /2 8 /1 5 (n = 2 9 ) 0 7 /0 5 /1 5 (n = 2 1 ) 0 7 /1 2 /1 5 (n = 1 5 ) 0 7 /1 9 /1 5 (n = 1 6 ) 0 7 /2 6 /1 5 (n = 3 5 ) 0 8 /0 2 /1 5 (n = 4 0 ) 0 8 /0 9 /1 5 (n = 2 5 ) 0 8 /1 6 /1 5 (n = 3 1 ) 0 8 /2 3 /1 5 (n = 1 2 ) 0 8 /3 0 /1 5 (n = 0 2 ) 0 9 /0 6 /1 5 (n = 4 0 ) 0 9 /1 3 /1 5 (n = 2 6 ) 0 9 /2 0 /1 5 (n = 2 1 ) 0 9 /2 7 /1 5 (n = 3 0 )

P

erc

en

tag

e

Week ending

% of SA Aggressor Patients w/ Complete Bundle* Applied

Starting 08/04/14

Percentage Median Goal (95)

*Complete Bundle includes % of SA Aggressor patients:

Identified/huddled

Mitigation plan discussed/developed Elevation plan discussed/developed SA concern in EPIC

(13)

Clinical Concepts

a. “Aggression Bundle”

b. “Psych Safe Hand-off”

c. Critical Failure Review

d. Whiteboards

(14)

Aggression Bundle

1.Identify risk for aggression:

a)

Brief rating of aggression by children and adolescents

(BRACHA) Barzman (2011)

b)

Overt Aggression Scale (OAS) Silver (1991)

2.PRN’s reviewed

3.Mitigation plan discussed (Huddle)

4.Contingency & Elevation plans developed

5.Situational Awareness aggressor

(15)
(16)

Patient list Screenshot

(17)
(18)
(19)

Outcomes

• Patient Harm – Days between chart

• Seclusions and Restraint – Control Chart

• Employee Harm – Control Chart

(20)

59

26

22

98

300

2 92

24

81

6

36

91

2

8

317

57

3

175

62

12/2/14 Level 7 incident on

P2S

893 Days

10/16/15

318 Days since

last self harm event

0

200

400

600

800

1000

1200

06

/22

08

/20

09

/15

10

/07

01

/13

11

/09

11

/11

0

2

/1

1

03

/07

05

/27

06

/02

07

/08

10

/07

10

/09

10

/17

08

/30

10

/26

10

/29

0

4

/2

1

06

/22

12

/02

10

/16

2008

2009

2010

2011

2012

2014 2015

Day

s

S

inc

e

P

re

v

ious

E

v

e

nt

Date of Incident of Harm

Psychiatry Harm Level 6 and Above

Days-Between Chart

Days Since Previous Event

This information is part of the quality assessment activities of Cincinnati Children's Hospital Medical Center (CCHMC) and, as such, is confidential information not subject to discovery pursuant to Ohio Revised Code Section 2305.25, 2305.251 and 2305.252. All Committees involved in the review of this information, as well as those individuals preparing and submitting information to such Committees, claim all the privileges and protection afforded by ORC 2305.25, 2305.251 and 2305.28 and any subsequent

SSE

*Level 6 - Attempt, MD Intervention/Procedure *Level 8 - Attempt, Admission to Medical Service

*Level 7 - Attempt, ED or Emergent Consult *Level 9 - Death

Last Updated 10/16/15 by Kim Whitesell

15'

CHECKS

Baseline

SUICIDE

RISK

ASSESSMENT

SAFETY

BUNDLE

Baseline

(21)

This information is part of the quality assessment activities of Cincinnati Children's Hospital Medical Center (CCHMC) and, as such, is confidential information not subject to discovery pursuant to Ohio Revised Code Section 2305.25, 2305.251 and 2305.252. All Committees involved in the review of this information, as well as those individuals preparing and submitting information to such Committees, claim all the privileges and protection afforded by ORC 2305.25, 2305.251 and 2305.28 and any subsequent legislation.

(22)

July 2013 Supervisor Review Implemented August 2014 SA Aggressor Spread October 2014 Leadership Analysis of All Events

0.00

0.20

0.40

0.60

0.80

1.00

1.20

1.40

7/

14

/1

2 (n=

21

7)

7/

28

/1

2 (n=

23

4)

8/

11

/1

2 (n=

23

0)

8/

25

/1

2 (n=

22

0)

9/

08

/1

2 (n=

22

5)

9/

22

/1

2 (n=

23

4)

10

/06

/12

(

n

=

2

35

)

10

/20

/12

(

n

=

2

44

)

11

/03

/12

(

n

=

2

49

)

11

/17

/12

(

n

=

2

48

)

12

/01

/12

(

n

=

2

26

)

12

/15

/12

(

n

=

2

53

)

12

/29

/12

(

n

=

2

05

)

1/

12

/1

3 (n=

22

5)

1/

26

/1

3 (n=

24

4)

2/

09

/1

3 (n=

25

1)

2/

23

/1

3 (n=

24

0)

3/

09

/1

3 (n=

24

5)

3/

23

/1

3 (n=

25

3)

4/

06

/1

3 (n=

24

5)

4/

20

/1

3 (n=

24

8)

5/

04

/1

3 (n=

24

5)

5/

18

/1

3 (n=

25

1)

6

/0

1

/1

3

(n=

2

4

8

)

6

/1

5

/1

3

(n=

2

7

3

)

6/

29

/1

3 (n=

25

0)

7/

13

/1

3 (n=

22

9)

7/

27

/1

3 (n=

23

1)

8/

10

/1

3 (n=

22

3)

8/

24

/1

3 (n=

23

0)

9/

07

/1

3 (n=

23

6)

9/

21

/1

3 (n=

24

7)

10

/05

/13

(

n

=

2

49

)

10

/19

/13

(

n

=

2

46

)

11

/02

/13

(

n

=

2

46

)

11

/16

/13

(

n

=

2

59

)

11

/30

/13

(

n

=

2

48

)

12

/14

/13

(

n

=

2

63

)

12

/28

/13

(

n

=

2

25

)

1/

11

/1

4 (n=

23

6)

1/

25

/1

4 (n=

27

4)

2/

08

/1

4 (n=

27

6)

2/

22

/1

4 (n=

28

2)

3/

08

/1

4 (n=

27

7)

3/

22

/1

4 (n=

28

2)

4/

05

/1

4 (n=

27

7)

4/

19

/1

4 (n=

27

7)

5/

03

/1

4 (n=

27

4)

5/

17

/1

4 (n=

29

2)

5/

31

/1

4 (n=

28

8)

6/

14

/1

4 (n=

29

3)

6/

28

/1

4 (n=

28

4)

7/

12

/1

4 (n=

25

1)

7/

26

/1

4 (n=

25

6)

8/

09

/1

4 (n=

24

2)

8

/2

3

/1

4

(n=

2

5

3

)

9

/0

6

/1

4

(n=

2

6

3

)

9/

20

/1

4 (n=

26

4)

10

/04

/14

(

n

=

2

69

)

10

/18

/14

(

n

=

2

68

)

11

/01

/14

(

n

=

2

73

)

11

/15

/14

(

n

=

2

75

)

11

/29

/14

(

n

=

2

61

)

12

/13

/14

(

n

=

2

70

)

12

/27

/14

(

n

=

2

25

)

1/

10

/1

5 (n=

24

6)

1/

24

/1

5 (n=

29

1)

2/

07

/1

5 (n=

29

6)

2/

21

/1

4 (n=

28

0)

Rate

of OS

HA

Inj

urie

s

per

1

0

0

FTE'

s

/2

w

e

e

k

s

Psychiatry OSHA Injuries Per 100 FTE's/2 weeks

Related to Patient Interaction

July 2012 - February 2015

Biweekly OSHA Injuries

Average OSHA Injuries Related to Patient Interaction

Control Limits

n=

total # of hours worked in 2 week

This information is part of the quality assessment activities of Cincinnati Children's Hospital Medical Center (CCHMC) and, as such, is confidential information not subject to discovery pursuant to Ohio Revised Code Section 2305.25, 2305.251 and 2305.252. All Committees involved in the review of this information, as well as those individuals preparing and submitting information to such Committees, claim all the privileges and protection afforded by ORC 2305.25, 2305.251 and 2305.28 and any subsequent legislation.

(23)

SA Category

Family Concern

(FC)

Any family concern

judged to have the potential to impact patient and/or safety in the

immediate/near future

Concerns with family, i.e., Custody issues, Medication refusal

Poor family meeting

Disposition agreement

Aggressor (A)

OAS + (domains of aggression to others and/or objects) In seclusion and/or restraints within 24 hours

HIGH HARP patient

High Risk Designation on the BRACHA doc flowsheet Volatile Pacing

Self Threat (ST)

SRT score of 12 or more Having self injurious behaviors or suicidal gestures Expressing intent to harm self On Imminent Danger or Constant Observation precautions (as a result of SIB) Reclusive Withdrawn

Patient at risk for deterioration

Medical

Concerns (MC)

Unstable diabetic Escalating asthmatic 2 or more seizures in a 24 hr. period Eating Disorder patient refusing to eat or drink over a 24 hr. period

Repeated self-injurious behaviors causing injury i.e. head-banging, cutting, re-injury to current wounds (putting items in open wounds) EPS Lack of medication adjustments.

Boundary (BR)

Boundary Risk Assessment Score of 10 or higher

Flight Risk (FR)

A CCHMC patient at risk for leaving the facility or environment unsupervised/with out permission prior to completion of treatment or discharge Expresses the intent to AWOL History of AWOL attempts Exhibiting recent behavior, i.e., grabbing badges, preoccupation with keys, badges, and doors, loitering by exits

Watcher (W)

Known history in previous admissions of:

Aggression

Self-harm

Medical concern

Guarded

Flight risk

Staff’s gut feeling

Family’s gut feeling or concern placing patient at increased risk for decompensation

Expected Risk

patient meets criteria for admission

(24)

Next Steps

• Revised SA categories

Staff focus groups

• Upgrades with data collection for bundle

I-Rounding on I-pads

• Spreading methodology to other serious

safety issues such as Self-Injurious

(25)

References

Barzman, Drew; Brackenbury, Laruen; Sonnier, Loretta; Schnell, Beverly;

Cassedy, Amy; Salisbury, Sheila; Sorter, Michael; Mossman, Douglas – (2011)

Journal of the American Academy of Psychiatry Law 39: 170-9

Brief rating of

aggression by children and adolescents (BRACHA): Development of a tool for

assessing risk of inpatents’ aggressive behavior

The James M. Anderson Center for Health Systems Excellence, Cincinnati

Children’s Hospital Medical Center: Intermediate Improvement Science Series

Langely, Gerald; Moen, Ronald; Nolan, Kevin; Nolan, Thomas; Norman,

Clifford; Provost, Lloyd – (2009) The improvement guide: A practical approach

to enhancing organizational performance; 2

nd

Edition – Published by

Jossey-Bass

Nolan, Thomas; Resar, Roger; Haraden, Carol; Griffin, Frances – (2004)

Innovation Series:

Improving the reliability of health care

. Institute for

Healthcare Improvement White Paper

Silver, Jonathan; Yudofsky, Stuart – (1991) Journal of Neuropsychiatry Volume

3, Number 2: 522-529

The overt aggression scale: Overview and guiding

principles

Therapeutic Crisis Intervention, The residential child care project. Family life

(26)

References

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