Situational Awareness:
Developing a reliable system for
patient and clinical staff safety
Natalie A. Elsbrock, MSN,
RN-BC
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
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
I’m sure glad the
hole is not in our
end!
People
unclear on the
concept of a
What is Situational
Awareness?
SA Categories
•
Aggressor
•
Watch Hot
•
Watch Cold
•
Self Threat
•
Medical Concern
•
Flight Risk
•
Family Concern
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
Key Improvement Science
Principles
a. Key driver diagram
b. Run charts/ control charts
c. Plan, do, study, act cycles
d. Reliability principles
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 escalationplans (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
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
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
Clinical Concepts
a. “Aggression Bundle”
b. “Psych Safe Hand-off”
c. Critical Failure Review
d. Whiteboards
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
Patient list Screenshot
Outcomes
• Patient Harm – Days between chart
• Seclusions and Restraint – Control Chart
• Employee Harm – Control Chart
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
BaselineThis 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.
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.
SA Category
Family Concern
(FC)
• Any family concernjudged 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 higherFlight 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 exitsWatcher (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