Natalie A. Elsbrock, MSN, RN-BC

Transcription

1 Situational Awareness: Developing a reliable system for patient and clinical staff safety Natalie A. Elsbrock, MSN, RN-BC Cincinnati Children s Hospital Medical Center

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 -Patients range in age from 2-17 yrs.

4 People unclear on the concept of a system! I m sure glad the hole is not in our end! 4

5 What is Situational Awareness? SA

6 SA Categories Aggressor Watch Hot Watch Cold Self Threat Medical Concern Flight Risk Family Concern

7 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 identified)

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 Revision Date: 05/15/14 KEY DRIVERS Reliable Prediction of Patients at Risk INTERVENTIONS (LOR) Develop system for Staff to easily identify patients with positive OAS and BRACHA scores (LOR 1) Develop process for identify Watchers within the SA patients using definable criteria (LOR 2) SMART AIM To increase % of Reliable Mitigation Planning aggression bundle compliance from 0% to 95% by December 31, 2014 Reliable Escalation Identify strategies for managing escalating patient behaviors (LOR1) Improve code violet process for College Hill and main Campus (LOR2) Identify process for communicating escalation plans (LOR1) GLOBAL AIM 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. Reliable Communication Real Time Failure Review Staff Training Identify Code Violet resources for A4C2 (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) Define a process for reviewing staff injuries related to patient interaction/aggression and Patient Seclusion and Restraints (LOR2) Explore Option of implementing a Psychiatric Response Team Clear defined roles for staff responding to a Psychiatry response Code Cincinnati Children's Hospital Medical Center. All rights reserved.

10 Plan Do PDSA WORKSHEET Act Study PLAN: Briefly describe the test: DO: Test the changes. Was the cycle carried out as planned? Yes No Record data and observations. How will you know that the change is an improvement? What did you observe that was not part of our plan? What driver does the change impact? STUDY: Did the results match your predictions? Yes No What do you predict will happen? Compare the result of your test to your previous performance: PLAN List the tasks necessary to complete this test (what) Plan for collection of data: Person responsible (who) When Where 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

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12 08/10/14 (n=62) 08/17/14 (n=47) 08/24/14 (n=52) 08/31/14 (n=57) 09/07/14 (n=46) 09/14/14 (n=70) 09/21/14 (n=49) 09/28/14 (n=70) 10/05/14 (n=77) 10/12/14 (n=38) 10/19/14 (n=73) 10/26/14 (n=61) 11/02/14 (n=70) 11/09/14 (n=52) 11/16/14 (n=57) 11/23/14 (n=43) 11/30/14 (n=62) 12/07/14 (n=61) 12/14/14 (n=44) 12/21/14 (n=51) 12/28/14 (n=37) 01/04/15 (n=46) 01/11/15 (n=36) 01/18/15 (n=47) 01/25/15 (n=40) 02/01/15 (n=33) 02/08/15 (n=53) 02/15/15 (n=51) 02/22/15 (n=35) 03/01/15 (n=80) 03/08/15 (n=72) 03/15/15 (n=45) 03/22/15 (n=43) 03/29/15 (n=52) 04/05/15 (n=54) 04/12/15 (n=55) 04/19/15 (n=51) 04/26/15 (n=43) 05/03/15 (n=46) 05/10/15 (n=51) 05/17/15 (n=69) 05/24/15 (n=54) 05/31/15 (n=37) 06/07/15 (n=46) 06/14/15 (n=47) 06/21/15 (n=16) 06/28/15 (n=29) 07/05/15 (n=21) 07/12/15 (n=15) 07/19/15 (n=16) 07/26/15 (n=35) 08/02/15 (n=40) 08/09/15 (n=25) 08/16/15 (n=31) 08/23/15 (n=12) 08/30/15 (n=02) 09/06/15 (n=40) 09/13/15 (n=26) 09/20/15 (n=21) 09/27/15 (n=30) Percentage 8/11 Residential Low 100 SA respread- Census SA Algorithm and 10/22 Unit 90 Critical 11/6 11/25 Closed 12/31 Failure Held 11/12 Critical Critical 8/28 Review Frontline Critical Failure Failure 80 12/3 SA Topics 9/29 10/14 TOC2 Focus Failure Review Review Critical 12/19 Video #1 Group Review TOC4 TOC8 8/11 Elevation Critical Failure Critical 70 TOC3 A4C2/LCOH added to Failure Review SA Failure 8/29 11/26 SA respread- doc flowsheet Review TOC6 Review SA education 10/9 ICMP Critical SA Algorithm & Psych Safe TOC1 module process map Failure TOC7 60 Handoff launched & 4-prong Review (job aid 10/3) for all message TOC5 50 IP staff 8/4 40 All CH IP SA respread- SA Algorithm /3 ICMP Epic report and updates to SA doc flowsheet video during TCI Refresher Epic ICMP quickshot Go Live w/ job aid % of SA Aggressor Patients w/ Complete Bundle* Applied Starting 08/04/14 Week ending *Complete Bundle includes % of SA Aggressor patients: Identified/huddled Mitigation plan discussed/developed Elevation plan discussed/developed SA concern in EPIC Percentage Median Goal (95)

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 documented in electronic medical record

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16 Patient list Screenshot Doc flow sheet

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19 Outcomes Patient Harm Days between chart Seclusions and Restraint Control Chart Employee Harm Control Chart

20 06/22 08/20 09/15 10/07 01/13 11/09 11/11 02/11 03/07 05/27 06/02 07/08 10/07 10/09 10/17 08/30 10/26 10/29 04/21 06/22 12/02 10/16 Days Since Previous Event Psychiatry Harm Level 6 and Above Days-Between Chart 1200 *Level 6 - Attempt, MD Intervention/Procedure *Level 8 - Attempt, Admission to Medical Service *Level 7 - Attempt, ED or Emergent Consult *Level 9 - Death Baseline 12/2/14 Level 7 incident on P2S 893 Days SSE SUICIDE RISK ASSESSMENT ' CHECKS /16/ Days since SAFETY last self harm event BUNDLE Date of Incident of Harm Baseline 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 , and 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 , and and any subsequent Last Updated 10/16/15 by Kim Whitesell

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 , and 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 , and and any subsequent legislation.

22 Rate of OSHA Injuries per 100 FTE's/2 weeks 7/14/12 (n=217) 7/28/12 (n=234) 8/11/12 (n=230) 8/25/12 (n=220) 9/08/12 (n=225) 9/22/12 (n=234) 10/06/12 (n=235) 10/20/12 (n=244) 11/03/12 (n=249) 11/17/12 (n=248) 12/01/12 (n=226) 12/15/12 (n=253) 12/29/12 (n=205) 1/12/13 (n=225) 1/26/13 (n=244) 2/09/13 (n=251) 2/23/13 (n=240) 3/09/13 (n=245) 3/23/13 (n=253) 4/06/13 (n=245) 4/20/13 (n=248) 5/04/13 (n=245) 5/18/13 (n=251) 6/01/13 (n=248) 6/15/13 (n=273) 6/29/13 (n=250) 7/13/13 (n=229) 7/27/13 (n=231) 8/10/13 (n=223) 8/24/13 (n=230) 9/07/13 (n=236) 9/21/13 (n=247) 10/05/13 (n=249) 10/19/13 (n=246) 11/02/13 (n=246) 11/16/13 (n=259) 11/30/13 (n=248) 12/14/13 (n=263) 12/28/13 (n=225) 1/11/14 (n=236) 1/25/14 (n=274) 2/08/14 (n=276) 2/22/14 (n=282) 3/08/14 (n=277) 3/22/14 (n=282) 4/05/14 (n=277) 4/19/14 (n=277) 5/03/14 (n=274) 5/17/14 (n=292) 5/31/14 (n=288) 6/14/14 (n=293) 6/28/14 (n=284) 7/12/14 (n=251) 7/26/14 (n=256) 8/09/14 (n=242) 8/23/14 (n=253) 9/06/14 (n=263) 9/20/14 (n=264) 10/04/14 (n=269) 10/18/14 (n=268) 11/01/14 (n=273) 11/15/14 (n=275) 11/29/14 (n=261) 12/13/14 (n=270) 12/27/14 (n=225) 1/10/15 (n=246) 1/24/15 (n=291) 2/07/15 (n=296) 2/21/14 (n=280) Psychiatry OSHA Injuries Per 100 FTE's/2 weeks Related to Patient Interaction 1.40 July February July 2013 Supervisor Review Implemented October 2014 Leadership Analysis of All Events August 2014 SA Aggressor Spread n= total # of hours worked in 2 week Biweekly OSHA Injuries Average OSHA Injuries Related to Patient Interaction Control Limits 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 , and All Committees involved in the review of this information, as well as those individuals preparing and submitting information to

23 Next Steps Expected Risk patient meets criteria for admission 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 SA Category 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 Boundary (BR) Boundary Risk Assessment Score of 10 or higher 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 selfinjurious behaviors causing injury i.e. head-banging, cutting, re-injury to current wounds (putting items in open wounds) EPS Lack of medication adjustments. 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 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

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 Behavior (SIB)

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: 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: The overt aggression scale: Overview and guiding principles Therapeutic Crisis Intervention, The residential child care project. Family life development center. College of Human Ecology Cornell University

26 Questions?