Protecting the Nursing Workforce through an Aggression Prevention Team and Behavior Alert Response Deb Fabert RN MSN BC Joe Anderson MBA Copyright IU Health

Disclosure of Conflict of Interest Both presenters are consultants with Crisis Prevention Institute (CPI)   Copyright IU Health

Objectives Understand the components of an all-encompassing organizational response to threatening behavior Discuss the strategic development and implementation of a team response to threatening or violent behavior. Define how a similar aggression prevention process could be used at the participant’s place of work   Copyright IU Health

Indiana University Health Statewide System & Academic Health Center 17 hospitals and health centers, partners, affiliates and joint venture operations Academic Health Center Methodist Hospital 100,000+ annual ED patients Level 1 Trauma Center 30,000+ annual inpatient admissions 747 beds 100+ Behavioral Health beds (63 in program)   Copyright IU Health

Sentinel Alert Event – The Joint Commission – Issue 59, April 17,2018 Burning Platform The American Nurse Association has petitioned OSHA to require mandatory comprehensive programs to prevent workplace violence Sentinel Alert Event – The Joint Commission – Issue 59, April 17,2018 Healthcare workers are victims of the highest numbers of workplace assaults 20% of patients admitted to acute psychiatric wards act violently against staff Only 30% of nurses report workplace violence Prevalence of violence is high but number of police-reported incidents are low High percentage of assaults against nurses (76% of all assaults at AHC) Altered mental status is most common perpetrator trait (64% of assaults against nurses classified as non-intentional) De-escalation training by itself is ineffective in reducing acts of violence Copyright IU Health

They spoke and we listened! Call for Action Nurses/Support Staff were experiencing increased assaultive behaviors, violence and were fearful at work as evidenced by declining engagement scores They spoke and we listened! Organization Cares about the Employee Safety 2012 4.05 2014 3.84 2015 3.39 2016 4.16 Copyright IU Health

Who Gets Assaulted? Nurses Assaults against nurses Assaults against others Copyright IU Health

Zero Tolerance of Copyright IU Health

Strategic Plan for Improvement Inter-professional team included clinical and non-clinical services Goal Caregivers need to feel safe and supported while giving care to patients Current state analyzed and ideal state included a rapid response team that responded to the threat of violence Aggressive Prevention Team The Behavior Alert was developed for imminent danger situations Evaluation process for effectiveness Copyright IU Health

Comprehensive Security and Safety Responses Training for Active Shooter is widespread though incidents are low in healthcare (2.5%) Experts recommend all hazards approach AHC Police Department Parking Lot Shift Change Crisis Prevention Institute (CPI) Domestic Violence Committee Panic Alarms – Personal Desktop Hard-wired Panic Alarms Dr. Armstrong Page/Response Visitation Policy - Enforcement 24/7 Law Enforcement Presence AHC Workplace Violence Workgroup Daily Operations Safety Report APT/Behavioral Alert Response Active Shooter training Threat Response Protocol Hot Spot List 24/7 Metal Detection “No Weapons” Signs at All Entrances No Information Patients “Are You Safe? Access to Hospital Entrances – Control Internal Access Controls Copyright IU Health

Maslow’s Hierarchy of Needs If just ONE of the basic needs are met, the chance of a violent outburst drops by 50%. If TWO of the basic needs are met, the chance of a violent outburst drops by 70%. Copyright IU Health

Social Triage / Violence Risk Factors History of Violence Mental Health Disorders Social Stressors Relationship Legal Action Financial Loss Physical and Metabolic Head injury Addiction Dementia Copyright IU Health

Type of Violence - Affective Copyright IU Health

Tiered Approach to Safety Prevention Early recognition of grievance Meet the patient’s needs De-escalation techniques Response Aggression Prevention Team – APT -Escalating conduct Behavior Alert Response - BA - Imminent threat of physical violence Recovery Critical Incident Response Team – CIRT Employee Assistance Program for individual counseling - EAP Copyright IU Health

A Positive Trend Copyright IU Health

De-escalation Training - Prevention Instruction on non-violent de-escalation techniques Currently have ten instructors at the AHC All APT-BA responders trained Goal 24/7 coverage of trained staff available Training module required for bedside patient care staff Now available for all team members Copyright IU Health

APT Process - Response Aggression Prevention Team – APT Before Violence Occurs (Breach) Anyone can activate by calling Security Maximum 10-minute arrival Pre Huddle Social Worker/Chaplain de-escalate and support staff Security is present for show of force as needed If necessary a Care Contract is initiated to set boundaries Associate Administrator may provide support Post Huddle Copyright IU Health

Majority of Assaults - Non Intentional Copyright IU Health

Behavior Alert Response Violence is Occurring (Attack) Anyone can activate by calling the Operator Announced overhead Security PCD Behavioral Health Staff Access House Orderly Physician Psychiatrist Pharmacist Chaplain/ Social Work Copyright IU Health

Copyright IU Health

IUH APT and Nursing Assaults At IUH APT responses increased, 12% reduction in assaults ‘16 to ‘17 April study by CDC found violent injuries to nurses had almost doubled Higher % of assaults now being reported Each APT response is an opportunity to improve staff safety Copyright IU Health

Sustainability Copyright IU Health

APT/BA compared to Violent Restraint use Copyright IU Health

APT/BA compared to Staff Assaults with injury Copyright IU Health

Critical Incident Response Team - Recovery Responders certified in Critical Incident Stress Management Immediate intervention Staff have access to resource 24/7 Intervention and follow-up key to emotional healing Debriefs Conducted Number of Participants in Debrief 2014 29 313 2015 36 536 2016 20 250 2017 52 796 Copyright IU Health

Roll Out Available to present to all teams Over 70 presentations to teams in the AHC Open forums – panel discussions Behavior Alert Drills Presenting at national conferences Copyright IU Health

APT/BA Decision Tree Copyright IU Health