Improving Employee Safety Through a Comprehensive Patient Behavioral Program.

BACKGROUND: Health care workers in the United States are facing increasing rates of exposure to aggressive behavior, resulting in an increase in employee injuries related specifically to patient behavioral events. By leveraging interprofessional collaboration and system-level innovation, we aimed to reduce the rate of employee injuries related to patient behavioral events at a children's hospital by 50% over a 3-year period. METHODS: An interdisciplinary quality improvement team comprising physicians, behavior analysts, nursing, and other key stakeholders developed a comprehensive behavior program in our children's hospital. The team developed 5 key pillars: aggression mitigation tools, clinical resources, advanced training, screening and management, and behavior emergency response. The outcome measure was rate of reported employee safety events related to patient behavioral events. This was tracked via prospective time series analysis statistical process control chart using established rules to detect special cause variation. RESULTS: The average rate of employee injuries resulting from patient behavioral events decreased from 0.96 to 0.39 per 1000 adjusted patient-days, with special cause variation observed on a statistical process control U-chart. This improvement has been sustained for 16 months. Staff members who experienced injuries included nurses and patient technicians, with common antecedents to injuries including medical interventions or patient requests that could not be safely met. CONCLUSIONS: A unified and multimodal system aimed to address pediatric patient behavioral events can reduce employee injuries and foster a culture of employee safety in the pediatric inpatient setting.

Evaluation of the difficult intravenous access (DIVA) scoring in hospitalized pediatric patients.

HIGHLIGHTS: The DIVA scoring tool has previously been validated in the pediatric ED setting. Our project applied DIVA to an inpatient pediatric sample. DIVA may not predict likelihood of PIV success in the inpatient setting.Background: First-attempt success rate for placing pediatric peripheral intravenous (PIV) catheters ranges from to 24% to 52%. Multiple attempts can increase risk of deleterious outcomes. It is essential to screen pediatric patients appropriately to identify those who will require additional resources for successful PIV placement. Methods: A convenience sample of hospitalized pediatric patients 0 to 18 years of age on a general care unit was used in this performance improvement project. Prior to attempting PIV access, nurses completed a data collection tool that included elements of established difficult intravenous access (DIVA) tools as well as first attempt successful PIV placement. The primary outcome measure was to determine if each DIVA scoring tool is accurate in predicting the need for additional resources to achieve successful first-attempt PIV placement. The secondary outcome measure was to compare the predictive value of each DIVA scoring tool among an inpatient pediatric population. Following data exploration and cleaning, a correlation analysis was performed with logistic regression to assess DIVA score effectiveness in predicting success of PIV insertion on the first attempt. Results: Out of 133 children, 167 PIV attempts were analyzed with 150 PIV attempts included in the final data analysis. Of the 150 PIV attempts analyzed, 60% (n=90) were successful on the first attempt. Performance of prediction for first-time insertion success was comparable among all 4 DIVA scoring tools. Conclusions: None of the 4 DIVA scoring tools were superior in predicting first-time PIV placement among hospitalized children. Vein palpability was more predictive, although not statistically significant.

Mitigating Pediatric Inpatient Aggression: A Quality Improvement Initiative.

BACKGROUND: Patient aggression in the health care workplace has increased significantly, and the impact of workplace violence can be profound, including psychological trauma and lost productivity. We suspect these safety events are often unreported, leading to missed opportunities to design interventions to reduce harm. The primary aim of the interdisciplinary quality improvement team was to increase staff reporting of safety events utilizing our event reporting system related to the care of verbally and/or physically aggressive pediatric patients by 10% over a 12-month period. METHODS: An interdisciplinary quality improvement team addressed existing gaps in the care of pediatric inpatients with escalating behavior. Interventions included a survey of staff knowledge, use of the care guideline for management, updates to the electronic medical record, patient aggression screening tool, an electronic order set, and an online education module. The primary outcome measure was the number of reported staff safety events related to the care of aggressive patients. Compliance with the use of the pediatric aggression risk screening tool was tracked as a process measure. RESULTS: The reporting of safety events related to the care of aggressive patients increased from just <1.0 events per 1000 patient days to 3.0 with special cause variation observed on a statistical process control chart. The compliance with the use of the pediatric aggression risk screening tool improved during the time of the project, nearing 90%. CONCLUSIONS: A variety of interventions aimed to address pediatric inpatient aggression can improve the reporting of events related to workplace violence and foster a culture of employee safety.