Screening and Intervention to Prevent Violence Against Health Professionals from Hospitalized Patients: A Pilot Study.

BACKGROUND: Health care providers, particularly nursing staff, are at risk of physical or emotional abuse from patients. This abuse has been associated with increased use of physical and pharmacological restraints on patients, poor patient outcomes, high staff turnover, and reduced job satisfaction. METHODS: In this study, a multidisciplinary team at Tufts Medical Center implemented the Brøset Violence Checklist (BVC), a screening tool administered by nurses to identify patients displaying agitated behavior. Patients who scored high on the BVC received a psychiatry consultation, followed by assessments and recommendations. This tool was implemented in an inpatient medical setting in conjunction with a one-hour de-escalation training led by nursing and Public Safety. The intervention design was executed through a series of three distinct Plan-Do-Study-Act cycles. RESULTS: This study measured the number of BVCs completed and their scores, the number of psychiatric consults placed, the number of calls to Public Safety, the number of staff assaults, nursing restraint use, and staff satisfaction. During the study period, restraint use decreased 17.6% from baseline mean and calls to Public Safety decreased 60.0% from baseline mean. In the staff survey, nursing staff reported feeling safer at work and feeling better equipped to care for agitated patients. CONCLUSION: The BVC is an effective, low-cost tool to proactively identify patients displaying agitated or aggressive behavior. Simple algorithms for next steps in interventions and training help to mitigate risk and increase feelings of safety among staff. Regular psychiatric rounding and the identification of champions were key components in a successful implementation.

Understanding Best Practices in Implementation of Behavioral Emergency Response Teams Through a Scoping Review.

BACKGROUND: Health care providers are at risk of suffering physical or emotional abuse from patients, family members, and visitors. This results in decreased job satisfaction, high turnover, increased rates of patient physical and pharmacologic restraint, and poor patient outcomes. Behavioral emergency response teams (BERTs) have proven effective in reducing workplace assaults directed at staff, reducing the rate at which behaviorally disruptive patients are physically or pharmacologically restrained and are associated with increased staff satisfaction. AIMS: This scoping review seeks to highlight the best practices and limitations of BERT use with adult populations in hospital settings to guide future implementation across academic medical centers. METHOD: A literature review was conducted using PubMed, Tisch Library, and Tufts University School of Medicine's search tool "Jumbo Search" to screen articles for a duration from 2000 to 2021. The review was conducted following PRISMA-ScR guidelines using three screens for the inclusion of papers most relevant to the review's aims. RESULTS: BERTs are commonly implemented with trained medical staff. The most common interventions used by the BERTs are de-escalation techniques and education for staff about the incidents. Most BERT implementation involves a proactive screening protocol for identifying high-risk patients and a team-based approach. CONCLUSIONS: BERTS are effective at reducing assaults directed at staff and are associated with increased staff satisfaction. Using a proactive process to identify high-risk patients for disruptive behavior in conjunction with a team-based response to behavioral emergencies, academic medical centers can decrease the use of physical restraints and increase staff satisfaction leading to a higher quality of care.

Development and Implementation of an Escalation Protocol for Internal Medicine Trainees.

Background: Overnight, physicians in training receive less direct supervision. Decreased direct supervision requires trainees to appropriately assess patients at risk of clinical deterioration and escalate to supervising physicians. Failure of trainees to escalate contributes to adverse patient safety events. Objective: To standardize the evaluation of patients at risk of deterioration overnight by internal medicine residents, increase communication between residents and supervising physicians, and improve perceptions of patient safety at a tertiary academic medical center. Methods: A multidisciplinary stakeholder team developed an overnight escalation-of-care protocol for residents. The protocol was implemented with badge buddies and an educational campaign targeted at residents, supervising physicians, and nursing staff. Residents and supervising physicians completed anonymous surveys to assess the use of the protocol; the frequency of overnight communication between residents and supervising physicians; and perceptions of escalation and patient safety before, immediately after ("early postintervention"), and 8 months after ("delayed postintervention") the intervention. Results: Seventy-five (100%) residents participated in the intervention, and 57-89% of those invited to complete surveys at the various time points responded. After the intervention, 82% of residents reported using the protocol, though no change was observed in the frequency of communication between residents and supervising physicians. After the implementation, residents perceived that patient care was safer (early postintervention, 47%; delayed postintervention, 72%; P = 0.02), and interns expressed decreased fear of waking and being criticized by supervising physicians. Conclusion: An escalation-of-care protocol was developed and successfully implemented using a multimodal approach. The implementation and dissemination of the protocol standardized resident escalation overnight and improved resident-perceived patient safety and interns' comfort with escalation.

Redesigning patient flow in orthopedics and radiology clinics via a three-phase 'Kaizen' improvement approach and interrupted time series analysis.

INTRODUCTION: The orthopedics clinic at an academic medical center has low patient satisfaction rates for patients that require an X-ray and have difficulty ambulating. The project aimed to reduce the 'non-value-added' time during appointments by using Lean and Six Sigma methodologies and enhance patient experience. METHODS: An analysis of the current state was conducted using Gemba walks, interviews with subject matter experts and an interrupted time study to assess baseline data. The project was implemented using a three-phase Kaizen event approach. RESULTS: Interventions implemented included: (i) re-engineering patient flow and (ii) standardizing appointment scheduling guidelines. The 'non-value-added' appointment time was measured post-intervention and it decreased from 17 to 8 min (51%), and 87% (N = 47) of patients rated the scheduling process positively. CONCLUSION: Lean, Six Sigma and Kaizen improvement methodologies are invaluable tools to improve operational efficiency. The implemented interventions enhanced patient experience and improved clinic efficiency.

Implementing structured handoffs to verify operating room blood delivery using a quality academy training program: an interrupted time-series analysis.

BACKGROUND: Blood transfusion is a complex process at risk for error. OBJECTIVE: To implement a structured handoff during the blood transfusion process to improve delivery verification. METHODS: A multidisciplinary team participated in the quality academy training program at an academic medical center and implemented a structured handoff of blood delivery to the operating room (OR) using Plan-Do-Study-Act cycles between 28 October 2019 and 1 December 2019. An interrupted time-series analysis was performed to investigate the proportions of verified deliveries (primary outcome) and of verified deliveries among those without a handoff (secondary outcome). Delivery duration was also assessed. RESULTS: A total of 2606 deliveries occurred from 1 July 2019 to 19 April 2020. The baseline trend for verified deliveries was unchanging [parameter coefficient -0.0004; 95% confidence interval (CI) -0.002 to 0.001; P = 0.623]. Following intervention, there was an immediate level change (parameter coefficient 0.115; 95% CI 0.053 to 0.176; P = 0.001) without slope change (parameter coefficient 0.002; 95% CI -0.004 to 0.007; P = 0.559). For the secondary outcome, there was no immediate level change (parameter coefficient -0.039; 95% CI -0.159 to 0.081; P = 0.503) or slope change (parameter coefficient 0.002; 95% CI -0.022 to 0.025; P = 0.866). The mean (SD) delivery duration during the intervention was 12.4 (2.8) min and during the post-intervention period was 9.6 (1.6) min (mean difference 2.8; 95% CI 0.9 to 4.8; P = 0.008). CONCLUSION: Using the quality academy framework supported the implementation of a structured handoff during blood delivery to the OR, resulting in a significant increase in verified deliveries.