APNA 29th Annual Conference Session 3031: October 30, 2015 - - PDF document

APNA 29th Annual Conference Session 3031: October 30, 2015 Drapeau 1

IMPLEMENTATION OF A DE-ESCALATION EMERGENCY ASSIST TEAM (DEAT) TO IMPROVE PATIENT OUTCOMES

Jason Drapeau BS RN Hannah Roosa BA MHW SN Kristen Kichefski BS BSN RN-BC

The speakers have no conflicts of interest to disclose

Objectives

• 1. Attendees will be able to describe the utilization of

shared governance to create a rapid response team which focuses on de-escalation and safety

• 2. Attendees will be able to describe the steps involved in

creating and implementing a DEAT

• 3. Attendees will understand the importance of staff

engagement and ownership in the implementation and success of a DEAT

APNA 29th Annual Conference Session 3031: October 30, 2015 Drapeau 2

Background

• Butler Hospital, a 190-bed free-standing not-for-profit

psychiatric and substance abuse treatment facility in Providence, Rhode Island

• Nine inpatient units including: 3 General Adult, 1 Geriatric Psych, 1

Adolescent, 1 Alcohol and Detox, 1 Transitional Care Unit and 2 Intensive Treatment Units

• Inpatient units are staffed by 159 RNs and 213 support staff
• Front line staff are unionized

Clinical Safety Committee (CSC)

• Butler Hospital’s Clinical Safety Committee (CSC)
• Is the hospital identified task force to evaluate safety concerns

related to patient care

• CSC membership comprises of 80% front line staff and 20%

nursing leadership

• CSC identified practice concerns:
• Episodes of restraint and seclusion exceeded national averages
• Episodes of significant patient on staff violence prompted concerns

from staff

• CSC formed a subcommittee to address critical need for change
• Shared governance is key to CSC’s successes

CSC Initiatives from 2009-2012

2009

• Sensory rooms
• n all inpatient

units (began prior to 2009)

• Clinical Safety

Committee (CSC) forms

• Art volunteers on

the Intensive Treatment Unit (ITU)

• First annual

hospital Safe Patient Handling fair 2010

• Brøset Violence

Checklist integrated into nursing progress notes

• De-escalation

training group adds new line staff trainers

• Security

rounding pilot is initiated 2011

• De-escalation

training updated and revised with input from line staff

• Practice change

from prone to supine restraints

• ITU clinical staff

initiate 2 hour

• rder limits for

all restraints and seclusions

• Moduform

furniture is piloted in ITU quiet rooms

• Safety

equipment implemented 2012

• DEAT trial on

evening shift

• Expand DEAT to

all three shifts

APNA 29th Annual Conference Session 3031: October 30, 2015 Drapeau 3

Response Teams In The Literature

“Effective team functioning means that the team’s tasks are coordinated, and cooperation is inherent because the work cannot be successfully accomplished by individuals working in isolation.”

Rapid Response Teams: Qualitative Analysis of Their Effectiveness.

American Journal of Critical Care, 2013 Vol. 22 Pages 198-209.

“Where a well- functioning team

• perated, nurses didn’t

hesitate to activate it, and the team was described as supportive

• f the nurses”

Rapid Response Teams Seen Through the Eyes of the Nurse.

American Journal of Nursing, 2010 Vol 110, Pages 28-34.

“Effective administrative and clinical structures and processes must be in place to prevent behavioral emergencies and to support the implementation of alternatives”

Position Statement: The Use of Seclusion and Restraint.

American Psychiatric Nurses

• Association. (Revised, 2014 )

DEAT Beginnings

• The change methodology employed by the CSC aligns

with Kanter’s 6 components of structural empowerment theory:

• The DEAT was created as a subcommittee of the CSC

tasked with developing a organized structure in response to crisis

Access to information Access to support Access to resources Access to

• pportunity

to learn and grow Informal power Formal power

Data Full support of nursing leadership Being empowered to create a team Additional training, peer to peer education Team is self sustaining at the staff level DEAT integrated through hospital culture

APNA 29th Annual Conference Session 3031: October 30, 2015 Drapeau 4

DEAT Mission & Vision

• Mission
• To provide assistance and support to patients in crisis in an

atmosphere of dignity and respect while maintaining a therapeutic milieu

• To collaborate with unit staff in implementing de-escalation

strategies while maintaining the safest and least restrictive interventions

• To continuously improve our strategies through education and

research in an effort to reduce the occurrence of restraint and seclusion.

• Vision
• DEAT’s charge is to help a patient during a crisis and assist staff

through a psychiatric emergency with understanding, support and compassion

• Team name and significance to the mission and vision

DEAT Concept & Design

• Goal is to provide immediate and/or anticipatory support

to assist in calming agitated patients through the safest and least restrictive means

• Concept & design includes:
• A team that focuses on verbal de-escalation and collaboration
• A team that provides individual and milieu support during a

potential crisis

• Shared governance is key to success
• Team is mentored by Director of Nursing Operations
• Members consist of peer nominated front line RNs, MHWs, Nursing

Leaders, Occupational Therapists and Security Officers

• Membership is voluntary after invitation

CSC Subcommittee Steps to Create DEAT

Reviewed literature Formed mission and vision statements Identified ideal member qualities Elicited nominations for membership Vetted nominees per identified qualities Identified team members Hand-delivered invitation letters Formed initial team from those who accepted membership

APNA 29th Annual Conference Session 3031: October 30, 2015 Drapeau 5

Team Development and Rollout

Team member steps:

Designed training modules and operational protocols based upon hospital policy and literature review Held 8-hour round table training day Trialed team on second shift Collected data and measured success Expanded team to 24-hour coverage

Team Design

Qualities for membership to the DEAT:

KNOWLEDGE/EXPERIENCE:

• Has 3-4 years

psychiatric experience

• Has been an instructor

(helpful)

• Has participated in

numerous trainings in de-escalation

• Demonstrates

knowledge of hospital policies and procedures

SKILLS:

• Demonstrates de-

escalation skills

• Demonstrates

leadership skills

• Can function as leader
• Is able to take direction
• Demonstrates mastery
• f techniques and

equipment

• Is bilingual (helpful)

CHARACTER TRAITS:

• Has proper attitude,

adaptability, flexibility, humility

• Is cooperative and

committed to mission

• Is a good communicator
• Is able to remain cool,

calm and collected in an emergency

• Is decisive and durable

DEAT Training

• Training developed by original team members
• Above and beyond annual de-escalation training for all

clinical staff

Modules

Psychology of aggression Providing leadership in a crisis Environmental and patient assessment skills Trauma informed care Special needs of developmentally delayed patients Safety equipment Communication equipment

APNA 29th Annual Conference Session 3031: October 30, 2015 Drapeau 6

Key Points for Success Transformation of Practice

• Post DEAT reduction in key indicators from DEAT’s kickoff in

Q1-2012 to Q3-2015

• Overall episodes of restraint reduced by 56.9%
• Overall episodes of seclusion reduced by 78.8%

0.0 2.0 4.0 6.0 8.0 10.0 12.0 14.0 Restraint Seclusion

Increases attributed to the addition of 26 Intensive Treatment beds and new patient population in 2014

Transformation of Practice

• Post DEAT reduction in patient to staff assault
• Overall episodes of patient to staff assaults while performing

restraint/seclusion reduced by 71.5%

• Overall episodes of Unprovoked Patient to Employee Assault reduced

by 29.9%

0.0 0.5 1.0 1.5 2.0 2.5 3.0 3.5 4.0 4.5 While Performing Restraint/Seclusion Unprovoked Patient to Employee Assault

Increases attributed to the addition of 26 Intensive Treatment beds and new patient population in 2014

APNA 29th Annual Conference Session 3031: October 30, 2015 Drapeau 7

Transformation of Practice

• Change in culture favoring verbal de-escalation over restraint

and seclusion as seen through staff surveys

• DEAT became the preferred first response intervention to

escalated behaviors

Improved Outcomes

Patients Staff Managers

• In-the-moment debriefing provided

positive and constructive feedback which improved collaboration between staff members

• Safer interventions for patients and

staff

• Adoption of DEAT afforded patients an
• pportunity to develop adaptive coping

and communication skills

Transformation of Practice

DEAT became part of the conversation

• n all hospital

safety issues and initiatives.

Maintaining Integration

DEAT consults provided to treatment teams for Unique Needs patients New Initiatives: Land Based Water Rescue DEAT bulletin boards on each unit provide continuing education to staff Monthly DEAT meetings Continued focus on staff as team leaders Annual training for DEAT members Annual nominations for DEAT members

APNA 29th Annual Conference Session 3031: October 30, 2015 Drapeau 8

Implications for Practice

• The CSC and DEAT are models of shared governance which

leads to staff engagement, patient centered care, and staff safety which can be replicated

• The DEAT model of early, trauma informed response to patient

crisis leads to reduced restraint and seclusion

• Staff empowerment, communication and a multidiscipline

approach to DEAT improves patient outcomes and a culture of safety

• DEAT continues to monitor and analyze quality and safety data

to ensure the hospital is meeting staff and patient needs.

• DEAT reflects a clinical structure to support the implementation
• f treatment alternatives to restraint and seclusion as call for by

the APNA’s position statement on Seclusion and Restraint.

References

Almvik, R., Woods, P., & Rasmussen, K. (2000). The Brøset Violence Checklist: Sensitivity, Specificity, and Interrater Reliability. The Journal of Interpersonal Violence, 15(12), 1284- 1296. American Psychiatric Nurses Association. (Revised, 2014). Position Statement: The Use of Seclusion and Restraint. Butler Hospital. (2015). About Butler. Retrieved from Butler Hospital: http://www.butler.org/about/index.cfm Johnson, R. (2014). In an Emergency. Advance for Northeast Nurses, 14(18), 12. Laschinger, H., Gilbert, S., Smith, L., & Leslie, K. (2010). Towards a comprehensive theory of nurse/patient empowerment: applying Kanter’s empowerment theory to patient care. Journal of Nursing Management, 18, 4-13. Leach, L. S., & Mayo, A. M. (2013). Rapid Response Teams: Qualitative Analysis of Their

• Effectiveness. American Journal of Critical Care, 22(3), 198-209.

Paterson, B. (2003). Restraint-related deaths in health and social care in the UK: learning the

• lessons. Mental Health Practice, 6(9), 10-17.

Shapiro, S. E., Donaldson, N. E., & Scott, M. B. (2010). Rapid Response Teams Seen Through the Eyes of the Nurse. American Journal of Nursing, 110(6), 28-34. Wale, J. B., Belkin, G. S., & Moon, R. (2001). Reducing the Use of Seclusion and Restraint in Psychiatric Emergency and Adult Inpatient Services— Improving Patient-Centered Care. The Permanente Journal, 15(2), 57-62.