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Be a Nurse, Not a Victim: Implementation of a Violence Prevention and Mitigation Program

Tonya Barlow, RN, MSN, CNS-BC, CEN, CPEN Belinda Shaw, RN, MS, CEN, NE-BC Porter Adventist Hospital Denver, Colorado Concurrent Session February 24, 2012 10:30 AM – 11:45 AM Emergency Nurses Association® Leadership Conference 2012

Centura Health
• A faith-based, nonprofit health care organization formed in 1996 by Catholic Health Initiatives and Adventist Health System
• Colorado’s fourth largest private employer with nearly 13,000 associates • The Centura system encompasses 13 hospitals, seven senior living communities, and Centura Health at Home – home care, hospice, infusion, home medical equipment and oxygen services
2

Parker

Centura Health
St. Mary Corwin St. Anthony North

St. Anthony Summit

Ortho Colorado

Avista

St. Thomas More

Penrose/St. Francis

Porter

St. Anthony

Littleton

Mercy

PhD.Porter Adventist Hospital • Acute Care Hospital Cancer Care Center Center for Joint Replacement Craniofacial & Skull Base Disorders Complex Medicine Heart Institute Centura Health Transplant Program Robotics Institute Spine Institute Sharon Pappas.Centura • 368 licensed beds with 1450 associates • Founded in 1930 • Magnet designation – January 12.Porter Adventist Chief Nursing Executive . NEA-BC Chief Nursing Officer . RN. 2009 4 .

• Integrate knowledge. • Appreciate the importance of violence prevention and mitigation. 5 . resources and tools to move towards an environmental culture of violence prevention and mitigation. • Assess the emergency department environment for potential threats.Objectives • Identify characteristics of an environment with potential for violence.

Outline of Presentation • • • • • Characteristics of a Potentially Dangerous Environment What to Expect When We Are Not Prepared for Violence Community Assessment Environment Assessment Violence Prevention Implementation 6 .

My Evolution as an ER Nurse New Graduate Nurse! Crusty/Jaded Nurse 7 .

My Evolution as an ER Nurse • Teamwork Among Staff. Security & Law Enforcement • Violence Prevention and Mitigation • Healthy Respect for My Patients While Still Retaining Control of the Situation • Dorothy still enters the subway without fear but she has her cash securely stashed and carries travelers checks. 8 .

Literature Review • Identify the Problem • Change of Culture for Emergency Nurses • Environment of Safety • No Tolerance for Violence Policy 9 .

or threatening. or coercive behavior in the work setting that causes physical or emotional harm.‛ The National Institute for Occupational Safety and Health (NIOSH) 10 . emotional or verbal abuse.Definitions What is Workplace Violence???? ‚Workplace Violence is generally defined as any physical assault. harassing.

8 of 8 RNs were 35-54 years of age • 45% of All Nonfatal Assaults against Healthcare Workers Result in Lost Work Days in the U. U.4 RNs received other Fatal Injuries .S. Bureau of Labor Statistics.Workplace Violence • 8 Registered Nurses were FATALLY Injured at Work Between 2003-2009 . (2011) 11 .8 of 8 RNs were Working in Private Healthcare Facilities .S.4 RNs received Gunshot Wounds .

Characteristics of a Potentially Dangerous Environment • • Environmental Design Round the Clock Access • • Long Waits Fast Paced Environment • • • Patient and Family State of Crisis Areas of High Crime Perception of Easily Attained Prescription Meds Emergency Nurses Association (2011) 12 .

Cross-Sectional Online Survey .May 2009 – January 2011 Findings .N= 7169 Emergency Room Nurses Surveyed Quarterly Emergency Nurses Association (2011) 13 .National Overview • Emergency Department Violence Surveillance Study .

National Overview Emergency Department Violence Surveillance Study May 2009-January 2011 n=7169 RNs Surveyed About Events in Their Past 7 Days! Verbal Abuse 43% No Abuse 45% Physical Abuse 12% Emergency Nurses Association (2011) 14 .

National Overview Verbal Abuse 43% of Survey Nurses = 3083 in 7 days! 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Cursed at Series1 89% Yelled at Called names 68% 89% Threat Legal Action 52% Sexual Harass ment 23% Threat Physical Assault 20% 15 Emergency Nurses Association (2011) .

National Overview Physical Abuse 12% of Surveyed Nurses = 860 in 7 days! 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Series1 Patient 98% Room 82% Lucid 73% Emergency Nurses Association (2011) 16 .

National Overview Physical Abuse 12% of Surveyed Nurses = 860 in 7 days! 60% 50% 40% 30% 20% 10% 0% Series1 ETOH 56% Drugs 47% Psych 45% Emergency Nurses Association (2011) 17 .

National Overview Physical Abuse 12% of Surveyed Nurses = 860 in 7 days! 40% 35% 30% 25% 20% 15% 10% 5% 0% Series1 Triage 40% Restraint 35% Procedure 29% Emergency Nurses Association (2011) 18 .

National Overview • Formal Reporting of Perpetrators – 66% of nurses physically assaulted did not file a formal report – 86% of nurses verbally assaulted did not file a formal report • Interestingly most of them did tell someone and still they did not report! Emergency Nurses Association (2011) 19 .

National Overview Actions Taken Against Perpetrators of Violence Verbal Abuse n=3217 Physical Abuse n=784 Treated Sooner/Faster Left Before Action Taken Arrested Asked to Leave ED Transfer to Psych Facility Warning Issued 0% 5% 10% 15% 20% 25% 30% 20 Emergency Nurses Association (2011) .

Series1 96% Not considered leaving ED 73% Considered leaving current ED 27% Considered leaving nursing profession 10% 21 Emergency Nurses Association (2011) .National Overview Impact of Workplace Violence 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Increased or remained the same over past yr.

National Overview • Zero Tolerance Policy – Hospitals must adopt a Zero Tolerance Policy in order to support Nursing to move towards a culture where violence is not a part of our daily work. Emergency Nurses Association (2011) • We must come together as a culture where this action is not tolerated or expected as “part of the job.” 22 .

ena.ena.htm • Emergency Department Violence Surveillance (EDVS) Study www.org/IENR/Pages/WorkplaceViolence.ena.org/about/position/position/ 23 .aspx • Emergency Nurses Association Position Statement www.org/IENR/ViolenceToolKit/Documents/toolkit pg1.National Overview • Workplace Violence Toolkit www.

(2012) 24 .National Overview •9 States have Legislation Mandating Employer Run Workplace Violence Programs •17 States have Laws That Strengthen Penalties for Acts of Workplace Violence Affecting Nurses American Nurses Association.

laws vary – either reflect required programs or establish penalties for assaults on nurses/healthcare personnel . NM. OK. IL. CT. NV. JANUARY 2012 . NC. CA . ME.The American Nurses Association’s Nationwide State Legislative Agenda WORKPLACE VIOLENCE WA MT OR ND MN VT M E WI NY MI PA IL IN OH wv KY TN MD NH MA CT NJ ID WY NV SD NE IA RI DE CA UT CO KS OK TX MO AR MS VA NC A Z NM AL GA SC LA FL HI (18 states) Enacted/ adopted: AL. CO. NJ. VT. NY. plus HI (resolution) *refer to report for distinctions. OR. WA and WV. VA. AZ.

National Overview • What can happen when we are not ready for violence? – Environmental Instability – Stress: Acute or Chronic – Injury – Disability – Death Emergency Nurses Association (2011) 26 .

staff and visitors.National Overview • The Joint Commission (TJC) – The Joint Commission’s Environment of Care standard require a written plan of how an organization will protect patients. 2010 27 . 45. June 3. The Joint Commission. Sentinel Event Alert.

45. Sentinel Event Alert. June 3. 2010 28 .National Overview • TJC Suggested Actions – Audit the facilities risk of violence – Identify strengths and weaknesses – Extra security precautions in the Emergency Department – HR to conduct thorough background checks and preemployment screenings – Violence prevention and mitigation training for all staff – Procedures for responding to and reporting violence – Counseling programs for victims of violence The Joint Commission.

Denver Metro Data 29 .

Denver Metro Data Reduction of Psychiatric Beds 700 600 500 400 300 200 100 0 Series1 Denver 1990 700 Denver 2009 230 Colorado 1990 541 Colorado 2009 273 30 Colorado Department of Human Services. (2009) .

(2009) 31 .5 Million – 2009: ~5 Million Colorado Department of Human Services.Denver Metro Data • Population Growth in Colorado – 1990: ~3.

Community Assessment Inner Circle = 1 mile radius or 25.000 people CrimeCast (2010) 32 .000 people Outer Circle = 3 mile radius or 100.

Facility Overview • 368 Licensed Beds • 1450 Associates • Founded in 1930 • Inpatient Psychiatric Services: 35 Beds (1936) • Psychiatric Emergency Dept: 5 Beds (2004) • Geriatric Inpatient Psychiatry: 14 Beds(2010) 33 .

Emergency Department Overview • • • • • • ~60 Staff Members ~24.000 Visits Annually 23 Bed Emergency Department 5 Bed Psychiatric Emergency Department 5 Bed Cardiac Short Stay Emergency Department Treatment Protocol .EDTP Program • “30 Minute Service Promise” • Sexual Assault Nurse Examiner Program 34 .

Geriatric Units or Nursing Homes Emergency Nurses Association (2011) 35 .Psychiatric Units .Emergency Departments .Waiting Rooms .Emergency Department Overview • Areas of the hospital that are most prone to violence .

Emergency Department Overview • Number of Psychiatric Evaluations 2500 2000 1500 1000 500 0 2008 1 2184 2009 2 1802 2010 3 1801 2011 4 2096 Series1 This translates into roughly one in every twelve patients we see at Porter! 36 .

Emergency Department Overview Factors Influencing Violence in the Past 6 Months by Patients Never Alcohol Use Drug Use Psychiatric 1 1 2 Rarely 1 3 0 Sometimes 11 17 20 Mostly 41 37 32 Always 9 5 9 Advanced Age 6 8 35 11 3 Hospital Shared Services (2009) 37 .

Emergency Department Overview Factors Influencing Violence in the Past 6 Months by Visitors Never Alcohol Use Drug Use Psychiatric 6 9 9 Rarely 10 13 12 Sometimes 27 26 24 Mostly 16 12 15 Always 4 2 2 Advanced Age 22 18 19 1 2 Hospital Shared Services (2009) 38 .

Meet Our Stretcher Side Staff 39 .

Proposal • Approached by Security Provider to Serve as a Beta Site for Violence Prevention and Mitigation Program • Assessed Need Within the Unit • Stakeholder Approval – – – – Unit Based Practice Council Physicians Security Administration 40 .

Proposal • Financial Implications • Program Costs • Training Costs – $6.000 • Installation of Light/Alert System • Physical Plant Improvements 41 .

Implementation • How to Measure Success • Unit Risk Assessment • Policies and Procedures • Training • Ongoing Training and Program Maintenance 42 .

Door to Room (Minutes) • • • • • • Associate Satisfaction (PES) Turnover Lost Time Injuries Code Green Data Metal Detector Light system changes 43 .Measurement Tools • Pre and Post Surveys • Patient Satisfaction – Overall. How Quickly Evaluated.

Unit Risk Assessment • Physical Assessment of the Environment • Interviews with Key Personnel • Presentation of Findings 44 .

Consider Solid Physical Barriers .Electronic Locks on Main Entrance Door .Risk Assessment: Environment • Front Entrance: Proposed Improvements .“No Weapons” Signs to Include Visual Warning 45 .

Risk Assessment: Environment

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Risk Assessment: Environment
• Ambulance Entrance: Proposed Improvements
- Consider Hand-Held Metal Detector - Guidelines for At-Risk Admissions

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Risk Assessment: Environment

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Signage .Risk Assessment: Environment • Patient Care Perimeter Doors: Proposed Improvements .Bold .Education and Accountability for Securing Access .Visible 49 .Consistent .

Risk Assessment: Environment 50 .

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Risk Assessment: Environment • Waiting Area: Proposed Improvements 24 X 7 Security Presence Metal Detector Hand-held Metal Detector Option Storage for Confiscated Property Secure Access to Waiting Area Consider Affixed Seating 53 .

Risk Assessment: Environment 54 .

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Raise Height of Counter .Risk Assessment: Environment • Admissions and Triage: Proposed Improvements .Install Physical Barrier from Ceiling to Counter 57 .

Risk Assessment: Environment 58 .

Move Framed Photos from Patient Care Areas .Glove Holders .Risk Assessment: Environment • Main Patient Care Area: Proposed Improvements .Equipment and Clutter 59 .Coat Hooks .Evaluate TV Mounts .

Risk Assessment: Environment 60 .

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Risk Assessment: Environment 64 .

Risk Assessment: Environment • Psychiatric Treatment Area: Proposed Improvements Affix Bed and Table Remove Un-affixed Items When Not in Use Remove or Lock Fire Extinguisher Remove or Affix Code Blue Alarms Change Window from Glass to Plexiglas Create Escape Exit Review Security Staffing Model 65 .

Risk Assessment: Environment 66 .

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Policies and Procedures • • • • • • • • • Violence Prevention and Mitigation Plan Care of the Psychiatric Patient in the ED Visitor Policy “Code Green” – Out of Control Patient TASER Policy Metal Detection and Screening Elopement and Escape Precautions and Response At Risk Patient Admission Pre-Divert. Advisory and Divert Policies 74 .

Policies and Procedures Violence and Mitigation Plan • Recognition and Response Framework • Communication – Red – Yellow – Green • Decision – – – – Security Charge RN Physician House Supervisor 75 .

Policies and Procedures Violence and Mitigation Plan • Business as Usual – One Security Officer at Metal Detector at Minimum – Access to Department May be Granted Remotely 76 .

Policies and Procedures Violence and Mitigation Plan • Environment with Potential for Escalation – Second Officer in ED – Consider Visitor Restriction – All Doors Secured – Focused De-escalation and Separation 77 .

Policies and Procedures Violence and Mitigation Plan • Potential or Loss of Control of the Environment – Two Additional Officers – No Remote Release of Access for Doors – Consider Lock Down of Exterior ED Doors – Restricted Visitor Access – Focused De-escalation and Separation 78 .

Policies and Procedures TASER Policy • Supervisor Training • Drills with Staff • Protocols • Reporting • Removal of Probes • Physician Exam Following Deployment 79 .

Staff Training • Security • All ED Staff Members • House Supervisors • Psychiatric Evaluators • Chaplains 80 .

ED Safe (2009) 81 .Training: Secure the Space and Train to the Environment • Environmental Controls Access Environment Security Presence • Response Local Police Participation Stages of Escalation Engaged and Educated Staff • Training At Risk Patients Effective Throughput • Policies and Practices Concept Used with Permission by Hospital Shared Services.

ED Safe (2009) 82 .Staff Training Prepare for Your Patient Own Your Work Environment Work Within Your Training Expect the Unexpected Remember Your Resources Acronym Used with Permission by Hospital Shared Services.

Measurement Lack of Security/Police Presence 45 40 35 30 25 20 15 10 5 0 Pretraining 1 yr PostTraining 83 .

Measurement Lack of P & P’s Regarding Violence 45 40 35 30 25 20 15 10 5 0 1 yr PostTraining Pre-Training 84 .

Measurement Patient Satisfaction Healthstream Percentile Ranking 2011 100 90 80 70 60 50 40 30 20 10 0 Jan Feb Mar Apr May Jun Jul Aug Sept Oct Nov Dec 85 .

Measurement Patient Satisfaction 100 90 80 70 60 How Quickly Evaluated % Ranking Door to Room (Mins) 50 40 30 20 10 0 86 .

1 3.85 2009 2010 2011 87 .Measurement Associate Satisfaction Practice Environment Survey 3.2 3.9 2.95 2.15 3.25 3.05 3 2.

Measurement Nursing Turnover Rate 12 10 8 6 4 2 0 2008 2009 2010 2011 RN Turnover Percentage (Voluntary and Involuntary) 88 .

Measurement Associate Injuries • Employee Injuries Due to “Patient Altercations” 2008-2011 – No Lost Time Injuries – July 2011: Wrist Strain During Restraint Episode • Limitation: Does Not Include Verbal and Threatening Behavior 89 .

Measurement “Code Green” Episodes 45 40 35 30 25 20 15 10 5 Facility ED 0 2008 2009 2010 2011 90 .

Measurement Metal Detector Items Confiscated Total for 2011 = 6831 900 800 700 600 500 400 300 200 100 0 Jan Feb Mar Apr May June July Aug Sept Oct Nov Dec 91 .

Measurement Light Color Changes 2011 Red • 3 hrs 15 min Yellow • 225 hrs 41 min 92 .

Conclusion • Implications for Practice • Outcomes • Limitations 93 .

Testimonials
‚Implementation of this program gave us the feeling of control and safety. ED Safe as a concept allows the emergency department staff and security to work as a team where each players opinion is valuable. I am supported in my decision to change the lights to yellow even if based solely on my gut feeling a patient might be a problem. The implementation and continued dedication to ED Safe gives me permission to expect nothing short of a safe work environment. – Brooke RN: Charge Nurse

‚The graphs and data that our Director and CNS have presented are great and they show you that the program works; but hearing the opinion of Brooke and other ED associates ‘Tells’ me that it works.‛ – Tom McDermott RN: ED Clinical Nurse Manager
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Next Steps
• Continue Current ED Safe Program and Ongoing Training • “OXY Free ED” (Cherry Hill ED, Seattle) • SBIRT • Non Violent Crisis Intervention Training • Team STEPPS

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Questions?

‚Change is not an invitation, it is an obligation and expectation.‛
-Tim Porter-O’Grady, 2008

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MSN. RN. NE-BC Porter Adventist Hospital Associate Chief Nursing Officer Director Emergency Department & Critical Care BelindaShaw@Centura. CNS-BC. CEN.Contact Information  Tonya Barlow. CPEN Porter Adventist Hospital Emergency Department Clinical Nurse Specialist TonyaBarlow@Centura. MSN.org  Porter Adventist Hospital Denver. CEN. Colorado 97 . RN.org Belinda Shaw.

htm. Available at www. 2009. Journal of Emergency Nursing. 2012. T. 39(7/8): 340-349.jointcommission. 2011. Case and demographic characteristics for work-related injuries and illnesses involving days away from work. and precipitating factors of nurse assault among three groups of registered nurses in a regional medical center.ena. (2009). C.hss-us. Denver Post (April 11. Hospital Shared Services. L.gov/cs/Satellite/CDHS-Main/CBON/1251575083520. L.References • • • • American College of Emergency Physicians (December 9.com. Boyett L. 2008). Retrieved from http://www.gov/iif/oshcdnew. Violence: Occupational hazards in hospitals. ENA Workplace Violence Toolkit. ED-SAFE: Workplace Violence Prevention and Mitigation Program. Auge. Accessed July 23. (2002). & Grubbs. MacLean SL. (2008) The escalating trend of violence towards nurses. Colorado Department of Human Services: Metro Crisis Triage Program (January 2009).aspx. Gacki-Smith J.colorado. Homeyer. • • • • • • • • • 98 . Retrieved from http://www. Joint Commission on the Accreditation of Healthcare Organizations (2010). Journal of Emergency Nursing.org.cdc.PDF.census. Denver Post (4/11/05). Retrieved from http://www.gov Accessed February 8. 11-17. 2B. 2009. Denver Post..emreportcard. Issue 45 (June 3. (2002). 2011 May.gov/niosh/2002-101. Accessed on January 8. D. 2009. (2010). Juarez AM. 2012. Accessed June 12. 2011. nature. 34. 2011. Psych Units Shutting Doors. Accessed on January 8. 2005). Psychiatric Resources in Colorado. January 25.denverpost. Retrieved from http://www. 28. Man commits suicide after walking into hospital emergency room. Robinson.bls. M. National Institute for Occupational Safety and Health. The extent. Retrieved from http://www. D. 2012. 130-133. Emergency Medicine Report Card. K. Emergency Nurses Association. Retrieved from http://www.com/healthcare-security/violence-prevention/.org/IENR/pages/WorkplaceViolence. Accessed on August 19. Accessed June 12. Whelan. 2011.org/assets/1/18/SEA_45. Accessed on August 19. Available at www. Violence against nurses working in US emergency departments. Retrieved from http://www. Sentinel Event Newsletter: Preventing Violence in the Healthcare Setting.html US Census Bureau (2010) Census 2010. Bureau of Labor Statistics. 2011. 2010). JONA: Journal of Nursing Administration.