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ORIGINAL ARTICLE

Care zoning in a psychiatric intensive care unit: piloting a model of
care in clinical risk assessment

Antony Mullen, RN, BN(Syd), MN(UTS), FACMHN,
Clinical Nurse Consultant,
Lake Macquarie Mental Health Service,
Hunter New England Local Health District.
Conjoint Lecturer, School of Nursing & Midwifery,
University of Newcastle.
PO Box 833
Newcastle NSW 2300
Antony.Mullen@hnehealth.nsw.gov.au
Phone: 02 4033 5031
Fax: 02 4033 5341

Vincent Drinkwater, RN, BHA(UNSW), GC Aged Care(UoN), MACMHN,
Nurse Unit Manager,
Psychiatric Emergencies Services,
Hunter New England Local Health District.

Terry J. Lewin, BCom(Psych)Hons.,
Research Manager, Mental Health Service,
Hunter New England Local Health District.
Conjoint Associate Professor, School of Medicine and Public Health,
University of Newcastle.

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ABSTRACT:
Care Zoning is a model of care that guides nurses in assessing clinical risk and planning
care. Concerns about the lack of routine clinical assessment, and the varying quality of nursing
documentation, prompted a pilot of the care zoning model in a Psychiatric Intensive Care Unit
(PICU) within a regional mental health facility. The care zoning model assigns patients to a ‘Zone’
according to their clinical risk, encouraging nurses to document and implement targeted
interventions required to manage those risks.
The model was piloted for three months utilising the evaluation frameworks of previous
authors. This included a pre- and post-implementation questionnaire, a pre-pilot file audit, and a
weekly file audit during the pilot. Informal staff feedback was also sort via the surveys and regular
staff meetings.
Results of this pilot demonstrated improvements in the quality of mental state
documentation, and clinical risk information was identified more accurately. There was limited
improvement in the quality of care planning and the documentation of clinical interventions. Initial
concerns from staff over the introduction of the model shifted into overall acceptance and
recognition of the models benefits.

Key words: risk assessment; mental state examinations; psychiatric intensive care

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and there needs to be a model of care that allows for a systematic and continuous process to identify risks and implement targeted strategies.INTRODUCTION Psychiatric Intensive Care Units (PICU) are highly specialised units catering for acutely disturbed patients. Ongoing risk assessment. Taylor et al. 2008). Recovery based psychosocial interventions that attempt to facilitate greater awareness and understanding of self help strategies are not always used (Mullen. al. associated risk behaviours and vulnerabilities (Bowers et al. 2002). risk assessment is a fundamental part of nursing practice. the information within these tools is often poorly integrated within clinical care. with monitoring and observation of risk. but the applicability of these tools in certain situations is not always clear. (2011) blame the dominance of a crisis approach within acute inpatient mental health facilities for a lack of knowledge and skill in providing proactive and targeted strategies including psychosocial strategies. clearly articulating strategies to manage identified risks does not necessarily occur (Mullen. These documents do provide a framework for assessing risk. Current risk assessment protocols follow the NSW Mental Health Outcome and Assessment Tools (MHOAT). Mental health nursing practice requires a model that can guide all facets of practice from assessment and planning of care. 2009). are seen as the main strategies to manage risk behaviours within inpatient units (Bowles. is often seen as the intervention in itself. Added to this. Admissions to a PICU facility can be seen as the solution in itself for managing such risk factors (Bowers et.. This is despite the questioning of the evidence to support PICU as an intervention in itself (Crowhurst & Bowers. 2000). However. 2008) Therefore. 3 .. Crowhurst and Bowers (2002) do describe psychosocial methods within PICU facilities. 2008). but these seem to be generalised to cover any non-pharmacological approaches or those processes which minimise patients’ restrictions. although incidents associated with risk factors such as self harm or aggression still occur regularly within these facilities (Duxbury et al. Hospitalisation. 2009). through to the implementation and evaluation of strategies.

Bowles. referred to as ‘protected time’. Since this original work. 1999. 2009). as it proposes that nurses articulate specific strategies and interventions in response to identified risk factors and behaviours. Gamble et al.. As a result. for to be provided satisfactory care to be provided. (1997) in a community setting. 1997). 2005). Therefore the Care Zoning Model would have legitimate applicability in this setting.. there was a lack of evidence of ongoing clinical risk assessment. and.. due. Hurst et al..Within the PICU investigated in the current study.. 1998. Higgins et al. risk assessment at the time of admission was clearly identifiable. to evaluate the model’s ability to facilitate ongoing clinical risk assessment and management. there was considerable variation in the amount of detail recorded in the nursing progress notes. 2004. the literature reveals a decline in the amount of time nurses spend with patients (Bowers et al. It makes sense that the nurse needs to spend individual time with all patients. Aims The aims of this project were three-fold: to pilot the Care Zoning model of care as a standardised tool within an 8 bed PICU. 2011). through improvements to the quality of nursing documentation 4 .. Nurse patient interaction is intrinsically linked with positive treatment outcomes (Rydon. This model also emphasises the time nurses spend with patients. The authors had become aware of a model being used in similar PICU facilities. 1997). to a lack of suitable standardised tools to guide and support clinicians in this process. Gamble. Mullen. called Care Zoning. others have applied this to various acute mental health facilities in Australia and the UK (Guy & Henderson. in part. varying quality of information about risk assessment. with the aim of guiding nurses in assessing clinical risk and planning care (Ryrie et al.. The Care Zoning model utilises a traffic light system which identifies clinical risk and levels of care required. 2000. However. amber is for medium levels of risk and care. according to three zones: the red zone identifies a high level of risk and high levels of care. Despite this. therefore. 2005. and green is for low levels of risk and care (Ryrie et al. Taylor et al. 2006. This was originally developed by Ryrie et al. 2010.

This PICU services the entire Hunter New England Local Health District that has a population of approximately 840.000. METHODS Study design This study is essentially a quality improvement project. which seeks to develop nursing practice in risk assessment and care planning.and the handover of clinical risk information. Setting This study took place in an 8 bed Psychiatric Intensive Care Unit (PICU) within a specialist 100 bed Mental Health Facility in a regional centre of New South Wales. Australia. and to assess how Care Zoning can facilitate a greater emphasis on nurse patient engagement. 5 .

and green (low risk). and a Mental State Examination guide were also produced. and treatment noncompliance. including a Clinical Nurse Specialist. as follows: mental emotional state. Occupational Therapist and Seclusion and Restraint Project Officer. along with proposed interventions and space to evaluate the outcome of these interventions. Information sheets. violence/aggression/arousal. A meeting with staff from the Clinical Information unit was essential to 6 . including a step-by-step clinician’s guide with examples. amber (medium risk). The working party decided upon five risk items. Major tasks for the working party were to finalise the tools. Registered Nurse. Several items considered to be similar were grouped together. One recommendation from our colleagues with experience in Care Zoning was to identify the relevant risk items for ourselves. a one page document that incorporated the traffic light colours representing the clinical risk across the three agreed zones: red (high risk). The Care Zoning documents and tools were modified to suit the PICU. Mental State Examination headings were listed with space to document information.Procedure As previously mentioned. rather than adopting their existing items. from whom assistance was sought to implement the model locally. Site visits and meetings with staff at the units where Care Zoning was the model of care were carried out. impulse control/disinhibition. The central document within the Care Zoning model was the Care Zoning Shift Review Form. suicidality/self harm. Benefits as well as potential problems were discussed and worked through. In addition. procedures and guidelines for the models implementation. the authors became aware of Care Zoning through the work of colleagues in other Local Health Districts. A working party to guide the project was formed from staff of the PICU. considerably less than the nine items our colleagues used. This provided a critical opportunity to engage staff in the project and ensure ownership. as well as establishing the risk items and planning for the pilot roll-out. This enabled the authors to experience and observe how Care Zoning operated. in addition to the authors.

The 23 items asked respondents to nominate whether ‘current risk management strategies’ made ‘no difference’. 7 . A 3 month pilot was implemented. primarily to compare care zoning with practices prior to its implementation. ‘some difference’. to identify ways to support the ‘protected time’ component of care zoning. The similar staff survey tool to Ryrie et al. 1997. As a result of this. Taylor et al. provide information to medical staff or relatives. Ryrie et al. brief nurse: patient encounters were encouraged in order for staff to . and to support other colleagues. between June and August. respond to phone calls. (2011). by auditing documentation from the morning and afternoon shifts over 7 days.ensure that the document design complied with local protocols and form design principles. (1997) was administered both pre. A pre-pilot file audit was also carried out on 7 patients.. or a ‘noticeable difference’ to their practice. Regular meetings with staff took place throughout the pilot to gauge progress and gather feedback about implementation. General discussions also took place within the working party. This was a challenging exercise as it represented a departure from the existing approach which prioritised managing the staff office and being available for any unforseen circumstance. 2010.. 2011).g. and with other staff. The evaluation plan for this project essentially sought to replicate previous studies (e. utilising the same audit tool as used by Taylor et al.. Weekly file audits were conducted during pilot period using the same audit tool.and post-pilot.

. with a Chronbach’s alpha of 0. minimal. post-implementation) included 283 records from day shifts and 289 from afternoon shifts (and covered a 15 week period). Analysis of Variance (ANOVA) based techniques were used.e.to post-implementation. and changes across the post-implementation period. Chicago.. evidence of 1:1 time with the patient. and a relevant care plan). therefore.. This score was used to examine shift differences. Overall chi-square tests were used for each of these indices to compare the percentage of audited records with the desired characteristic pre. USA). An aggregate quality score (potentially ranging from 0 to 14) was also calculated for each record using the weights listed on the left-hand side of Table 1. while the remaining three audit indices (i.versus post-implementation. The aggregate quality index displayed good internal consistency. for these analyses. risk assessment.versus post- 8 . IL.e. did not require formal approval. comparisons between these percentages pre. interventions. The pre-pilot file audit included 48 records from day shifts and the corresponding records from afternoon shifts (and covered a one-week period). and evaluation outcomes) characterised the quality of the information provided (not present. (2011). satisfactory or good).Ethical issues The Hunter New England Research Ethics Committee was consulted and concluded that the proposed study represented an audit/quality improvement exercise and. Data coding and analysis Data aggregation and analysis was conducted using the Statistical Package for Social Sciences (SPSS version 17. For convenience. mental state. Following Taylor et al.e. the ‘some difference’ and ‘noticeable difference’ responses to the individual items in the PICU staff surveys were collapsed together in calculating the percentages reporting ‘a difference’ to their practice. patient observation. overall improvement from pre. five of the eight audit indices simply noted the presence or absence of the desired characteristic within the record for that shift (i. management measures. while the audits conducted during the actual pilot period (i.0.86.

median = 9 . despite being an integral part of the Care Zoning model.5% of audited records.and post-implementation audit. post-implementation).00) to 8.001). median =2. The mean quality score rose from 2. (2011) study using correlational analyses.31 post-implementation (SD = 3.90.4%) displaying satisfactory or good quality during the post-implementation audit. RESULTS File audit Table 1 summarises the findings from the pre.vs. the quality of information recorded about interventions provided and associated outcomes was still less than optimal.implementation were undertaken using chi-square tests.6%) were coded as minimal quality. which rose from 13. with only 31.5% and 42. but also led to improved accuracy of information regarding mental state. Some of these improvements simply reflected the fact that particular characteristics were largely absent from the pre-pilot audit (e. and the quality of mental state examinations. These response profiles for the 23 survey items were also compared with findings from the Taylor et al.5% to 81. As displayed in the right-hand column. However. there were statistically significant improvements across all eight audit indices.5% respectively displaying satisfactory or good quality post-implementation. the introduction of Care Zoning improved the assessment of risk against standardised criteria. but no shift or interaction effects. information about interventions. compared with two-thirds (64. afternoon) by phase (pre.. evaluations of outcomes. The most notable improvements related to risk assessments. p < 0. Insert Table 1 near here Aggregate quality scores were analysed using a two-way ANOVA – shift (day vs.39 preimplementation (SD = 1.00. for which initially two-thirds (65. which revealed a significant main effect for phase (F(1. 664) = 218.51. Thus. and shift level care plans).g.

and Table 2C: six questions with relatively low endorsement (< 60% of respondents). there was little scope to demonstrate postimplementation improvement. Thus. responses to four questions may raise some concerns. Consequently.00).87. and only one question (Q13 – meetings commitment) with a low endorsement rate. SD = 3.01). 566) = 6.and post-implementation ratings of the extent to which ‘current risk management strategies’ made a difference (defined as ‘some’ or a ‘noticeable’ difference). SD = 4. representing response rates of approximately 74% and 72% respectively. which revealed a significant audit period effect (F(2. for many questions.21. responses to the PICU staff surveys have been grouped on the basis of post‐implementation endorsement rates ‐ Table 2A: eight highly endorsed questions (> 80% of respondents).08). Survey of PICU staff The PICU staff surveys were completed by 15 staff pre-implementation and 13 staff postimplementation. 13 moderately endorsed. Applying similar criteria to the pre-implementation survey would have seen nine highly endorsed. The timing of post-implementation improvements was subsequently examined using a twoway ANOVA – shift (day vs. so there is only likely to be a modest overlap in responders. For each of the 23 items surveyed. to contextualise these post-implementation profiles.9. p < 0. The post-implementation mean aggregate quality score was higher in the third 5-week block (9. there was no statistically significant difference (based on chi-square analyses) between pre. suggesting that improvements in documentation took some time to be fully implemented.00) or second block (8. compared with the first block (7.07. but no shift or interaction effects. particularly given the small sample size.31. to aid presentation and discussion. afternoon) by audit period block (divided into three 5-week blocks). in that they displayed a tendency for lower 10 . several staff changes occurred between these surveys. Table 2B: nine moderately endorsed questions (60% to 80% of respondents). it should be noted that a score of 8 on this aggregate audit index is the equivalent of all elements being at least minimally present.62). On the other hand. SD = 4.

Staff were also more prepared to commit to a 11 . Q14) and communication (Q20.70 (p < 0. Q5. and included: staff absences (Q11). Q18). team structure (Q15). This issue was worked through and the fact that this form replaced current documentation allayed some of this concern. risk management strategies. Q12 – promoting liaison. high quality. despite the pre-pilot file audits revealing otherwise. the questions receiving the lowest postimplementation endorsement were less likely to be about direct patient care or immediate relationships with colleagues. the major perceived benefits of current risk management strategies included: raising intuitive concerns (Q7). Q21. Q4). The right-hand columns of Tables 2A to 2C display the corresponding endorsement rates from the study by Taylor et al. Q22. r (21) = 0. Q12) and support from colleagues (Q2. suggesting that there is some level of consensus between staff in PICU and those in other New South Wales mental health units about the likely benefits of workable. The overall profile of endorsement rates from the two studies (across the 23 questions) was moderately correlated. (2011). As shown in Table 2C. Q19. Insert Tables 2A to 2C near here As shown in Table 2A. Q1 – policy adherence. systematic. identification and sharing of clinical and risk information (Q3. and relapse prevention (Q9). Q10).001). targeted and prioritised crisis interventions (Q8. and Q23 – resource reallocation). Q6. patient loads (Q17). The questions with moderate endorsement rates (see Table 2B) focused largely on relationships with (Q16. There was a perception among some staff that the information within the Care Zoning model was already being documented. policy adherence (Q1).endorsement rates post-implementation (Q18 – awareness of other patients’ needs. meetings commitment (Q13). and resource reallocation (Q23). Other observations There was initial concern from staff about implementing a new form and the perceived resulting increase in ‘paperwork’.

particularly the mental state examination. “Protected time”. Improvements in the overall quality of nursing documentation were 12 . As the pilot progressed. Taylor et al. This was linked to the successful increase in the completion of Mental State Exams’ on the Care Zoning form. was a challenging concept to implement. This process generated a lot of discussion and debate about psychiatric terminology and the use of jargon and clinical descriptors. it was observed that staff were taking much more care in documenting information.. which may not be the case in other acute inpatient units. 2011) and performed well. staff verbalised their appreciation of the structure and direction within the risk items and mental state sections of the Care Zoning form provided. The consistency of the audit findings across day and afternoon shifts probably reflects the similarity in nursing characteristics and staffing demands across these shifts within the PICU. The inclusion of an aggregate quality score also facilitated an examination of other influences. Nurses spent more time with patients in order to more effectively assess and complete their mental state examination.. Ryrie et al. as previously mentioned. 1997. Attempts were made to roster nurses to timeslots within their shift but this was not successful. However. this pilot demonstrated a successful implementation. the audit and survey evaluation measures were similar to earlier studies (e. However.. Once implemented. This is a comparable result to the Taylor et al. DISCUSSION This pilot project sought to implement a Care Zoning model within a PICU and returned varying results. with subsequent review and evaluation. such as potential shift differences and the timing of changes during the post-implementation period.g. with high levels of completion of the Care Zoning forms throughout the pilot. with previous approaches to handover being preferred. Overall. the Care Zoning form was not really utilised as a handover tool. the results did demonstrate an improvement in 1:1 time spent with patients (see Table 1).time limited 3-month pilot. (2011) study. There was an obvious improvement in knowledge and understanding of the mental state examination and presenting symptoms. Likewise.

Staff were able to embrace this part of Care Zoning. This is a valid point and is based on clear assessment careful clinical decision making . perhaps because they were already reasonably positively disposed to 13 . Articulating targeted strategies and evaluating these strategies showed less improvement. Protected time that quarantines 1:1 nurse patient interaction did not get formally introduced.. An interesting point to note on this the view among many nurses that patients within a PICU environment. Taylor et al. and subsequent management strategies. In some ways this is a puzzling finding. Existing processes and conflicting responsibilities. where staff were torn between patient interaction and administrative roles. particularly psychotic or acutely disturbed patients. The use of the Care Zoning form as a clinical handover tool did not get established. In terms of specific sections within the Care Zoning form. was one of the major obstacles for this. 2000. as the Care Zoning form provides an ideal framework with which to deliver a verbal clinical handover. In addition. 2010). 2011). the staff survey did not show that Care Zoning made a difference to the clinical practice of nurses in the PICU. the patients’ mental state. Mullen. nurses did not opt to use the Care Zoning form in this way. This is consistent with the literature that expresses concern over the lack of targeted strategies to manage risk (Bowles. It summarises risk information. and that longer-term monitoring and evaluation is probably warranted. but merely a quarantined time where the nurse is solely available for that one patient (Taylor et al. mental state examination and risk assessment information and documentation improved dramatically. This is despite evidence from the audits that 1:1 time had improved as a result of the pilot. to try to ascertain how protected time can be more formally established for the benefit of staff. This requires further examination. 2006.also more marked after the first ten weeks.. or even no interactions at all. This is at odds with results found in other studies within inpatient settings (Gamble. 2011). patient engagement and care provision. only tolerate brief frequent interactions. as well as an evaluation of outcomes. Taylor et al. The concept of protected time does not prescribe intimate and continual face to face contact. 2009. suggesting that change takes time. Despite this.

establishing the concept of Protected Time was a more challenging exercise. Since the pilot completion. 2010) study. It is also a demonstration in the process of implementing a change in clinical practice.. The 14 . as did the consistency of risk assessment information. critical incidents rates. once the benefits to their practice were realised. 2009. it was not attributed to Care Zoning. This is largely to address the real problem of poor file chronology due to the insertion of the Care Zoning form into the medical record. This needs to be considered. LIMITATIONS Despite the encouraging results there are some limitations that need to be highlighted. it was difficult to demonstrate improvement. there is anecdotal evidence that staff welcomed the structure that Care Zoning provided and this also served as an educational tool as well as a clinical assessment and documentation tool. 2011). the handover meeting was not seen as necessarily a place to gather support and communicate clinical needs. CONCLUSIONS AND WAY FORWARD This pilot has shown that formalising the mental state examination brings improvements in the consistency and quality of assessment documentation.. 2006. Again. discussions have led to the development of a Care Zoning sticker as demonstrated by Taylor and colleagues (2010). despite the efforts to provide comparisons with the Taylor (et al. Therefore.the existing strategies for managing risk – and. Despite these somewhat mixed results. This result may also be explained in part because Care Zoning was not part of the clinical handover. seclusion rates. If in fact handover meetings are seen in this way. This pilot did not measure the impact of Care Zoning in terms of patient satisfaction or clinical outcomes. especially with a small number of survey respondents. Despite this. or to measure ward atmosphere. Gamble. therefore. this is a finding at odds with previous studies (Gamble et al. would be to compare patient length of stays. In this pilot there was initial staff reluctance that translated to overall acceptance. The standard of mental state examination documentation improved. Other variables that would add to an evaluation of the Care Zoning model. Furthermore this pilot only involved one unit with a small sample of data. Taylor et al.

One of the next challenges to be addressed by the authors is to improve the quality and consistency of care planning and their evaluations. Another ongoing process. is continuing to facilitate a greater emphasis on nurse patient engagement. It are also discussion about rolling this sticker out more widely across other acute inpatient units. 15 .implementation of the sticker has a similar evaluation plan to that of this pilot discussed.

Kelly Hobden for entering the data. the authors express much gratitude to Justin Steel and Belinda Weston for valuable contributions to the working party and the pilot’s implementation. Also. and to Stuart Guy for his generous provision of time and resources. Rose Leahey for assisting with file audits and Jon Chesterson for supporting the implementation of this pilot.ACKNOWLEDGEMENTS The authors would like to thank all the staff of the PICU where this pilot took place. 16 .

H. J. 10 (4) 14-17.. (2002) Philosophy. 9... D. M... Mellor. O'Conner. R. 79-86. (2005) Reason for admission and their implications for the nature of acute inpatient psychiatric nursing. J. A. Journal of Advanced Nursing. Crowhurst. Mental Health Practice. 596–606. Hever. Chipere.. Gamble. Clarke. trends and future practice Journal of Psychiatric and Mental Health Nursing. L. 179-184. 231-236.. 17 . & Pulsford. Jarrett. (2010) Zoning: focused support: a trust wide implementation. (2006) The zoning revolution.. L. Journal of Psychiatric and Mental Health Nursing (Commentary) 7. (2000) Therapeutic nursing care in acute psychiatric wards: engagement over control. G. M.. D. 689–695 Duxbury. Dodd. Journal of Psychiatric and Mental Health Nursing. Grellier. J.. C. N. care and treatment on the psychiatric intensive care unit: themes.REFERENCES: Bowles. & Bowers. Simpson. S.. Jones. Journal of Psychiatric & Mental Health Nursing. M. Ness.. Bowers. 12. T. L.. I. (2008) Psychiatric Intensive Care Units: a literature review. Bowers. C. A. 17(1).. (2008) The Management of Aggression and Violence Attitude Scale (MAVAS): a cross-national comparative study. Bilgin. Gamble. International Journal of Social Psychiatry. 54(1):56-68. Jeffery. 62(5). Needham.. C. M. Hahn.

A. (2005) The attitudes. D. (2011) Care Zoning: A Pragmatic Approach to Enhance the Understanding of Clinical Needs As it Relates to Clinical Risks in Acute In-Patient Unit Settings. & Wistow.. C.. K. Miller. Le Brun. I. M. R. R. Hurst.. Higgins. Taylor. R. K. S. M. Private correspondence unpublished internal report. & Thomas. knowledge and skills needed in mental health nurses: The perspective of users of mental health services. 2. 78-87. Issues in Mental Health Nursing. 29 (1). Hellard.. (1998) Mental health nursing in acute settings. D. Guy.. Stewart.. D.. Robinson. L. & Higgins. B. (2004) The Stockport interim pilot report of zoning. Wistow. 14. 515-523. & Henderson.. J.. Ryrie.Guy. Kearns.. Ayling. International Journal of Mental Health Nursing. Bajuk. 8-11. 52-63. L. (1997) Zoning: A system for managing case work and targeting resources in community mental health teams. (1999) Nursing acute psychiatric patients: a quantitative and qualitative study.. Anthony. A. 32 (5). G. Gregory. S. K. & O’Sullivan.. I. S.. G. Journal of Mental Health.. Pathmanathan. Mental Health Practice.. 6 (5). Journal of Advanced Nursing. Shearer. G. 318–326. 18 . Rydon. Hurst.

4 65.06) 2.9 219.0 0.9 80.90) 33.0 0.8 24.0 58.0 0.0 29.14*** *** p <0.0 0.5 19.0 31.8 14.0 41.0 0.4 31.0 0.8 39.4 83.6 14.6 27.7 0.42 (0.0 0.1 15.0 13.0 0. 19 .8 81.01.89*** 186.0 20.and post-implementation (Care Zoning) audit data – 8 bed PICU Audit Index: % of records with identified characteristic (value in brackets = weight in Aggregate Quality Score) Number of Records Management measures (1) Patient observation (1) Risk assessment (1) Mental state: Not present (0) Minimal (1) Satisfactory (2) Good (3) Interventions: Not present (0) Minimal (1) Satisfactory (2) Good (3) Evaluation-Outcomes: Not present (0) Minimal (1) Satisfactory (2) Good (3) Evidence of 1:1 (1) Care Plan (1) Aggregate Quality Score (0-14) Mean (SD) Pre-Care Zoning (Pilot) Post-Implementation Overall Chi-square (Pre vs.6 64.2 (N = 48) 43.71) 8.3 36.0 0.6 22.9 52. Summary of pre.4 251.8 4.0 0.5 81.6 46.7 43.39 (1.6 60.8 0.0 15.0 34.5 12.1 35.8 16.4 21.3 14.0 100.0 50.0 0.1 19.Table 1.0 0.27*** 100.0 0.0 87.4 61.08) 8.35 (1.3 17.3 (N = 289) 80.94) 2.19** 124.0 30.5 0.92*** 75.1 18.3 0.0 0.0 0.6 0.5 39.0 0.2 41.00) 8. Post) Day Shift Afternoon Shift Combined Day Shift Afternoon Shift Combined (N = 48) 66.2 38.0 0.95*** 7.3 20.2 70.6 (N = 572) 81.31 (3.91*** 70.7 68.0 100.49 (4.0 0.8 33.0 82.5 (N = 283) 83.4 60.3 18.6 16.9 23.0 0.1 40.7 13.5 30.44*** 2.001.6 19.3 61.4 0.9 15.2 21.0 25.0 12.3 79.2 59. ** p < 0.0 100.6 138.9 (N = 96) 55.14 (3.2 61.0 13.

7 92.7 92. PICU staff Care Zoning survey – Questions highly endorsed (> 80%) post-implementation Survey Questions – about the potential benefits of current risk management strategies Number of Respondents Q7 helping clinicians raise intuitive concerns regarding patients? Q8 helping clinicians to focus on those patients who require crisis intervention in a more systematic manner? Q5 helping to promote the delivery of targeted proactive mental health care? Q3 (helping clinicians) share clinical information with colleagues? Q6 helping clinicians identify clinical/risk issues with patients? Q4 (helping clinicians) share risk information with colleagues? Q10 helping focus the teams work on those patients whose needs are considered serious? Q9 preventing catastrophic relapse in patients? % Reporting a difference (“Some” or “Noticeable”) Pre-Care PostOverall Zoning Implementation N=15 N=13 N=28 Corresponding % Improvement from Taylor et al.7 100.9 82 86.3 72 86.7 92.3 89.3 92.8 84 73.6 85.3 90 93.Table 2A.0 92.3 89.6 87 86.6 78.7 69 86.7 84..7 84.7 60 See Note to Table 2C.3 84. 2011 86.3 89. 20 .3 92.3 71 86.6 85.

9 71.4 74 80.0 76 86.5 67.3 61. 2011 66.7 76.4 47 60.Table 2B.2 71.7 61.5 # 75.9 78.7 43 73.0 60 See Note to Table 2C..9 71.5 60.7 61.7 76. 21 . PICU staff Care Zoning survey – Questions moderately endorsed (60% to 80%) post-implementation Survey Questions – about the potential benefits of current risk management strategies Number of Respondents Q20 providing the opportunity for clinicians to discuss patients and gain ideas from colleagues? Q2 (helping clinicians) receive support from colleagues? Q19 providing the opportunity for clinicians to request help from colleagues with patients? Q16 complimenting existing clinical supervisory frameworks? Q21 providing the opportunity for clinicians to be told they have done well with a patient? Q22 providing the opportunity for clinicians to receive informal peer support during the remainder of the day? Q14 promoting a culture of openness enabling practitioners to discuss and safely voice uncertainty surrounding patients in the care they feel able or competent to offer? Q18 raising clinicians’ awareness of other clinicians’ patients whose needs are currently considered serious? Q12 promoting liaison and co-ordination with others involved in patients care? % Reporting a difference (“Some” or “Noticeable”) Pre-Care PostOverall Zoning Implementation N=15 N=13 N=28 Corresponding % Improvement from Taylor et al.0 76.4 72 66.0 61.5 60.8 68 86.7 28 60.6 62 73.3 69.5 # 75.0 61.

p < 0.Table 2C.8 67.0 53.5 42.64 (Pre-).3 62 57 75 46.5 57.3 80. Respective correlations with entries in last column: r (21) = 0.70 (Overall).0 73. # Possible concerns – lower postimplementation rates.2 46..001.7 38.0 46.7 64.2 53.3 38. PICU staff Care Zoning survey – Questions with lower endorsement (< 60%) post-implementation Survey Questions – about the potential benefits of current risk management strategies Number of Respondents Q11 promoting the continuity of care for patients whose allocated nurse/care coordinators are on leave/off sick? Q15 promoting structure within the team? Q17 how clinicians manage patient loads? Q1 (helping clinicians) adhere to policy? Q13 commitment practitioners have to attend meetings? Q23 providing the opportunity for the reallocation of resources? % Reporting a difference (“Some” or “Noticeable”) Pre-Care PostOverall Zoning Implementation N=15 N=13 N=28 Corresponding % Improvement from Taylor et al.6 60.and post-implementation rates.1 51 # # Note: There were no statistically significant differences between pre. 0.9 37 73.2 46.8 54 60. 22 .62 (Post-) and 0. 2011 80.