Aggressive behavior, documented in an estimated 3% to 7% of the behavioral and mental health population children's hospitals serve, is one of the most challenging concerns for children's hospitals. Aggression is more prevalent in children with psychiatric disorders, including oppositional defiant disorder (ODD), antisocial personality disorders and autism spectrum disorder (ASD).
Over a four-year period at Nemours/Alfred I. duPont Hospital for Children in Wilmington, Delaware, there was a substantial increase in aggressive child events, enough to warrant concern for safety of patients, family caregivers and members of the health care team.
To address the issue, the organization focused on aggressive patient activity in the emergency department (ED) and inpatient units, which has now transcended into the ambulatory/outpatient settings. The goal was to standardize processes and successfully implement processes to provide the care team the tools they need to create a safe patient care environment. Here's how the organization created a safer environment for patients, families and staff members.
Implementing a behavioral toolkit in the ED
In the first quarter of 2015, the organization's inpatient units and ED began to experience a surge in aggressive child events. In response, the Aggressive Child and Workplace Violence Committee formed to address aggressive child emergencies (ACE). Aligning with the organization's philosophy of team-based continuous improvement process, a sub-committee created a behavioral toolkit, offering the care team the use of an individualized plan of care and safe care environment package.
The toolkit is built into the electronic medical record (EMR), provides the team easy access to the most current care plan and streamlines shift-to-shift documentation and communication. It includes:
- Behavioral assessment
- Behavioral plan of care
- Patient and staff member safety checklists
Additionally, the EMR includes a banner to highlight a patient's history of aggressive behavior. The banner links the care team with quick access to the toolkit and plan of care, not only for inpatient use, but across the continuum to include ambulatory settings.
Initiation of the toolkit occurs when an aggressive event alerts the ACE response team. This team collaborates to implement a plan of care with the goal of promoting patient and family safety, along with support and injury prevention for providers. Once ACE team members initiate a behavioral plan of care, they provide daily assessment through family centered rounds, which are adapted throughout the patient's acute emergent and inpatient experience.
Crossing the continuum of care
After implementing the toolkit in the ED, the organization began translating it for ambulatory and outpatient settings. While outpatient sites within the hospital have the advantage of the ACE team on premises, the number one tool available to the ambulatory sites is the optimization of the EMR. The inpatient banners and alerts are transferable to the ambulatory EMR interface, allowing providers to be aware of historical behaviors, triggers and soothers.
Implementing staff training
While the outpatient settings lack specialized resources, these teams have made strides to train and educate all staff members. But one barrier continues to exist: the training and education on identifying aggressive behavior and the use of de-escalation techniques. The organization addressed this concern with mandatory skills fairs for support staff, along with providing additional educational offerings at an ambulatory conference.
The skills fair focused on identifying aggressive behavior, de-escalation techniques and building awareness of EMR tools, including a personal safety checklist modified for ambulatory sites. The personal safety checklist outlines what a team member can take to ensure his or her safety, such as:
- Removing hanging jewelry and lanyards
- Maintaining a clear path to exit
- Pulling hair back out of reach of a patient
The ambulatory team modified the environment of care checklist, which can create a safer environment by removing small trash cans from the exam room or items that can be used as projectiles and ensuring the patient's room is close to the nurses' workstation.
Implementing de-escalation techniques and seeing success
Successful results and outcomes demonstrated improvement in strategies to increase de-escalation techniques and reduce multiple ACE events per patient within the organization. As a result, the percentage of encounters utilizing de-escalation techniques has increased from about 62% in 2015 to 86% in 2018.
Multiple ACE calls per patient decreased:
- 23% in 2015
- 16% in 2016
- 14% in 2017
These numbers indicate improvement and continued progress until 2018, when this number increased to 20%, identifying a need to re-evaluate, an important ongoing process.
The organization also saw a decrease in the number of assaults on staff members during aggressive child emergencies. Assault injuries per quarter decreased from 55 events in the first quarter of 2015 to the lowest number of four events in the second quarter of 2017.
Improvement into the future
Ongoing training and development for staff members is a key aspect to success. The creation and implementation of a new Patient Safety Companion role has offered a model to ensure the child's plan of care needs are achieved and the goal of safe patient care is a priority. Nemours has also started deploying behavioral health providers into satellite sites, which may allow outpatient ACE team development to progress.
While the hospital continues to see a decrease in the number of aggressive patients in the ED and ambulatory/outpatient settings, aggressive child events continue to increase in the inpatient setting. It is impossible to expect total prevention of aggressive child events, but creative thinking and team planning can help address the ongoing problem.