Project Description Conclusions !

mplications Background
Purpose
Future Plans
ProbIem:
Although yearly training augments clinician
knowledge and expertise, critical identification of
appropriate strategies to maintain safety can be
challenging while in the midst of a crisis are often
lacking. Emergent, potentially dangerous
situations, potentially dangerous
scenerios/imminent danger are most effectively
safely managed by role-specific interventions
and the establishment of a crisis team leader
that coordinates role specific interventions
nsert picture of crisis situation
Nurse-driven Algorithms provide useful information to reduce the use
of seclusion/restraints and assault rate (better in a graph??)
Rate of Initiation of Seclusion/Restraint
Assault Rate
Nurses possess unique skills and
talents to de-escalate behaviors.
Further testing of the algorithm in
other patient care environments
shows promise in future research
studies
Lori- add diagram
Or pic-placeholder
only
ontinue to employ algorithmic problem
solving in psychiatry
Benchmark the significance of a reduction of
falls, self-harm behaviors in episodes of
seclusion /restraint and assaults
Develop algorithms for the management of
patients with other behavioral and neurologic
conditions as our hospital standard of care
%o share evidence-based operationaI aIgorithms deveIoped by
our team in the care and treatment of for inpatient psychiatric
units to psychiatry inpatients which promote an environment
of safety and minimize the use of restraints whiIe improving
staff satisfaction.
&sing an algorithmic approach, a nursing crisis team leader is empowered to create a safe environment for patients, families and staff
through identification of behaviors necessitating appropriate de-escalation interventions to de-escalate behaviors. situations.
&singtilizing the algorithm, the crisis team leader offers therapeutic listening, creates strategic environments to facilitate de-escalation
and communicates support in a healing environment.
These strategies include use of calm soothing tones, relaxed body structure, observation of personal space, and ultimately
communicate ing a the desire to help. Appropriate use of strategies supports the patients efforts to identify specific stressors, thereby
fostering a nd ability to problem solving partnership with the clinician. Patients are instructed on distress tolerance techniques such as
deep relaxation breathing, appropriate distraction activities, decreased stimulation by spending time alone in a quiet place, and
appropriate medication management. Seclusion and restraint is are identified as a last resort measure for imminent danger only.
ue/escala7on!lnLerven7ons!!
Calmlng!
ulsLress!
1olerance!
Ac7vl7es!
LnvlronmenL! hyslcal!
Crlsls!1L!lnsLrucLs!
securlLy!Lo!place!
radlos!ln!nurslng!
sLa7on!and!Lurn!
volume!off!!
(excepL!supervlsor/!
who!Lurns!radlo!
down)!
l den7fy!self!as!Crlsls!1L!
and!only!one!Lo!speak!
Lo!pa7enL!
Clve!securlLy!
gloves!
ulscuss!plan!
for!
addl7onal!
securlLy!
personnel!lf!
needed!
SecurlLy!AlgorlLhm!
a7enL !goes!Lo!quleL!r oom!
Crlsls!1L!Con7nue!lnLer ven7o ns! Lo!de/escalaLe!behavlor!as! lndlcaLed!
a7enL!behavlor!de/!escalaLes! and!poses!no!danger!
!
a7enL!behavlor!sLays!Lhe!same! or!escalaLes!and!pa7enL !poses! l m mlnenL!danger!
Part !B!!
Crlsls!1L!encour ages!pa7enL!Lo ! r emal n !ln!quleL!r oom!Lo! decr ease!s7m ul a7 on!Con7nue! lnLerven7on!L o!de/escalaL e! behavl o r!as!lndlcaL ed!and! encourage!dlsLress!Loler ance!
a7enL !agr ees!and!sL ays!ln!quleL! ro omCrlsl s!Leam!leader!offer s!po! medlca7onsCrlsls!Leam!leader! offer s!po!medlca7ons!
!
a7enL !r efuses!Lo!sLay!ln!quleL ! roo m!
a7enL !does!noL!pose!danger!
!
!
a7 enL!does!pose!a!dan ger !
CC!L o! ar L!3!
a7enL!ref uses!Lo!go!Lo!quleL! room!
a7enL !behavlor !de/escalaL es!
!and!poses!no!dan ger !
Co!L o!arL!A!
a7enL!behavlor!unchanged!
uoes!noL!pose!d anger !
!
a7enL !do es!pose!a!danger!!
8epeaL!arL !8 !
a7enL!behavlor!escalaLes!and! poses!a!danger! !!
Cr lsls!1L!agaln!asks!pa7enL!!Lo!go! L o!quleL!room !explalns!safeLy! and!Lher apeu7 c!r a7 onal e!
!!
a7 enL!agr ees!and!goes!L o!CuleL! 8oom!
Co!L o!ar L!8!
Secu rlLy!lnsL rucLed!by!Leam! lead er !Lo!physlcally!move! pa7enL!Lo!quleL !r oom!
Co!Lo!arL !3!
Other examples of algorithms
developed for psychiatry:
(noLe!when!pa7enL!no!longer!poses!an!lmmlnenL!danger!and!Lhere!ls!no!longer!a!need!for!Lhe!use!of!secluslon!or!resLralnLs!
Crlsls!1L!wlll!offer!quleL!room!for!one!hour!Lo!Lransl7on!back!Lo!mllleu!provlde!opporLunlLy!for!debrleflng!and!allow!pa7enL!7me!
Lo!demonsLraLe!behavloral!conLrol!!(compleLe!debrleflng!prlor!Lo!pa7enL!reLurn!Lo!mllleu)!
Crl sl s!1e am !l e a de r!l ns Lruc Ls! pa7 e nL!r eg ardl ng!crl Le rl a!for! dl s con7nul ng !l ock ed!se cl usl on!
SLa ff!ass l g ned!by !Cr l s l s !1 L! Che ck !vl La l !sl g ns !e ve ry !4 !P ! doc um e nL!re fusal !on! f requenL!obs erv a7 on!s he e L!
Crl sl s!1L !l nsLrucL s!sLaff!Lo!sLe p!ouL! of!qul e L!room !al l ow l ng !pa 7e nL! prl va cy!Lo!chang e!l nL o!p[ s ! monl Lor!Lhroug h!w l ndow! Crl s l s!1L!offer s!po!fl u l ds ! a nd!food!e ve ry!4 !P ! uoc um e nL!re fusal !on! fre quenL!obse rv a7 on! shee L!
Crl sl s!1l !l nsL ruc Ls!sLa ff!!Lo!rem ove ! cl oLhl ng !fr om !pa 7 enL' s!room!and! sLore!l n!ba ck!of!nursl ng!sL a7 on!
Crl s l s !1 e am !L ea der!offer s! Lol l e 7ng !docume nL!refusa l !on! fre que nL!obse rva 7 on!she eL!e ve ry! 4 !P!
lf!pa7enL!relucLanL!
Crlsls!1L!no7fles!
pa7enL!LhaL!
securlLy!wlll!asslsL!
changlng!lnLo!p[s!lf!
Lhey!do!noL!do!so!
lndependenLly
lf!pa7enL!
refuses!Crlsls!1L!
lnsLrucLs!
securlLy!Lo!
change!pa7enL!
lnLo!!s!(8n!Lo!
hold!up!gown!Lo!
proLecL!pa7enL!
prlvacy)!
a7 e nL!re fuse s!and! a 7 enL!sLrl k es !ouL! durl ng !chang e! pr oc es s!
Crlsls!1L!lnsLrucLs!SecurlLy!Lo!physlcally!
move!pa7enL!Lo!resLralnL!room!and!
place!on!resLralnL!bed!SecurlLy!holds!
each!llmb!whlle!resLralnLs!are!applled!
Lo!all!4!llmbs!by!nurslng!sLaff!
!Lo!arL !3!
lf!pa7enL!agrees!Lo!change! Crlsls!1L!l nsLr ucL s!sLaff!Lo! sLep!ouL!of!quleL !room! allowlng!pa7enL!prlvacy!L o! change!l n Lo!p[s!monlL or! L hrough!wlndow!
on/ nue&to&reassess&the&risk&of&imminent&danger&and&need&for&con/ nued&seclusion.&&
Door&must&be&open&and&room&entered&by&staff&every&hour&unless&too&dangerous.&&
Document&i n&assessments&of&frequent&observa/ on&sheet&
Reminders:&Seclusi on&order&dur a/ on&&is&a&maximum&of&3&hours&(then&will&need&reForder &if&appropriate)&
&&&&&&&&&&&&&&&&&&&&&&

" " " "

" " "

2.84 1.67 1.13 5.92 1.24 0.00 0.00

" " " "

" " "

1.85 2.69 1.63 0.54 0.66 0.67 0.00
Patient demonstrates signs of distress with
actual or potential loss of
behavioral control Staff intervenes to de-
escalate
Patient does not pose an imminent danger
alming
Distress Tolerance
Environment
Interventions as
appropriate
Patient behavior escalates and/or patient
poses an imminent
danger
Establish Crisis team Leader (TL) [RN]
assigns crisis team roles
Staff assigned to keep hallway clear Staff assigned to call security "STAT
Go to security algorithm
Staff assigned to keep patient in view
Staff ensures quiet room ready, remove all items
except mattress with
clean bedding and pajamas
Assigned RN preps PO &M meds (Call MD for
Stat M meds and brief
re. situation
Crisis team leader intervenes to de-
escalate behavior
Patient
alming
Distress Tolerance
Environment
Interventions as
appropriate
Patient behavior unchanged or escalates
and patient poses
imminent danger
Crisis TL explains safety and therapeutic
rationale, TL patient to
go to the quiet room
Go to Part 2.
Part 1: Initial Response