NUBE 2024

Background
Workplace violence is a persistent threat in emergency departments, impacting both staff safety and patient care quality. A rise in patient acuity has been observed within Atrium Health Behavioral Health Charlotte where patients often exhibit symptoms and behaviors of aggression, agitation, and psychosis. This facility has an emergency department (ED), ED observation (BH observation), and inpatient units. Staff injuries have also risen in part where patients required restraints. Multiple interventions can be found in the literature; however, their effectiveness varies in this specialized setting.
Objective
Implement purposeful nursing rounds and employ Dynamic Appraisal of Situational Aggression (DASA) to enhance patient safety, staff safety, and reduce the need for restraints.
Method
Pre-surveys were developed by an interdisciplinary safety committee and distributed to nurses and psychiatric technicians in the ED. The pre-surveys gauged views on existing safety measures. There were 22 nurses and 28 technicians who responded. Plan-Do-Study-Act (PDSA) cycles were used to implement recommended process changes. The safety committee developed a tailored nursing round protocol specifically for psychiatric emergency patients, with rounds scheduled every 3 hours to align with staffing levels. The Dynamic Appraisal of Situational Aggression protocol underwent refinement shifting responsibility from psychiatric technicians to nurses for a more thorough assessment of patient aggression risk. A minimum of 3 assessments per shift became required, alongside an agitation protocol order set that guided de-escalation techniques and a stepwise agitation protocol based on DASA scores.
Results
All patients (adults, children, and adolescents) admitted to BH observation from July 2023 to February 2024 were included in the assessment. Pre-intervention (July-October 2023) data showed 67 child restraint events, 85 adult restraint events, and 25 staff injuries. Chart audits showed that nurse rounding was 5%, and DASA scores completion rate was 100%. However, utilizing DASA scores for early identification and protocol intervention for aggression or follow up was at 62%.
Post intervention (November 2023-February 2024) data showed decreases in all areas: 45 children restraint episodes (55.22% decrease), 36 adult restraint episodes (57.62% decrease), and 8 staff injuries (68% decrease). Educational initiatives, such as DASA training, appear to have had an impact on reducing patient restraints and staff injuries. Reinforcement of the protocol during nursing huddles, improved staff proficiency and compliance.
Conclusion
We show that the integration of purposeful rounding, the DASA tool, and following stepwise interventions based on DASA scores has helped to mitigate workplace violence. This resulted in enhanced staff safety and decreased ED observation patients in restraints. Implementation of this protocol underscores the importance of proactive interventions and interdisciplinary collaboration in addressing complex healthcare challenges. Cost savings were achieved as there were 17 less staff being injured resulting in less time missed from work due to injury and less workman compensation claims.

Learning Objectives:

To reduce staff injuries

To minimize the need for patient restraints

Institute purposeful rounding and a stepwise agitation protocol with interventions based on DASA scores