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Cool, Calm and CollectED

Wollongong Hospital
Project Added:
19 August 2014
Last updated:
9 October 2014

Cool, Calm and CollectED

Implementation and Compliance to Aggression, Seclusion & Restraint (NSW Policy (PD2012_035)

By Wollongong Hospital Emergency Department, Illawarra Shoalhaven Local Health District

Summary

Incident Information Management System (IIMS) reports and the Restraint and Seclusion Register in Wollongong Hospital Emergency Department (WH ED), did not support the anecdotal reports of aggressive incidents. Well documented evidence of the frequency and type of aggression that staff encounter, assists in the planning for a safe, stable environment and appropriate services. It also ensures that the patient is receiving the appropriate treatment and management, with the least restrictive practice.

This project developed training and solutions to ensure a standardised approach to minimising, managing and documenting patient aggression to improve safety and experience for staff and patients.

Download a poster about this project from the Centre for Healthcare Redesign graduation, August 2014. 

Aim

To prevent, minimise and manage aggression in WH ED in accordance with the NSW Health policy directive Aggression, Seclusion & Restraint in Mental Health Facilities in NSW, (PD2012_035).

Benefits

  • Improved patient and staff safety
  • Improved documentation demonstrating the appropriate management of the aggressive patient within the WH ED
  • Improved staff moral and working environment
  • Improved patient and staff satisfaction
  • Reduction in risk of injury to patients and staff
  • Reduction in the incidence of staff sick leave and staff turnover by minimising occupational stress related to violence in the WH ED
  • Reduction in adverse outcomes (SAC 1, SAC 2) relating to patient or staff injury
  • Improved NEAT whole-of-hospital targets by ensuring patients care and transfers are facilitated in a timely manner
  • Improved the quality of care planning, coordination and transfer to the appropriate facilities for patients Improvement in the quality of data relating to Restraint and Seclusion in WH ED.

Project status

Started August 2013

Background

Anecdotally, it had been reported that patient aggression was a common occurrence in the WH ED. However, IIMS reports and the Restraint and Seclusion Register in WH ED, did not support that claim.

Data obtained from the Wollongong Hospital security logs recorded 261 instances of service within the WH ED for the period June 2012 to June 2013. Security logs documented incidents ranging from assisting staff in preventing, minimising and managing patient and/or visitor aggression, including assisting WH ED staff in patient restraint and seclusion.

Well documented evidence of the frequency and type of aggression that WH ED staff encounter, assists in the planning for a safe, stable environment and appropriate services. It also ensures that the patient is receiving the appropriate treatment and management, with the least restrictive practice.

Solutions implemented

  • Education of the policy directive PD2012_035
    The WH ED staff were supported in the development of educational tools and management pathways.

    ISLHD ED Clinical Nurse Consultants, Nurse Educators and WH ED Medical Officer (MO) Educators all contributed to the education of staff in the management and documentation of aggression.

    Wollongong Hospital security staff were also provided education and training in their role of clinical management of the aggressive patient.

  • Policy documentation support
  • IIMS alerts
  • Resource allocation for emergency department triage
  • Development of a procedure in the management of the aggressive patient
  • Behavior and aggression management training

Results

  • Rollout of discipline specific tools for the education of Aggression, Seclusion & Restraint in Mental Health Facilities in NSW Policy (PD2012_035) and use of the Restraint and Seclusion Register
  • Rollout of security staff education on their role within the Aggression, Seclusion & Restraint in Mental Health Facilities in NSW Policy (PD2012_035)
  • Development of a seclusion and restraint workflow procedure in the management of the aggressive patient/visitor in WH ED
  • IIMS alerts placed in Restraint and Seclusion Register for every new episode of restraint and/or seclusion
  • Auditing of reports of aggression and reconciliation with IIMS by WH ED Clinical Manager
  • Change in the use of language identifying the patient who is aggressive as ‘the aggressive patient’ rather than the ‘mental health patient’
  • Reduction of callouts to WH ED for security assistance
  • Improvement in the reconciliation of the Restraint and Seclusion Register and IIMS
  • Improved compliance and access to the IIMS and the Restraint and Seclusion Register with external auditors e.g. Official Visitors.

Lessons learnt

Change can be implemented when the necessary systems and education are in place for the change to occur. Once these systems have been established, sustaining change is possible.

Education needed to be tailored to the specific needs of the various disciplines working within WH ED and in context to the environment where change was sought.

WH ED staff were motivated to develop solutions in the reporting and management of aggression.

During the Implementation Stage the WH ED has undergone significant other activities (listed below) as priorities which have limited the full compliance with Policy PD2012_035

  • Accreditation
  • Rotation and Orientation of new ED MO’s
  • Relocation of the ED
  • Annual leave by Reinforcing Sponsors
  • Concurrent projects implemented within the WH ED.

Despite this, the motivation for change by the WH ED staff was highlighted in the improvement in reporting of aggression and the improved reconciliation of IIMS and the Restraint and Seclusion Register.

There was an unexpected reduction in the number of call outs by security to WH ED, after implementation.

The IIMS system of reporting was and remains a barrier to full compliance, due to its perceived complexity by the staff in WH ED.

References

American College of Emergency Physicians (ACEP)  Public Health and Injury Prevention Committee. (2011). Emergency Department Violence: An Overview and Compilation of Resources. ACEP. Retrieved from: www.acep.org/clinical---practice-management/ed-workplace-violence-prevention 

Bureau of Health Information. (2013). Patient Perspectives: Mental health services in NSW public facilities, Volume 1, Inpatient Care

Illawarra Shoalhaven Local Health District, Aggression, Seclusion & Restraint Working Party. (2012). Recommendations [internal document] 

Jelinek, G.A., Weiland, T.J, Mackinlay, C., Gerdt, M. and Hill, N. (2013) Knowledge and confidence of Australian emergency department clinicians in managing patients with mental health-related presentations: findings from a national qualitative study. International Journal of Emergency Medicine. 2013 Jan 15;6(1):2 

Lyneham, J., (2000), Violence in NSW Emergency Departments. Australian Journal of Advanced Nursing 2000 V 18 N2

Munroe, V. (2002) Why do nurses neglect to report violent incidents? Nursing Times. 2002 Apr 23-29; 98(17):38-9

National Institute for Health and Clinical Excellence (NICE). (2005). Violence: The short-term management of disturbed/violent behavior in in-patient psychiatric settings and emergency departments. NICE guidelines [CG25]. NICE, Manchester, UK. Retrieved from: www.nice.org.uk/guidance/cg25

NSW Health. (2012) Aggression, Seclusion & Restraint in Mental Health Facilities in NSW (PD 2012_035)

NSW Health. (2012). Aggression, Seclusion & Restraint in Mental Health Facilities - Guideline Focused Upon Older People (GL2012_005)

NSW Health. (2012). Violence Prevention & Management Training Framework for the NSW Public Health System (PD2012_008)

NSW Health. (2012). Emergency Department Models of Care.

Policy and Strategic Projects Division, Victorian Government. (2005). Occupational violence in nursing: An analysis of the phenomenon of code grey/black events in four Victorian hospitals. Department of Human Services, Melbourne, Victoria, Australia. Retrieved from: www.health.vic.gov.au/__data/assets/pdf_file/0008/17585/codeblackgrey.pdf 

Rew,M., and Ferns, T., A Balanced Approach to Dealing with Violence and Aggression at Work, British Journal of Nursing, 2005, Vol 14, No 4

Rose, M. (1997), A survey of violence toward nursing staff in one large Irish Accident and Emergency Department. Journal of Emergency Nursing. 1997 Jun; 23(3):214-9 

Thompson, J. (n.d.) Staff Turnover in Hospitals. Chron. Retreived from smallbusiness.chron.com/staff-turnover-hospitals-77444.html 8/8/14 

White Paper Care of the Psychiatric Patient in the Emergency Department Emergency Nurses Association, 2013

Winstanley, S. and Whittington, R., (2003) Aggression towards health care staff in a UK general hospital: variation among professions and departments, Journal of Clinical Nursing Volume 13, Issue 1, pages 3–10, January 2004

Contacts


A/Nurse Educator-Specialist Mental Health Service for Older People
Wollongong Hospital, Illawarra Shoalhaven Local Health District
Phone: 02 4253 4300


Clinical Redesign Coordinator
Illawarra Shoalhaven Local Health District


Clinical Redesign Coordinator
Illawarra Shoalhaven Local Health District
Phone: 02 4253 4626

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