Adult ED Staff Meeting

January 12, 2010

Thanks to all of our Guest Presenters

• Health Promotion/Disease Management– MHTAV Care

Coordinators

• Patient Boarding– Carol Wilson

• EVS– Mike Jolley

• Mike Daly– Restraints

Mike Daly

Restraints

Objectives

• What we have done?• Restraints data• Audit Tool• Stumpers

What have we done?

• Updated policy• Approved policy

– Clinical practice– MCMB

• Education

Restraint TrendRestraint orders

– Average of 1445 restraint orders per month• 1438 restraint orders per month for VUH• 7 restraint orders per month for Children’s Hospital

– Average of 48 restraint orders per dayRestraint Data from HED per month

– X = Y/19*(30)– 1528 Restraint Days, 416 Restrained Patients– Average of 3.6 restraint days per patient

Restraint orders for violent patients (all have been in VUH)– Estimate of 58 restraint orders for violent patients per month

Auditfor

Violent Patients

Patient’s Initials/MRN

Patient Location

Primary Service:

Was patient restrained prior to being restrained as a violent patient?

Date/Time the patient was initially restrained as a violent patient:

Patient’s behavior at the time of the order:

Type of restraint order (verbal, protocol, etc)?

How long was the patient restrained as a violent patient?

Did a face-to-face evaluation get documented?

Did a debrief get documented?

Did the psychiatric service get consulted?

Did the nurse document restraint monitoring assessment every 15 minutes?

Did the nurse document the safety priority problem in HED?

Was the appropriate people notified (AC in VUH, hospitalist service in VCH, psych team in VPH)?

Should this patient have been restrained as a violent patient?

Welcome to Stumpers!

RestraintToday we’ll be playing

StumpersCase

Studies

The Violent Patient

Orders The Non-Violent Patient

Definitions

2004006008001000

2004006008001000

2004006008001000

Restraint

2004006008001000

2004006008001000

StumpersCase

StudiesOrders The Violent

PatientDefinitions The Non-Violent

Patient

A 1 200

• 15 yo with known head injury from Motor vehicle collision. He is combative to staff. What should you do first? Give examples.

Q 1 200• What is consider alternatives to restraints:

bring parents in the room, reassure patient, treat his pain, and/or provide distractions, etc.?

A 1 400• For a violent category 17 y/o in restraints, how

often does the order need to be renewed?

Q 1 400• What is every 2 hours?

A 1 600

• 45 y/o male s/p liver transplant that has been weaned from the vent and is beginning to wake up. He is currently in the SICU and continues to try and pull off his EKG leads and pull out his IVs.

• The patient gets an order for “nonviolent” restraints. Why is the order for “nonviolent” restraints instead of “violent.”

Q 1 600

• What is - the patients behavior is interfering with our ability to provide medical care and is not severely aggressive or violent.

A 1 800• 35 y/o male has just been admitted to a trauma s/p self-

inflicted GSW. He has a known history of paranoid schizophrenia. The patient begins pulling off his leads yelling that they are uncomfortable. He also starts pulling out his IV’s and tells his nurse that the IV is hurting.

• Does this patient fit the violent or non-violent category?

Q 1 800• What is non-violent? The patient’s behavior is

interfering with your ability to provide medical care. It is not severely aggressive or violent. The behavior is related to the discomfort and pain she is experiencing from the EKG leads and IV.

A 1 1000• A 67 y/o woman has just been admitted to a telemetry unit for

observation from the ED (where she has been for 18 hrs) because of syncopal episode related to atrial flutter. She has a known history of paranoid schizophrenia. The patient begins pulling off her leads yelling that the they are feeding information from her soul to the government. She also starts pulling out her IV’s and tells her nurse that she believes the IV is our method of implanting a computer chip in her so that the government can monitor everything she does. She tries to choke herself and her nurse with the iv tubing before this occurs.

• Does this patient fit the violent or non-violent category?

Q 1 1000

• What is violent category? The patient’s behavior can be considered severely aggressive or violent and seems to be due to the patient’s mental health condition, not a medical condition.

A 2 200

• For a violent category 11 y/o in restraints, how often does the face-to-face have to be done by the provider?

Q 2 200

• What is every 4 hours?

A 2 400

• For a violent patient in restraints, nursing documentation needs to be done how often?

Q 2 400• What is every 15 minutes?

A 2 600• For the Non-violent patient in restraints,

nursing documentation needs to be done how often?

Q 2 600• What is every 2 hours?

A 2 800• The initial restraint order must be placed

within what time frame in Wiz/HEO for both non-violent and violent patients?

Q 2 800

• What is within 1 hour?

A 2 1000• What is the difference for Violent patients

between order renewal every 1, 2, or 4 hours versus a new order every 24 hours?

Q 2 1000• Requires discussion

A 3 200• What must be completed within 1 hour of

initiation of restraint by a trained staff member for all violent patients placed in restraints?

Q 3 200• What are a face-to-face evaluation and a

restraint order?

A 3 400

• In the rare event a violent patient requires restraints >24 hours, notification must be made to the _______.

Q 3 400

• Who is the medical director?

A 3 600• Name at least 3 things that must be included

in the Q 15 minute nursing documentation for the violent patient in restraints?

Q 3 600

• What are : Nutrition, hydration, circulation, skin condition, patient response, ROM, pain, elimination, hygiene, and discontinuation goal?

A 3 800

• How soon should restraints be removed from the Violent patient?

Q 3 800

• When is as soon as possible?

A 3 1000

• How often does the face-to-face need to be repeated for the violent 65y/o patient in restraints?

Q 3 1000

• When is every 8 hours?

A 4 200

• Any manual method, physical or mechanical device, material, or equipment, that immobilizes or reduces the ability of a patient to move his or her arms, legs, body, or head freely.

Q 4 200

• What is a physical restraint?

A 4 400

• Require restraint to support patient safety and/or provide optimum medical care. These are patients who present with behavioral changes that are primarily related to their medical/surgical condition (e.g., delirium due to high fever/sepsis, alcohol/drug withdrawal, dementia, or pulling IVs, endotracheal tube, or feeding tube).

Q 4 400

• What is a non-violent patient?

A 4 600• Patients suffering from severely aggressive or

violent behavior that poses an imminent danger to self or others. These are patients who present with mental or emotional health symptoms for which a medical etiology is ruled out, and who are identified as primarily requiring mental health services (e.g., psychotic episodes, manic, attempted suicide, physical assault, or violent/aggressive behavior).

Q 4 600

• What is a violent patient?

A 4 800

• Involuntary confinement of a patient in a room alone or areas from which the patient is physically prevented from leaving. This is only used for the management of violent or self-destructive behavior.

Q 4 800

• What is seclusion?

A 4 1000

• A drug or medication when it is used as a restriction to manage the patient’s behavior or restrict the patient’s freedom of movement and is not a standard treatment or dosage for the patient’s condition, is not a drug that is used within the patient’s normal dosage to help patient interact more appropriately with their environment.

Q 4 1000

• What is a chemical restraint?

A 5 200

Daily Double!

Do You Feel Lucky?

Make a Doubler bet!

Doubler

Q 5 200

A 5 400

• How soon should restraints be removed from the non-violent patient?

Q 5 400

• When is as soon as possible?

A 5 600

• Is a face-to-face evaluation necessary for a non-violent patient in restraints?

Q 5 600

• What is no?

A 5 800

• When are restraint orders renewed for non-violent patients?

Q 5 800

• When is during daily rounds?

A 5 1000

• How often is nursing assessment documented on non-violent patients in restraints?

Q 5 1000

• When is every 2 hours?

Nursing Documentation• What are 3 things that must

be included in the every 2 hour nursing documentation for the non-violent patient in restraints?

Doubler #1 and the topic is:

Do You Feel Lucky?

Make a Doubler bet!

Doubler

Doubler Question here

• What are : Nutrition, hydration, circulation, skin condition, patient response, ROM, pain, elimination, hygiene, and discontinuation goal?

The Grand Finale• Each side make a bet.

This is your last wager of the game, so make it a thoughtful one.

Finale Answer

• What steps are used to determine if a patient should be in the non-violent or violent category?

Finale Question1. After considering alternatives, nurse decides

patient needs to be restrained.2. Nurse formulates his/her assessment as to the

cause of the behavior.3. Nurse contacts the provider.4. Nurse and provider collaborate and make

decision together.5. Provider enters orders for restraint.

Collaboration is the key!

Thank you for playing Stumpers.

• This game board was made from a template created at the Mountain Area Health Education Center in Asheville North Carolina as part of its Family Medicine Residency program. Feel free to adapt it but please cite MAHEC Stumpers.

• http://www.mahec.net/stumpers

ED Quality Data

Cathy Wilson

RRT Triggers• Triggers for calling the Rapid Response Team• • If the patient exhibits any of the following EARLY WARNING SIGNS, call the Rapid Response Team without delay • and call the patient’s primary team physician. • Staff Concerned/Worried• "THE PATIENT DOES NOT LOOK/ACT RIGHT", gut instinct that patient is beginning a downward spiral even if none of the physiological triggers have yet occurred• Change in Respiratory Rate• The patient's RESPIRATORY RATE is less than 8 or greater than 30• Change in Oxygenation• PULSE OXIMETER decreases below 90%• Labored Breathing• The patient's BREATHING BECOMES LABORED• Change in Heart Rate• The patient's HEART RATE changes to less than 40 bpm or greater than 120 bpm• Change in Blood Pressure• The patient's SYSTOLIC BLOOD PRESSURE drops below 90 mmHg or rises above 200 mmHg• Hemorrhage• The patient develops uncontrollable bleeding from any site or port• Decreased LOC• The patient becomes SOMNOLENT, DIFFICULT TO AROUSE, CONFUSED, or OBTUNDED• Onset of Agitation/Delirium• The patient becomes AGITATED OR DELIRIOUS• Seizure• The patient has a SEIZURE• Other Alterations in Consciousness• ANY OTHER CHANGES IN MENTAL STATUS OR CNS STATUS such as a sudden blown pupil, onset of slurred speech, onset of unilateral limb or facial weakness,

etc.

RRT Triggers

• Why do we need to know these?– The floors are held to these for calling for help. If

your patient meets them they might be moved again.

• What do we do about the patient’s if they meet these?– Call the team and get them to reevaluate the

patient and don’t back down. – Have your Charge Nurse involved

Pneumonia Core Metrics

Urine Contamination

Dec-09 Jan-10 Feb-10 Mar-10 Apr-10 May-10 Jun-10 Jul-10 Aug-10 Sep-10 Oct-10 Nov-10 Dec-100%

5%

10%

15%

20%

25%

30%

Contaminated Urines

Perc

enta

gego

al 1

5%

Blood cultures

July. 09 Aug.09 Sept.09 Oct.09 Nov.09 Dec.09 Jan.10 Feb.10 Mar.10 Apr.10 May.10 Jun.10 Jul-10 Aug-10 Sep-10 Oct-10 Nov-10 Dec-100.0%

1.0%

2.0%

3.0%

4.0%

5.0%

6.0%

7.0%

8.0%

9.0%

10.0%

6.0% 6.0%6.3%

5.9%

9.2%

5.2%

7.0%

3.3%3.8%

2.5% 2.6%2.1% 2.2%

2.8%3.0%

1.9%

3.7% 3.9%

Blood Cultures Reported as Possible Contamination

% o

f Blo

od C

ultu

re C

onta

min

ation

per

Tot

al

Hand Hygiene

Jason Reed and Emily McBride

Hand WashingJan 2011

Hand WashingBY Type of Person Observed Monthly Numerator Monthly Denominator Monthly Compliance Rate

Ambulance Personnel 1 3 33

Nursing 8 12 67

Patient Care Technician 1 1 100

Physician 2 2 100

Radiology Technologist 1 1 100

Transport Services 0 1 0

       

Total 13 20 65

Smooth Moves

Kristy Bishop RNNurse Wellness CommitteeSmooth Moves Facilitator

SPINE TOLERANCE LIMITS

Compression Forces = 3400 - 6400 Newtons (Equivalent 748 – 1408 LBS)

Anterior/Posterior Shear1000 Newtons = 220 LBS

Lateral Shear1000 Newtons = 220 LBS

The Issue Lifting involves the same physical forces generated by

a lever and fulcrum. The low back becomes the fulcrum. The stress on the back is multiplied many times when bending and lifting patients, such as turning.

If a 150 lb. caregiver turns a patient from side to side, the reach is between 34 and 36 inches. This caregiver will create the following stress on the low back with each turn: “Little” 100 lb. person: 1002 lbs stress on LOW back

“Average” 150 lb. person: 1314lbs …..

200 lb. person: 1695 lbs…….

250 lb. person: 2024 lbs…..

Adult ED Smooth Moves Injury Report1/1/2010 to 12/31/2010

Patient Handling Injuries Reported to Occupational Health

8 Patient Handling Injuries Between 1/1/10 And 12/31/10

Adult ED Smooth Moves Injury Report1/1/2010 to 12/31/2010

Adult ED Smooth Moves Injury Report1/1/2010 to 12/31/2010

Adult ED Smooth Moves Injury Report1/1/2010 to 12/31/2010

Adult ED Smooth Moves Injury Report1/1/2010 to 12/31/2010

Adult Emergency Department

StedyTransport Aid

(265 LB Max Weight)

Hover Matt & Pump

Air Mattress System

Sara 3000

Sit to Stand Lift

Maxi MoveTotal Lift (Max Weight

500 lb)

Slippery Sheets PAR level item stocked daily

All Health Care Workers

Emergency Department Champion List

Lori Kelso, RNGayle Kilts, Asst Mgr-PCS

Lori Martin, RN Rose Wheeler, CP

Thank You

Emergency Department

Nurse Wellness Committee

“working smarter not harder”

ED Competencies 2011

Competencies 2011 New binders with 2011 forms. Forms from NEAD. Customized to the ED. Deadline: December 31, 2011 for spring 2012

eval. Some items will cross over to VPES…

eventually, all will.

SAFETY FAIR

Hands OnClinicalSafety

Sessions for 2011:

January 20 & 217a-6p

March 31, April 17a-6p

September 22 & 237a-6p

N-95 Mask Fitting

TB Skin Test

Restraints (even yrs)

There will no longer be POCT at Hands On Clinical Safety!!!

Offered the first Tuesday of every month in POCT 4th

floor! 0730-1400

The Joint CommissionSentinel Event Alert

In 1998, The Joint Commission issued a Sentinel Event Alert on preventing inpatient suicides.

The goal of this new Alert is to assure that patients outside of psychiatric units are appropriately screened and cared for.

A Few Final Thoughts – Marsha Price

• Our new attendance incentive plan begins this month that rewards those staying mindful about minimizing tardies and no shows.

• Continue to be mindful of situations that may be potential HIPPA violations – Glass installed around the Pod B Nurses station to assist with that effort

• The problems with TV’s in the Pod B patient rooms have been resolved!!!

• The Pod B WhiteBoard Monitor has been ordered to replace the one that is out of service.

Meeting Evaluation – Marsha• 5 – Excellent• 4 – Very Good• 3 – Average• 2 – Below Average• 1 - Poor

Use the poll on our Team Member Only Website to Evaluate the Meeting. We will send you a link today.

Share any comments now.