New Inpatient Program Stems 'Epidemic of Violence'

Deborah Brauser

April 03, 2018

HONOLULU, Hawaii — A novel interdisciplinary program can improve care of hospitalized geriatric patients who have behavioral disturbances ― while increasing staff safety and satisfaction, new research suggests.

The Behavioral Optimization and Outcomes Support Team (BOOST) program uses a rapid response team to address problems in the acute care setting. The system provides early identification of high-risk/high-needs patients who demonstrate aggression owing to psychiatric illness, delirium, or dementia and then dispatches a BOOST team, comprising psychiatrists and two advanced practice nurses trained in geriatric psychiatry.

A survey of the pilot program showed that 4 years after implementing BOOST, 78% of a hospital's staff reported that it enhanced workplace safety. In addition, there was a significant increase in patient consults and a significant decrease in staff burden scores on the Geriatric Institutional Assessment Profile (GIAP).

"What started all of this was recognizing that staff, especially nurses, who were not psychiatrically trained do care for patients with psychiatric comorbidity. And they really struggle," Mavis Afriyie-Boateng, RN, clinical nurse specialist and part of the geriatric-psychiatry consultation-liaison team at Sinai Health System, Toronto, Ontario, Canada, told Medscape Medical News.

"Our goal for this program was to give staff the tools and the training so that they can give the care that they want to provide. Also, patients have the expectation that they'll be cared for by staff who are trained for what they need to have done. And BOOST works both ways," said Afriyie-Boateng.

The findings were presented here at American Association for Geriatric Psychiatry (AAGP) 2018.

"Epidemic of Violence"

A recent survey from the Ontario Council of Hospital Unions showed that about 68% of nurses and personal support workers had reported being assaulted or harassed on the job. Another Ontario study suggested that "healthcare workplace violence is underreported," Afriyie-Boateng told meeting attendees.

"Healthcare workers face an epidemic of violence, which is why the Ontario Council has urged the Ministry of Labour to do more to protect [the] workers who face daily threats of violence on the job," she said.

She noted that many medical and surgical nurses don't feel prepared to manage patients with psychiatric and/or behavioral comorbidity — and that traditional models delay help in addressing disturbances. In addition, Ministry of Labour laws require employers to protect employees.

"But unmanaged aggression creates safety risks for both patients and staff. That's why it's imperative to have a dual focus on the safety of both patients and staff," said Afriyie-Boateng.

Sinai Health System and its 442-bed acute care Mount Sinai Hospital has long treated geriatrics as a flagship program, with an existing psychiatry consult-liaison service, and a particular focus on the psychogeriatric patient.

The organization also implemented the Safe Patients/Safe Staff program, which concentrates on a four-pronged standardized, skill-building, collaborative, and proactive approach.

Under the "proactive heading" was the creation of BOOST, " a comprehensive screening system consisting of a...flagging system and a proactive policy for frontline clinicians, coupled with a rapid response team," said Afriyie-Boateng.

Although BOOST is available for all staff to use and can deal with patients of all ages, its particular focus is on those in geriatrics.

How BOOST Works

First, a healthcare worker calls for the BOOST team while a patient is flagged via electronic medical record (EMR). Examples of things that can flag a BOOST report include transfer from another psychiatric facility or geriatric unit or a patient being combative, on clozapine, or in restraints.

"We added clozapine as a marker because we had several cases where patients would come in for a surgery or for pneumonia and be on clozapine. But a medical or surgical resident didn't know much about [the medication] and would discontinue or withhold it. And then a few days into the admission, issues would arise," said Afriyie-Boateng.

After flagging, a BOOST clinician is dispatched and talks with the staff member who made the report. "This was encouraging for our nursing staff because they felt that their documentation was leading to action," said Afriyie-Boateng.

The BOOST clinician then conducts the initial assessment and informs the most responsible physician (MRP). If determined that the patient does not need a psychiatric assessment, the BOOST clinician makes recommendations for referrals and a care plan. If determined that the patient does need this type of assessment, the clinician consults with a psychiatrist.

Within 4 years after the start of BOOST at Mount Sinai Hospital, there were 551 BOOST consults. In addition, the GIAP staff burden score was significantly reduced from 4.6 in 2011 to 4.2 in 2012 and 2015.

"What didn't change was the number of behavioral issues, which indicated to us that our staff was still seeing the same number of these patients but were less burdened by it," said Afriyie-Boateng.

Staff satisfaction surveys showed that access to psychiatric support and service was greatly improved and that "individual and standardized care plans and proactive consults and debriefs were the most valuable components" of the program, Afriyie-Boateng reported.

Expandable to Other Sites?

She also described the patient case example of "Mrs L.,"a 78-year-old woman diagnosed with dementia and severe aphasia, which made communication difficult for her. Mrs L. had been living with her husband but was brought to the hospital because of her tendency to wander away from home and her aggression toward her husband when redirected. In the hospital, she was confused, refused medication, and became physically aggressive with the staff.

After she pulled out her IV, tried to go home, and kicked an RN during her first night on the unit, she was flagged the next morning via the EMR BOOST report. A BOOST advanced practice nurse conducted the initial assessment and developed a nonpharmacologic care plan.

It was determined that being touched or being around unfamiliar people were triggers and that she responded better when her husband was present. The subsequent care plan included assessing whether an IV and frequent bloodwork were actually needed, postponing intrusive care until the husband was there, and transferring her to a secure unit. A psychiatrist later prescribed medications for severe agitation or aggression, as needed.

Afriyie-Boateng noted that another study is currently underway evaluating routine screening of all patients for the risk for aggression. As for BOOST, there are plans to evaluate its impact on "other metrics," including satisfaction and costs.

She added that at least parts of the program could be easily implemented by other centers, especially the idea of using the same team to "float" among various departments.

"I think having that consistency makes a huge difference. Because it's the same people, the nurses and medical staff, surgeons, and residents get to know us. So they know that when we're involved, they can trust us," said Afriyie-Boateng.

"And the piece where patients are flagged through their medical record, that can be done for patients with diabetes or any other condition. Flag them when they come in" to make sure their care plan takes that information into consideration, she added.

Shorter Stays

Session moderator Smita Varshney, MD, a geriatric psychiatrist in Rome, Georgia, noted that "it's a great thing" to flag certain patients immediately.

"By flagging as soon as they come and keeping an eye on them, they'd have fewer problems while in the hospital and so the hospitalization is shorter," Varshney told Medscape Medical News.

She agreed with Afriyie-Boateng that the flagging and having a dedicated team are both components that could be expanded to other facilities.

"To me, as a hospitalist, it's important to have more support from other people to help take care of the patient," said Varshney.

Mavis Afriyie-Boateng has disclosed no relevant financial relationships.

American Association for Geriatric Psychiatry (AAGP) 2018 Annual Meeting. Session 307, presented March 17, 2018.

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