Managing Behavioral Issues in Medical Settings - Aventri

11th Annual Meeting of PSOs

Thomas Heinrich, MD, FACLPProfessor, Psychiatry and Family Medicine Froedtert and Medical College of WisconsinTammy Williams, MSN, RN, CPPS Vizient PSO Program Director

May 1 - 2, 2019

Managing behavioral issues in medical settings

Disclaimer

The opinions expressed in this presentation are those of the presenter and do not reflect the official position of the Department of Health and Human Services (HHS), the Agency for Healthcare Research and Quality, or the Office for Civil Rights.

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Vizient PSO

• One of the first 10 AHRQ-listed PSOs in 2008• Component PSO of Vizient Inc.• National presence and thought leadership in patient safety

with over 250 participating organizations in 35 states including general, critical access or specialty hospitals, academic medical centers, community health centers, group practices and clinics, surgical centers, and other healthcare services

• Long history of collecting and analyzing safety data across healthcare organizations since 2002

• Offers a full range of patient safety activities from individual feedback to many educational and collaborative learning opportunities.

3©2019, Vizient Inc. and Vizient PSO Do not distribute outside of your institution without permission from Vizient. Disclaimer: For informational purposes only and does not, itself, constitute medical or legal advice. This information does not replace careful medical judgments by qualified medical personnel.

Safety Project and Safe Table

4©2019, Vizient Inc. and Vizient PSO Do not distribute outside of your institution without permission from Vizient. Disclaimer: For informational purposes only and does not, itself, constitute medical or legal advice. This information does not replace careful medical judgments by qualified medical personnel.

Behavior-related issues in medical settings

Vizient Patient Safety Organization aggregate data for January 2017-March 2018; Total number of events = 2,725; excludes behavioral health areas. Location was not identified in 599 events and were not included. *Ancillary services include radiology, rehabilitation, diagnostic, cardiovascular, respiratory, laboratory, pharmacy, etc.

©2019, Vizient Inc. and Vizient PSO Do not distribute outside of your institution without permission from Vizient. Disclaimer: For informational purposes only and does not, itself, constitute medical or legal advice. This information does not replace careful medical judgments by qualified medical personnel.

Key findings in behavior-related issues

Primarily committed by patients against staff or other patients

Most common in ED Common causes

• Mental health issues• Delirium or dementia • Substance use• History of violence

Types of articles• Most common was illegal

drugs, alcohol or unauthorized pills

• Sharps or weapons Ingested, snorted, or

injected drugs via their own syringes or I.V.s. and in some cases, patients were found unresponsive, hypotensive and/or lethargic.

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Most common method was strangulation or hanging using cords from equipment, sheets, belts or clothing and ligature points

14% of events led to serious harm or death; more were reported on 24 hour care units.

More common among older adults in medical than behavioral settings

Vizient Patient Safety Organization aggregate data for January 2017-March 2018; Total number of events = 2,725; excludes behavioral health areas.


Key recommendations

• Establish proactive processes for screening, assessment and ongoing management of patients with behavioral issues.

• Complement proactive processes with behavioral emergency response plans.

• Identify and mitigate environmental safety hazards, conditions and situations that can lead to violence, suicide or self-harm.

• Conduct education and training programs on managing behavioral issues based on staff members’ roles and responsibilities.


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No Inpatient Psychiatry Unit: No Problem

Thomas W. Heinrich, MD, FACLPProfessor of Psychiatry & Family Medicine

Froedtert and the Medical College of [email protected]

mailto:[email protected]

Vizient PSO Expert Advisory Team

Opportunity to discuss and identify key safety issues Share actions organizations are taking Learn from others including national

leaders

9©2019, Vizient Inc. and Vizient PSO Do not distribute outside of your institution without permission from Vizient. Disclaimer: For informational purposes only and does not, itself, constitute medical or legal advice. This information does not replace careful medical judgments by qualified medical personnel. The information represents the views of one institution, and not necessarily the standard of care for the issues presented, and does not represent the views of Vizient.

The Problem:“We didn’t sign-up for this.”

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Making the Case…

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Making the Case…

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Making the Case…

Making the Case…Negative Consequences

Solutions:An incomplete list…

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Continuum of Care

Behavioral health integration into general medical settings

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The Continuum of Care (and Service)

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Reactive Psychiatric Consult ServiceNot all its cracked up to be..

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The Continuum of Care (and service)

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BERT: The Approach

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BERT: Utilization

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BERT: Utilization

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BERT: Nursing Satisfaction Survey Results

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BERT: Results

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BERT: Results

Rosen J, Burgio L, Kollar M, et al. The Pittsburgh Agitation Scale: A User-Friendly Instrument for Rating Agitation in Dementia Patients. Am J Geriatr Psychiatry. 1994;2(1):52-59.

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BERT: Results

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BERT: Results

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BERT: Results

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BERT: Results

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Proactive Inpatient Consultation

Sledge WH, et al. Psychother Psychosom. 2015;84(4):208-16.

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The Process Psychiatric provider assigned to the primary

medical team• Rounds with team daily

Referral sources for consultation• Medical staff• Medical record


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Proactive Inpatient Consultation: Results


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Proactive Consult Service

F&MCW Pilot A consultation-liaison psychiatry fellow met with 2

medical teams 3 times per week• Duration of pilot was two weeks

The psychiatry fellow was available during those times to• Answer any BH-related questions• Provide insight and advice• Perform formal consultations if necessary

Now in second iteration

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F&MCW Pilot

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F&MCW Pilot Results

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F&MCW Pilot Results

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Dissemination of Leading Practices

Toolkit highlighting common issues in the data, leading practices and member case studies – Proactive and emergency response processes– Environmental safety – Staff education and training

Vizient PSO webinar spotlighting members leading work

IHI presentation with speakers that participated in the project

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Questions

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References

Desan PH, Zimbrean PC, Weinstein AJ, et al. Proactive psychiatric consultation services reduce length of stay for admissions to an inpatient medical team. Psychosomatics. 2011;52(6):513-20.

Herisko CA, Puskar KR, Mitchell AM, et al. Medical emergency team response processes for behavioral health inpatient units: implications for nursing education. Issues Ment Health Nurs. 2015;36(9):678-84.

Loucks J, Rutledge DN, Hatch B, et al. Rapid response team for behavioral emergencies. J Am Psychiatr Nurses Assoc. 2010;16(2):93-100.

Muskin PR, Skomorowsky A, Shah RN. Co-managed care for medical inpatients, C-L vs C/L psychiatry. Psychosomatics. 2016; 57(3):258-63.

Sledge WH, Gueorguieva R, Desan P, et al. Multidisciplinary proactive psychiatric consultation service: Impact on length of stay for medical inpatients. PsychotherPsychosom. 2015;84(4):208-16.

Sockalingam S, Alzahrani A, Meaney C, et al. Time to consultation-liaison psychiatry service referral as a predictor of length of stay. Psychosomatics. 2016;57(3):264-72.

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Managing Behavioral Issues in Medical Settings - Aventri

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