EP18EO Workplace safety for nurses is evaluated and improved.
Provide two examples, with supporting evidence, of improved workplace safety for nurses resulting from the safety strategy of the organization. Supporting evidence must be submitted in the form of a graph with a data table that clearly displays the data.
Example 1
NAME OF INITIATIVE
ICU Ceiling Lift
BACKGROUND/PROBLEM
Nursing is known as an occupation with high risk for musculoskeletal injury. Studies have identified an increased risk of injury for those tasks more specific to critical care units like repositioning patients in bed; making occupied beds; and lateral patient transfers. At Baptist Health South Florida (BHSF), 53% of injuries sustained in 2012 related to patient handling were from repositioning and lateral transfers. At Homestead Hospital, the patient demographic also included morbidly obese patients making this an even more labor intensive and potentially harmful task to accomplish for the nurses. According to Intensive Care Unit’s (ICU) National Database of Nursing Quality Indicators (NDNQI®) RN Survey 2013 results, 79% of nurses reported they had enough help to lift/move their patients. This was above the average of 71%, but still concerning given that 21% felt they did not have enough help. Critical Care consisted of the ICU and Progressive Care Unit (PCU). During this time, there was no dedicated staff for PCU and clinical nurses were cross-trained and floated from one area to the other. Thus, PCU did not qualify as a reporting unit for the annual NDNQI RN Survey.
Organization Safety Strategy
Safe Patient Handling is a part of the organizational culture. BHSF and Homestead Hospital consider employees as its greatest asset, thus, investing in processes and equipment to keep them safe and healthy for all patient handling tasks is fundamental to retaining skilled clinical employees. The Safe Patient Handling and Mobility (SPHM) program, which provides lift equipment and clinical education, was founded by Ergonomics and Employee Health departments at BHSF in partnership with Diligent Clinical Consultants in 2005. A phased implementation began in 2005 and was completed in early 2007. In late 2007, internal teams were created to sustain the program at each hospital. The BHSF Safe Patient Handling program is coordinated by three separate stakeholders: 1) Entity Specific Teams, 2) Ergonomics and 3) Employee Health Office. These stakeholders combine to form the Safe Patient Handling Core Team, which is comprised of nurse leaders, physical therapists, Employee Health Practitioners and Ergonomics Specialists. They work together to integrate SPHM into daily clinical practice.
GOAL STATEMENT(S)
The goal was to improve clinical nurse’s perception of the safety and ease of patient handling by 5%. This was measured by averaging their response scores to the following statements:
- Transferring patient is a safe task for staff and patients.
- I have enough help to safely move and transfer patients.
- Transfer and lifting devices make moving/transferring patients easier.
- The ceiling lift will make lifting heavy patients safer and easier.
DESCRIPTION OF THE INTERVENTION/INITIATIVE/ACTIVITY (IES)
Workplace Safety Initiative
Homestead Hospital’s Safe Patient Handling Team Champion and Clinical Nurse Educator. Sandra Jones, RN and Ergonomic Specialist Eve Rostran, as well as the Medical-Surgical 4 (MS4) Patient Care Manager Maureen Allen, RN, identified that MS4 staff had not been using the ceiling lift that had been previously installed in one of the rooms in their department. The patients that were generally admitted to that room were able to mobilize independently. Allen then contacted ICU Patient Care Manager Leslie Everett, RN to discuss the option of having the ceiling lift relocated to the critical care unit. Everett, recognizing a need for such a device, reached out to construction management in October 2012 and began the process of budgeting for the installation of the ceiling lift. In the November 2012 ICU/PCU staff meeting, Everett announced the plan and received positive feedback from the staff.
There were delays on the construction side of the project but Everett continued to update the staff on its progress. During this time, Everett informally received input from the staff nurses on the location in which the ceiling lift should be installed. Everett decided to put the ceiling lift in room 2116. In August 2013, she handed out a survey to the clinical nurses and staff to determine their perception of current safe patient handling practice with specific questions with regards to the ceiling lift. The survey asked them to rate their level of agreement or disagreement with several statements on a scale of 1 to 5, where 1 means “strongly disagree” and 5 means “strongly agree”; the lower the number the less favorable the response.
In September 2013, the ceiling lift was installed in room 2116. Safe Patient Handling Coaches Jones and Rostran, together with the equipment representative provided “train-the-trainer” education to Clinical Nurses Tashi Benjamin, RN, Raydel Garcia, RN, Everett, and Patient Care Supervisor Eileen McMahon, RN on the use of the lift. Thereafter, they trained the rest of the ICU staff over the next few weeks. In November 2013, the staff started using the lift. Over time, clinical nurses started integrating the lift into their care and receiving positive feedback from the patients and their families. Everett deployed the post-implementation surveys in December and February 2013.
As a result of the attention given to the ceiling lift and safe patient handling, 2 staff members volunteered to become certified as safe patient handling coaches. In the April 2014 staff meeting, Everett introduced the new coaches, Clinical Nurse Laura Cox, RN and Clinical Partner Ayomidamope Adejola. She also reminded the staff to utilize the other safe patient handling coaches already in the unit as resources. In the same staff meeting, she directed them to an online educational video on the ceiling lift that was available for their review through the intranet. Several employees took advantage of this video demonstration.
In May and August of 2014, Everett once again handed out the surveys to the staff to ascertain their perceptions over time on safe patient handling.
PARTICIPANTS
Name/Credentials |
Title |
Department |
Role in the Team |
Leslie Everett, BSN, RN, CCRN |
Patient Care Manager |
Critical Care |
Lead |
Maureen Allen, BSN, MSHA, RN, CMSRN |
Patient Care Manager |
MS4 |
Facilitator |
Sandra Jones, BSN, RN, CMSRN |
Clinical Nurse Educator |
3South |
Training Coach |
Tashi Benjamin, RN |
Clinical Nurse |
Critical Care |
Training Coach |
Raydel Garcia, BSN, RN |
Clinical Nurse |
Critical Care |
Training Coach |
Eileen McMahon, BSN, RN |
Patient Care Supervisor |
Critical Care |
Training Coach |
Laura Cox, RN CCRN |
Clinical Nurse |
Critical Care |
Training Coach; Safe Patient Handling Coach |
Ayomidamope Adejola |
Clinical Partner |
ICU/PCU |
Training Coach; Safe Patient Handling Coach |
Eve Rostran, OT, CEES |
Occupational Therapist |
Ergonomics |
Resource |
Natalie Campaniera, PT, CEES |
Supervisor |
Ergonomics, Leave & Disability |
Resource |
OUTCOMES(S)
Improved Workplace Safety
Since the implementation of the ceiling lift, no musculoskeletal work-related injuries related to patient handling have been reported in Critical Care. The last reported patient handling-related injury involving only 1 RN was in 2012. The department has also increased the number of safe patient handling coaches.
Exhibit EP18EOa: Clinical Nurses’ Overall Perception of Safety and Ease of Patient Handling in Critical Care
Analysis: Above graph demonstrates a more positive perception among clinical nurses on the safety and ease of patient handling as evidenced by a 17% increase (exceeding the 5% goal) in favorable responses to the survey questions sustained for 4 consecutive data points post implementation of the ceiling lift.
Exhibit EP18EOb: Critical Care Clinical Nurses’ Perception of Having Enough Help in Safely Moving and Transferring Patients
Analysis: Above graph shows that the clinical nurses’ perception of having adequate help with moving and transferring their patients safely has increased by 31% from baseline after the implementation of the ceiling lift.
Summary of Attachments/Hyperlinks/Evidences
Exhibit EP18EOa: Clinical Nurses’ Overall Perception of Safety and Ease of Patient Handling in Critical Care
Exhibit EP18EOb: Critical Care Clinical Nurses’ Perception of Having Enough Help in Safely Moving and Transferring Patients
Example 2
NAME OF INITIATIVE
Improving Nurse’s Workplace Safety by Addressing the Suicide Precaution/ Baker Act Process
BACKGROUND/PROBLEM
Organization Safety Strategy
Homestead Hospital plans and implements an annual Security Management Plan that focuses on providing for a reasonable level of safety and security among employees, patients, visitors, and staff. The scope of the plan includes providing security for the immediate hospital and its property. Security/Safety Manager Ellen Sordo, RN reports this plan at the Safety Committee and obtains approval from the Board of Directors. In January 2011, an unexpected incident in the ED bathroom led to a re-evaluation of the existing process for patients who were violent, on suicide precautions and placed under Baker Act. As a result, the Engineering department changed the bathroom locks hospital-wide. Additionally, the Safety/Security department started posting an off-duty Homestead Police Officer in the ED from 8pm to 2am on Fridays and Saturdays in the latter part of 2011 due to growing concerns from the staff and increased incidents of violent/aggressive behavior in the ED. ED Director Sherine Craig, RN also began sending ED staff to de-escalation training. In October 2012, the Safety/ Security Department implemented Fast Pass in the Post Partum area and a 24/7 on-duty security officer in the ED. Fast Pass is an electronic visitor management system that could identify, track and control visitors to Homestead Hospital. Security officers required all visitors to go through Fast Pass to enter the hospital building. By the end of 2012, Fast Pass also became fully implemented in the ED main lobby.
Through collaboration among Administration, Nursing, Case Management, Risk Management and Security/Safety, the Safety Committee began identifying trends. The committee noted that that many cases were related to potential suicidal patients and/ or patients that had been placed under Baker Act (involuntary commitment). Some issues that contributed to this were: (1) many patients presenting to the ED were already violent; (2) a recent decrease in inpatient bed availability for these patients within the community and the inability to transfer them out increased their length of stay; (3) lack of a consistent process in identifying and managing this group of patients; and (4) insufficient training and education of staff on de-escalation. At this time, Craig made it mandatory that all ED staff and clinical partners attend a continuing education course offered within the system named, “Healthcare Workplace Safety: Recognizing and Responding to Aggressive Behavior”.
The interprofessional group described above, with the addition of Performance Improvement (PI) and Medical Staff, met to discuss staff concerns; review reported incidents/ occurrences; and evaluate the policies and procedures that were in place. They embarked on a Failure Mode Effect Analysis (FMEA). It highlighted internal and external challenges and opportunities for improvement. While the Baker Act volume was increasing, the number of Baker Act beds at receiving facilities was decreasing. It became clear to the team that staff needed support to care for Baker Act patients by aligning with evidence-based best practices and guidelines in the sister entities.
Special Projects Coordinator Alicia Brown-Rowe, RN, in collaboration with Administrative Project Analyst Jackie LeBoeuf reviewed existing literature and best practices. In their findings, they concluded that the best way to help nurses was to have a checklist or a packet to standardize the complex steps and processes to be followed when caring for suicidal/Baker Act patients. Brown-Rowe and LeBoeuf developed a packet for the staff to use when a suicidal/Baker Act patient was identified. They put together the packet, which included a checklist with guidelines and forms that were required for proper documentation. At the request of Chief Nursing Officer and Vice President Gail Gordon, RN, Brown-Rowe met with clinical nurses who represented various nursing units in October 2012 to obtain their input. The goal for this group was to realign the suicide/Baker Act process and convey a consistent message to staff, visitors and patients. The group reviewed the draft of the Baker Act packet. The clinical nurses provided several helpful recommendations. For example, Clinical Nurse Andrea Tilleman, RN requested to include pre-printed patient education (e.g. Micromedex) at the end of the packet so the nurses could easily share the information with the patient’s family.
As the FMEA action plan moved along, in January 2013, the Code Greens being reported for disruptive patients, visitors, and/ or families, as well as an increase in the reporting of threats to staff, including assault and battery in the ED rose to 23%. Code Green was the emergency code announced overhead by the hospital operator that could be initiated by any staff member for combative/violent patients, families, visitors, or employees or in the event that a staff member feels threatened or unsafe. Gordon also heard from nurses in the ED and Perinatal Department during her “Round Table” concerns regarding their safety, particularly with regards to aggressive and potentially violent patients and/ or families. This theme was further echoed on the medical/surgical units.
GOAL STATEMENT(S)
- To decrease the number of Code Greens called among suicide/ Baker Act patients in the ED from 23% to less than 5%. This number was calculated by: % Code Greens = Number of Code Greens called on Suicide/Baker Act Patients divided by Number of Suicide/Baker Act Patients x 100.
- To improve the staff’s perception in the management and safety of both patients and staff in relation to suicide/ Baker Act patients.
DESCRIPTION OF THE INTERVENTION/INITIATIVE/ACTIVITY (IES)
Workplace Safety Initiative
Further recommendations were made to include Security in the process for securing belongings because there were inconsistencies between shifts and different practices for personnel. In reviewing the literature, Brown-Rowe identified healthcare systems with challenges mirroring Homestead Hospital’s and used lockers as a standard, reliable approach for securing belongings. After several meetings with the Security leadership team and administration, a process was agreed upon and included in the packet and policy. Based on the FMEA findings, Brown-Rowe revised the packet and made recommendations to administration, which included the purchase of lockers for securing belongings.
Thereafter, in January of 2013, Social Worker Care Manager Carla Green, MSW provided physicians with an educational program concerning the new suicide/Baker Act process. The program entailed criteria for initiating and rescinding Baker Acts as well as the expected process for getting the patients the appropriate care in a timely manner. Throughout the months of January and February 2013, security officers, case managers, nurse leaders and clinical nurse educators were instructed and educated on the process by Brown-Rowe. In March of 2013, the clinical nurse educators formally educated the clinical nurses on the new process. The team implemented the revised policy and procedure (400-2000-1220 Suicide Prevention Guidelines), together with the Baker Act packet and lockers, in April 2013. In the following 2 weeks, Brown-Rowe completed bedside rounds to ensure compliance with the current process. She provided feedback to the individual departments and gave weekly updates to Gordon and the nurse leaders.
Despite the new process, an unexpected incident with a Baker Act patient occurred in May 2013, which alarmed and impacted several staff. As a result, a debriefing was completed with an interdisciplinary team consisting of nursing leadership, clinical nursing staff, safety, security, and risk management. The group identified that additional processes were needed to increase the safety of both patients and staff. These included: (1) having nursing staff replace the sharps container with new ones upon admission of any Baker Act patient; (2) reinforcing staff education to escalate security support if aggression/ violence was observed; (3) asking Patient Care Supervisors to round each shift on Baker Act patients; (4) having engineering inquire about securing hospital beds; (5) requesting the Performance Improvement team to include Baker Act patients in the Joint Commission (TJC) mock tracers; and (6) recommending for care of Baker Act patients to be included as a topic in Nursing Grand Rounds.
Several months after the implementation of the action plan, a smaller group consisting of Case Management, Nursing, Performance Improvement, Risk Management, and a Medical Staff member began meeting again to identify additional improvements that could be made to the process. The team began researching best practices and protocols that could be used to better identify the potentially violent/ aggressive patient. To date, this group is working on a physician order set to proactively identify violent/ aggressive behaviors and provide guidelines for their management.
PARTICIPANTS
Name/Credentials |
Title |
Department |
Role in the Team |
Alicia Brown-Rowe, BSN, RN |
Special Projects Coordinator |
ICU |
Project Lead |
Jackie LeBoeuf, MBA |
Administrative Project Analyst |
Administration |
Project Lead |
Ana Cabrera, DNP, ARNP, ACNP-BC, CCRN, NEA-BC |
Vice President of Nursing |
Nursing Administration |
Administrative support and leadership/ facilitated policy development |
Gail Gordon, MSN, RN, NEA-BC |
Chief Nursing Officer and Vice President |
Nursing Administration |
Administrative support and leadership |
Jill White, RN, CPHQ |
Director |
Performance Improvement/ Case Management/ Medical Staff |
Facilitated FMEA |
Patricia Brodie, RN |
Manager |
Case Management |
Provided input and staff support |
Ellen Sordo, MN, RN |
Manager |
Safety/ Security |
Provided input and staff support |
Andrew Seaman, BSN, RN, CEN |
Patient Care Supervisor |
Emergency Department |
Provided input and suggestions relevant to the ED |
Carla Green, MSW |
Social Worker Care Manager |
Case Management |
Educated staff, physicians, and allied health |
Susan Bunting |
Manager |
Risk Management |
Provided input and suggestions based on risk assessment |
Edwin Ruiz |
Supervisor |
Security |
Provided input and suggestions to policy and workflow |
Daniel Mandri, MD |
Physician |
Medical Staff |
Provided guidelines and best practices |
OUTCOME(S)
Process measures
By the end of the year in 2013, 159 employees had attended “Healthcare Workplace Safety: Recognizing and Responding to Aggressive Behavior”. Case managers in 2013 saw 277 Baker Act cases with 8% of them being rescinded; - a 4% a decline from the previous year. Brown-Rowe conducted rounding to observe compliance with the new process and reported the results weekly to nurse leaders during the Operations meeting. She also addressed observed variances in the process while rounding with the staff involved with “just-in-time” teaching and collaborated with the clinical nurse educators.
Sample of rounding questionnaire:
Question |
Yes |
No |
Comment |
Staff aware of role (why they were “sitting”) |
|
|
|
Staff using suicide baker/ act packet |
|
|
|
Staff located in proper area (sitting between patient and door) |
|
|
|
Room “sweep” completed |
|
|
|
Non-essential furniture and equipment removed |
|
|
|
Patient belongings secured properly |
|
|
|
Staff belongings secured properly |
|
|
|
Education provided to patient/ family |
|
|
|
Improved Workplace Safety Outcome Measures
Security noted that there was a decline in number of threats to patient/ staff and the number of cases involving assault and battery despite an increase in the number of arrests made on hospital grounds. The overall number of Code Greens called were reduced by 4.5% despite having an increasing number of visitors and patients. In 2013, it was noted that there was an increase of more than 25% in the number of visitors, totaling 260,403. For the same period, the ED had more than 92,000 visits.
|
2012 |
2013 |
% change |
Code Greens |
245 |
235 |
-4% |
Threats to patient/ staff |
13 |
7 |
-46% |
Assault & Battery |
4 |
3 |
-25% |
Exhibit EP18EOc: Percent of Code Greens among Suicide/Baker Act Patients in the ED
Analysis: The graph shows a significant improvement in the number of Code Greens in the ED. The team met its goal of keeping the percentage of Code Greens among suicidal/Baker Act patients below 5% and sustained it for 5 consecutive months.
Prior to implementation of the new process, the team conducted a brief survey of the nursing staff, in all areas, to gain their perspective on the existing process. Thirty (30) nursing staff members from ED, ICU, and Med/ Surg units were asked to rate the following questions using a Likert scale (1= strongly disagree to 5= strongly agree.) This survey was then repeated after the changes had been implemented. The survey findings were as follows:
Question |
Pre-intervention |
Post- intervention Mean Score |
Difference |
p value |
I am comfortable in managing suicide/ Baker Act patients. |
2.891 |
3.833 |
0.943 |
<0.000 |
We do a good job of keeping suicide/ Baker Act patients safe. |
2.633 |
4.200 |
1.567 |
<0.000 |
We do a good job of keeping staff who work with suicide/ Baker Act patients safe. |
2.133 |
3.733 |
1.600 |
<0.000 |
I am able to safely manage suicide/ Baker Act patient’s belongings. |
2.067 |
4.233 |
2.167 |
<0.000 |
I know what is expected of me in caring for suicide/ Baker Act patients. |
3.000 |
4.100 |
1.100 |
<0.000 |
I have easy access to information about my role / responsibilities in caring for suicide/Baker Act patients. |
3.233 |
3.700 |
0.467 |
0.0059 |
Families understand the process when we are caring for a suicide/Baker Act patient. |
2.133 |
3.233 |
1.100 |
<0.000 |
Average |
2.8 |
3.86 |
1.28 |
|
Based on the pre/ post-implementation survey, the team noted a significant improvement in the nursing staff’s perception in the management of suicide/Baker Act patients as well as the safety of both the patients and staff.
Summary of Attachments/Hyperlinks/Evidences
Exhibit EP18EOc: Percent of Code Greens among Suicide/Baker Act Patients in the ED