1. health and fitness

Strategies for
Managing Disruptive
Patient Behavior
UCSF Medical Center
Risk Management
A View from the Trench
Susan L. Penney, JD
Director of Risk Management
California Society for Healthcare
Attorneys
Annual Meeting & Spring Seminar
April 17, 2015
Overview
 Patient Behavior
 Contraband: Smoking, Alcohol and
Drugs
 Searching Patients’ Rooms and
Belongings
 Weapons and Violence
 Social Media
2
1
Patient Behavior
I Want Patient
Centered Care,
Or Else!
Background:
• National Statistics
• UCSF Medical Center
Data
• Research Results
• Behavioral Management
Measures
• Next Steps and
Recommendations
The Crux of the Problem –
Conflicting Interests and Forces
Control of
the environment
decrease
Focus on
patient/familycentered care
increase
ED volume
and wait time
Mental health
Issues
Bigger risk of
violence
4
2
Background—National Data
Problem
Patient Characteristics
•Pathologic/Psych issue
•Drug/Alcohol Abuse
Possible Explanation
•↓ from 650K psych beds to 57K from
1990 to 2000
•1 out of 5 hospitalizations have psych
as a principal or 2nd Dx
•Chronic illness
•1.4 million hospital stays—psych was
a principal condition
•Borderline personality
•7.1 million mental health condition a
secondary Dx
External Forces
•Decrease in mental health funding
•8% of ED visits relate to mental health
•Economy
•Increased Patient out-of-pocket costs
•Under treatment and reliance on PCP
Increasing Communication
demands & Technology
•E-mail/texting
•Cell phones
•Internet “research”—inaccurate
information
Background—National Data
Bureau of Labor Statistics
– Health care workers are at high risk for violent assault at work
– Nurses are among those most frequently attacked
OSHA
– Incidents of disruptive behavior underreported because health
care workers believe it is “just part of the job”
The Joint Commission—inconsistent message?
– Recognition of increasing problem with workplace violence—
Sentinel Event Alert June 3, 2010
– BUT, ability to limit visitation is limited under standards
– Reported acts of violence: (not all hospitals report sentinel
events)
• 2007: 36
• 2008: 41
• 2009: 33
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3
What’s next? Workplace violence
Prevention Plans: SB 1299
• Hospitals are currently required to have
programs to reduce workplace injuries.
• Cal/OSHA must issue regulations by July 1,
2016 related to hospital requirements on work
place violence protection plans. (WVPP)
• WVPP must be in effect at all times in all patient
care units.
• The employer cannot retaliate against any
employee for seeking assistance and
intervention from local law enforcement when a
violent incident occurs.
7
Definition of workplace violence
• Use of physical force against a hospital
employee by a patient or visitor that causes or
has a high likelihood of causing, injury,
psychological trauma or stress regardless of
whether the employee sustains injury.
• Incident involving the use of a firearm or other
dangerous weapon, regardless of whether
employee sustains an injury.
• Labor Code section 6401.8
8
4
Workplace Violence Protection
Plans must include:
• Annual personnel education and training
policies (for both permanent and temporary
employees) on:
• Recognizing potential for violence and how to seek
assistance and respond
• How to report to law enforcement
• Availability of coping resources
• Systems for incident handling, investigating etc.
• Annual assessment of plan, looking at staffing,
security systems, job design, equipment and
facilities and security risk.
• Employees and unions must be involved.
9
Work Place Violence
• Hospitals will have to report workplace violence
incidents as of January 1, 2017 (must also post
on its website).
– Must report violent incidents to Cal/OSHA within 72
hours, but must report within 24 hours if incident:
• results in injury
• Involves use of firearm or other
dangerous weapon
• Presents urgent/emergent threat to
welfare, health or safety of personnel
• NOTE: will this result in improved mental health
services?
10
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The Landscape in Hospitals

Complex demographic and psycho-social
issues

Extremely sick patients and extremely
anxious family and parents

Long and repeated hospital stays

Potential over-familiarity with the
patient/family and associated issues

Multiple and ever-changing attending
physicians (teaching hospitals)
11
The Landscape in Hospitals

Patients/families at the end of a long path or
facing continued life-long issues – at the end
of their rope

Angry at physicians they believe have failed
them

Lack of resources

Acting here like they act in life

The electronic world of texting, social media,
filming
12
6
The Landscape

Patients in search of special favors

Refusal to comply with treatment plan

Refusal to pay a bill

Threatening legal action—great way to get
attention

Abuse of patient or staff

It’s all about the family member, not the
patient

Excessive use of e-mail, telephone, texting

Staff splitting
13
Setting Boundaries with Patients—
Why Do We Hesitate?

Empathy for the patient/family

Can I just hang on? Things might improve

Lack of knowledge of “who is in charge”

Physicians varying tolerance for behavior or
support of staff

You don’t want to make it worse

You are worried about liability

Difficulty in assessing whether behavior related to
underlying condition or just bad behavior
 We just aren’t sure what to do—lack of
psych training
14
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Overarching Message to
Clinicians—Managing Patients
• We want to reinforce the Professionalism (UCSF
PRIDE) values and address legitimate
complaints
• While your style of patient centered care and
shared decision making with patients and families
will work for most patients---It may not work for patients or families with serious personality problems , mental illness or other psycho social issues.
• You will need to develop a basic skill set for
recognizing the potential for inappropriate
behavior or personality issues and make a
different plan of care
Message to Counsel
• The day-to-day reality of the provider-patient
relationship may be extraordinarily different
from traditional views
• It’s important to develop realistic strategies to
manage these situations
• Reliance on statute and case law alone doesn’t
always do the trick
• Be ready for creativity, experimentation and
thinking outside the box
• Thinking about patient and employee safety is
key
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Who is involved in managing disruptive
patient behavior?
Secondary
Primary
• Physicians
•CMO
•CNO
•CEO
•Chancellor
•Dean
•DHS
•Lt. Governor
•Joint Commission
•Medical Board
• Nurses
• Social Work
• Security
• Risk Management
• Patient Relations
• Police
• Threat
Management Team
• Legal
Points of Management
Risk Management
Consultations for
Patient Behavior
Establishment of
Grievance
Oversight Team
-Patient Relations
-Risk
-Legal
-Quality
Pt Behavior Percentage of Total Consults
40.0%
35.0%
30.0%
25.0%
20.0%
15.0%
10.0%
5.0%
0.0%
% Pt Beh Calls in Relation to Total
Threat Management Team
-Psychologist--Lead
-Risk
-Security
-Legal
-Involved department managers and
staff
9
Common Management Strategies
 Essential: legal, risk management and
leadership support for setting limits with
patients
 Behavior management training—train the
trainer: goal is consistent response to
certain behaviors
 Behavioral response teams
 Psych nurses or tech-psych liaisons
 Increased use of sitters—costly
 Interdisciplinary teams/committees to
discuss and strategize cases per request of
staff
19
Common Management Strategies
 Coding and alert systems in the
medical record—easier with electronic
health record
 Risk assessment checklists
 Handouts to visitors and patients re:
behavioral expectations—admit
packets and waiting rooms, terms and
conditions of admission
 Behavior management policies setting
forth levels of escalation
20
10
Additional Activities related to
Patient Behavior
• Training of Security on Policies
• Physician Training: patient behavior
management is everyone’s job
• Residency Program: Specific training being
developed on responding to difficult and
inappropriate behavior
• Use violence prevent budgets for additional
training
• Remember, the new law will make all of this
mandatory
21
“In the Trench” Management of
Disruptive Patient Behavior
 Strengthen policies:
□ Visitors
policy
□ Smoking policy
□ Alcohol/drug use by patients/visitors
policies—processes in place
□ Discontinuation of care policy to add more
detail as to what constitutes disruptive/
inappropriate behavior
□ Disruptive
Behavior Policy
22
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“In the Trench” Management of
Disruptive Patient Behavior
 Put it in writing with patient warning letters
 Developed Templates
□
Warning Letter and/or Patient Contract
□
Discontinuation of Care letters
23
“In the Trench” Management of
Disruptive Patient Behavior (cont.)
 Developed model care plan for managing
complex patient situations
 Continuing education for and by security on
diffusing disruptive behavior
 Root cause analysis on cases involving at-risk
behavior
 Reinforcing the need to determine the patient’s
capacity to make health care decisions.
24
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Examples of inappropriate behavior
• Firing physicians, nurses or other staff during
an inpatient stay
• Limiting pain medication—independent legal
obligation to manage pain
• Limiting when staff come into the room
• Limiting which members of health care team
attend meetings
• Having staff sign in when they come into a room
Examples of inappropriate behavior
• Refusing to meet when requested
• Invasion of privacy of other patients
• Interfering with the care of patient or other
patients
• Filming the delivery of health care without
providers’ knowledge or agreement
• Patients who are clinicians or attorneys
dictating care based on their status
• Patients who refuse care to maintain medical
instability and continue hospitalization
• Difficult discharges
13
Overarching Message
• Address inappropriate behavior WHEN it occurs
• Decision as to whether patient should receive a
memo warning of behavior is made on a case by
case basis
• Warning Memo/Letter is not a substitute for
nursing/physician management of the situation
• Behavior needs to be documented in medical
record
• Communication from shift to shift is key to
success
• Compliance with policies important-staff needs
to know where the policies reside
Overarching Message
• Unit Manager is at the core of coordinating
communication when urgent patient behavior
occurs
• Escalation Policy needs to be utilized by nurses
• Risk Management is a consulting service, not a
direct manager of patient behavior—The core
competency has to reside with the providers
• Warning letters will now come from the Medical
Team, Risk and Security—all need to own it
14
Electronic Health Record related
Issues
• Make sure you look at the FYI related to Patient
Behavior
• Patient warning letters should be scanned or in
letters (not outside documents)—we are not yet
consistent with this practice
• If things are happening on a Friday or with a
new attending coming on, orient the new team
to the problem
• COMMUNICATION IS KEY
29
The Patient Behavior Huddle
• Make a plan before a blow up occurs
• Initiated by Nursing or anyone on the team
• Different than patient rounding—huddle
includes:
– Attending MD and trainees
– Nursing
– Social Work
– Risk
– Security
– Psych as appropriate
– ED as appropriate
30
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Example—Without the Huddle
Recipe for
Miscommunication
PCM
Resident
UCPD
Security
Psych
Risk
Attending
Social
Work
31
The Huddle—the new dance
• Patient here for anti-coagulation for several
days.
• Therapeutic value nearly non-existent because
he had eloped 7 times, and could not stay in the
hospital for more than 12 hours
• During huddle discussed alternative treatment
to in-patient care and made a plan for outpatient
anti-coagulation—coached the hospitalist
• Patient given a warning letter outlining
elopement history with the directive that if he
leaves again, care will be converted to
outpatient
• He stayed!!!
32
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My Way or the Highway Hilda
• Patient here for extended period of time, with
chronic conditions
• Patient dictated all aspects of care and refused
vital signs, bowel and bladder care (patient is
paraplegic)
• Patient refused to leave the hospital.
• Finally is discharged
> Then…….
33
My Way or the Highway Hilda
• Patient re-admitted with serious skin issues
• Huddle with nursing, MD’s social work etc
• Prepared a directive memo on the care that
would be rendered
• Nurses counseled on the manner of addressing
patient—we don’t ask if care can be done, we
state what care is going to be done
• The team on the same page
• A poster with the schedule of care put in the
patient’s room
• Same instructions when patient transferred to a
different floor
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M. Revels – Successful Huddle
• 34 year old male patient with history of aplastic anemia has
refused discharge. Patient and father advised that team
determined that there is no longer an acute need for
hospitalization.
• Both patient and his father have refused discharge and
have had several warning regarding aggressive behavior.
• Patient and father were unwilling to speak with team
regarding discharge.
• Huddle held with several team members to discuss
upcoming discharge and options.
• Patient was discharged with assistance from Security and
UCPD
• Team developed an ED protocol detailing treatment plan
for patient if he presents to the ED.
35
Keys to Success
• Focus equally on patients’ and families’ rights and
responsibilities
• Set expectations up front before you have a
problem—Patients and families DO NOT know what
you know (consistent with message from Studer
Group)
• Involve social work to address the source of the
behavior if possible—do your best to avoid
escalation.
18
Keys to Success
• Address legitimate complaints—listen to the
patient and family—a key method of
defusing issue
• Address inappropriate behavior as it
occurs—don’t wait weeks or months
• TEAM WORK is essential to avoid staff
splitting
37
Patient Behavior
Policy
•
Behavior Management Task developed policy
approved by Senior Leadership
•
Sends a message to staff that it is acceptable to
set limits to maintain safety
•
A single reference point for all hospital policies
relevant to patient, family and visitor behavior
•
Copy of policy provided for educational
purposes
38
19
Sample Policy: Management of
Disruptive Behavior
• Purpose of Policy:
• To establish guidelines to assist staff with risk
assessment and management of those patients,
family members and/or visitors who are
engaging in disruptive behavior, in both
inpatient and outpatient clinical settings, with
the goal of maintaining a safe environment for
staff and patients.
39
Sample Policy
 Algorithm for patient behavior with
defined response plan:
□
Level I behavior—address it early:
 Increasing staff demands
 Perpetual dissatisfaction despite staff
effort
 Family controlling care, caregivers
40
20
Sample Policy
□
Level I behavior—address it early: (cont.)
Response:
 Assess (social work, psych liaison, nurse
manager)
 Take it up the chain
 Directly express inappropriate behavior with
patient/family
 Clinical care conference—get physician
involved
 ID family spokesperson
 ID goals
41
Sample Policy
 Algorithm for patient behavior with
defined response plan:
□ Level II behavior:
 Family angry about everything
 Refusing discharge
 Interference with care
 Family appears under the influence
 Lawsuits threatened
42
21
Sample Policy
□
Level II behavior: (cont.)
Response:
 Escalated response (RM, patient relations,
security)
 Consider warning letter/behavioral plan
 Limit visitation
 Consider having two staff people with
patient/family for encounters
 Security standby for critical events
43
Sample Policy
□
Level III behavior:





Raising voices
Threatening gestures
Verbal threats
Possession of weapons
Physical assault
44
22
Sample Policy
□
Level III behavior: (cont.)
Response:
 Clear your calendar
 Involve CMO, CNO
 Evaluate medical status of patient for
consideration of discharge
 Involve Security/Police
45
Ideas on how to Document
• Pain management: This has become her most
challenging issue… The incident yesterday in
which she manipulated the IV pump to increase the
rate of dilaudid infusion is very concerning for
significant dependence and suggests that this is a
contributor, perhaps the major contributor to her
ongoing high opioid needs. We stopped her prn IV
dilaudid and advised that manipulation of the pump
was Serious issue (which she recognized herself).
She took oral dilaudid only but later this evening
developed severe pain and required a single dose
of Iv dilaudid (witnessed infusion) for relief.
46
23
Documentation
• PT found by RN changing IVF setting to 700 cc/hr
after IV dilaudid given via piggyback IVF. PT given
education on dangers of this, Pt in agreement not to
do this, though PT had previous episode on AM
shift. MD notified. IV pump locked.. Will continue to
monitor
47
Documentation
• Pt and partner had been escalating in confrontational
behavior all day. When I entered the room with rest of
care team and security guards pt's partner told
team/guards to stop looking at his wife. Pt was clothed
but then covered up with 2 blankets. The husband had
some words with the security guard but was not
physically aggressive. Then patient started yelling that
she wanted to leave and that we were not helping her. I
told her repeatedly that we wanted to help her but she
would have to stop screaming and engage in a
constructive interaction. The patient and her partner left
the hospital floor. She refused to sign out AMA. She was
told many times that we recommended that she stay in
the hospital.
48
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Documentation--warning
• This patient had unfortunate friction with other
patients so prior to the start of my clinic, I spoke
with the patient at length about maintaining civil
behavior and positive interpersonal
relationships. The discussion ended with an
improved positive outlook and a promise from
the patient to improve her interpersonal
interactions.
49
One final thought—on surrogate
rights
A HIPAA nugget more protective of the patient—
A physician’s right to not treat a person as a personal
representative if the physician has a reasonable belief
that:
–
The patient has been subjected to domestic violence,
abuse or neglect by that person, or
–
Treating that person as the personal representative
could endanger the patient, and
–
In the exercise of professional judgment, the physician
decides it is not in the patient’s best interest to treat the
person as the patient’s personal representative
45 C.F.R Section 164.502 (g)(5)
50
25
Not the Way to Respond to a Patient’s Demand
51
Is That What I Think It Is?
26
Smoking, Drugs and Alcohol & Visitor
Policies
• Purpose of policies:
– Health and safety of patients, visitors and staff
– Zero tolerance of drugs, alcohol or smoking
– This is everyone’s responsibility—knowing something
is going on and not doing something about it isn’t
acceptable
– There are no designated smoking areas
– Make sure tobacco consultation initiated
– Patients are not allowed to leave nursing units for
purpose of smoking—there is no such thing as an
“order” to be allowed to smoke
Procedure-contraband
Procedure if you observe or suspect
use/possession
– Inform manager, hospital supervisor, risk
management (RM), attending physician
– RM, security and nursing supervisor, in consultation
with physician, will decide if patient’s room will be
examined
– Complete incident report
– Make a note in medical record
– Note: Safety decisions primarily lie with hospital
54
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Procedure
• Examination of patient’s room
– Patient advised of examination
– Done by 2 staff, one of whom is from Security
– Security should document
Examination of Patient’s Room &
Belongings: How far can you go?
• Policy: To balance the patient’s right to
privacy with the safety and security of
patients, staff, and visitors
• Policy: Decision to examine room or
belongings should be based on reasonable
cause for a search and when it is the least
invasive and most effective means available
to meet the safety, security and medical
needs of the patients and staff
•
!
It’s All About Safety
28
Examination of Patient’s Room &
Belongings: How far can you go?
• Why do we have a right to examine a patient’s
room?
• Smoking products: flammability of oxygen and
other gases
• Sharing of drugs among patients
• Fairness to other patients who are engaged in
smoking cessation programs
• The increased risk of criminal activity with the
presence of illicit drugs
Procedure
• Examination of patient’s belongings
– Patient advised of examination
– Done by 2 staff, one of whom is from Security
– Security should document
– If patient refuses, then belongings will be
sequestered and patient will be allowed reasonable
access in the presence of a staff person (only
necessary if there clearly isn’t a medical need to
examine belongings)
29
Procedure
• Delivery and Disposal of illicit drugs
– Follow notification procedure
– Security will contact Campus Police for disposal
– These drugs should not be sent to Pharmacy
– These drugs should not be disposed of in a sink or
toilet
Procedure
• Consequences:
– Conference with patient, attending and nurse manager
– Potential for discharge
– Potential for restriction of visitors per Visitors Policy
• Flagging of Patient: Registration
– Violators of policy will be flagged in system in the event of
re-admission—personal belongings will be sequestered
and decision made regarding visitation
• Reg Alert are now “FYI’s” in Apex—But you
have to look at the FYI on admission
30
Three Final Considerations
1.
We must not ignore the potential for involvement
by hospital employees
2.
For any serious injuries or death related to the use
of contraband or weapons there should be a
protocol for involving the authorities:
3.
□
Medical examiner or coroner
□
Police
Mental health patients: search/deprival of
contraband may constitute a denial of rights –
interpretation varies by county
61
Should you create a physicianpatient relationship?
• For the vast majority of patients, the steps to
create a physician-patient relationship are
smooth
• Red flags that it is a potential problem even
before an appointment is made:
– Extraordinary utilization of resources through
telephone calls, e-mail, personal appearance
– Abusive behavior to staff
– Unrealistic expectation about services
• Once an appointment is made, some will argue
that a relationship has been created
62
31
Discontinuation of Care
• Policy outlines the steps needed to discontinue
care
• Will most often apply in outpatient setting, but
the policy has been used as appropriate in the
inpatient setting, e.g.
– Patient non-compliant with treatment, nothing more
to offer and patient is medically stable
• Documentation is very important
• Policy contains safeguards to allow for
objective review of desire to discharge
63
Discontinuation Policy 6.03.03
• UCSFMC will make “all reasonable efforts to
prevent and/or resolve problems between
providers or staff and patients prior to
considering discontinuance of care”
• Decision will balance “patient’s health care
needs and the obligations of UCSFMC related to
the safety of its employees, visitors and patients
and responsible use of institutional resources”
64
32
Examples of basis for
discontinuation
• Serious breakdown in communication….
resulting in a lack of trust (e.g. patient
repeatedly verbalizes lack of confidence in
UCSF
• Treatment options have been exhausted
because patient is non-compliant with tx plan
and in the provider’s judgment no further
treatment options exist
65
Examples of basis for
discontinuation
• Serious abuse of institutional resources and
efforts to correct…. Behavior have been
exhausted or not possible
• Patient repeatedly fails to keep appointments
• Patient is abusive, disruptive, threatening or
violent or is in violation of UCSF policies
66
33
Discontinuation of Care Policy
• Discontinuation of patient care will be managed
in a thoughtful manner with attention to
providing alternatives for care, either within or
outside UCSF Medical Center.
• There are internal resources available to assist
with difficult patient situations or patients who
exhibit the above referenced behavior. Those
resources include Social Work, Spiritual Care
Services, Nursing and departmental managers
and supervisors, Ambulatory Services
Administration, psychiatric consultation
services, Patient Relations, Risk Management
and Security.
67
Discontinuation of Care-Policy
• Address the inappropriate behavior and request
behavioral modification: Whenever possible,
discussions should occur with the patient
regarding problematic behaviors.
• The physician or responsible health care
provider and/or staff should meet with the
patient and, as appropriate, the patient’s family
or surrogate to discuss the specific behavior
that is felt to be problematic and any expected
changes, and the consequences for failure to
modify the behavior. Patients may be given
suggestions for preventing discontinuation
from care through behavior modification or
alternative courses of action.
68
34
Process
• Address the inappropriate behavior
• Request behavioral modification
• Review the patient’s clinical condition
• Consider letter of warning
• Documentation
• Review health insurance/health plans
• Determine options for alternate sites of care
• Notify appropriate departments
69
Discontinuation of Care--approval
• Patients must be informed in writing of decision
to discontinue care—Risk Management will
review all letters
• Outpatient from a Practice: determined by
practice with assistance from Risk-letter signed
by Practice Manager, Med. Director or designee
• Outpatient from UCSF Medical Center:
discuss/inform all providers: Executive
Director or Director of Risk and CMO
• Inpatient: attending physician, Risk
Management and Chief Medical Officer
70
35
Discontinuation of Care
• Exceptions to procedural requirements
– Made on those rare occasions where there may be a
threat to other patients, providers or staff
– Needs Executive Director approval after conferring
with Director of Security or designee, Risk
Management and providers or staff involved.
– Risk and/or Security will determine if referral to
Threat Management Team is appropriate
71
Visitor Policy-1.03.14
• New language strengthens our visitor policy:
– In determining the appropriateness of visitation
restriction, the health care providers and hospital
staff may exercise their best judgment, taking into
account all aspects of patient health and safety
72
36
Visitor Policy
• UCSF Medical Center may restrict visitation privileges to
ensure the health and safety of patients, staff and visitors.
Visitation privileges may be restricted or terminated under
circumstances that include, but are not limited to, the
following: inappropriate, abusive or threatening behavior,
violation of any hospital policy, including but not limited to
smoking, drug or alcohol policies, interference with the
care of patients, infection control, court order limiting or
restraining contact, excessive numbers of visitors,
performance of a medical procedure, pandemic or
infectious disease outbreak, substance abuse protocols
requiring restricted visitation, the patient’s need for privacy
or rest or the need for privacy or rest by another individual
in the patient’s shared room.
73
37
A few words about Elopement-key
response elements
•
Notify patient’s medical team and supervising
nurse
•
Primary team and nursing assess the patient’s
medical status and risk
•
Document time last seen and where
•
Complete IR
•
Make efforts to contact patient to discuss
treatment options and follow-up care
•
Document
75
Assessment-let’s avoid elopement
•
This is a clinical evaluation of patients re: their
capacity to make decisions related to their
safety
•
Have clarity on patient’s capacity status and
make all members of the treatment team aware
•
Past history may be a guide, as well as
information from family, caregivers, friends
•
Determine the frequency of your assessment
76
38
Elopement Assessment
considerations
•
Does patient have capacity or surrogate?
•
Is the patient a danger to self or others?
•
Does this patient lack cognitive ability to make
relevant decisions?
•
Does the patient have a history of elopement?
•
Does the patient have physical or mental
impairments that increase risk?
77
Prevention Ideas for at risk patients
•
Place patient on an observation protocol-this
does not take a physician order--nursing
•
Room patient close to nursing station
•
Partner patient with a roommate
•
Perform routine risk assessment and make
changes if patient’s risk changes
•
Partner with family
•
Sitters
•
Take photos of high risk patients-one in the
record; one with Security
78
39
Prevention Ideas for at risk patients
•
Enhance awareness of high risk patients with
armbands, gowns of a specific color, signals on
the patient’s door
•
Identify risk in handoffs –shift to shift and when
internally transporting patients for procedures
•
Keep suitcases, shoes, street clothes out of
patient’s view
•
Manage expectations about leaving unit
79
Social Media
40
Friending Patients
• Campus Guidelines on Social Media
http://www.ucsf.edu/about/social-mediaguidelines
• Risk recommends that you maintain clear
separation between personal and professional
life
• Advise patients that you have a policy of not
friending patients and stick to it.
• Remember, if your “friend” a patient, if will likely
impact other nurses because they will get
“friend” requests
• In general, be very careful about sharing
personal information with patients
81
Case Example: The
Lingerie Model
•
Patient Bob with history of behavioral issues
•
Inappropriate display to staff of highly
suggestive images using his laptop
•
Assertively engages staff in personal
discussions
•
One staff mentions to Bob that “Betty” has a
side job as a “lingerie model”
82
41
Case Example: The
Lingerie Model
•
Betty comes into Bob’s room to do some
therapy; Bob engages Betty in conversation
about her modeling career—asks if she has
pictures; tells her he might be able to help her
•
Betty does not want to be impolite and so she
succumbs to Bob’s request and “friends” him
on Facebook
•
She leaves the room and “un-friends” him, but
by then he has “re-posted” her pictures
83
Drinking Buddy Debacle
• Family with complex psycho-social issues
comes to UCSF for treatment of minor child.
• The couple has other children and is staying
near UCSF
• CPS has an open case for all three children
• During the child’s stay in the hospital, personal
contact information is exchanged between a
staff person and the parents
84
42
Drinking Buddy Debacle
• Staff person visits the parents where they are
staying
• Staff person decides to take two small children
home over night
• Staff person then returns to party with the
parents and provides the alcohol
85
Drinking Buddy Debacle—Liability
issues
• Is the staff person acting in the course and
scope of her employment?
• What information was exchanged via e-mail or
text messages?
• What if parents say that the staff person did
something inappropriate when the children were
in her custody?
• If not in course and scope and there is a claim,
the staff person will not receive coverage for
claim
• Can UCSF successfully argue that staff person
was not an agent of UCSF?
86
43
Conclusions
• Be ready to assist with workplace
violence protection plans
• Look at your client’s set of policies
• Help set expectations of behavior up
front
• Be creative with solutions
• Assist in getting senior leadership
support for setting limits---it will help
public image of the provider and
facility
87
44
Management of
Disruptive Behavior
Office of Origin:
I.
POLICY 6.07.19
Patient Care
Management of Disruptive Behavior
Issued: 12/12
Last Approval: December 2012
Risk Management Department
Security Department
PURPOSE
To establish guidelines to assist staff with risk assessment and management of those patients,
family members and/or visitors who are engaging in disruptive behavior, in both inpatient
and outpatient clinical settings, with the goal of maintaining a safe environment for staff and
patients.
II.
REFERENCES
The Joint Commission Accreditation Standards for 2012, Standard EC 02.01.01
UCSF Medical Center Administrative Policies:
1.01.09
Dangerous Items (Weapons Possession)
1.01.19
Smoke Free Environment
1.01.03
Alcohol/Drug Usage or Possession by Patients/Visitors
1.03.14
Visitors: Identification, Hours and Control
2.01.06
Workplace Violence
6.03.03
Discontinuation of Care
6.04.04
Patient Complaints and Grievances
6.04.10
Patient’s Rights and Responsibilities
6.05.06
Evaluation of and Consultation for Psychiatric Risk in Adult Patients
6.07.10
Restraints
6.07.12
Psychiatric Holds (5150/5250)
Environment of Care Manual
Security Management 2.1.0
UCSF Medical Center Nursing Department Administrative Policies:
Elopement/AMA
UCSF Medical Center Security Department Procedures:
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POLICY 6.07.19
Patient Care
Management of Disruptive Behavior
Issued: 12/12
Last Approval: December 2012
Security/Safety Notification and Escalation Process
III. DEFINITIONS
Disruptive Behavior - behavior by patients, family members and/or visitors which is
disruptive to the patient’s own care, the care of other patients, the safety of staff, patients,
visitors and institutional operations.
These disruptive behaviors include, but are not limited to:
1. Pattern of non-compliance with care (refusal of meds, refusal of medically necessary
procedures, refusal of monitoring necessary for patient safety, dictating care (e.g.
medication regimens, diagnostic testing, wound care, vital signs, etc.), firing staff,
missing appointments, etc.)
2. Demanding care that is medically contraindicated
3. Violation of Hospital Policies (drug, alcohol, smoking, visitors, etc.)
4. Violation of Outpatient Pain Management Contracts and Inpatient Pain Medication
Protocols
5. Obtaining prescriptions (opiates in particular), via fraudulent means
6. Verbal and/or Physical Abuse of staff and/or other patients or family members
7. Threats of Violence
8. Property Damage or Theft
9. Entering clinical or restricted areas without permission of the staff
10. Refusal to follow instructions by staff
11. Refusal to be discharged when medically stable and/or to participate in safe discharge
planning (potentially impacting patient care/safety)
12. Parental/ Visitor Disputes erupting into violence
13. Refusal to meet with providers
14. Repeated violations of Patient Responsibilities
15. Elopements/AMAs
16. Excessive phone calls and/or emails to providers, practices, etc.
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POLICY 6.07.19
Patient Care
Management of Disruptive Behavior
Issued: 12/12
Last Approval: December 2012
Huddle – a team meeting/conference call scheduled to develop a plan of action to manage
behavior. It may be requested by the nurse manager or any member of the medical team
and/or Administration, Risk or Security in situations where disruptive behavior continues to
escalate despite attempts at intervention, in order to strategize and develop a plan of action to
address the behaviors.
Threat Management Team (TMT) – A multi-disciplinary group meeting on an ad hoc basis
to evaluate threatening/unsafe situations to ensure that proper measures are immediately put
in place to manage the incident and provide for a safe and secure work environment.
IV. POLICY
It is the policy of UCSF Medical Center/Benioff Children’s Hospital (UCSF) to create and
maintain a safe working environment for all staff members. This policy supports this goal by
providing guidelines for managing situations in which patients, family members and/or
visitors are engaging in disruptive behavior.
UCSF is also committed to patient safety and as such has a goal to prevent or mitigate such
disruptive behavior that has the potential to impact the safety of patients.
This policy is meant to act as guidelines only. UCSF Medical Center will evaluate situations
on a case by case basis, based on the severity of the involved behavior and the risk to
patients, staff and visitors.
UCSF has adopted a zero tolerance standard for workplace violence. As such, UCSF is
committed to maintaining a safe workplace that is free from threats and acts of intimidation
and violence.
UCSF understands that hospitalization is a stressful event for patients and their family
members/visitors. UCSF recognizes and respects patient rights and is committed to
responding appropriately to patient complaints about care. Actions and interactions
related to disruptive behavior will include consideration of both the patient’s health
care needs and psychosocial issues as well as the obligations of UCSF related to the
safety of its employees, visitors and patients and responsible use of institutional
resources.
V.
PROCEDURES
The appropriate response to disruptive behavior is based on the level of disruption exhibited.
A. Level One (1 ) Behavior consists of demanding, dissatisfied and/or excessive questions
about care. The attached inpatient (adult and pediatric) algorithms and outpatient
guidelines provide a framework for managing these types of behaviors (See attached
Appendix A, Appendix B and Appendix C).
B. Level Two (2) Behavior consists of non-compliance with care and/or hospital policies
and/or verbal abuse by patients, family members and/or visitors. The attached inpatient
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POLICY 6.07.19
Patient Care
Management of Disruptive Behavior
Issued: 12/12
Last Approval: December 2012
(adult and pediatric) algorithms and outpatient guidelines provide a framework for
managing these types of behaviors (See attached Appendix A, Appendix B and Appendix
C).
C. Level Three (3) – Behavior including verbal threats, physical abuse, violence and
aggression. The attached inpatient (adult and pediatric) algorithms and outpatient
guidelines provide a framework for managing these types of behaviors (See attached
Appendix A, Appendix B and Appendix C and Appendix D).
In the event that a response by Security does not stabilize the situation, Security Officers
will take steps to escalate the situation to UCPD following the guidelines as set forth in
the Security/Safety Notification and Escalation Process (See attached Appendix D).
Once the situation has stabilized, a huddle may be called by the nurse manager or any
member of the medical team, Risk or Security to strategize next steps and develop a plan
of action. UCPD may also be asked to participate if necessary. Risk will notify and/or
request participation of the Associate CNO & Associate CMO as necessary.
Documentation: Disruptive behavior and the responses to such behaviors must be
documented in the medical record in order to assure that these behaviors are addressed in
a consistent manner.
VI. RESPONSIBILITY
Questions about the implementation of this policy should be directed to the Security
Department (885-7890) or the Risk Management Department (353-1842).
VII. HISTORY OF POLICY
Reviewed and approved by Behavior Task Force in September, 2012
Reviewed and approved by Patient Safety Committee in October, 2012
Reviewed and approved by Policy Steering Committee in December, 2012
Reviewed and approved by Executive Medical Board in December, 2012
Reviewed and approved by Governance Advisory Council in December, 2012
VIII. APPENDIX
A. Disruptive Behavior – Adult Inpatient Setting Algorithm &Action Plan
B. Disruptive Behavior – Pediatric Inpatient Setting Algorithm & Action Plan
C. Guidelines for the Management of Disruptive Behavior in the Outpatient Setting
D. Security/Safety Notification and Escalation Process
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POLICY 6.07.19
Patient Care
Management of Disruptive Behavior
Issued: 12/12
Last Approval: December 2012
This guideline is intended for use by UCSF Medical Center staff and personnel and no representations or
warranties are made for outside use. Not for outside production or publication without permission. Direct
inquiries to the Office of Origin or Medical Center Administration at (415) 353-2733.
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Last Approval: December 2012
Appendix A: Disruptive Behavior – Adult Inpatient Setting Algorithm &Action Plan
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Management of
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Management of
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POLICY 6.07.19
Patient Care
Management of Disruptive Behavior
Issued: 12/12
Last Approval: December 2012
Appendix B: Disruptive Behavior – Pediatric Inpatient Setting Algorithm & Action Plan
i
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Management of
Disruptive Behavior
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POLICY 6.07.19
Patient Care
Management of Disruptive Behavior
Issued: 12/12
Last Approval: December 2012
Management of
Disruptive Behavior
POLICY 6.07.19
Patient Care
Management of Disruptive Behavior
Issued: 12/12
Last Approval: December 2012
Appendix C: Guidelines for the Management of Disruptive Behavior in the Outpatient Setting
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Patient Care
Management of Disruptive Behavior
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Last Approval: December 2012
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Patient Care
Management of Disruptive Behavior
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Last Approval: December 2012
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Patient Care
Management of Disruptive Behavior
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Last Approval: December 2012
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Patient Care
Management of Disruptive Behavior
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Last Approval: December 2012
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Patient Care
Management of Disruptive Behavior
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Last Approval: December 2012
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Patient Care
Management of Disruptive Behavior
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Last Approval: December 2012
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Management of Disruptive Behavior
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Management of Disruptive Behavior
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Last Approval: December 2012
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Management of Disruptive Behavior
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Last Approval: December 2012
Appendix D: Security/Safety Notification and Escalation Process
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