Nursing - Theses
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ItemAn evaluation of violence risk screening at triage in one Australian emergency department( 2015)Background: There is an increasing focus in the published literature on the problem of patient violence in hospital emergency departments (ED). Patient violence negatively impacts staff safety and ultimately the quality of care provided to patients. Research and clinical practice guidelines indicate that the prevention of patient violence in hospital EDs requires a systematic process for identifying patients who are at risk; however the evidence supporting the implementation of risk screening processes in practice is limited. This research was conducted to evaluate the processes and outcomes of a violence risk screening decision support process at triage in one Australian ED. A decision support process for identifying patients at risk of becoming violent was developed and integrated into usual patient assessment practices at point of entry (triage). An evaluation of the risk screen process was then conducted to measure its influence on staff, patient, and organisational outcomes. Design : A mixed methods design incorporating both qualitative and quantitative approaches was utilised. Three studies were sequentially conducted to; explore the feasibility and need for a risk screening process, implement a brief risk screening process and evaluate its influence on the use of security and clinical responses to incidents of patent violence (Code Grey events). Setting: The study site was a level one trauma centre located in Melbourne, Australia. This ED has an annual census of 60,000 presentations with a 40% admission rate. Methods: Study One was conducted to explore the need for, and feasibility of, violence risk screening in practice. Semi-structured observations of triage nurses conducting routine patient assessments were made at the study site. In addition, a retrospective analysis of Code Grey responses matched with demographic and clinical information was performed to characterise the patients and situations in which Code Grey responses were activated. Patient and carer interviews were performed to explore the public perceptions and acceptability of violence risk screening at triage. In Study Two, the violence risk screening decision support process was developed and pilot tested. Levels of agreement between independent raters was determined using the risk screening process for a series of triage assessments. In Study Three, a before and after evaluation was conducted of the risk screening process for its influence on Code Grey responses and access to clinical care. Analysis of the predictive ability of the risk screening process including estimates of its sensitivity and specificity, likelihood ratios and predictive values were performed. Matched pair analysis compared triage nurse self-efficacy before and after the intervention. Results : In Study One structured observations of routine patient assessment at triage (N=167) found nurses used the existing triage process to identify at risk individuals. Based on their assessments the nurses identified a small number of patients requiring risk assessment (6%:10/167) This integrated approach to determining risk was observed to be used in all cases and deviated from standard operating procedure that recommended the use of pre-scripted questions. The 12-month retrospective review of Code Grey responses (N= 1959) identified a high risk group of patients who attended the ED on more than one occasion and required a Code Grey response for violence. Although this group represented 12% (105/857) of patients, they accounted for 32% (577/1796) of all Code Grey events audited. Of the 950 presentations requiring a Code Grey, 67% (639/950) were male, 66% (623/950) arrived by ambulance and 36% (350/950) were referred for a mental health assessment. Factors such as arriving escorted by police and requiring a mental health assessment significantly increased the risk of an individual having a Code Grey response while in the ED (OR=18.88; 95%CI=12.9,27.97; OR=11.68, 95%CI=9.13,14.94 respectively). Analysis of the Code Grey data showed that 25% (500/1959) of events occur at entry points to ED and 50% of a Code Grey responses occurred within the 77 minutes of arrival to the ED. Patient and carer interviews found there is a community expectation that patients at risk of violence are identified to allow an opportunity for prevention and improve safety (N=19). In Study Two, pilot testing of the risk screening process showed that triage nurses correctly identified 52% (122/233) of the patients who required a Code Grey response. Emergency department nurses (n=6) reviewed the triage notes for a sample (n=29) of patients not correctly identified at risk of violence. There was an acceptable level of agreement between triage nurses 69-82%, (kappa .25-.65). Of the 29 presentations of patients who required a Code Grey but were not identified at triage, 45% (13/29) did not have warning signs for violence at triage. In Study Three following the introduction of the violence risk screening decision support process, the proportion of Code Grey response at triage reduced from 29% before (258/904) to 22% after (200/897) implementation p<.001. The median duration of Code Grey events decreased from 14 to 13 minutes p<.009. The proportion of planned Code Greys increased from 52% (468/904) before to 62% after (556/897) p<.001. The sensitivity of the risk screening process was estimated at 56% and the specificity 97%. The total number of coercive interventions (physical restraint, medication given during the Code Grey and mechanical restraint) increased from 822 before to 1007 after p<.001. The median time from triage to first Code Grey increased from 71 minutes before (IQR=7-226) to 124 after (IQR=21-304) p<.001. Patients who required a Code Grey response were seen more quickly by medical staff (Median= 47, IQR=19-106) compared to baseline data (Median=51, IQR=14-114) p<.002. The revised violence risk screen resulted in ED nursing and medical staff being alerted to risk of violence by the electronic alert symbol for 61% (494/817) of Code Grey responses. Conclusion : On arrival to ED, the risk for violence was determined by the triage nurse using clinical judgement. This process was found to be feasible, acceptable to clinical staff, integrated into current triage processes, and reflected the public’s expectations of care. Communication of risk was facilitated using the existing clinical information system and normal work flow within the ED. High risk patient groups and locations were identified. Not all patients who require a Code Grey response were found to have observable warning signs at triage. Following the intervention there was an overall reduction in time staff engaged in emergency responses for aggression. Access to care was unchanged following the introduction of the risk screening; however the increase in the use of coercive practices following implementation of the risk screening process is of concern and warrants further exploration.