JCAHO hails reduction in mealtime violence
JCAHO hails reduction in mealtime violence
When you’re having lunch with 1,000 dangerously mentally ill men, you really hope that everyone has a good meal and walks away happy. Otherwise, a fork can become a weapon.
Mealtime violence is a serious problem for the patients and staff, so efforts to keep the peace became a top priority at California’s Atascadero State Hospital, which recently won a Codman award from the Joint Commission on the Accreditation of Healthcare Organizations for its efforts. The hospital has 1,700 staff and, in just one year at the 1,000-bed psychiatric hospital, 134 of them were injured through patient-related violence. Most of the injuries occurred at mealtimes. The injuries cost the hospital more than $766,000.
Violent events reduced by 40%
Once the hospital leaders decided to take decisive action against the problem, violent events in the dining room were reduced by 40% in one year. Attacks with silverware, the natural weapon of choice at mealtimes, were eliminated. By switching to plastic ware, the facility also saved 70 nursing staff hours a day that had been devoted to silverware control procedures in the dining room, the equivalent of 14.5 full-time nursing staff positions per year.
In addition, the violence reduction strategies contributed to a 24% reduction in the hospital’s workers’ compensation and industrial disability leave expenditures for fiscal year 1994/1995.
The turnaround required a new way of thinking at the facility, says Cindy Ramage, RN, the standards compliance coordinator. Ramage and others at the facility put together a quality assessment team with the goal of taking a hard look at the violence in the facility and with instructions to do almost anything necessary to reduce it. Mealtimes were clearly the most risky time for patients and staff, so that was the first focus of the team, says Colleen Carney Love, DNSc, RN, director of the clinical safety project.
"We’ve made it explicit that we won’t accept violence as part of the job, which is the way it’s been accepted in mental health," Carney Love says. "The issue of violence really is not addressed as vigorously as it should be in many settings, and this is an industry where it sometimes is just taken as a part of the workplace, something that had to be accepted."
The team already realized that mealtimes were especially emotional for psychiatric patients, with large groups brought together, often against their will, and required to follow certain procedures in order to eat. The logistics exacerbated stress levels that already were high, and patients often exploded in rage.
But even though the problem was a familiar one, the team addressed it by first collecting data on exactly what sorts of incidents were occurring. Without specific data, the team would not be able to develop effective solutions, explains Carol Constien, RN, risk management coordinator.
"Mealtimes triggered a high level of incidents, and the injuries from those incidents were much more severe than injuries that occurred elsewhere," Constien says. "We needed to know just how they were happening."
The team involved the patients in the solution because they were most directly involved and at high risk of injury. Their involvement was consistent with Atascadero’s whole philosophy of seeking patients’ input in their care and their environment. Patient representatives surveyed the patient population, providing valuable advice to administrators about realistic ways to reduce injuries. That turned out to be important when outside regulators came in and took a look at some of the changes.
"When we told them we were going to switch to plastic ware, there was a negative reaction because, from an outside perspective, that seems less normalized," Carney Love says. "But we were able to show that the patients themselves supported the move. Patient anxiety is a lot lower now that the person across the table just has a plastic fork when he gets angry, not a whole complement of silverware in his hands."
Despite the overall success of the violence reduction program, Carney Love notes that the team had a few false starts. "If we had taken our first-blush ideas, we would have come up with some crazy schemes," she says. "We first thought we needed more officers, metal detectors, maybe even build a wall in the dining area. We weren’t thinking outside the box. Fortunately, we kept going and eliminated those ideas as we went along."
The team also considered providing meals on the patients’ housing units, instead of bringing them to the dining room for meals. That was prompted by data that showed the incidence of violence was lower on weekends, when patients were allowed more freedom to skip meals and vary mealtimes. Providing meals on the housing units proved too labor-intensive, and some patients did not like being kept in the same area for meals. (See p. 34 for details on the solutions that worked.)
In the end, the team’s safety recommendations were considered a major success, as evidenced by the sharp reduction in injuries and by the Joint Commission’s hearty endorsement. "We got Accreditation with Commendation, no small feat for a public-sector industry," Carney Love says. "Our experience shows that you can tackle a problem that a lot of people see as an inevitable part of the job."
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