Report and Prevent: A Quality Improvement Project to Protect Nurses From Violence in the Emergency Department

IntroductionMost nurses experience some form of workplace violence resulting in a stressful work environment, employee injury, and turnover. The aims of this project were to develop and evaluate strategies to improve the reporting of workplace violence as well as to empower emergency nurses to prevent assaults and protect themselves.MethodsThis quality improvement project had 2 phases. The phase I educational intervention focused on the importance of reporting workplace violence. Pre- and postintervention surveys measured experiences with workplace violence and reporting. The phase II educational intervention focused on de-escalation and self-protection strategies, training, safety, confidence, and emergency nurses’ preparedness to defend themselves. Responses were analyzed using Wilcoxon signed-rank and McNemar tests.ResultsTwenty-five emergency nurses participated in phase I, with >90% reporting that they had been assaulted in the past month. Most did not report a workplace assault, which was unchanged after the intervention. Thirty-four emergency nurses participated in phase II, with a postintervention increase reported in the perceived helpfulness of learning self-protection techniques for the emergency nurses’ work life (Z = –2.179, P = 0.029).DiscussionThis study was consistent with the literature in that emergency nurses often do not report workplace assaults. Most of the emergency nurses surveyed had been assaulted. Although the educational interventions did not achieve the desired outcome, it is clear that additional interventions for individual nurses and institutions need to be developed and refined to increase reporting and prevent workplace assaults.     

Intimate Partner Violence Screening in the Emergency Department: A Quality Improvement Project

IntroductionIntimate partner violence is a serious public health issue that can be addressed through identification and early intervention. Although screening for intimate partner violence in health care settings is recommended by medical and nursing organizations, it is underperformed. The project objectives were to increase intimate partner violence screening rates, identification, and the referrals/resources provided.MethodsThis project was a quality improvement intervention. Intimate partner violence screening training was provided to emergency nurses along with a computer prompt for screening in the emergency department, with a standard referral process to a social service agency. The project data included patient ED visits, partner violence screening rates, positive and negative screening rates, and the number of referrals/resources provided to the patients.ResultsThere was no increase in the screening rates (28%). Although the screening rates varied considerably from week to week, the highest rate of screening was during the intimate partner violence training week. Pre- and postintervention data showed a significant increase in the number of positive screens obtained per week after the nurse intimate partner violence training (7.80 vs 5.22, t = –4.33, P < 0.01). In addition, the referrals/resources provided to the patients doubled from 9 to 18 after the training, which is clinically significant for patient care.DiscussionThis project demonstrates that nurse training along with a computer prompt intervention and standard referral process can contribute to intimate partner violence identification and the referrals/resources provided to the patients. Ultimately, the patients exposed to partner violence may benefit from increased identification and delivery of the referrals/resources.     

Staff Duress Alarms for Workplace Violence in the Emergency Department: A Mixed-Methods Evaluation

IntroductionComplex personal duress alarms may be implemented as part of a multicomponent approach to preventing and mitigating workplace violence in emergency departments. Evaluation of duress alarms after implementation has been identified as a gap in the literature. The purpose of this quality improvement project was to examine the impact of a duress alarm system on workplace violence and user experience in an urban emergency department.MethodsA comprehensive system evaluation was performed using a mixed-methods approach, which included retrospective data review, key informant interviews, observations, and a survey. Forty clinical staff at an emergency department in North Carolina were interviewed and provided feedback on the duress system.ResultsFindings indicated that the duress system was not associated with a decrease in workplace violence, and that the majority of clinical staff did not even wear the duress alarm. Staff indicated that the primary barriers to use of the alarm were the bulky design of the alarm badge, inadequate education about the alarm device and process, and the lack of a reliable and timely response from security.DiscussionOngoing engagement of clinical staff is critical to the success of health care technology implementations. Staff feedback, periodic re-education, and recurring process evaluations are vital to ensuring the continued relevance of systems, especially when staff safety is the intended purpose.     

Violence Prevention in the Emergency Department: Future Research Priorities

The 2009 Academic Emergency Medicine Consensus Conference working group session participants developed recommendations and research questions for violence prevention in the emergency department (ED). A writing group devised a working draft prior to the meeting and presented this to the breakout session at the consensus conference for input and approval. The recommendations include: 1) promote and facilitate the collection of standardized information related to violence victimization and perpetration in ED settings; 2) develop and validate brief practical screening instruments that can identify those at risk for perpetration of violence toward others or toward self; 3) develop and validate brief practical screening instruments that can identify victims at risk for violent reinjury and mental health sequelae; and 4) conduct efficacy, translational, and dissemination research on interventions for violence prevention. The work group emphasized the critical need and role of ED-based research to impact surveillance and prevention of future violence-related injury.     

Violence Risk Assessment in the Emergency Department

IntroductionWorkplace violence is a prevalent problem in health care, with mental health and emergency departments being the most at-risk settings. The aim of this evidence-based practice project was to pilot use of a violence risk assessment tool, the Broset Violence Checklist, to assess for risk of type II violence and record the interventions that nurses chose to implement to mitigate the situation. Additionally, reports made to the hospital reporting system were tracked and compared to previous reporting frequency.MethodsFollowing staff education, nurses were instructed to complete checklists for all patients who have a score of 1 or higher, which indicates the presence of at least 1 high-risk behavior, and continue hourly scoring until the score returned to 0 or the patient was dispositioned. The number of incidents recorded, time of day, scores, interventions applied to mitigate violence, and change in scores after interventions were evaluated. The number of Broset Violence Checklist scoring sheets submitted and reports made via the hospital reporting system were compared.ResultsIncidents were most frequent from 11 am until 3 am. The highest scores occurred in the late evening and early morning hours. There were significantly more incidents captured with the use of the Broset Violence Checklist as compared to the hospital reporting system. Incidents significantly associated with higher scores included providing comfort measures, addressing concerns, and applying restraints.DiscussionThe Broset Violence Checklist was used successfully in the emergency department setting to identify behaviors associated with violence. Under-reporting to the hospital report system was identified in this project, consistent with reports in the literature. Specific interventions were not associated with a decrease in Broset Violence Checklist scores.     

Staff Perception of Interprofessional Simulation for Verbal De-escalation and Restraint Application to Mitigate Violent Patient Behaviors in the Emergency Department

Problem

Violent behaviors in the emergency department are on the rise. Mitigation efforts are essential for staff and patient safety. The goal of this quality improvement project was to improve staff perception of knowledge, skills, abilities, confidence, and preparedness when managing violent patient behaviors using interprofessional simulation training and to evaluate staff learning style satisfaction and self-confidence using simulation.

A Quality Improvement Initiative on Reducing Blood Culture Contamination in the Emergency Department

IntroductionContaminated blood cultures may have detrimental effects on patients, the organization, and antimicrobial stewardship. Patients in the emergency department may need blood cultures collected before antimicrobial therapy. Contaminated blood culture samples may contribute to prolonged hospital stay and also are associated with delayed or unnecessary antimicrobial therapy. This initiative aims to improve the emergency department’s blood culture contamination rate that will eventually benefit the patients who will receive timely and proper antimicrobial therapy, and benefit the organization fiscally.MethodsThis quality improvement initiative used the Define–Measure–Analyze–Improve–Control (DMAIC) process. The organization targets blood culture contamination rate of ≤2.5%. Control charts were used to study how blood culture contamination rate changed over time. In 2018, a workgroup was formed to work on this initiative. Improved site disinfection using 2% Chlorhexidine gluconate cloth before the standard procedure of blood culture sample collection was initiated. Chi squared test of significance was used to compare blood culture contamination rates 6 months before and during feedback intervention as well as contamination rate from source of blood draw.ResultsBlood culture contamination rates 6 months before and during feedback intervention showed significant decrease (3.52% before intervention and 2.95% after intervention; P < .05). Contamination rates differed significantly based on the source of blood culture draw (7.64% via line, 3.05% via percutaneous venipuncture, and 4.53% via other; P < .01).DiscussionBlood culture contamination rate continued to decrease with the use of a predisinfection process with 2% Chlorhexidine gluconate cloth before blood sample collection process. Practice improvement also was evident with effective feedback mechanism.     

Introducing a Digital Occupational Violence Risk Assessment Tool Into an Emergency Department: A Pilot Implementation Study

IntroductionOccupational violence in emergency departments is prevalent and detrimental to staff and health services. There is an urgent call for solutions; accordingly, this study describes the implementation and early impacts of the digital Queensland Occupational Violence Patient Risk Assessment Tool (kwov-pro).MethodsSince December 7, 2021, emergency nurses have been using the Queensland Occupational Violence Patient Risk Assessment Tool to assess 3 occupational violence risk factors in patients: aggression history, behaviors, and clinical presentation. Violence risk then is categorized as low (0 risk factors), moderate (1 risk factor), or high (2-3 risk factors). An important feature of this digital innovation is the alert and flagging system for high-risk patients. Underpinned by the Implementation Strategies for Evidence-Based Practice Guide, from November 2021 to March 2022 we progressively mobilized a range of strategies, including e-learning, implementation drivers, and regular communications. Early impacts measured were the percentage of nurses who completed their e-learning, the proportion of patients assessed using the Queensland Occupational Violence Patient Risk Assessment Tool, and the number of reported violent incidents in the emergency department.ResultsOverall, 149 of 195 (76%) of emergency nurses completed their e-learning. Further, adherence to Queensland Occupational Violence Patient Risk Assessment Tool was good, with 65% of patients assessed for risk of violence at least once. Since implementing the Queensland Occupational Violence Patient Risk Assessment Tool, there has been a progressive decrease in violent incidents reported in the emergency department.DiscussionUsing a combination of strategies, the Queensland Occupational Violence Patient Risk Assessment Tool was successfully implemented in the emergency department with the indication that it could reduce the number of incidents of occupational violence. The work herein provides a foundation for future translation and robust evaluation of the Queensland Occupational Violence Patient Risk Assessment Tool in emergency departments.     

Agitated Geriatric Patients and Violence in the Workplace

Older adults may suddenly exhibit behaviors that are viewed as noncompliant, noncooperative, and threatening. They may even lash out verbally and physically causing injury to health care staff. In addition to taking actions that prevent harm to the staff and the patient, determining what caused this behavior (dementia vs delirium or other cases) will be critical, as well as debriefing the staff after the incident.     

A Systematic Review of Violence Risk Assessment Tools Currently Used in Emergency Care Settings

IntroductionViolence risk assessment is commonplace in mental health settings and is gradually being used in emergency care. The aim of this review was to explore the efficacy of undertaking violence risk assessment in reducing patient violence and to identify which tool(s), if any, are best placed to do so.MethodsCINAHL, Embase, Medline, and Web of Science database searches were supplemented with a search of Google Scholar. Risk of bias assessments were made for intervention studies, and the quality of tool development/testing studies was assessed against scale development criteria. Narrative synthesis was undertaken.ResultsEight studies were included. Three existing violence risk assessment tools featured across the studies, all of which were developed for use with mental health patients. Three newly developed tools were developed for emergency care, and 1 additional tool was an adaptation of an extant tool. Where tested, the tools demonstrated that they were able to predict patient violence, but did not reduce restraint use. The quality issues of the studies are a significant limitation and highlight the need for additional research in this area.DiscussionThere is a paucity of high-quality evidence evaluating the psychometric properties of violence risk assessment tools currently used along the emergency care pathway. Multiple tools exist, and they could have a role in reducing violence in emergency care. However, the limited testing of their psychometric properties, acceptability, feasibility, and usability in emergency care means that it is not possible to favor one tool over another until further research is conducted.     

The Clinical Impact of Health Behaviors on Emergency Department Visits

Modifiable health behaviors are an important cause of visits to emergency departments (EDs). Substance use, unsafe sexual behavior, interpersonal violence, unintentional injury, and other risky behaviors account for a large proportion of ED volume, as well as up to 40% of all deaths in the United States. While emergency physicians commonly treat the illnesses and injuries caused by these behaviors, additional opportunities exist to screen, intervene, refer, and initiate treatment for patients with these health risks. This article reviews the epidemiology and clinical impact of risky health behaviors on ED visits and suggests strategies for creating a research agenda in these areas.     

Preventive Care in the Emergency Department: Screening for Domestic Violence in the Emergency Department

OBJECTIVES: The most effective methods for identification and management of domestic violence (DV) victims in health care settings are unknown. The objective of this study was to systematically review screening for DV in the emergency department (ED) to identify victims and decrease morbidity and mortality from DV. METHODS: Using the terms "domestic violence" or "partner violence," and "identification" or "screening," and "emergency," the authors searched MEDLINE, the Cochrane Database, and Emergency Medical Abstracts from 1980-2002. They selected articles studying screening tools, interventions, or determining the incidence or prevalence of DV among ED patients. The studies were analyzed using evidence-based methodology. RESULTS: Three hundred thirty-nine articles resulted from the literature search. Based on selection criteria, 45 were reviewed in detail and 17 pertained to the ED. From references of these 17 articles, three additional articles were added. Screening can be conducted using a brief verbal screen and existing ED personnel. A randomized, controlled trial did not demonstrate a difference in screening rates between experimental and control hospitals. No studies assessed the effect of ED screening for DV on morbidity or mortality of domestic violence. An ED-based advocacy program resulted in increased use of shelters and counseling. CONCLUSIONS: Because of the paucity of outcomes research evaluating ED screening and interventions, there is insufficient evidence for or against DV screening in the ED. However, because of the high burden of suffering caused by DV, health care providers should strongly consider routinely inquiring about DV as part of the history, at a minimum for all female adolescent and adult patients.     

Workplace Violence and Bullying Faced by Health Care Personnel at the Emergency Department of a Tertiary Care Hospital of Karachi,Pakistan: A Cross-Sectional Study

IntroductionThe emergency department is the most affected by physical and verbal abuse and bullying in health care. Violence against health care workers not only affects their safety, but also their performance and motivation. This study aimed to determine the prevalence and associated determinants of violence against health care personnel.MethodsA cross-sectional study design was used with 182 health care personnel at the emergency department tertiary care hospital of Karachi, Pakistan. Data were collected through a questionnaire comprised of 2 sections: (1) demographic questions and (2) statements to identify the prevalence of workplace violence and bullying among health care personnel. Nonprobability purposive sampling was used for recruitment. Binary logistic regression was used to identify the prevalence and determinants of violence and bullying.ResultsMost participants were younger than 40 years of age (n = 106, 58.2%). Participants were mainly nurses (n = 105, 57.7%) and physicians (n = 31, 17.0%). Participants reported experiencing sexual abuse (n = 5, 2.7%), physical violence (n = 30, 16.50%), verbal abuse (n = 107, 58.8%), and bullying (n = 49, 26.9%). The odds of experiencing physical violence were 3.7 times greater (confidence interval = 1.6-9.2) when there was not a procedure for reporting workplace violence compared to when there was a procedure.DiscussionAttention is required to identify the prevalence of workplace violence. Creating effective policies and procedures for a reporting system would potentially lead to lowering violence rates and positively impacting health care workers’ well-being.     

Implementing Bedside Handoff in the Emergency Department: A Practice Improvement Project

Introduction

Handoff in the emergency department is considered a high-risk period for medical errors to occur. In response to concerns about the effectiveness of the nursing handoff in the emergency department of a Midwestern trauma center, a practice improvement project was implemented. The process change required nursing handoff at shift changes to be conducted at the bedside, using an adapted situation, background, assessment, recommendation (SBAR) communication tool.