Stopping Workplace Violence Before It Starts

00:00:00:07 - 00:00:17:07
Tom Haederle
Welcome to Advancing Health. Violence in the healthcare workspace may not always be preventable, but the chances of it happening can be greatly reduced with preparation and de-escalation training, as we hear today from Saint Louis Children's Hospital.

00:00:17:09 - 00:00:30:09
Jordan Steiger
Hi everyone, I'm Jordan Steiger, I'm the director of behavioral health and violence prevention at the AHA. And I'm really happy today to be joined by my friend and my colleague Tom Saggio. Tom, thank you so much for joining us today.

00:00:30:12 - 00:00:35:00
Tom Saggio, R.N.
Jordan. Great. I am so glad to be here and I really look forward to our discussion.

00:00:35:02 - 00:00:55:04
Jordan Steiger
Me too. So we are here today to talk about your Behavioral Assessment Response Team or your BART, which is a little bit different from the behavioral Emergency Response Team that I'm sure maybe many of our listeners are more familiar with. So just to get us started, can you just tell us what is a BART team and what does it do?

00:00:55:07 - 00:01:27:12
Tom Saggio, R.N.
The BART team essentially is that response team that people are familiar with. We took the tack to really focus in on the assessment. We wanted to have a more proactive approach to patient escalation situations. So our BART team consists of behavioral health RNs, and behavioral health associates. And the associates are a two year degree obtained with two years of behavioral health experience.

00:01:27:12 - 00:02:16:25
Tom Saggio, R.N.
And they are available 24/7. And we also have a close working relationship with our BCB, and that's our board certified behavioral analyst. So they not only present to emergent assistance but also do daily touchpoints with the patients. They do therapeutic interactions with them, and they provide educational support to the staff. Their primary responsibility is to respond to those code white events - or the escalation situations, but their daily expectation is to identify patients with behavioral needs, establish relationships with those kids, and connect with the staff to ensure that they understand the behavioral plans to maintain treatment integrity.

00:02:16:26 - 00:03:02:14
Tom Saggio, R.N.
So we've created standard work for each of these roles. At shift change we get report from the previous shift of any unusual activity at patient escalations or high needs patients. But then they utilize Epic to the run reports on the identified kids with 1 to 1 behavioral observation. They look at all the kids who have behavioral consults entered, and all the kids that have suicide precautions. So they prioritize the kids that have had escalated events round on all of the kids on the list and perform touchpoints, do engagement activities, and even therapeutic sessions under the guidance of our BCBA, and then additionally work with the nursing staff so that they are aware of the triggers,

00:03:02:18 - 00:03:06:26
Tom Saggio, R.N.
identify de-escalation techniques, and understand the behavioral plans.

00:03:07:00 - 00:03:16:19
Jordan Steiger
I love this approach for so many reasons, but before we get into that, I just want to make sure we all are on the same page with what a code white is at Saint Louis Children's Hospital.

00:03:16:21 - 00:03:41:07
Tom Saggio, R.N.
That is the escalated patient event where the staff in the moment need additional assistance. So we have personal activation devices. We have the emergent line that we can call from the desk. And they send out a page and that activates everybody's iPhones and notifies that this particular unit at this particular room needs some assistance.

00:03:41:09 - 00:04:09:01
Jordan Steiger
Perfect. Thank you. So what I love so much about this is that this incorporates, I mean, violence prevention techniques. It incorporates behavioral health, all of the things that we know really work to prevent violence. And its focus so much on that prevention aspect rather than being reactive to a situation. So can you tell me a little bit more about how you, at your organization, shifted the mindset to focus more on prevention, and why getting involved so early matter so much to your patients?

00:04:09:03 - 00:04:33:04
Tom Saggio, R.N.
Absolutely. Shifting the mindset - it really was a result of our executive leaders asking the question, well, what is the team going to do when they're not responding to an escalated event? And since we were asking for additional FTEs, we want to make sure the BART team had worked to actually do. I think often our hospital leaders think that a crisis response team can be delegated to frontline staff as part of their job,

00:04:33:04 - 00:04:58:26
Tom Saggio, R.N.
and in the event that a code white is called, they can just leave their assigned team and come to provide support. Well, we knew that that just wasn't optimal. So we were addressing the increase in the workplace violence injuries that were happening. So we got back to the basics. And what it comes down to is that it takes time and repeated encounters to build relationships with patients.

00:04:58:28 - 00:05:14:10
Tom Saggio, R.N.
We knew that building the relationship with the patient is so important, and is basically the fundamental practice in behavioral medicine, establishing the relationship with the patient not in crisis establishes trust and psychological safety.

00:05:14:10 - 00:05:22:10
Jordan Steiger
And so what changes for the patient when they have those relationships built with your staff already before something escalates?

00:05:22:16 - 00:05:45:26
Tom Saggio, R.N.
So when we have trust in psychological safety established with the patients, when that patient becomes escalated, they're more apt to accept verbal direction or even accept PRN medications from a non-staff, because the BART team has worked with that patient. Triggers may have already been identified, such as phrases, commands or even appearances, so they can avoid further escalation.

00:05:45:28 - 00:06:28:02
Tom Saggio, R.N.
They also may be aware of de-escalation techniques or coping mechanisms that the patient and family have already done. So because that relationship has been established, they can use the familiarity to de-escalate the patient. This has greatly shown to decrease the need for physical intervention, restraint, seclusion, all potentially resulting in workplace violence injuries. So over the last three years since the onset of our BART team, we have cut our OSHA recordable events in half. And we've also reduced our number of code whites and really shown a lot of support to the staff,

00:06:28:02 - 00:06:33:18
Tom Saggio, R.N.
so their whole staff engagement and safety in the workplace has been improved.

00:06:33:25 - 00:06:58:27
Jordan Steiger
I mean, we know workplace violence is on the minds of everybody that works in a hospital in every role. So I think showing this commitment that you have to your staff is incredible. And it sounds like you do a great job too of incorporating the family and the support system of the patient. I know you're at a children's hospital, but I do think that there is a way that our adult, you know, people who care for adults can kind of incorporate that into their approach as well.

00:06:58:27 - 00:07:00:08
Jordan Steiger
So it's a great example.

00:07:00:09 - 00:07:01:08
Tom Saggio, R.N.
Oh, absolutely.

00:07:01:09 - 00:07:26:15
Jordan Steiger
So one thing I wanted to touch on a little bit more to is you mentioned using evidence based assessments and, you know, using Epic and things to kind of track people's behaviors and triggers and things like that. But sometimes, you know, this kind of can feel disconnected and kind of clinical, you know, when you're talking about like, oh, they scored on, you know, this number on this assessment, it's not really translating to the behavior, if that makes sense all the time.

00:07:26:15 - 00:07:34:10
Jordan Steiger
So how do you take some of those evidence based tools that you're using and make them feel like meaningful and patient centered?

00:07:34:13 - 00:07:58:08
Tom Saggio, R.N.
Sure. We really use two assessment tools: the Violence Assessment Tool, otherwise known as the VAT and the Broset. Both of those tools really are highlighted in our ED space. We have created an electronic staffing assignment tool, and within that assignment sheet, we've incorporated an acuity rating that looks at the VAT and the Broset. So bear with me

00:07:58:08 - 00:07:59:18
Tom Saggio, R.N.
this is all complicated.

00:07:59:19 - 00:08:00:16
Jordan Steiger
That's okay.

00:08:00:18 - 00:08:26:10
Tom Saggio, R.N.
But every behavioral health patient presenting to the ED will get assessed using the VAT in triage. That score gets entered into Epic. And that alerts all staff what the initial acuity would be with that patient. We have a dedicated behavioral health space in our ED with five rooms, and for those five rooms we have a daily assignment tool.

00:08:26:13 - 00:08:50:18
Tom Saggio, R.N.
Now, in that tool there is a section for each room that VAT from triage gets put as a standard score in that room for that patient in those five rooms. And we assess the patient using the Broset on admission and any time there is an escalation. Behind the scenes there's a whole lot of formulas going on. And

00:08:50:21 - 00:09:28:01
Tom Saggio, R.N.
while the VAT is scored 0 to 3 and the Broset is scored 0 to 6, those numbers are totaled for the area, and it results in an overall acuity score. So we as a behavioral health leadership team, have identified numeric thresholds. And at each threshold, we have outlined clear action items as interventions for potential workplace violence avoidance. At the end of the day, when the charge nurse enters in all of that data, it will score green, yellow, orange or red and it will have associated interventions.

00:09:28:01 - 00:09:56:28
Tom Saggio, R.N.
It can be as simple as sending out a group text to our behavioral health leadership team and our Ed leadership, or it can be a simple awareness text, and I need the BART team to more frequently round. I need public safety here to more frequently round or I need somebody here consistently. Sounds very complicated, but at the very end of the day, you fill out the form, you follow the provided guidance, and you send out a text with your needs.

00:09:57:01 - 00:10:15:22
Jordan Steiger
I mean, that makes total sense to me. And what I really like about what you just said is that it really takes the opportunity for bias out of the situation and stigma and just, you know, keeping it very objective and saying, this is what this patient needs to be successful in their care, and this is what the care team needs to be successful in caring for that patient.

00:10:15:25 - 00:10:38:21
Jordan Steiger
And so I think that's a really great example for listeners to maybe take back to their own organizations. For leaders listening to this podcast, other behavioral health leaders, maybe violence prevention leaders - what do you think is your biggest lesson learned from using this BART approach? And if somebody wanted to kind of take this and adapt it to their own organization, what would you tell them to do?

00:10:38:24 - 00:11:05:04
Tom Saggio, R.N.
I think the biggest lesson that we've learned is be proactive in addressing the potential for workplace violence. I can't stress that enough. It's being prepared. It's getting the needed training to the staff, providing the care for that patient. And it isn't just the RNs and the texts, it is the therapist. It is anybody who may come in contact, even down to your dietary people.

00:11:05:07 - 00:11:29:00
Tom Saggio, R.N.
The other things that I would promote is that just being a responder isn't effective if you have a responsibility to another job. So you can't do it as a second job to be on that team. But for the organizations who are looking to create this type of a team, you don't need a huge team to establish a standalone response team.

00:11:29:02 - 00:11:52:22
Tom Saggio, R.N.
Four years ago, when I started this journey to establish the BART team, I was looking at a team of dedicated 4 to 5 people. And now three years later, we found it very effective to have two people dedicated to that rule, one RN and one support staff. They've been very effective not only in our ED, but the inpatient areas in all areas of our campus and even the outpatient areas.

00:11:52:22 - 00:12:15:27
Tom Saggio, R.N.
So we've found very good success in our wound care center and our same day surgery. So we're finding new and creative ways to use the BART team here on campus. And we're working with our partners every day to see how we can help them and avoid the next workplace violence. So I think the best place to start is always data gathering.

00:12:15:28 - 00:12:48:16
Tom Saggio, R.N.
Take a look at your number of code events, number of your restraint events, and really do a deep dive into your workplace violence injuries. You should be able to get a cost of those injuries - the OSHA recordable and what they call the "dart" rate, days away restricted and transferred. Organizations should evaluate how much workplace violence events and injuries are costing your facility due to not only injury, but absences or even turnover.

00:12:48:19 - 00:13:13:04
Tom Saggio, R.N.
Engage your employees through surveys and get their feedback on the culture of safety surveys. Over the last three years, we have found that the BART team has had not only a huge impact on reducing the workplace violence injuries, but also affecting our turnover. This was really apparent on our medical floors, where the kids had behavioral health needs but were admitted for medical reasons.

00:13:13:07 - 00:13:37:18
Tom Saggio, R.N.
The nursing staff on the unit didn't feel prepared to take care of high needs behavioral health kids, and we experienced a lot of turnover. But because they had a person in the moment that they could reach out to provide support and education, within a year, we cut down the turnover rate and improved our satisfaction from our nurses on the medical units.

00:13:37:20 - 00:13:57:19
Jordan Steiger
That's incredible. As I know many people are out there figuring out how they can decrease turnover and keep the staff that they have and, you know, make sure that they're supported. I think that this is just such a great example that more people need to be aware of. Again, really focusing in on that prevention piece instead of the reactivity.

00:13:57:21 - 00:14:02:25
Jordan Steiger
So thank you so much for being here today and for sharing some of the amazing work that you've done.

00:14:03:02 - 00:14:15:18
Tom Saggio, R.N.
Thank you so much for having me. And you know, I am an open book and willing to share anything that I've learned. So if you want to include my name and contact information, I am more than happy to do that.

00:14:15:19 - 00:14:27:28
Jordan Steiger
We will definitely do that. And we have a short case study coming out about this approach in a new de-escalation resource that we're coming out with in September, so please be sure to read that as well.

00:14:28:01 - 00:14:36:24
Tom Haederle
Thanks for listening to Advancing Health. Please subscribe and rate us five stars on Apple Podcasts, Spotify, or wherever you get your podcasts.