A specialized care pathway for patients with autism spectrum disorder (ASD) reduced workplace violence events by nearly 50% while decreasing behavioral health stays by 19 days at St. Louis Children’s Hospital.
The pathway equips staff to help patients like Myles who spent nearly 18 months on a medical floor, says Thomas Saggio, the hospital’s director of behavioral health operations. “He kind of languished. The observers were afraid to interact with him. It wasn't until we put this program together and found people who wanted to work with him that we started to see results,” Saggio says.
‘Mylestones’ Treatment Pathway
Patients who don’t qualify for admission to the hospital’s inpatient behavioral health unit but can’t be discharged safely from the emergency department (ED) often end up on a medical floor. Staff who are accustomed to medical patients may not feel confident providing care.
The “Mylestones” Treatment Pathway was developed to give staff tools to prevent escalations while allowing patients opportunities for engagement and social interaction.
- At admission, the hospital’s applied behavioral analysis (ABA) therapist creates a behavior plan in the patient’s electronic medical record. The plan includes known triggers and de-escalation strategies.
- If the patient has a history of violence, the treatment team flags it in the EMR and provides a link to the behavior plan.
- To the extent possible, the same attending psychiatrist, nurses and observers work with the patient. The hospital maintains a pool of 30 “observers” who provide one-on-one care and a float pool of 10 behavioral health registered nurses who assist on medical floors.
- The team stays apprised of patients through twice-daily huddles and a shared document that’s updated in real time. Weekly discharge huddles identify barriers that may require additional resources and planning.
- Therapy schedules remain consistent so patients can anticipate their daily routines. Patients receive a visual schedule and digital timer so they can anticipate changes.
- Staff conduct environmental risk assessments to ensure patients are safe to visit other areas of the hospital.
The ABA therapist plays a vital role in developing the treatment plan and offers tips and tricks to help front-line staff care for the patient. Staff are also made aware of behavioral health personal protective equipment, such as face shields, bite guards and blocking shields.
Targeted education
Hospital leaders expanded learning opportunities by adding a behavioral health clinical educator who helps throughout the organization. Nurses and patient safety attendants received specific training on ASD. In its first year, more than 850 staff members completed the module.
Crisis response
Saggio says staff is adapting how it responds to crises. The team has linked the Broset Violence Checklist to PRN medication administration as a way to identify the correct medication to give during an escalated event. “We are also working on calling those events earlier so that the Behavioral Assessment and Response Team can arrive before the escalation becomes critical,” he says.
Enhanced staffing
St. Louis Children’s added two attending psychiatrists and five advanced practice nurses to work with patients on the medical floors. Additional RN navigators and social workers were added to facilitate transfers and make referrals to community resources. Registered Behavioral Technicians (RBTs) were brought on to support front-line staff.
Facility changes
The facilities department created six “preferred” rooms that transition between medical and behavioral health patients. The team removed blind corners and access to countertops. Window guards can be installed if needed. In one room, the team removed the code blue call button and nurse call system. This room is reserved for the highest acuity patients and cannot be used for medical patients. Behavioral patients in the room must always have an observer.
Additionally, a space in the ED was equipped with a shower and bathroom specifically for behavioral health patients. “It’s a quieter environment than the ED, which can be stimulating for this group of patients,” Saggio says.
Decreased workplace violence, shorter length of stay
The changes had a profound impact on Myles. During his last six months at St. Louis Children’s, his problem behavior decreased by 98.5% and caregivers saw a dramatic decrease in his PRN medication doses.
“The most beneficial piece was his social engagement went from one hour a day, just sitting in the dark, to 15 hours a day, where he was doing things like making brownies with our therapy department,” Saggio says.
Hospital-wide, the program made a significant difference:
- In 2021, there were 78 OSHA-recordable workplace violence events; in 2022, there were 40.
- Nursing turnover decreased from nearly 33% to around 13% a year later.
- Patients in the specialized pathway had an average length of stay of 26 days compared to 45 days for those not in the pathway.
Moving forward
The hospital’s Behavioral Assessment and Response Team (BART) will continue to respond to escalating situations, but Saggio says its primary role is interacting with high-risk patients.
“We reviewed the kiddos that had events for the last several years. We found seven or eight individual patients cause 50% of the workplace violence events. We want to engage these patients early, and we want to engage with these patients often. We want the team working ... to engage and to educate about the importance of adherence to behavioral plan and other things that attribute to successful outcomes,” Saggio says.
Saggio’s presentation, “Reduction in Workplace Violence Using a Specialized Care Pathway,” was an educational session at CHA’s 2023 Annual Leadership Conference.
