Buddy Up for Safety

Aim: : The goal of this project was to reduce the ED nurse verbal/physical assault rate through improved ways of identifying patients and visitors who could become aggressive, and finding a creative, non-threatening way to mark the room, so caregivers and support staff know to enter in pairs for safety.

Framework:: ADKAR (Awareness, Desire, Knowledge, Ability and Reinforcement)

Setting:: The setting of this project is a community hospital, level 2 trauma center, with 42,000 ED visits annually in the Midwest.

Stakeholder Team:: ED Clinical Director- Together with the Behavioral Health Specialist, we determined there was an opportunity to better identify ED patients who were not responding to de-escalation attempts. The clinical director provided subject matter expertise to ED nurse workflows and supported the implementation of the project.
Clinical Practice Specialist-provided staff training, leader rounding and accountability
Behavioral Health Specialist- explored best practices of other health system hospitals and EBP literature search. Proposed the adoption and implementation of the buddy signs. Created workplan education and communication plan. Tracked the data.
Risk Manager- assisted in developing a workflow and criteria for informing clinical staff of patients who may become violent
ED Medical Director- supported the new initiative by partnering from a provider perspective

Methods: : A nurse co-led a team including Risk, ED leadership, and a Behavior Health Educator reviewed past assault cases. Identification of the risky patient rooms was a key issue. They created a discrete, non-offensive sign to hang on doors of patients with history of aggression, medical record risk flag, or aggressive behavior currently. They determined parameters for when the sign should be used. Signs were ordered, a 4x4” magnet, later changed to 8x11 for better visibility. Tip sheets and flyers were emailed to 100% of ED staff, leaders, providers, and ancillary leaders. Workflow discussions occurred at daily shift huddles and when rounding. Sign usage was tracked.

Outcomes:: ED Buddy Sign usage is a success in reducing workplace violence. Baseline nurse assault rate/100 patient visits= 16.84%. Post-implementation nurse assault rate =10.04%/100 visits, (a 40.38%/100 patient decrease in physical and verbal assaults), improving the nurse care environment in the ED. Teamwork has improved, sharing when patients or families may be at risk for aggression, so the sign can be placed. Anecdotal reports of nurses and other caregivers also indicate that staff feel supported and empowered by the organization’s leadership to set limits on aggression and protect themselves.

Implications:: The success in the ED resulted in the dissemination and adoption of Buddy Signs house wide. Room numbers with Buddy Sign alerts are reported at the organization’s interdisciplinary leadership Daily Safety Huddle so that other leaders can inform their staff caring for those patients. The aim of this work is to empower the emergency department staff to proactively identify patients with prior history of aggression or currently aggressive and implement the buddy sign process and safety precautions to ensure their safety, reducing physical and verbal assaults.