Alright, so we're going to get started. Thank you all for being here. I was just waiting for the last person to arrive. Welcome to this cloudy Monday morning in New York City. Thank you for attending our talk on workplace violence, a very important topic. This is the program for today. I am Laura Safar. I am going to start with an overview about violence in the healthcare setting, including some definitions, prevalence, and interventions that we can put in place. Then Becky McCarthy, who is a member of our violence prevention committee at Lakey Hospital, will talk about a specific pilot that took place in our hospital, and Dr. Aquino will focus on the impact of violence for healthcare workers and measures we can take for their support. We have no disclosures. And these are just a couple of case vignettes that happen every day in our country. Healthcare workers who undergo a situation of violence, in this case two nurses in the emergency department who were attacked in different ways by patients. And when we analyze these situations and we do a root cause analysis, the questions we want to add are if these events are preventable and predictable. But also, is the level of injury preventable? So if we cannot prevent the violent event from happening, can we do things so that the injury of the healthcare worker is less severe? So we're going to start now with this overview. This is my outline. First, some definitions and prevalence data, then the evaluation aspects, and then the interventions. Definition from the Joint Commission, as you can see, is very wide. The definition of workplace violence is an act or a threat that takes place at the workplace that may include any of the below, but also is open to other possible events that may happen. And one key element when you are working in your health setting is also the perception of the healthcare worker, even if the event that happens is not included in this definition. Do they feel threatened? Do they feel intimidated? Did the situation feel unsafe? You want to pay attention to that as well. So as you can see here, workplace violence includes verbal violence, nonverbal, written or physical aggression, threatening, intimidating, harassing, humiliating words or actions, bullying, sabotage, sexual harassment, physical assaults, or any other behaviors or concerns that are brought forward. These are some of the types which are already included in the definition. And this is one of the common ways of classifying workplace violence is according to the relationship between the perpetrator and the workplace. So number one, the perpetrator has no relationship with the workplace. Let's say somebody comes and steals at the hospital. Type two, the perpetrator is a patient, and this is the most common nationwide. Type three, the perpetrator is a current or a former employee. This is the second most common in healthcare. Type four, the perpetrator has a relationship with an employee member. Let's say a husband who comes and abuses wife who is a nurse for instance in the workplace. We're going to look at some prevalence and incidence data. So nationwide, overall, workplace violence, about 60% of healthcare workers reported at some point during their career being the victims of workplace violence. Verbal violence, about 67%. Physical violence, 20% or so. The incidence and prevalence varies a lot between different settings. So the emergency department and the psychiatric wards are two of the settings with a higher rate of violence. And these are data for the emergency room. Both nurses and physicians can be victims of violence. As you can see, the incidence is higher for nurses, and that tends to correlate with patient contact time. When the physician is the victim, perpetrators, 90% of cases are the patients, 9% family members, 2% friends. What about us psychiatrists? 40% of psychiatrists, and this is over their career as opposed to the ED data which was in the previous year. So 40% of psychiatrists reported physical assault in a psychiatric setting. Typically the inpatient psych setting is more violent than outpatient or others. For all staff members in a psychiatric hospital, the annual incident of verbal conflict is 99% minded, so this includes security members, right? And physical assault, 70%. So that is the higher rate of violence in psychiatric settings, forensic psych hospitals. What about non-hospital settings outside of the hospital? Healthcare workers who practice emergency medical services, healthcare workers who practice home healthcare, and those in nursing homes are the most likely to be victims of violence. Something that grabs the national attention is shooting incidents in hospitals. And what is important, and we should pay attention to this, you have data here for more than a decade, year 2000 to 2011, there were 154 shootings reported in hospitals and hospital grounds in the whole country. So it's important to pay attention, but also not to over-focus on this, and when we train our healthcare employees to also take into account their training for more common situations, including the escalation of verbal assault or general physical assault without firearms. Another recommendation from this that is implemented nowadays in all hospitals is that no weapons are allowed in hospital grounds unless it's a security member or a police officer who is in active duty. So not even if they are here as a patient, et cetera, the weapons are not allowed in hospital grounds. Some factors that can contribute to workplace violence include clinical factors, factors related to the pace of the work and the scenario, and factors that have to do with specific locations. So we're going to talk later on some clinical examples in terms of work conditions, situations of high stress, high pace, poor communication, poor education of the staff, working at night, working in more isolated areas of the hospital. Those are some of the factors that increase the risk. From the emergency department, busy, long wait times, we all have patients now in our hallways, so the frustration, patients or family members who have a patient with a severe illness, they don't get information, they escalate. So crowded places, long wait times, lack of information, those are some of the contributing factors in the emergency department. What are the effects of workplace violence in our employees? You can see the list there. So the graphic on your left is missed days of work in different industries. The higher bars are for the state or federal healthcare settings. So the healthcare workers miss days of work because of violence at a higher rate than in other industries. In addition to missed workdays, having health problems, having injuries, a feeling of burnout, of decreased safety, decreased well-being, job dissatisfaction, decreased productivity and decreased quality of the care they provide, and then decreased retention. People leave and go to another job, but they also can leave the career. They leave healthcare in general. All this data that we are presenting, there are many limitations, even among different government agencies. The data they present is varied from one to the other. Academic studies because of recall bias, because of different definitions of violence events, because of using different instruments to measure violence. So all these data are limited. One of the big factors on data being limited that happens everywhere, including our hospital, is underreporting. Healthcare workers tend to underreport for a number of reasons. They don't think that it's important. They don't think that nothing will come of it. I'm going to waste time reporting and nothing will happen. Also because of the efforts of the work, right? It's part of the job. Sometimes patients, they are psychotic, right? So why should I report the situation? It's part of the clinical situation. So you have here some other examples of why people don't report. This happens among physicians and nurses. And the fear of retaliation or disapproval from a manager is something that we want to make sure you listen to. The importance of creating a culture of safety in the hospital where reporting is considered important and is expected. So some data from our hospital. This is for calendar year 2023. Here you see per month the number reported for verbal in red and physical abuse in blue. And as you can see, it hovers around 10 events of each per month, roughly. Again, this is grossly underreported. We know that the verbal events for sure are much more frequent. There is a further breakdown. So was there a threat of violence? Was there actual violence, et cetera, in different categories? And this is according to location of the nine places in our hospital with higher incidence. And you see that the emergency department, according to our congruent with national data, is a place where physical abuse is reported the most. If you take into account all reports in the year of physical violence, you see that there are many, many different units that reported one event in the whole year. This is another data that we look at is the employees' injuries. And you classify it according to the level of injury. So a minor one where there was no attention needed, and then from there first aid was required, medical attention was required, and then the more severe, both medical attention and missing days of work were required. This is for location of verbal abuse. You see here that the emergency room goes down in the incidence and prevalence, and you have now the operating room and some of the inpatient medical units. I want to clarify at this point, we do not have a psychiatry inpatient unit in our hospital. So all the data we're presenting is for the different clinics, the inpatient medical floors, and the emergency department. In our hospital, as it is the case nationwide, the perpetrators, 82% of cases are patients, and the healthcare workers affected, 78% of cases are female. Now we're going to move to assessment, and I'm going to discuss two different parts in the assessment. One is violence risk screening tools that we can use, formal tools, and then as a psychiatrist, what do we include in a clinical assessment? The goal for violence risk assessment tools, as the name indicates, is to be able to, in a practical manner, in a short period of time, and also predicting short-term risk in the next, for instance, 24 hours, identify patients who may be at increased risk of violence in the health setting where they are, so that we can implement measures to prevent violence or to prevent injuries. Typically, the tools are classified according to the setting they were developed for and the setting where they were tested, right, to assess their validity and reliability. So there are some tools that were developed for long-term psychiatric wards, others for short-term psychiatric wards, and then some for medical acute settings and the emergency department. They tend to assess some static factors, so for instance, the psychiatric diagnosis or if the person had a history of violence before, and some dynamic factors, which is, what is the behavior right now? Is the person agitated right now? This is a long list. As you can see, there is a large number for the first category, those developed for long-term psychiatric wards. This is just for your reference and the alphabetic list of all the developed tools. And for the purpose of our talk, in the general healthcare setting, we know that those that are short, brief, that can be implemented by a nurse or any other healthcare provider and that assess the behavior right now, more than prior history, are the most useful ones. And these are two of the set violence checklists that Becky will discuss more in detail, that even when they were developed initially for acute, for inpatient psych wards, they are also found to be helpful in the general healthcare setting. Besides contributing to a screening, what are other ways a psychiatrist and a mental health team that we can help our hospital and colleagues prevent and reduce violence or the effects of violence? That includes, we participate from the review of violent events, including the root cause analysis. We are members, we have representatives, in our case, Becky, of our hospital violence prevention committee. If there is a patient with risk of violence or who had a violent behavior, as you all know, we help with a consultation, with diagnosis, a risk assessment, and intervention, psychopharm, and behavioral to manage the violence. And then after events, we provide support to our colleagues and contribute to a culture of safety. In terms of the clinical assessment, so sometimes we forget, I think, as psychiatrists, to assess when we meet a patient, their risk for violence, the same way we do when we assess their risk for suicide. That may be different according to the setting where you practice. I know that I practice in outpatient psychiatry, and I'm always more focused on assessing for suicide risk and violence risk. It may be different if you're in the inpatient setting, in a forensic unit, of course, et cetera. But typically, what does it entail? The assessment of the risk of violence clinically, evaluating with a clinical interview. Sometimes you can add one of these screening tools. Having some degree of risk stratification. Is the risk mild, moderate, severe? Is it in the short term, imminent, or is the risk in general that this person presents? And as a psychiatrist, you can comment on what are the motivations behind the violence? Why is this person violent? What are the behavioral motivational factors for their behavior? Is the violence planned or impulsive? Do they have access to the target? Do they have a specific target? Do they have the means to do what they say they want to do or they are thinking of doing? And then the creation of a safety plan that depending on the situation may include psychiatric hospitalization, warning to the potential victim, et cetera. What happens with diagnosis? There are certain psychiatric diagnosis. So acute substance use, meaning somebody who is intoxicated, somebody who is detoxing, schizophrenia, spectrum disorders, especially during acute decompensated states, and personality disorders that have increased risk for violence. On the other hand, in the long term, you have some data here, the absolute rate of violence over five or 10 year period is typically below 5% for people with mental illness. So you don't want to fall into stigmatizing and based on somebody just having a diagnosis, assume that they are going to be violent. And certainly, a diagnosis does not predict violence in the short term in the healthcare setting. So besides the diagnosis is a long list here of demographic and clinical factors, but some factors that increase within a certain diagnosis, the risk for violence include a past history of violence, a criminal history, and comorbid or concurrent substance use. And these are the elements, and I think you probably all are familiar with this, of how do we do a violence assessment includes starting with evaluating, did you ever have these thoughts? How specific the thoughts were? Is it something that you have intent that you think you might do? Do you have a specific plan, target, the means? Did this ever happen to you before? And if it happens, what were some mitigating factors or some factors that may increase the risk of you doing this? So this takes you through all the steps to follow in a violence evaluation with a patient. If we don't have enough information from the patient itself, himself, themselves, then we're going to get data from collateral informant. And the APA, as well as other organizations, have clinical guidelines for the assessment and management of violence in different disorders. However, we have to, and you can go into the APA and look at each specific disorders, but there is more work that is needed in this regard. It's not something that is developed in detail for all the disorders. Now, moving on from assessment to interventions, we divide interventions in the literature. They are divided in interventions at the level of the organization, interventions that focus on education of the healthcare worker, and environmental modifications, how to engineer the place to reduce the risk of violence in the place. Before we go into specific interventions, some general discussion. Number one, why is so difficult to prevent workplace violence in the healthcare setting? One of the reasons is that there are so many factors involved that are so varied, right? So a variety of perpetrators, many times they are not part of the healthcare system, so we cannot totally control their behavior. The variety of events we discussed at the beginning, verbal, physical, et cetera. Different clinical situations, and also different settings. What works in the emergency department is not going to be the same that works in the outpatient psychiatric clinic. So the idea is that you want to have a general policy in your hospital, but then you need some specific site, specific situations or solutions. So the general framework needs to be multifaceted and with input from a multidisciplinary team. The joint commission has a certain workplace violence prevention requirements that all hospitals seeking joint commission of approval or accreditation need to comply with. And pretty much they are listed here. So you want first a general safety culture. So you want your employees to know that you're taking them seriously, that the expectation is that there is not going to be violence in the workplace, that if things happen, they have to report it. You want to educate your employees about how to screen for violence and how to respond to violence. You need to have a reliable reporting system. You need to be able to track the data. If you implement interventions, you need to be able to monitor if the interventions are being successful. You need to engage the healthcare workers in the different settings. Because of what I said before, that different settings have different problems and solutions. You need to pay attention to staffing, including having enough security staff. And you need to pay attention to the environment, the physical environment. And I'm gonna give some examples of this in a moment. So we have such a program in our hospital that counts with all these different components. In terms of the legislation, there is a current proposal of a law, the workplace violence prevention law that didn't go through the Senate. And different states have implemented state laws to protect healthcare workers. The organizational interventions are classified according to this Hadon matrix. In those that target the situation before the event happen, those that target the event itself and the post-event. And you can also classify them according to if the target of intervention is the healthcare worker, the perpetrator, or the environment in general. So you have some examples. This is a busy slide, but just to take you through some of them. If you focus on the healthcare worker, organization-wide interventions pre-event are going to be to teach them about risk assessment. During the event, you're going to explain or teach them and also practice skills for de-escalation. And post-event, we already discussed reporting. For the patient pre-event, you want to provide education to patients about zero tolerance for violence in your hospital. During the event is where, after the assessment of the situation, interventions such as restraints or medications will need to take place. And the follow-up, it could go from barring the patient from the healthcare setting or investigating why did this person become violent and what were the triggers and how can we reintegrate the patient into our health setting. The educational interventions need to have two components. Ideally, one is education content itself, and the other one is the practice of actual skills, for instance, in de-escalation or self-defense. This is a Cochrane review of educational interventions in the US that were tested. And as you can see from top to bottom, they go from shorter online interventions to longer interventions that also include a face-to-face component and practice. And what were the effects? In general, and this also applies to organizational interventions, interventions have not demonstrated a reduction in the rate of violence events taking place. What the interventions can do is to increase healthcare worker awareness, maybe reduce the severity of the injury they may have, having a higher sense of confidence, a higher sense of accomplishment, a higher sense of security in that they can tackle such situations, but they have not demonstrated reducing the prevalence or incidence itself. And lastly, environmental modifications is where you pay attention to the work setting and what changes can you bring to improve safety. And typically, again, you want to include the healthcare workers from the specific setting because they know in their inpatient psych unit, for instance, there is this blind spot where when a patient is there, I don't see them, right? And these are some examples of environmental modifications. Number one, access control. Do you have a unit or an area that is locked or unlocked? Do people need to show their ID or not? Natural surveillance, where I mentioned about the psych unit with the blind spot. People need to be seen at all times, both patients and staff members, illumination of the area. And then in general, designing the space so that it has all the resources physically so that you can provide safe care. So that is the end of my talk. Thank you for your attention. And now we're going to listen from Rebecca McCarty who will talk about the pilot in our hospital. Thank you. Good morning. Thank you for joining us today to discuss this very important topic. Today I'll be discussing violence risk assessment and response initiatives in psychiatric care with a focus on the pilot study conducted at our teaching hospital using the BROSET violence checklist or BVC screening tool. Violence in healthcare and settings, as Dr. Safar talked about, is a significant challenge and our pilot aimed to address it directly with use of a risk assessment screening tool. I'll be sharing some outcomes of our study, its implications, and how it can hopefully inform our practice moving forward. As we just heard from Dr. Safar, violence against healthcare workers is increasing and regulatory agencies like the Joint Commission are taking notice. Studies have shown that exposure to workplace violence affects our ability to provide effective care, can lead to psychological distress, job dissatisfaction, early burnout among healthcare workers, just to mention a few. It's no surprise that this often results in high turnover rates and lower retention rates and ultimately driving up costs for healthcare organizations. So when we talk about violence risk assessment and response initiatives, we're not just talking about checking off boxes or meeting regulatory requirements. We're talking about safeguarding the well-being of our colleagues, preserving the quality of patient care, and ensuring sustainability for our healthcare programs and healthcare systems. Today I'll be sharing a case study using our hospital as an example. I'll be focusing on our workplace violence prevention initiatives and on the process of the implementation of a violence risk assessment tool and a tertiary care academic hospital where we conducted a 90-day pilot using the BBC screening tool. Here's a little background about our hospital. As Dr. Safar mentioned a little, it's Lahey Hospital Medical Center. We're located in Burlington, Massachusetts. For those of you not around here, it's about 12 miles northwest of Boston. Lahey's a level one trauma center with 335 inpatient beds. As Dr. Safar mentioned, we do not have an inpatient psychiatry unit in this hospital, but we do have an active CL psychiatry service. We are also part of a larger healthcare network that's Israel Lahey Health. All right, so by having clear definitions and policies in place, Lahey aims to address and prevent workplace violence effectively. The measures contribute to fostering a culture of safety and respect within the hospital environment. And Lahey Hospital Workplace Violence Prevention Program includes in its policy that Lahey seeks to create an environment of healing and safety where patients, visitors, and employees are safe from acts of violence. And when it comes to workplace violence, Lahey does follow the Joint Commission's guidelines and definitions as Dr. Safar reviewed. Here's a brief review of our timeline and some highlights from our initiative. So starting back in November of 2021, Lahey formed the Workplace Violence Prevention Committee. In December of 21, the committee had discussions about the potential value of incorporating a clinical violence assessment tool. In April of 22, members of the committee met with the Nursing Quality and Safety Council to explore further integration of the violence assessment tool. And then in May of 23, we initiated a 90-day pilot assessment phase with the BROSET screening tool and two inpatient units in our hospital that then concluded in August of 23. And then we'll go into some of that in a little more detail. Our Workplace Violence Prevention Program at Lahey is committed to providing a safe, respectful, and non-threatening environment for everyone. As part of our hospital code of conduct, we emphasize treating each other with respect, inclusion, and belonging, fostering a safe workplace. The expectation is that no individual may engage in conduct that intimidates, threatens, or harms patients, visitors, or employees. The program aims to prevent such behavior and, if unavoidable, respond promptly and effectively to minimize harm and prevent recurrence. In addition, reporting acts of violence, as Dr. Safar discussed, is crucial so they can be investigated thoroughly, responded to appropriately, and so victims can be supported. Lahey is dedicated to implementing policies, procedures, and training programs for all employees, including equipping staff with the knowledge and skills necessary to recognize, prevent, and respond to acts of violence within our facility. So, to achieve this goal, Lahey formed the Workplace Violence Prevention Committee for the development and implementation of the practices, policies, training, and supports needed to maintain a safe, non-threatening environment for all colleagues, patients, visitors, and others. Our committee members represent various departments and disciplines, to name a few, security, risk management, nursing, psychiatry, emergency department, legal, human resources, and employee health. This broad representation promotes that all perspectives are considered in efforts to maintain a safe environment for everyone. The actions of the Workplace Violence Prevention Committee are varied and encompass multiple responsibilities, such as attending monthly committee meetings, reviewing workplace violence incidents, analyzing STARS safety incident reporting data, and providing feedback and suggestions for improvement. Sorry about that, okay, here we go. Moving along, in December of 21, our Workplace Violence Prevention Committee members engaged in discussions regarding the potential value of integrating a clinical violence assessment tool into our safety protocols. During these meetings, we discussed rolling out a pilot program within our hospital and considered carefully several different tools. Among the tools we considered were the Bureau of Violence Checklist, the BBC, the Aggressive Behavior Risk Assessment Tool and the Stamp Observation Tool. And additionally, we discussed the potential intervention of implementing a behavioral emergency response team, which we do not currently have at our hospital. And then after deliberation and review, we did ultimately choose the BBC, which you'll hear more about, and so I won't go into the others in detail. So the Bureau of Violence Checklist, BBC, is an evidence-based risk assessment tool used in healthcare settings to predict the risk of inpatient violence. It was developed in Norway in the mid-1990s. The checklist consists of six items that assess the presence of symptoms, such as irritability, confusion, verbal threats or physical aggression. Healthcare professionals use the BBC to identify patients at risk of exhibiting violent behavior, allowing for early intervention and preventive measures to ensure the safety of patients, staff and others in the healthcare environment. A systematic review published in 2022 underscored the effectiveness of the BBC in predicting inpatient violence. The review concluded that the BBC demonstrates high predictive validity and good clinical utility across diverse settings and cultures. Also notably, the BBC is designed to be brief and easy to use, making it accessible for healthcare professionals in various settings. So let's take a closer look at the BBC screening tool and how it works. The tool consists of six items, each designed to assess specific behaviors associated with potential violence. The six items include behaviors such as confusion. This item evaluates whether the individual appears obviously confused and disoriented. They may be unaware of time, place or person. Irritability, is the individual easily annoyed or angered and unable to tolerate the presence of others. Boisterousness, this item evaluates whether, this item evaluates whether the individual's behavior is overtly loud or noisy, such as slamming doors or shouting out when talking. Physically threatening, is there a definite intent to physically threaten another person, such as taking an aggressive stance or raising a fist. Verbally threatening, evaluates whether there's a verbal outburst that goes beyond a raised voice and includes a definite intent to intimidate or threaten another person, such as verbal attacks or name calling. And then attacking objects, assesses whether the individual directs an attack at an object rather than an individual, such as throwing objects or smashing furniture. And these items are assessed based on observations from nursing staff. The scoring system is straightforward. Each item is scored based on the presence or absence of the behavior within the past 24 hours. A score of one is assigned to each behavior present, resulting in a total score ranging from zero to six. A higher score indicates a greater risk of imminent violence, prompting healthcare professionals to implement appropriate interventions to mitigate risk and ensure the safety of all individuals involved. Again, I'm having problems moving forward. There we go. And here's just another look at the BBC tool and how it could be incorporated into a nursing flow sheet. And our focus now shifts back to the implementation of our pilot study, where the Violence Prevention Committee took proactive steps to implement the BBC tool prior to initiating the 90 day study. The initiative aimed to bolster our workplace violence prevention strategies, ensure the safety of our staff and patients, and reduce use of restrictive measures such as restraints and seclusion. For the pilot study, two units were identified, one in an intensive care unit and another in a combined progressive care and general medical surgical unit. These units were selected to capture a diverse range of patient populations and healthcare settings. However, before delving more into that part of the pilot implementation, let's go back and highlight some of the additional steps and collaborative measures taken to prepare. So going back to April of 22, the Violence Prevention Committee met with the Nursing Quality and Safety Council with the objective to engage in dialogue about the BBC and solicit feedback from the bedside nurses. It's important to emphasize the significance of obtaining buy-in from nursing staff. As frontline caregivers, their perspectives and insights are invaluable in shaping the success of our initiatives. We sought to ensure their support and involvement from the outset. Additionally, efforts were made to navigate the logistical aspects, including obtaining financial and licensure approvals for the BBC. Here are some key factors we considered when developing our program. We chose two units, decided on a 90-day duration, determined assessment timing and frequency, and planned communication and response protocols. We collaborated with IT for EPIC integration, conducted nursing education, and designed pre- and post-pilot surveys for feedback. We also outlined psychiatry's role and potential for involvement in managing high-risk situations. Oh, my goodness. And... It's not moving forward again. When you're scrolling, it takes the focus from the... So, maybe I just click on this. You have to go back. Yeah. Yeah. Okay. All right. So, to begin with, we carefully selected two units for the pilot. And despite the emergency department's higher incidence of violent events in our hospital, we excluded it due to its unique workflow, which might not be easily applicable or translatable hospital-wide after a pilot. Our educational efforts focused on training nursing staff specifically in the BBC so they would be familiar with the tool. We also introduced pre- and post-pilot surveys for nursing staff, and these surveys aim to gather insights into their perception and experiences with the BBC before and after implementation. In collaboration with our nursing colleagues, we decided on scheduled assessments or screenings upon admission and then every 24 hours thereafter, with a particular emphasis on the evening shift. This decision aimed to capture behavioral changes such as sundowning in patients with dementia. Additionally, we considered the documentation burden for nurses. Nursing management expressed concerns about this, and they were separately working on efforts to reduce documentation burden for their nursing staff. Excessive documentation requirements can place strain on nursing staff, leading to increased stress, fatigue, and potential errors in documentation and patient care. So, it's important for healthcare organizations and initiatives to strike a balance between ensuring comprehensive documentation and minimizing the burden on nursing staff to maintain optimal patient care and staff well-being. Additional considerations included how we plan to activate responses and implement interventions within our pilot program. To ensure effective communication and response activation, we focused on enhancing security and nursing awareness. This involved collaborative efforts with our IT department to develop a flagging process within the patient's electronic record in Epic. We also devised interventions for patients identified as high-risk, meaning patients with a BBC score of greater than or equal to three. These interventions included implementing a risk behavior warning or flag within the patient's chart, visible to all users accessing the record in Epic. In addition, we implemented visual alerts outside the patient's room, signage on the door such as, stop, see the nurse before entering, signs to alert all staff to potential risks. We established protocols for notifying security to activate a response, fostering collaboration between security personnel and nursing staff. This included extra rounding and regular check-ins with the charge nurse. Furthermore, there were recommendations in the chart for the use of team interventions, such as implementing a buddy system for staff when entering the patient's room, such as to provide patient care. Okay, so now let's talk about how psychiatry was involved in the process. For patients identified as high-risk with a BBC score of greater than or equal to three, we implemented a best practice advisory alert prompting for the consideration to consult psychiatry. We went back and forth a little on whether to automatically or proactively consult psychiatry, and one concern was whether this would flood our CL service with too many consults, and we also wondered could our CL service handle that influx? And would we end up maybe with some consults that didn't really need psychiatric attention? So this raised questions about staffing and resource allocation. On the upside, this presented an opportunity and discussion for consideration of maybe a more proactive CL approach. For instance, we could target patients with conditions like dementia, delirium, or substance abuse and withdrawal, where early psychiatric intervention could be particularly beneficial. Before and after the three-month pilot, a nursing survey was given to all the nurses on the two relevant units. We asked questions like, I feel safe when caring for patients with potential risk behaviors, I feel confident in my skills, and the last 30 days, how often have you faced physical violence from a patient? Here's a list of the full survey, and responses were answered with a range from strongly agree, disagree, neutral, to all the way to strongly agree, and then after the pilot, we followed up with additional questions such as rate your experience using the BBC, and their nurses' responses helped us provide valuable insights into the experiences and perceptions of the nursing staff. And here, we have a comparison of the pre- and post-survey responses from our nursing nurses for each question, and the blue bar represents the pre-pilot answers, and the green bar represents the post-pilot responses. And overall, what you can see is it does seem to show a positive trend, suggesting that the implementation of the BBC and associated interventions had a beneficial impact on our nursing staff's sense of increased confidence and feeling more supported in caring for potentially violent patients. And here, we have the post-pilot survey response, rating their experience with the BBC, and as depicted in the graph, the majority of responses fell within the good to excellent range on the rating scale, indicating an overall positive experience. And then, in addition, the nurses were able to provide some of their own comments in the surveys, and here's a selection from the pre-pilot survey. Nurses commented that they would feel more reassured having a partner to work with, desiring more active involvement from security, expressing the need for more experiences to help them feel more confident in managing verbally and physically violent patients, and emphasizing the importance of having a clear plan moving forward. And then, here, we have some comments from the post-pilot survey. Nurses had comments like it was a very easy-to-use tool and does not take long at all either. Security was aware of potentially dangerous patients, and they rounded regularly to check in. It's quick and easy. I do believe it helped to identify some high-risk patients. And then, one nurse commented, during a float, I was unable to get support from a physician for an agitated patient. The patient was scoring on the Broset scale, triggering a security response to the bedside. Thereafter, I was able to receive physician support. And then, additional comments, just sort of highlighting, they felt pleased that the security was more present and that it was easy to use. And that it was very straightforward. One nurse commented, I liked how it flagged potentially violent patients, but I didn't like how it prompted a psych and security notification that would not go away if a patient scored. I didn't think all of these patients needed a psych consult, and it bothered me that the notification would not stop popping up in Epic. So, overall, though, the responses did convey a sense of increased confidence, support, and safety among our nursing staff who participated in the pilot program. All right, so now let's review some of the data collected from this three-month pilot period. We observed that a significant portion of our medically-admitted patients to the two relevant units underwent screening. Specifically, 882 out of the 927 total patients who were admitted during that time frame, so accounting for about 95% were screened during that pilot. Out of the screenings, 25 patients, so only about 3% of the total, screened positive, meaning considered to be high-risk with a score of greater than or equal to 3. The average age of these patients was 68. And additionally, a substantial majority, 68%, so 17 out of the 25 patients who screened positive were diagnosed with delirium during their stay. It's also noteworthy that all of these patients, so those 17 out of the 25, had a diagnosis of dementia. Furthermore, 10 out of the 25 patients, so 40% received psychiatry consults. So, continuing our review of the data, we'll take a closer look at the outcomes for those 25 patients who screened positive on the BBC. As previously mentioned, 10 out of the 25 patients who screened positive had consults placed for psychiatry. Eight out of those 10 patients who received psychiatry consults were diagnosed with delirium, highlighting the prevalence of this condition among patients at risk for violence. Three of the consults were specifically for managing agitation within the context of delirium. Additionally, four consults were placed, were initiated for depression or suicidal ideation, with one case later diagnosed as a hypoactive delirium. Two of the psychiatry consults were for opioid withdrawal management, underscoring the importance of addressing substance withdrawal in patients at risk for violence. One patient who was consulted as a result of a positive screen on BBC declined to be seen by psychiatry and was not evaluated. It's also worth noting that five out of the 10 consults were actually placed preemptively before the patients actually scored positive on the BBC, reflecting proactive intervention strategies implemented by our healthcare team. So after reviewing these outcomes and data, some key takeaways emerged. Overall, it seemed that the results and responses trended towards positive, with nursing staff expressing increased confidence and safely caring for patients at risk for violence. In the Workplace Violence Prevention Committee at Lee, he has recommended a full-scale rollout of using the BBC screening tool across our institution. While the pilot seemed to demonstrate improved comfort and confidence among staff in managing potentially violent situations, it remains uncertain whether we effectively reduced the number of violent incidents or use of restraints. And while our overarching goals certainly remain to reduce workplace violence incidents, enhance staff confidence in handling such situations, and ultimately decrease the incidence of physical injury and psychological distress among frontline workers, we acknowledge the potential challenges moving forward. Defining and accurately monitoring violent incidents pose notable challenges, and gathering comprehensive data to capture all instances of violence remains complex. So back to where we started. Violence in the inpatient setting is increasingly becoming a focus of hospitals across the country, and psychiatry consultation services are often relied upon to help manage difficult clinical situations involving agitation and risk of harm. These consultations may include recommendations for psychopharmacological interventions, safety precautions, level of care determinations, or collaboration with care teams, just to name a few. Providing support to frontline staff is essential in navigating these complex situations. Looking forward, I think there's an opportunity to explore proactive strategies for patients identified as high-risk for violence. For example, in our institution, we could consider implementing that more proactive psychiatry consultations for identified high-risk populations, such as those with dementia, delirium, or substance abuse and withdrawal. However, it is crucial to carefully evaluate the potential impact on psychiatry consultation volume, and ensure that resources are appropriately allocated to meet these demands. So, to sum up, we reviewed the importance of addressing violence risks in hospital settings. By implementing tools like the BBC and fostering collaboration among staff, there's opportunity to take steps forward towards creating safer environments for all. And as psychiatric and mental health professionals, our expertise and insights are invaluable in this endeavor. Our contributions in managing psychiatric conditions and addressing behavioral challenges can play a pivotal role in enhancing patients' safety and staff well-being. Moving forward, let's continue to refine our strategies, prioritize safety, and advocate for comprehensive violence prevention programs that integrate psychiatric perspectives. Thank you all for listening and for your dedication to making our hospitals a safer place for everyone. And that is my talk. Thank you. So good morning, everybody, and thanks for staying with us here. So I'm Patrick Aquino. And just a quick understanding of who's here in the audience, show of hands about where folks may work, your types of locations. So those in an inpatient setting? Outpatient? Anybody a part of any kind of physician or provider wellness programs? Anybody participate in any kind of hospital or initiatives on violence, workplace safety, et cetera? Fantastic, OK. So I'll jump in here in terms of trying to wrap us in where Dr. Safar had mentioned to us kind of what leads into some risk factors for violence, considerations of ways we may think about preventing future violent acts. Ms. McCarthy showed us what a potential intervention was in our hospital. And I'll try to focus a little bit more on what do we do in the aftermath and how do we support our colleagues and individuals who are themselves experienced violence in the workplace. These are some of the data that Dr. Safar had mentioned before. And I won't go through them except to just recognize that it affects all of us. So all members of the care team across that we work with can be victims themselves of workplace violence. And did want to highlight that last data point there that in this review of Phillips, they cited a particular article that surveyed pediatric residents. And in that survey, 71% of those residents reported that they had not received any type of learning or training about workplace violence and that the majority of them believe that they may benefit from the training in how to manage client anger. And going back to what Dr. Safar had mentioned, it's not that the trainings themselves may have sufficient evidence to demonstrate a reduction in violence, but there is a significant impact on the individual's sense of security and knowing that they may be able to handle specific situations. The Joint Commission, we've mentioned a couple of times, but is one of several agencies that's highlighted the importance of addressing workplace violence. This is the Sentinel Event Alert Newsletter. Some of you may get this or review this, but it identifies specific types of adverse events and high-risk conditions. It describes their common underlying causes and recommends steps that organizations can do to reduce the risk and prevent future occurrences. It's been circulating since 98, and the particular one we're focusing in on is from 2018 on the prevention of workplace violence in health care settings, which was later revised in 2021. What it highlighted were the contributing factors, which may be targets for us in terms of how we can connect them to interventions later to support colleagues that have experienced workplace violence. They specifically highlighted stressful working conditions, inadequate training, understaffing, and staff feeling isolated. And it's for us to think about what the experiences may be like for ourselves or our colleagues that work in these type of conditions and how they make us vulnerable. This kind of multifaceted framework is ultimately to create a culture of safety within organizations with the goal of prevention of violence and ultimately trying to counter this misheld belief that experiencing violence is part of the job of being in health care. Overall, we've been able to express the importance that any of these initiatives, it is about ongoing data collection and analyses, about understanding your different processes within your organization. And that ideally, these efforts to prevent violence as much as possible, and where our discussion thus far has focused on the potential for violence prevention, we're going to start to focus about caring for those individuals who do experience violence in the workplace. So if you can recall some of those contributing factors to workplace violence, reflect back on the experiences that many health care workers, yourselves may be included, had during the pandemic. So these are data from the CDC. They were published at the height of the pandemic and just documented the significant impact on our mental health that working in the pandemic had. So highlighted in this survey, respondents thought they had worsened symptoms that led to increases in exhaustion, in medical errors, and a lack of empathy. 40% reported of a mental disorder during that time. All of that to say is that health care workers were already a vulnerable population with an increased additional risk factors for experiencing violence and having, essentially, be an additional trauma in the workplace. And I don't want to gloss over that environment in which we and our colleagues are practicing. As we mentioned, solutions to understanding and preventing violence need to understand these environmental factors that are going to contribute to these overall experiences. So the epidemic of burnout, which was obviously present before the pandemic, was really only exacerbated during that time period. And many of the same contributing factors that increase risks for workplace violence, so isolation, understaffing, lack of support, are the same ones that also contribute to burnout in our individual colleagues. So these are pre-pandemic burnout data. They're from the National Academy of Medicine, which was part of their Action Collaborative on Clinician Well-Being. And so as psychiatrists and physicians, we obviously are alarmed by more than just the high rates of burnout that include our trainees who haven't even yet begun their professional careers, but kind of the significant impact on the mental health of our providers and caregivers that include increased rates of depression and trauma and suicide. So in 2017, as I mentioned, the National Academy of Medicine launched this Action Collaborative. The main goals were to raise the visibility of clinician anxiety, burnout, depression, stress, and suicide. So it was around raising national awareness, improving kind of the understanding of the challenges that exist to improving clinician well-being, and how they can advance kind of evidence-based, multidisciplinary solutions to improve patient care by caring for the caregiver. And the work is ongoing in other organizations, ours included. And what we propose is that many of the same interventions that are identified to care for the caregiver are going to be applicable to caring for colleagues who experience workplace violence. And that as organizations, if you're committed to this work, you can begin to align these efforts around patient and colleague safety, quality of care, and colleague well-being. And by aligning these strategies, can really create environments for sustainable action in the organization. These are data from Morbidity and Mortality Weekly Report published by the CDC. You can see that the dates align with the Joint Commission Sentinel event reports and the revised standards that I mentioned earlier, and just the worsening impacts on health care workers overall. So you can see that burnout rates have increased, as well as reported harassment has increased over that same time period. And when we look at harassment in particular, and noting that Drs. Farr had mentioned, definitions are important when we think about kind of how we report this. You see that the impacts separated in terms of anxiety, depression, and burnout worsen for those people who had reported or experienced harassment. The Agency of Health Care Research and Quality has posited this rise in violence during the pandemic has been attributed to increases in stress, anxiety, and isolation for our patients and our providers, as well as kind of the ongoing staffing issues and burnout that many of our organizations are facing. We've touched on the multiple impacts of workplace violence on organizations and individuals. And though we will discuss some of those interventions at the individual level that may target the personal toll one can experience, it really can't be under-emphasized the role and responsibility of our organizations to be the catalyst for change. So these are impacts that the organization can be measured by key performance indicators that many of your administrators are going to be tracking and accountable for. We talked about missed days of work, cost of care, and turnover for colleagues. But as we begin to consider how to approach our colleagues who have experienced workplace violence, it's helpful to have a framework to consider that experience of violence. And here I just share with you one model. These are the three E's from SAMHSA. It can be a useful tool for us, where we begin to kind of consider the effect of the experience of trauma at the individual level. So as it moves from kind of event and experience, we'll now start to focus on the effects. And when we think about the effect, there are many, but one in particular is the development of psychiatric illness, and in particular, depressive illness, and how among physician professionals and health care workers in general, there already is a gap in kind of the recognition and treatment of our colleagues in the health care setting. In depression in particular, it really is thoughtful about how it can manifest differently in physicians. So on the left, for many folks here, this is that rubric for the symptoms of major depressive disorder we've all used and trained with over the years. So it should be very familiar. But what I really want us to focus in on is how it may present differently or be experienced differently for health care professionals or physicians, thinking that they may be the language they may use or how they present may be different in terms of depletion or denial, criticism and decisiveness, irritability, and a tendency to either avoid help and unfortunately, having increased risks or access to substances. And though this isn't a talk on physician suicide, it is worth mentioning in this context, depression is a major risk factor for suicide completion. For physicians, we have a higher rate than the general population, and we tend to be more lethal when it does occur. And when we think about interventions to support our colleagues in the workplace, we should understand that there are barriers that exist to accepting support or seeking treatment by individuals and what we can do to kind of help break down some of those barriers. This is an older article from Academic Medicine that looked at medical students versus faculty and reasons that they may or may not seek care. And there are differences between the two cohorts. And though in the intervening decades, really, we've had or seen growth in different types of physician and provider health programs and advocacy, obviously, for the mental well-being of physicians and our health care colleagues, including here through the APA, it's allowed us to have some more conversations about acknowledging the challenges and struggles of working in health care and the health, the impact on our own mental health. But there still are barriers that people won't and don't seek care. This is a part of a framework from the Joint Commission, which is one of those agencies we've mentioned several times. And I want to focus about where this particular framework overlaps and aligns with those threes from SAMHSA. And if we focus here on the right, what we're seeing are areas of potential intervention with our colleagues who have experienced workplace violence. So thinking about things that could be targets for us in supporting them are increasing team cohesiveness, positive and timely psychological supports, and enhancing the workplace. These are those Joint Commission standards you saw earlier. And I just show them here for you as a reminder that this really is a continuous process and that any single intervention that's targeted at the individual level, that's not really our final destination, but is part of our ongoing efforts around stakeholder engagement with data-driven analysis and continued process improvement, much what you saw with Ms. McCarthy's presentation in terms of our particular efforts in growing that service. The Joint Commission that we've talked about several times is not the only organization doing this. The American Hospital Association also has a playbook and framework for this. What's helpful about their framework is different is that they actually add in the idea of trauma support. So as a specific call out in terms of what they should be doing as organizations in terms of managing this. For those of you who may be doing this work or are working on this work, I want to encourage you to reach out to the Joint Commission For those of you who may be doing this work or working in hospitals and health organizations, some of these types of supports or names may be familiar to you. I'm going to spend a little bit of time so we have a shared definition about them, review some of the older interventions that people may still be experiencing in some of their places and some of the more recent interventions that others may have experience with. So I'll start with critical instance stress debriefing. This is an older intervention that some of you may be familiar with. It is a process that's intended to prevent or limit the development of post-traumatic stress in people that are exposed to critical incidents. It is professionally conducted debriefings. They're generally done in small facilitated groups, conducted within days to weeks of the events or experience. And I won't go into more of the details, but there's seven phases around it that folks go into as a part of this kind of structured intervention. Unfortunately, there was an early Cochran review back in 2002 that looked at a number of different trials around the use of critical instance stress debriefing. The trials were generally of low quality, but there was no evidence that debriefing reduced any general psychological morbidity, depression, or anxiety. In fact, one of the trials that was reported, there was a significantly increased risk of PTSD in those who had received the debriefing. Oftentimes, these were mandated types of debriefing in critical incidents or events. The reviewers at that time had reported there was no current evidence that this was a useful treatment and said that compulsory debriefing of victims should not be completed. From that evolved something called critical instance stress management. I don't know if folks use this. It's a broader framework to think about how to manage kind of stressful incidents or critical incidents. These are guidelines for early intervention after trauma and disaster. Their goals, ultimately, similar to the stress debriefing, was to promote safety, calm, connectedness, efficacy, and ultimately hope. It really is a comprehensive and integrative multi-component type of system to do that. And I'll talk about kind of what some of those core elements are of this. You can see the core elements there are seven. But to highlight in the middle there is number four, which is that critical instance stress debriefing is actually still a core component of this particular intervention. So just to think about this model. So if you happen to work in certain organizations that might partner with other agencies to help provide some of the support, some of this still occurs. But just so you have a knowledge and understanding of kind of what's actually being delivered to your folks. What's added here, different from just critical instance stress debriefing, is really the final steps, which are thinking about kind of having a specific call out for follow up and referral mechanisms for individuals. Recent meta-analysis looking at critical instance stress management did not find any consistent evidence that psychological debriefing helps to prevent or reduce PTSD symptoms following work-related trauma. So we do it, and institutions provide debriefing. But it's for us to think about kind of what is the role of debriefing in our teams and what are we expecting to have as the outcome of it. And thinking about the Red Cross as one particular agency that works in this space, they actually do not recommend their group to utilize critical instance stress debriefing or stress management in the settings of critical traumas. Wanted to show another type of debriefing model. This is something called learning-oriented debriefing. It's a newer type of model. And it's really set up to promote a culture of safety. And though it shares the word debriefing, it is very different. It's learning-oriented, so this isn't around trauma orientation. It's about learning. And it's about creating a health care team to think about events and how, as a team, we can do this. And this is part of that team cohesiveness and connectedness and ability to provide support. And this is a model that can allow one to do that. What's very important in this particular learning orientation is that leaders who are doing this are very intentional about what the framework is in terms of they're doing and that they are listening for signs of individuals who may be reporting kind of signs of distress or stress and are able to switch from a learning orientation and to help those individuals get connected to specific, individualized, and targeted supports. Psychological first aid is another potential intervention that you may encounter in your organizations. And this relies on field-tested, evidence-informed strategies that can be provided in a variety of disaster settings. It's going to emphasize a flexible approach to implement supportive activities and it's going to do so through a number of basic objectives. Psychological first aid is supported by many mental health providers and disaster providers when responding to the needs of both individuals and communities, but the model itself still requires ongoing systematic empirical support. The components of the model, though, are themselves individually research-informed and there is variable expert consensus about kind of the effectiveness of the components themselves. So psychological first aid has been adapted for specific situations, including one adaptation is stress first aid for healthcare workers, and this is an example that our institution rolled out during the early part of the pandemic as part of a multifaceted toolbox to support our colleagues during the time. You can see its core functions really are related to and based on the stress continuum model, and I'll talk a little bit about what that is. And its goal is trying to really promote recovery from these stressful reactions and how we're going to provide immediate responses and support for individuals. So the stress continuum model, I don't know if folks use this or are familiar with this in your organization, what we've liked about it and the reason we used it or based some of this off is that it really is a system of classification. It uses a common language and identification system, recognizing kind of that stress is different and injury is different across a spectrum and that there is an empirical validation for this use in individuals, especially at the higher categories. So stress first aid for healthcare workers, these are those five essential elements. Ultimately it is around promoting a sense of safety, promoting calming, connectedness, a sense of self and collective efficacy and ultimately helping to provide a sense and promote a sense of hope. The seven core functions of stress first aid begins with assessing current levels of distress and function, including the immediate risks. It works to ensure immediate safety and protection from additional stress, creates a calming environment to reduce arousal and intensity of negative motions through empathic listening, connecting and problem solving to remove obstacles to support and ultimately helping to rebuild back the individual to functioning and helping them to foster trust back in their team and their environment. The model of this kind of stress first aid and the stress continuum is that it can be adapted across a number of different traumatic experiences. So if we think beyond just workplace violence and what we've really been focusing in on is this kind of traumatic injury that can occur, but there are many other injuries that occur to our colleagues in the workplace and those include grief injuries, moral injuries and fatigue injuries. And so this is a model that can be flexible in order to support and work with individuals across their experiences in the healthcare setting. This is from the National Center for PTSD. This is the stress continuum really in action and you can see it moves from ready to reacting to injured to ill. It's color coordinated in a way that folks can easily connect with and understand. Some may have seen this before. It provides clear definitions, features and causes that are accessible to folks. It fosters a common language and understanding and ultimately that we can see it as individuals and be able to use it to understand and evaluate kind of our peers as well. So during the height of the pandemic within our own organization, we really wanted to understand how we could best support our colleagues and we implemented stress first aid for healthcare workers and we adapted the stress continuum model for our own organization and colleagues. This is what we shared and we did this in large format settings, in small teams and in safety huddles and individual units. We publicized and printed these materials for colleagues so they could socialize them as well as information about the model and we worked with leaders to make it a part of regular check-ins on individual teams and emphasizing among our colleagues and our staff that we really wanted to have a common language and a common purpose to look out not just for ourselves but our teammates and peers through this process and really inviting people to take a moment to pause and reflect when they were meeting about where they were along this continuum. There are multiple other models of interventions that one can utilize in different healthcare settings. This is a recent resource looking at the role of institutional-based peer support for healthcare workers that are emotionally affected by workplace violence. Just looking out here, so peer support is a growing work in a lot of different healthcare settings. Does anybody do or work in any kind of peer support programs in your organizations? So a few people, okay. In peer support models, volunteer peer responders are trained in crisis support and stress management. They're going to provide a timely psychological first aid to address the initial emotional distress after a traumatic event. And in these settings it's really thought that healthcare worker peers can relate to the clinical scenarios that the individual is experiencing but they themselves are not impacted by the event or directly connected to the individual with whom they're working. And the goal in peer support is to help them manage their feelings and reactions using many of the essential elements that we've heard in some of these other interventions like stress first aid. And really it is around providing an opportunity for empathic listening and if needed connecting them to other specific or specialized increased levels of support. And we use this to train individuals, we train managers and leaders about how they can identify some of these common reactions after event and ultimately kind of utilize and leverage these services to help their teammates. Peer support in general is an effective, low cost and sustainable approach, continues to expand over time and using an increasing levels of organizations. In our larger health system we have both in-person peer support services at member institutions and hospitals as well as access to a virtual peer support network as well so it doesn't all have to be individual at your organization. It can think about kind of leveraging larger networks in order to provide that support to your workforce. The interventions we've discussed are not the only resources that organizations are going to deploy to support and respond to kind of workplace violence. So as the individual experiences to trauma and violence it's important to have a real suite of potential interventions and tools available. So within our own organization we've scaled up our employee assistance program, our mental health treatments, our training programs which include peer support as I mentioned, de-escalation training to enable team members to confidently and safely play a role in preventing workplace violence, practicing a culture of safety to empower our colleagues to intervene when they witness harassment, discrimination, incivility and violence, education that's going to emphasize trauma-informed care and particular venues that can happen for colleagues to be able to share the difficult experience of being healthcare providers and caregivers like Schwartz Rounds which some of you may do. We've emphasized kind of leadership rounding across our institution where we can get colleague feedback and begin a part of kind of continuous process improvement and ultimately really trying to seek a broad array of potential solutions and interventions to support our growingly diverse workforce. And as we wind down here I want us to kind of highlight what the future holds. So we've been discussing kind of the recognition of violence in the workplace as well as the processes to prevent and respond to that violence but ultimately as organizations that are committed to the individuals that work there and sustain us it's about creating an environment for the success of our colleagues so they can thrive and prevent the distress and cultivate their own professional fulfillment. Some of you may be familiar with the work of Shana Feld and this is from one of his summaries that's really thinking about how we think about professional fulfillment in medicine and it describes for us the various eras of medicine we've gone through at time and it begins with that era of distress over the last several decades and centuries. So where we collectively as individuals and organizations really didn't have an awareness about the impact of this on our colleagues. Ventured into an era of well-being and what he calls well-being 1.0 where that awareness begins to surface and we think about environmental distress and the importance of providing well-being and professional fulfillment within that organization and ultimately where we all want to go and I think where we're headed which is kind of the shared future what he calls well-being 2.0 and this is where organizations can focus on the needs of people and that includes individual supports when needed, fostering an environment where colleagues can thrive and grow through a shared responsibility of the individual and the organization together kind of aligned in purpose. And for those of you who are interested in supporting organizations to grow both on how we support one another and how we transform our environments to create greater opportunities for professional fulfillment and safer and more resilient individuals and organizations. These are a number of groups that provide frameworks and maps on how to begin and track your journey and interventions including our own American Psychiatric Association but I mentioned there's National Academy of Medicine, the ACGME, the American Medical Association and Joy of Medicine, Mayo Clinic, Stanford University all have kind of large playbooks that you can utilize to help move your organization through structured steps in terms of going to this effort. But ultimately it really is a collective effort for us to kind of look out and care for one another in this challenging work environment and all that we do and hope that we can continue to marshal and develop those resources and that skills we need to care for our workforce and our colleagues going forward. And with that I think we're done and wanted to open it up and invite questions from the audience here. If you do have questions if you could please come to the microphone for the Q&A. Thank you. I appreciate the talk very much. Interestingly we implemented a program almost exactly like the one at Leahy Hospital where we do have an inpatient psychiatric unit. Something dynamic arose when I wanted to do a survey to sound the effects of trauma on our staff not only in psychiatry but in the other branches of medicine on the various units in the hospital. And I ran into a legal barrier where our legal department basically didn't want to find out. And I think I haven't had a chance to really address it more in depth with them but I plan to where I think the dynamic was that they were concerned that if we found that the environment of the hospital had contributed to their trauma that we might be held liable for that trauma. Have you encountered anything like that? I think so. Starting with the more specific questions, I have not. And I think it's part of the culture of the institution, right? I think you need to be able to separate liability from a culture of safety. I think our leadership has been very deliberate about the culture of safety and in terms of education and training, in terms of implementing organization-wide the just culture model, right, where a review of adverse events is important, is necessary and is required, right, so that we can learn from them, not a culture of blame but a culture of improvement. So I can say that that starts with leadership and I would, in your situation, I think that's where I would go if I'm getting a different message from the legal team. I don't know, Patrick or Becky, if you would add anything to that. I would agree with Laura there. I think it is around having a, understanding what the environment is for your hospital. Everyone has different processes, whether through peer review processes or how they're going to look at the data. It hasn't been an experience that I've had in doing this work in our organization or others. But to Laura's point, I think where we have had success, it's where leadership has led it. So oftentimes our hospital leaders and administrators getting their buy-in and then essentially council is supporting them in this effort and finding ways around that. So I mean, I think what I'm hearing though is we need to understand the feedback and we need to find a way to get it. If that one particular route wasn't working, hopefully there is another way that you can get the feedback from your staff about what that experience is because it is key to understanding how you're going to create a program and develop it that's going to be meaningful and impactful for the workers. Excellent. One small additional thing. Would any of you be willing to provide a grand rounds for us at our, we have a very large hospital system. I know your names are in the APA list right for the talk. Could I reach out to you for a grand round? We can give you the contact info if you approach us after. Excellent. Thank you. Thank you. Hello, my name is David Finn from Melbourne, Australia. Thanks very much for your talk, which I really appreciate. One of the issues we've been trying to grapple with is the culture of medicine of course is that we treat all patients at all times at whatever cost. That's been our background, our history. Increasingly we've become concerned that there are some patients we simply cannot treat because they're too dangerous for our staff to look after. And in one or two very rare instances in recent months, we've actually banned one or two people from the hospital unless you're in absolutely urgent, requiring urgent physical medical care. Has that been your experience here? Is there a similar process happening here? It definitely rises in violence that have been experienced in healthcare. I think Becky showed one of those posters that we've used to try to create and help a violence in our environment. And our policies have been reflective of that. But yes, I mean there are instances where we do that. Here in the States we can't decline emergency care obviously for folks presenting it. And so we do have to take care of those individuals and they do create a challenge. I think our organization has created a system to try to create and bring in as many resources as possible to try to get around that. And we have multiple kind of care teams. But yes, I mean we all care for kind of really challenging, difficult situations and individuals with increased risks or levels of violence and try to manage as a hospital. But I don't know, Becky, if you want to talk about kind of some of the specific things we've done in some of those high-risk situations. We have flags in the chart. So if patients are coming to emergency rooms multiple times, we can see that and we can see a whole care plan. Care plans can be implemented in there. There might be like a recommendation to notify the local police department that this patient is here to coordinate with security and things like that. So all staff can be aware that this patient has a history of aggression or whatnot. So to help increase the sort of safety of caring for that patient. I do know that there have been incidents, like Patrick, Dr. Kim said, we can't refuse care to a patient. But there have been patients who have been sort of, and I don't know if restraining order is the right legal term, but they've had those restrictions. But yet if they do present to the emergency room, we are required to care for them. Another thing that happens is that we assess, and as members of the psychiatry consultation team, sometimes we also assess what is the right setting for a patient. So for instance, we have a very violent patient in the ICU, which is sometimes a more difficult place to secure because of the access to all different tools. So we will consider what is the level of care medically that the patient needs. Can they be transferred to a floor that is safer in terms of environment, but if not, security, et cetera. So what is the level of other security that you need? I'm very curious to hear if other colleagues from other countries or states where you do things differently were really interested in hearing experiences also in your hospitals. Hello, I'm Dr. Chita. So I work at an interfaith medical center here in Brooklyn. So as she was saying, throughout the hospital, the times that we will mostly see these kind of issues, agitated patients, is generally when they're coming into the ED. They may come to the medical ED first, before our psychiatric ED. In that case, as she was saying, that we have a consult team during the week. And then also on the weekends, we'll be sending a psychiatrist from our own emergency department. There's always going to be this aspect in psychiatry with us. Depending on your patient population, substance use is also part of this. So when they come in, the most important thing is, of course, you want to have a plan in general. But you want to have good relations with your security. The security is crucial in what we do, and especially in regards to any kind of agitation. They're also truly the front line. When anything's going on, we can order medication. But they're the ones who actually have to restrain the patient. And in this country also, the patient has rights. There's only certain ways that we can restrain a patient. There's only certain ways we can physically, our staff, can physically interact with a patient. So a security guard may be doing everything they can to help you out. And they may end up paying the price. They may end up being fired for not just doing something right. So in their case, you have to understand from their point of view as well. So the main thing is, you try to have the appropriate staff that is there, security. Also, obviously, you try to verbally de-escalate as much as you can. You do your part where you don't agitate the patient. You never take anything they say personally, because there's many things they're going to say when they're coming in. And that's what we can do. But then you try verbal de-escalation. And if it comes to the point of medication, if they are given that after that, again, you try to calm them down at that point. But it's really teamwork. You have to have security. You have to have a policy in place. And everyone has to get along together. Thank you. Absolutely agree with the importance of the security team. We are lucky to have a pretty robust security team. And they have, of course, the escalation, verbal de-escalation training, but a very clinical perspective. I have worked in other institutions where it felt more like police-like. And we are lucky to work in a team where our security agents really work side by side with the clinicians, with the care in approach and the escalation approach. Yes. Hi, I'm Jacqueline Chipkin. I'm a resident soon-to-be addiction fellow at the University of Washington. And my research is also on inpatient violence and specifically on trying to proactively screen patients at risk for violence using AI. And so in kind of concrete terms, honestly, what we're doing is trying to teach the computer to read inpatient notes for the BROCIT violence checklist. So I use the BBC a lot. I think the hardest thing that we're struggling with right now in terms of the algorithms getting written and we're ready to go and we want to implement it is understanding the kind of two sides of the same coin in terms of bias. And so on the one hand, we as health care professionals are going to be more likely to rate certain patients at high risk of bias based on our own kind of internalizations and perceptions. And patients of certain races or socioeconomic levels might be more at risk for substance use and might have had terrible experiences with the health care system, which make them not trusting of nurses and doctors very understandably. And so trying to create a system that doesn't over-represent people and doesn't miss people. And I guess it's kind of a very broad question that probably can't be answered in one talk. But I didn't know if you had any thoughts about other analyses you were running to understand if the way that your pilot went, if that felt like bias played a role in how people were evaluated or things that you did proactively to try to reduce bias. But yeah, very big question. Sorry. Yes, it is. And that's a really important point and not one that we really spoke of much, I guess. Not that we didn't consider it, but it wasn't really a key aspect. But it is very important. And I am actually curious, are you looking at AI would be less bias versus the person doing it? And that would be the goal with that? Yeah, so what our project is right now is we also are trying to create a human baseline. And so we're having psychiatrists in our department read notes. And at the end of the note, decide yes, no, do we think a violent event will occur? And then having the computer read the same note and also have the same outcome. So we have our human baseline and our machine baseline. And so for both of them, I mean, I can see the name of the patient in the note. And I can obviously guess their gender and their age. But I don't have some biases. Yeah, it's not perfect. But yes, and then we're trying to compare those baselines. But it's also bias data creates biased algorithms. And so a lot of the notes that end up being the most rich is most of what we're doing is natural language processing. And so when nurses are really good at recording things, like patient is yelling and hitting and whatever. But that still might be biased if someone perceives that someone is being more violent than they actually are based on their own internal. So it's just such a. Again, goes to the challenging, like how to define and how to define violence, basically. And bias does play a lot of role into that and how we communicate it. It is challenging. Yeah, that's why I was wondering if that was like a future step of looking at who in your data set got rated highly on the brosent violent checklist. Yeah, that would definitely be an interesting. Because you do have that data to be able to look back. And yours does have the advantage, unlike ours, of you had real nurses looking at real patients, whereas mine is just doctors reading notes. So I can't quite evaluate for the human bias as well in my project. So one of the things to consider is that. So we have EPIC as our electronic health record. And it has a searchable function, where you can search for keywords like violence, et cetera, agitation, et cetera. So very quickly, you can see historically if the patient had in previous hospitalizations, it goes, at this point, 10 years back, if there are other reports of violent behavior. To the point of bias, though, right? So certainly, as we mentioned in our talk, the difference between the static and the dynamic factors. The factors that are static, history of violence, will tell you about the overall risk of the person in general, not necessarily in the current hospitalization, right? So if the question is, how much will that predict that the patient will become violent this time in the emergency room, is a lot less useful, right? So I think that that would be my concern, right? Depending on what elements you include in the algorithm, right, how to account for current behaviors. When you say that clinicians and the AI system are looking at notes, are you referring to current notes from the current, yeah, time in the hospital? So right now, what we're doing is, the data set we got is of patients who had what at Harborview is called a co-gray, which is some sort of violent event or threat that occurred where security gets called. And so it's a data set of like 400 patients. And so from the time of the violent event, we went back 72 hours, and all of those notes are what we fed to the algorithm. Got it, okay. I mean, we filtered out like useless notes, so it's HNPs and progress notes and nursing notes that fed back. And so it is during the current hospitalization. And then the other question is, it's the same thing, is in order to employ it proactively, is we'd have to decide when to run the algorithm. Like, can we run it based on just one HNP? Can we, do we need to wait 24 hours? Is waiting 24 hours too late? And that's the other thing we're trying to balance. Report back to us after you have the results. It might be a bit, I'll let you know. Super interesting, thank you, thank you so much. One of the things we do is work with our community mental health system with these difficult patients that keep coming back and coordinate with the outpatient team, with people on court orders. There are some people that we find admission does not help. We put that in the treatment plan. There are some people that, there's a couple people that come to the hospital to intentionally act out. We find they're actually safer in the community than in the hospital. We don't ban them, but we put that in the treatment plan. They get an assessment in the ER and out. That's a great suggestion, and again, it speaks to the opportunity of really developing kind of treatment plan, developing community partners that we can work with, and realizing it is a system of care that's around them, not just kind of who's working with them face-to-face at that moment, but engage as many community and stakeholders in that. So thank you very much for that suggestion. We have some of the same struggles that you guys have. We also, we are one big organization on main campus, so like 900 patient beds. We had to set expectation management with our nursing staff because we rolled this out, and they're like, oh good, we're firing all the patients. And we're like, wait, hold on. We aren't firing everyone just because they said mean things. And so I find that, and I don't know if you guys have had that same struggle, but I find that to be our biggest struggle is you roll this out and then everybody, like they're sick, and I get that they don't deserve to be hit and things like that, but even like someone cussing at them. We're getting like all of these reports where it's like they were verbally aggressive to me, and I was like, well, you did a dressing change on a burn unit, it's not comfortable, like no matter how many drugs we give them. How are you guys balancing that piece of things where it's like, yes, we understand that this isn't okay, but at the same time, like some expectation management with your staff, filing all these reports and expecting patients to just leave the unit the day after they write the report up. Yeah, I mean, in my experience, more than staff members wanting to discharge patients or leave in the unit, what I have observed is sometimes in some cases, perhaps a tendency to over-medicate, right? So to keep the patient calm and use the PRNs too much, so over-calling agitation, right? So that is one of the trends that sometimes I have observed and where as a CL member, I educate the team, you know, about that, what are you calling agitation, what are the levels, when do you need to be escalated verbally, when to use Haldol, et cetera. I don't know, Patrick and Becky, if there are other examples or how would you answer that? I think it's a, the good news is they're reporting, right? So, and I think it is around, it's yes and, so it's thinking about, you know, thank you for letting us know and showing that you wanna hear from them, support them and understand, like that's a hard environment to work in and how can we make the environment better? And part of that may be looking at how, what their care paradigm is, right? So maybe looking at how we are doing dressing changes, like do we need to rethink that? So, I mean, I think it's always, it's an opportunity to have a conversation with your team about where they are, where their challenges are and, you know, who's on that team that's on the, the leader on that team that's gonna be able to try to address some of those challenges. Some things can change some, you know, more quickly than others. And engaging them in that solution. So I think you have that opportunity to, it's not just I'm gonna report and I expect that back, but how do you get feedback from the reporting? How do you engage them in that ongoing change process and finding ways of solution? And that even comes to the point where, you know, there may be instances or policies around, you know, individuals who make kind of specific violent threats, racist comments, you know, I won't be taken care of by X providers or whatever. And it really is developing as a culture in your organization how you're gonna approach those situations. And so that the individual who's experiencing them has the right supports in place, right? So that they're not kind of there on the front line alone doing that, but can draw on other supports in terms of helping them to navigate that particular situation. And that ultimately gets to a point of support. So I think we found in our organization, it doesn't ultimately lead to the idea that like, this happened to me, so like they're out. But it's like, this happened to me and this is our response and it becomes very much ingrained into this is our response and this is how we handle that situation. And so it just becomes a kind of automatic and kind of the culture in what we do. All right, thank you very much for your questions, comments and your attention. Thank you, I appreciate it.

workplace violence

healthcare

emergency departments

psychiatric settings

Joint Commission

BROSET Violence Checklist

underreporting

psychological support

staff turnover

trauma-informed approaches

Lahey Hospital

peer support programs

institutional resistance