BEHAVIOR CLINIC conference/AC2019/AC2019...• Spaulding Hospital Cambridge is a 180 bed long term acute care hospital • A member of Partners Healthcare Network • Severity of Illness

BEHAVIOR CLINICDEVELOPMENT AND IMPLEMENTATION

DANIELLE DREYFUS, PT, DPT

REBECCA LUCENTE

LINDSAY MAUS, PT, DPT

Objectives1. Identify suggested steps to creating a Behavior Clinic.2. Identify common underlying medical issues to problematic behaviors

3. Appreciate the importance of interdisciplinary buy-in in the process of improving behavior

4. Develop a creative behavior plan for a patient with a brain injury.

Background and Development• Spaulding Hospital Cambridge is a 180 bed long term acute care hospital

• A member of Partners Healthcare Network• Severity of Illness index ranks patients 1-4, with 4 being the most severe. Spaulding Hospital

Cambridge has a higher percentage of SOI4 patients than intensive care units

• Spaulding Hospital Cambridge’s Disorder of Consciousness Program began in April 2011, providing evidenced-based care to patients with severe brain injuries

• As patients progress through stages of recovery, problematic behavior frequently emerges

• Behavior Clinic was developed in September of 2017 • Purpose: A multi-disciplinary discussion on problematic behaviors resulting in development of a

plan to reduce or eliminate behaviors to improve participation in care

GoalsCLINIC GOALS HOSPITAL BENEFITS

Reduced 1:1 use Save $$$

Reduced restraint and 1:1 use Reduced LOS

Eliminate dangerous behaviors Improved safety for staff and patients

Reduce falls Improved patient safety and hospital statistics

Reduced antipsychotic use and use of PRNs Improved patient care and reduced LOS

Improved clinical reasoning skills of staff members Staff empowerment

Improved quality of life for patients and staff Improved results on patient safety and LTRAX surveys

Clinic DevelopmentLogistics:

• Every Thursday after rounds• Up to 3 patients per unit per day • Discussion lasts 5-15 min per patient• All team members should be present

including nurse, nurse manager, PCA, MD, CM, OT, PT, SLP, PMR, dietary, MT, and TR (when applicable)

Inclusion Criteria:• Restraints• 1:1 or Avasys• Fall in the last 7 days• Code white in the last 7 days• Single ABS score >21• Clinical judgement for problematic behavior

including but not limited to yelling, screaming, kicking, delusions, wandering, lethargy, etc.

ProtocolReferral Process:

• If a patient satisfies at least one of the inclusion criteria, any staff member can email Behavior Clinic leads (2 physical therapists)

• An email is sent out Wednesday announcing the schedule

Format:• Behavior Clinic lead introduces the patient, problematic behaviors, and interventions tried

thus far• The team is invited to add any pertinent information• Creative solutions are discussed and a plan is created• Each plan will be posted at the nurses station. Detailed documentation on whether or not

the plan is working is required by all disciplines in Epic• If the plan is not successful, the patient should be reviewed again the following week

Behavioral Patterns DetectedMost common behavior listed for consult: 1. Attempts out of bed

2. 1:1 sitter (or Avasys)

3. Pulling lines/trach

4. Crying/yelling

5. Agitation/physical aggression

6. Poor sleep

Most common underlying issues:

1. Medication adjustment recommended

2. Toileting needs

3. Impaired cognition

4. Positioning needs

5. Sleep impairments

6. Psych conditions

Barriers to success of Clinic• Unit that houses the brain

injury program has the most consults and therapists are the most frequent consulters

• Consults aren’t placed as often as they should be

• Need to track data more strictly in order to objectively calculate benefits

• Spoke to each department and on each unit about what Behavior Clinic is, how it can be beneficial, and how to submit a consult

• Gave short presentations on each unit at 7:30 and 3:30 to target the nursing staff

• New spreadsheet for tracking data and new Behavior Plan sheet created

Interdisciplinary Buy-In• First month

of hospital-wide roll-out: 7 consults

• Mini presentations given in December and January

Location of Consults

2S 2W 3S 3W 4S 4W

Consulters

Therapy Nursing Unknown

The Management of Agitation Among Inpatients in a Brain Injury Rehabilitation UnitShannon Janzen, Amanda McIntyre, Matthew Meyer, Keith Sequeira & Robert Teasell (2014) The management of agitation among inpatients in a brain injury rehabilitation unit, Brain Injury, 28:3, 318-322, DOI: 10.3109/02699052.2013.860478

•Retrospective chart audit 102 patients

•Restlessness and agitation most commonly documented behavior

•Highlighted the need for detailed documentation of agitation to determine triggers, target treatments

•Lack of documentation reduces ability to provide patient care

•Behavior plans are an important tool in the rehab process and to help reintegrate patients back into community

Behavioral strategies for assessing and promoting community readiness in brain injury rehabilitationSchaub, C., Peters, C., & Peters, S. (2012). Behavioral strategies for assessing and promoting community readiness in brain injury rehabilitation. NeuroRehabilitation, 31(1), 41-49

•Behavioral problems can be due to cognitive deficits, pain, vestibular issues, disrupted sleep, and ineffective medication regimens

•Events in environment can contribute to likelihood of specific behaviors

•Stability triangle

•Individualized treatment plans need to be specific to be carried out reliably

Care management of the agitation or aggressiveness crisis in patients with TBI. Systematic review of the literature and practice recommendationsJacques Luaute, David Plantier, Laurent Wiart, Laurence Tell, the SOFMER group (2015) Care management of the agitation or aggressiveness crisis in patients with TBI. Systematic review of the literature and practice recommendations, Annals of Physical and Rehabilitation Medicine, 59, 58-67 http://dx.doi.org/10.1016/j.rehab.2015.11.001

• External factors leading to agitation: pain, contention, excessive stimulation, aggressive attitudes

• Overmedication leading to consequences

• Non-pharmacological interventions

• Pharmacological interventions

◦ Beta blockers

◦ Mood regulating anti-epileptics

◦ Antidepressants

◦ Neuroleptics

◦ Benzodiazepines

◦ Amantadine

◦ Buspirone

◦ Methylphenidate

◦ Hydroxyzine

Decreasing patient agitation using individualized therapeutic activitiesAmerican Journal of Nursing, October 2013, Vol 113, No. 10, 32-39

•A nurse-led quality improvement

•Inner city level 1 trauma and teaching center with >850 beds

•Purpose: offer individualized therapeutic activities to patients who were on constant observation and measure the effect of therapeutic activities on decreasing agitation

•Despite supervision, patients were falling, disrupting treatments and the level of agitation escalated with use of restraints

•Sitters were encouraged to engage with the patients after developing a Personal Approach Form

•ABS completed before, during, and after activity

•Overall agitation levels decreased

Case StudyConsult Email:“Sam and I have a patient appropriate for behavior rounds. Mr. P –currently on a low bed, B mitts, 1:1 sitter”

Chart Review• Dx• Behaviors exhibited• Precipitating factors

• Is the patient sleeping?• Is he continent?

• Medication regime• Dosage?• Timing?

• Successful vs unsuccessful techniques

Chart Review•74 y.o. male s/p cerebellar hemorrhage and suboccipital craniectomy and evacuation

•Admitted to SHC 3/12-3/18• Out acute on 3/18 secondary to cardiac arrest

•Readmitted 3/27

•Consult email placed 4/11

Chart ReviewBEHAVIORS EXHIBITED

•Agitation•Restlessness•Falls•Pulling at lines

SAFETY TECHNIQUES PUT INTO PLACE

•Moved closer to Nurses station•2:1 initiated 1:1 initiated•B mitts•B wrist restraints

Chart ReviewPRECIPITATING FACTORS

•Toileting/incontinence

•Not sleeping

MEDS ON BOARD

•Seroquel 12.5mg q8 PRN•Seroquel 50mg at night•Flomax .4mg daily

Examples of DocumentationGOOD“Pt started shift on wrist restraints, NP eval, changed to bilateral mitts. Pt tolerated well through shift, found with 1 mitt off x1, calm until end of shift, became agitated, found to need bedpan, large BM, calm after cleanup.”

Pt seroquel decreased 4/1. Pt with increased restlessness, agitation, and pulling at tubes overnight. Moonlighter made aware and pt assessed. One time dose of seroquel 25 mg ordered and given. Improved behavior as the night progressed.”

“…Attempt multiple OOB with 2:1 sitter, pulling at O2 tube. Bladder scan at that time 761 mL, cath for 725 mL clear amber urine. Bx immediately calm down…”

“Pt slept well at beginning of the shift but became agitated and restless around 0100. Pt voided two large amounts and had 1 bowel movement. PRN Seroquel was given with no effect. At 0500 patient was bladder scanned for 601cc. While straight cathing the pt, he became physically aggressive, yelling out in pain, and this RN needed two staff members to help with assistance. Blood was noted after inserting catheter. Total amount retrieved was 740cc. Post straight cath, pt was significantly more comfortable. Consider inserting a foley. Will continue to monitor”

BAD“Close monitoring while on restraints. Pt in ‘low bed.”

“Pt remains on 2:1 supervision, mitts, has tab alarm/bed alarm on for safety”

“Pt continues with mitts for safety 2:1 supervision”

“Pt became tachy around 1830. HR went into 150's. Lopressor 50mg due at 2100. It is a new order so unable to pull it until 2100. Paged Dr. … who called back saying to give 50mg now. Went to pharmacy to get dose early. BP is stable 107/64 and pt is in normal sinus. Will monitor.”

Making a Behavior Plan•Pt transferred to room close to nurses’ station, bed closest to door

•Toileting schedule

•Medication changes

•Education

•Reinforcement of call light when in room

•Bell when in common area

•ABS every shift and therapy session

•Additional OOB time in the evening

•Need for detailed documentation

Thank You