Development and Implementation of an Emergent Documentation Aggression Rating Tool: Quality Improvement

Introduction: Workplace violence is prevalent in the emergency department, putting patients and staff at risk for harm. An ED-specific standardized tool is needed to promote a consistent assessment process to strengthen documentation of escalating patient behaviors, give justification for de-escalating interventions, and reduce restraints. The purpose of this project was to design, implement, and evaluate feasibility of an ED-specific tool to help nurses proactively identify and intervene with patients' escalating behaviors, capture better documentation of aggressive/violent patient events, and reduce restraint usage.

Methods: A quality improvement design was used. The Emergent Documentation Aggression Rating Tool was constructed by combining evidence-based behavioral cues for potential aggression/violence with observed behaviors and successfully implemented interventions in patients. Nurses were trained on how to use the tool to rate patients' behaviors and take necessary action. Chart data were collected from August 2018 to December 2019 at a Midwestern suburban hospital emergency department. Chart audits and just-in-time education were conducted after implementation. Survey data were collected to evaluate nurses' perception of the tool's usefulness.

Results: Use of the novel Emergent Documentation Aggression Rating Tool increased over time (67.36% in Quarter 3 2018 to 97.55% in Quarter 4 2019). After Emergent Documentation Aggression Rating Tool implementation, visual inspection of the time series indicated a decrease in percent restraints, and there was an overall increase in documented escalations de-escalations over time. The patients that escalated most frequently had diagnoses of alcohol use, suicidal ideations, pain-related complaints, or mental health issues.

Conclusion: The Emergent Documentation Aggression Rating Tool was feasible for emergency nurses to proactively identify and intervene with patients at risk for aggression/violence.