Podcast: How an Emergency Room Eliminated Staff Injuries

Injuries from patient violence virtually eliminated. Zero lost time in the ED.

These are two of the positive results Bob Durand has facilitated in a California health system—where stress runs high but Bob ensures that staff have skills to make each other and their patients safer.

How a military career helped a safety expert understand the value of de-escalation

Bob Durand is an emergency management planner and practice leader working in the medical group support services division of Kaiser Permanente's Northern California region. Prior to his work in the health care field, Bob spent 21 years serving in the US Army, often in leadership positions, including tier one special ops. So he’s well acquainted with stressful situations that require training and expertise to manage safely and effectively.

Solders in field at twilight

Bob’s desire to join the military began back when he was 12, when a desire to “jump out of planes and kick in doors” eventually led to a career in the armed forces. After completing his military service, Bob transitioned into security and training roles in the health care field. Today, in his role with the industry giant Kaiser Permanente, Bob is a regional asset for 21 separate facilities. He develops national strategy and conducts security officer training for postings within the emergency department, including management of the ED environment, patient management, physical intervention leadership, and staff protection. Bob was also instrumental in the introduction and training of the Workplace Violence Prevention Program at the Kaiser Permanente San Francisco Medical Center.

CPI’s Nonviolent Crisis Intervention^® training is a significant component of violence prevention at the Center and other Kaiser facilities.

So how does a successful military career help prepare an emergency manager to understand the value of training that is based on least-restrictive environments and verbal de-escalation skills?

Bob explains: “My 21 years of experience helped me understand that sometimes we can take one path or we can take another path that ultimately decides where we go and how we do things. And when I translate it into the subject of what CPI is all about, and what we do to manage health care environments for safety, is that it's very simple to overcome an at-risk patient through brute force, but using appropriate principles that allow us to de-escalate before we ever get there is much more valuable than just physically managing patients. And that history, that background of mine with the military is what ultimately helped me understand the value of de-escalation, the value of communication, and the value of interaction with our patients.”

It's simple to use force, but #prevention is much more valuable. —Bob Durand

Eliminating injuries in Kaiser’s San Francisco Medical Center ED

Part of Bob’s role as an emergency management planner at Kaiser’s San Francisco ED was ensuring compliance with California’s AB-508 regulation, which includes 11 items that relate to mandatory safety education and training. Training topics include:

General safety measures.
Personal safety measures.
The assault cycle.
Aggression and violence predicting factors.
Obtaining patient history from a patient with violent behavior.
Characteristics of aggressive and violent patients and victims.
Verbal and physical maneuvers to defuse and avoid violent behavior.
Strategies to avoid physical harm.
Restraining techniques.
Appropriate use of medications as chemical restraints.
Any resources available to employees for coping with incidents of violence, including, by way of example, critical incident stress debriefing or employee assistance programs.

Bob managed the program put in place to meet these requirements, including annual training for all hospital employees assigned to the ED, and the results are remarkable. “Through that training program [including CPI’s Nonviolent Crisis Intervention^® training], we were able to virtually eliminate injuries within our emergency department from violent, unpredictable patients. And we are now into our fourth workplace safety year with no lost time from injuries.”

“And that's a significant achievement when you think about the emergency department environment that we face. We have more angry patients. We have more unpredictable patients,” explains Bob. Helping to counter that reality is the increased confidence that security staff possess as they deal with the increasing variety of patients that visit the ED.

How a training budget became automatically built in at Kaiser Permanente

“Well, I’m going to tell you, it was tough, right?” was Bob’s good-kind-of-tired response when asked how he convinced administration to provide him a training budget. “Because training health care workers is expensive. By nature, their time—in any program, it doesn't matter what work segment you're in, what profession you’re in, what industry you’re in—the most expensive piece of any training program is the time, right? And so the actual program you select, the cost of that is negligible. It’s very minimal compared to the cost of the employees’ time. And so we had to look at what can we do and what's it going to cost us. And more importantly, what is it going to do for us. And so, the first year that we did the training, we did it with unbudgeted funds, which was really tough. And I will tell you that once leadership saw the benefit, it became automatically budgeted in. We've already budgeted in the amount for training for 2017,” says Bob.

Why physicians need de-escalation training

Although physicians might sometimes be seen as above the fray of challenging or violent patient behavior, and therefore beyond the scope of staff that will benefit from verbal de-escalation training, Bob makes a strong case for including them: “The biggest reason why I believe this is physicians are the frontline care, just like nurses, just like technicians, just like a number of other parts of the care continuum. They often put themselves in close contact, one-on-one, in closed rooms with someone who might be aggressive or agitated, right? . . . Physicians often put themselves in situations where they are in closed rooms, doors closed. They are private with their patients as they should be. That leaves them exceptionally vulnerable. And a lot of times, when the patient is agitated, when they are anxious, when they are aggressive, the physician is the target of those [feelings].”

Bob points to the current opioid epidemic as a timely reason why physicians should be trained to effectively set limits with patients they encounter in the ED. According to Bob, Kaiser is seeing an increasing number of patients exhibiting drug-seeking behavior. When a physician recognizes this behavior and refuses the request, they become vulnerable: “It's absolutely dangerous because that patient is now unpredictable. That patient is a wild card. Their next action is totally unpredictable because most often, they immediately become defensive, and they immediately become aggressive, and they immediately become a threat. And so how the physician manages that through limit setting, and through a myriad of other tools that they can use, helps them maintain their own personal safety,” explains Bob.

Speaking army—or why vocabulary matters

At the close of our interview, Bob offered a final thought about his professional transition from the military to health care, and how learning the variations in language that evolve around a structured culture can make a big difference. “The funniest thing is that when I went into the health care world post-army, I spoke army; I spoke Department of Defense. I was a soldier, right? And I can tell you that there were some times where my vocabulary wasn't the same as the vocabulary of health care. And so I had mentors who helped me learn how to communicate and how to teach with the most impact through utilizing terminology that's prevalent in the health care world. And I can tell you that when it comes to structuring a training program, you need to make sure that as a fundamental trainer, everything is geared to how well you deliver the material, how well you help,” says Bob. Judging by the outcomes Bob and his team have achieved, they've learned the language of de-escalation exceptionally well.

Guest Biography

Before transitioning to civilian life, Bob Durand spent 21 years in the US Army in various leadership positions. After his military service, Bob transitioned into security and training roles in the health care field. In his role with the health care giant Kaiser Permanente, Bob is a regional asset for 21 separate facilities, developing national strategy and conducting security officer training for postings within the emergency department, including management of the ED environment, patient management, physical intervention leadership, and staff protection. Bob is certified as a health care environment manager and a HIPAA Security Specialist.

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