Director: Cherry Hospital staff still adjusting to new policies
By Matthew Whittle
Published in News on September 22, 2010 1:46 PM
Philip Cook
Responding to concerns by his nursing staff of unsafe working conditions, Cherry Hospital Director Philip Cook admitted that the past several months have been rough at the state psychiatric facility.
A large part of that, he said, was that from January to June, the hospital had "five or six of the most difficult patients I've seen here."
He also acknowledged that the jobs that nurses and health care techs do, especially when they are required to get hands-on in a situation, are tough and sometimes dangerous.
"These are physical interventions that carry some potential for injury," Cook said. "It's what our staff members do day in and day out. They're at risk every day, and it's something they don't get enough appreciation for."
But, he continued, that doesn't mean there aren't still guidelines to which each nurse and health care tech must adhere.
Recently, the hospital has been working to train employees in and enforce the use of the Crisis Prevention Institute intervention method -- the nationally recognized method of physical intervention for psychiatric facilities -- which is a change from the methods previously used at the hospital, and also the source of much of the consternation among employees.
"(CPI) is the gold standard," Cook said.
Under the CPI methods, nurses and other health care staff are not only taught the proper techniques for physically restraining and moving patients, but also ways to verbally intervene and de-escalate a situation before physical force becomes necessary. The key to that, though, Cook said, is intervening before the patient becomes aggressive -- something that is not happening now.
"You have to act more quickly. This is a major change of culture at Cherry," he said. "We're waiting too long."
It begins, he explained, with building relationships with patients and becoming familiar with their personalities and their triggers, as well as with providing them with the proper structure and programing.
"If you pay attention to folks, then most people are more likely to settle down and not act out," he said. "We really need to be sure we're attending to each patient and understanding their style of behavior."
That means knowing when they need to be left alone and when they need to be pulled aside. It also, he said, could mean knowing when PRN (short for a Latin term meaning "as needed") medications might be necessary.
"There are some types of medications that can be a part of a tool to help bring them under control," he said.
CPI also means understanding how to talk to patients who are agitated or who are escalating, as well as understanding how body language and spacing can affect a situation.
But when physical interventions are called for, the goal is to have at least two people responding.
"It should always be two or more people. When we have problems performing here at Cherry Hospital, it's almost always when we have one person trying to control a patient," Cook said.
And in fact, he said, when problems occur, it usually is a situation when CPI was not being properly performed.
For example, he said, in a recent case where 911 was called because of an over-aggressive patient -- a situation that ended with a nurse being hospitalized -- that was a case where CPI directions were not followed properly.
First of all, he explained, the staff on hand should have been able to handle that situation, and should have handled it before it got out of hand. Furthermore, he continued, it's not the role of the Cherry Hospital Police Department, and especially not the role of the Goldsboro Police Department, to come onto wards and intervene in patient problems.
"That's not what police do," Cook said. "We had every resource to manage it internally, and we should have managed it more effectively."
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But even when things go wrong, he said, that does not mean that the hospital's administrative staff -- with all of its cameras -- is looking to punish nurses and health care technicians for improper techniques.
"There is a myth that, 'If I touch a patient, I'm going to get fired.' The reality does not support that," Cook said. "The urban legend that people are getting in trouble because they touched a patient is not supported in any way by fact. You have to do something pretty bad to really get serious discipline."
In 2009, he said, only two people were fired because of patient abuse, and both were clear-cut cases, including one who hit a patient with a closed fist.
The behaviors they are trying to prevent, he explained, are things like bear hugs, headlocks, tripping, pulling patients by their arms or legs, patients with their airways threatened and patients being held across the stomach.
"We're hoping not to see any actions on the part of our staff where they're endangering patients or themselves," Cook said. "If you're being a lone ranger or a cowboy and you're not following hospital technique, you're going to be fired. But I don't feel any pressure to be extra stringent here at all."
But, he said, if you're responding and attempting to use the CPI method properly, then a misplaced hand or wrong move might result in a warning or a mild disciplinary action, but would not be considered a serious offense. Intent and past record, he said, are taken into account, as is whether or not a nurse or health care tech recognizes that a mistake was made and understands how it can be corrected.
"We're working to be as fair and consistent as possible," Cook said. "We need our staff here. We want people here to succeed. I believe we have a lot of really good folks who are trying to change their behavior. If they will do that, I think it will be safer for the patients and safer for the staff."
And while videos have only been reviewed if there was a complaint or an unusual incident, Cook said they are in the process of forming a committee of hospital administrators, nursing administrators, psychologists and patient advocates to review 100 percent of instances where there is a physical intervention.
"This may be hard for folks to understand, but it really is intended to be more of a support for our staff than looking over their shoulder," he said. "It's kind of a quality check, if you will."
Similarly, Cook said, in response to the recent staff injuries, the hospital is putting together a workplace improvement team made up of a mix of administrators and front-line staff to look at how to make Cherry Hospital a safer facility.
Among the things the team will be looking at are the creation of the new psychiatric intensive care unit for the most aggressive patients, the emergency call buttons each front-line worker carries, but which Cook acknowledged don't always work properly, and how the hospital can strengthen its programming and daily structures.
And, he said, because he is aware of the concerns about the use of PRN medication, reviewing that will be part of the team's effort, though those decisions ultimately are up to the medical staff, which has changed in recent months.
"I couldn't tell you how medication writing and prescriptions have changed. It probably has changed over the last 12 months. Things have changed a lot in that span. Doctors and personnel have changed, and different doctors practice medicine in different ways."
Still, he explained, the best use of medications is what is defined in each patient's medical plan for their specific illness, rather than just giving them something to sedate them.
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Answering whether or not Cherry Hospital is adequately staffed, Cook responded, "No, we're not right now."
He said the hospital could use up to four more psychiatrists, about 30 nurses -- many of whom could then replace the 35 or so agency nurses being relied on to fill the gaps -- and a number of health care techs.
"We're recruiting in all areas," he said.
The goal, he explained, is a 1:4 in acute care areas and a 1:3 in rehabilitation areas -- one health care staff member for every three or four patients, not counting those staff members caring for patients who are a danger to themselves or others in a 1:1 ratio -- without having to resort to mandatory overtimes or too much shifting people around units, which can affect morale.
"We all know morale is a big issue for us," Cook said. "Morale is not a problem easily fixed overnight. Cherry Hospital is changing, and in the middle of change it is very hard on everybody."
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But, 17 months into his tenure, Cook does see a light at the end of the tunnel.
"We're in a state of change. Sometimes things get worse before they get better," he said.
And, he admitted, that has some people upset.
"There are people who want to take potshots at Cherry, who want to take potshots at the chair I sit in," he said. "But it will get to a point, over time, these days will be long behind us."
Contributing to the recent difficulties, though, has been the fact the hospital has been without a medical staff director, a psychiatric director or nursing director for the last several months.
"That kind of instability leads to difficulties," he said.
Now compound that with the difficult patients of the last few months, he said, and "it's kind of like a perfect storm."
But things are starting to get better, he said.
"Our July data is starting show we're returning to injury rates that are more like they were early in the year or last year," he said, adding that while even those are not acceptable, they are better than they were.
Part of that, he believes, is the fact that those extremely violent patients have moved out of the facility. But part of it, he believes, also is because the staff's advanced training in CPI, which was taught in early to mid-spring, is starting to catch on.
"It takes a little while for that to start to kick in," Cook said. "I'm hopeful we're on an improved level of performance."
And now that they are, he hopes Cherry and its employees will be able to better deal with difficult situations like those it faced earlier this summer. Because after all, he said, that's part of the mission of Cherry Hospital -- to serve people with no place else to go.
"It's just random (having that many difficult patients at once). I think it just happens," he said. "Cherry Hospital has worked hard to serve these folks. We come under criticism as a hospital for not serving people, and now there's kind of a backlash on the other side for maybe extending too far.
"But we provide care for people in eastern North Carolina that nobody else in eastern North Carolina can take care of, or will take care of. That's part of our mission -- about as pure a mission as you can have.
"My interest is very simple -- to have Cherry Hospital be a great hospital, a great place to come and receive care, and a great place to give care. You can't have one without the other. I have no doubt (Cherry Hospital's) reputation has been kind of iffy, and it's not where we want it to be, but I believe Cherry is in the process of getting where we want it to be."