Presented by Mavis Afriyie-Boateng Jocelyn Bennett Carla Loftus Lesley Wiesenfeld Mount Sinai Hospital, Toronto, Ontario

1. Giving Nurses and Patients a “BOOST”
An Innovative Model of Support for Nurses
Caring for Patients with Challenging Behaviours
Mavis Afriyie-Boateng
Jocelyn Bennett
Carla Loftus
Lesley Wiesenfeld
Mount Sinai Hospital, Toronto, Ontario

2. Context
• Mount Sinai Hospital is a 472 bed
academic tertiary care center in
downtown Toronto, Ontario
• Our medical and surgical nurses
reported difficulty caring for
patients with behavioral issues
related to dementia, delirium and
other psychiatric issues
• To address both patient and staff
safety, improvements in this area
were prioritized

3. Problem
• Some medical and surgical inpatients exhibit challenging behaviours due
to delirium, dementia and other psychiatric issues
• These behaviours include aggression and resistance-to-care
• Risks of these behaviours:
– Unintentional patient/staff harm
– Physical restraint and constant care use
– Compromised care delivery
– Leading to longer lengths of stay and increased costs
• Results from two surveys demonstrated that Mount Sinai Hospital staff
were challenged in providing safe and effective care to these patients
• The care of these patients was historically managed by psychiatric
consultation-liaison teams
– However, these teams required physicians to initiate consultation and were staffed by
physicians, despite the burden of challenging behaviors falling to nursing staff
• Thus, support for patients with behavioral issues and their nurses was
prioritized

4. Intervention - BOOST
• The Behavioural Optimization and Outcome Support Team (BOOST) was
implemented in 2012
• BOOST is staffed by psychiatric advanced practice nurses (APNs)
• Patients and nurses needing support are identified through:
– Automated daily report of inpatients meeting high-risk criteria documented in the
electronic health record
– Attendance at nursing huddles
– Incident reporting
– Referrals from psychiatric consultation-liaison teams
• For identified patients, the BOOST nurses:
– Complete a standardized assessment
– Develop a patient-specific care plan, with a focus on the safe delivery of nursing care
– Provide support to implement the care plans through one-on-one coaching and
discussion at team huddles
– Liaise with psychiatrists for pharmacological management, if necessary

5. Measurement
Activity data for July – September 2014:
Referral
source
Number Action Number
Nursing staff
request
31 BOOST consult
Arrange
consultation by
psychiatrist
None*
18
8
3
Automated
report of
patients with
aggressive
behaviour
158 BOOST consult
False positive
(documentation
error)
Already followed
None*
38
93
21
2
Incident
reports
8 BOOST consult
Already followed
None*
2
2
4
• The success of BOOST is
tracked through activity data
and survey results
• Staff report less burden from
caring for patients with
challenging behaviours (the
Geriatric Institutional
Assessment Profile score on
burden decreased from 4.6 in
2011 to 4.2 in 2012, a
statistically significant
decrease)
*Main reasons for no action: imminent discharge, incident report
about an outpatient or psychiatric visit

6. Contribution to Patient Safety
Safe Patients/Safe StaffTM
• BOOST has a dual focus on both patient and staff safety
• Patient safety is ensured because:
– Care planning focuses on supporting the delivery of needed medical
and surgical care
• Staff safety is ensured through:
– Care plans that minimize the likelihood of resistance-to-care and other
aggressive behaviour
• The innovative BOOST model can be adapted to other settings
– The multiple strategies used for case-finding allow for adaptation to
your setting
– The assessment and care planning tools have been packaged into a
toolkit for others to use

7. Partnership
• The BOOST nurses are able to engage patients and
their families through focusing on the goal of
ensuring the delivery of needed medical and surgical
care
• Thus, despite the presence of challenging
behaviours, the nurses form successful partnerships
with patients and their families
• Lastly, both patients and their families find the
challenging behaviours a source of distress and, thus,
helping to minimize the behaviours also reduces this
distress

8. Lessons Learned and Sustainability
• A key lesson learned was in using the organization’s responsibility to
ensure staff safety and fiscal concerns as drivers for implementation of
BOOST
– For others looking to implement a similar program, consider aligning with organizational
priorities, rather than only good clinical care
• Sustainability has been achieved through early and continued successes in
partnering with nursing staff to address patients’ challenging behaviours
– The BOOST nurses work with frontline nurses to develop and refine the care plan
– The BOOST nurses are frequently present on the unit to monitor behaviours and coach
nursing staff
– Thus, the success has relied on the BOOST nurses having dedicated time and the skill to
partner with the nursing staff
For any questions or further information, please contact Carla Loftus
at 416-586-4800 x7292, cloftus@mtsinai.on.ca