Introduction: Harm prevention is a multidisciplinary collaboration.  A Tier Zero Huddle (TZH) is a proactive review of harm prevention strategies for patients who are perceived to be at high-risk for harm. The TZH reviews patient risk factors, barriers to bundle compliance, opportunities for caregiver education, and action items to prevent harm. A test of change was developed to include a behavioral health (BH) provider in TZH discussions for patients with behaviors that may put them at risk for harm, helping to identify strategies that may decrease those behaviors and/or decrease the impact of their behaviors.

Case Description: Dee is a 15-year-old male with a significant behavioral health history, admitted in decompensated heart failure with cardiogenic shock and multi-organ failure requiring Impella support. His devices included a ventricular assist device, endotracheal tube, nasoduodenal tube, Swan Ganz catheter, femoral central venous catheter, radial arterial line, brachial peripheral intravenous line, and foley catheter. Dee was identified as a candidate for a TZH due to scratching and pulling at central lines, a Braden QD score of 20, and locked hair, risks for CLABSI and HAPI.

Discussion: The TZH included Dee’s frontline team, nursing leadership, CLABSI and HAPI co-leaders, the BH resource RN, vascular access service, wound care nurse, and patient’s mother. Dee’s mother was able to share his trauma history related to previous medical treatment and identify the need for trauma-informed care and developmentally appropriate, supportive language. Mother helped to identify the techniques of talking to the patient before touch and reassuring Dee that he was safe to help lessen anxiety. 
The TZH outlined barriers to CLABSI bundle compliance in the setting of Dee’s known behavioral complexities. His vascular access plan was revised to move his central line to an upper extremity, mitigating the risk for scratching. Additionally, Dee was at risk for both immobility and medical-device related pressure injury (PI) as indicated by the maximum Braden QD.  PI risk was addressed through partnership with Dee’s mother to promote therapeutic positioning. To lessen the risk of PI due to his locked hair while respecting their importance to him and his family, Dee’s mother supplied a hair wrap for containment. The team maintained a heightened awareness of risk.

Conclusion: Preventing Harm for a patient that is requiring complex medical and behavioral care can be challenging.  Implementing a BH TZH for Dee gathered insight into his history of trauma and developmental needs while identifying opportunities to keep him safe in a hospital setting.  The interdisciplinary team of experts helped implement real-time preventative measures, identify bundle compliance barriers, and decrease risk for harm.  The sharing of knowledge while building a partnership with the family was vital in encouraging Dee’s mother to advocate for her child’s needs in a high stress environment.