Fifty Shades of Code Grey A clinical team response to acute

behavioural disturbance

Dr Andrew Walby

6 October 2014 : State Election

"We are a leader not by choice but by necessity," he said.

"Police and the ambulance service will preferentially bring

patients here because they know we do this quite well."

6 October 2014

Dr Walby said St Vincent's had a "very robust" internal

security response, and staff were well trained on when to

call for back-up.

"You find staff in EDs (emergency departments) become

fairly resilient, you get used to that high level of alert," he

said. "You learn to read the cues that someone's going to

go off, that's where the experience comes in."

17 July 2015

Summary

• Tracking our 20 year journey from Code Grey, to the

BAR, to SOOTHE.

• Transforming the management of behaviourally disturbed

patients from a security response to a clinical team

response.

• Training a multidisciplinary team to respond in a timely,

safe manner whilst preserving patient dignity.

Profile of the SVHM ED

• One of five adult tertiary referral hospitals in metropolitan

Melbourne

• No paediatrics, obstetrics & gynaecology

• No major trauma – designated as a Metropolitan Trauma

Service (MeTS) since 1999

• Complex care…

• Aboriginal and Torres Strait Islanders

• Alcohol and other drugs

• Correctional Health

• Domestic violence

• Elderly

• Homeless

• Mental Health

• Overseas visitors

• Refugees

• Young Adult Complex Disability

Complex and Challenging Patients

Profile of the SVHM ED

• Annual ED attendances = 41500 (~115/day)

• Ambulance attendances ~ 40/day

• Admission rate ~ 1/3

• Care Coordination – Allied Health

• EDMH 24/7

• ALOs

• Residential Aged Care In-Reach

• Other – PCP; NP (x1)

“Boutique ED”…

The fish pond…

Homeless = primary homelessness (ABS) people without conventional

accommodation (living in the streets, in deserted buildings, improvised

dwellings, under bridges, in parks, etc)

This excludes rooming/boarding house; hostel; refuge; “couch surfers”

(ie secondary homelessness)

Homeless

Homeless : 2014

Geography

Geography

EDMH : Contacts

Mental Health Catchment Areas

Inner Urban East vs Inner West

17 July 2015

Section 351 (formerly section 10)

History of Code Grey

In 1994, as a result of a serious injury to a staff member

caused by a patient

• It was identified by Executive that there was no

coordinated clinical response to assist with incidents of

aggression (whatever the clinical cause)

• Executive supported development of an emergency

response team led by senior clinicians to deal with

patient aggression

• The name of the emergency response was called Code

Grey

Move to new Inpatient Services Building :

1995

7 May 2002 : Code Ivory

Behavioural Assessment Room

2002 : Funding obtained to re-develop the triage area,

including ambulance reception.

2003 : Behavioural Assessment Room (BAR) opened.

Safety and Quality Framework

BAR

Code Grey Clinical Team

Response

Training Multi Disciplinary

Team

Policies Internal

and External

Partnerships

Police

Ambulance

RAS Syndrome

“PIN Number”

“ATM Machine”

“HIV Virus”

“VIN Number”

“DC Comics”

“NEAT Target”

“BAR Room”

Development of Code Grey

Team structure – security; senior medical and nursing; support staff; EDMH

Training of staff – specific Code Grey training; annual refresher training

Incident analysis – weekly review of Codes; VHIMS / RiskMan; Aggression

Investigation Coordinator

Governance – Aggression Prevention Committee reporting to Emergency

Codes Committee (and onto Executive); monthly OH&S reporting

Partnerships – VicPol; Ambulance Victoria

Best practice model

Definitions : Victoria

Code Grey = an unarmed threat or aggressive, violent

episode involving a patient

Code Black = presence of a weapon, or threatening and

violent behaviour from someone who is not a patient (and

therefore not requiring treatment)

Positive Outcomes

1

Safer work environment.

Positive impact on all patient care in the ED.

Improved time-to-care for the behaviourally disturbed patient.

Empowered staff to manage complex, volatile presentations.

Positive impact on interaction with other Emergency Services.

Collaborative education tool development with Victoria Police.

Patient dignity preserved.

Day/Month/Year Footnote to go here Page 33

The Room

• Located at the ambulance entry to the ED

• Cat and kitten doors

• 02, suction and power in secured cupboard

• Perspex window from adjoining cubicle

• No sharp edges or hanging points

• Security Camera

Day/Month/Year Footnote to go here Page 34

Day/Month/Year Footnote to go here Page 37

May 2007

May 2007 : AoD

May 2007 : Restraint

July 2011

July 2012

18 February 2014

6 October 2014 : State Election

October 2014

SOOTHE

14 May 2015

Code Greys : growth over six years

Code Grey in ED : 2014

Location Number

ED Cubicles 606

ED unspecified 239

Ambulance Bay 183

BAR 177

Resus Room 68

Waiting Room 42

Short Stay Unit 10

Staff Base 10

Triage 6

Minor Clinic 2

Mental Health Area 2

TOTAL 1345

Time of Day

May 2015

May 2015

Other Strategies to Improve Safety

Locked ED – ID swipe card access only

Limiting visitor numbers

Visitor stickers

Identifying “patients of interest”

Management plans (& alerts) for patients

with past aggressive/violent behaviour

A “patient of interest”…

The Future : PECC

The Future : PAPU

Acknowledgements

Sue Cowling, Emergency Department NUM

Barb Stevens, Emergency Management Coordinator

Paul Cunningham, Security Manager

Tracey Weiland, Emergency Practice Innovation Centre (EPICentre)

SVHM EDMH

Victoria Police (especially Fitzroy)

Ambulance Victoria

All the staff of the SVHM Emergency Department

Questions?