danielle austin - st vincent's hospital sydney
TRANSCRIPT
Code BlackImplementing a Team Approach
to Managing Violence and Aggression
Safe and Secure Hospitals Conference18th October 2016Danielle Austin
Incident Response Manager
18/10/2016 Page 2
• The development and implementation of a multi-disciplinary team approach
to managing Personal Threat in St Vincent’s Hospital, Sydney
• Our Duty of Care - Clarifying capacity, consent and discharging against
medical advice for our clinicians and providing lawful direction to our
Security team
• Risk assessment - Identifying and flagging those patients at high risk of
violence and aggression and communicating that effectively to our staff
Code Black – Implementing a Team Approach
to Managing Violence and Aggression
Page 3
Code Black – Implementing a Team Approach
to Managing Violence and Aggression
St Vincent’s Hospital, Sydney
Page 4
Code Black – Implementing a Team Approach
to Managing Violence and Aggression
Code Black – Implementing a Team Approach
to Managing Violence and Aggression
Our Neighbourhood
Page 5
Code Black – Implementing a Team Approach
to Managing Violence and Aggression
Code Black – Implementing a Team Approach
to Managing Violence and Aggression
The beginning…
May 2012 - request for Code Black data
ICU Neurology D+A Aged Care CCU
“This begs the question - is it time to review our Code
Black practices given the high number each month?
Should there be an audit of the clinical records to see
what, if any, the common factors are and discuss how
these will be managed in the future”
Page 6
Code Black – Implementing a Team Approach
to Managing Violence and Aggression
Code Black – Implementing a Team Approach
to Managing Violence and Aggression
The beginning…
Review of existing process
“No one cares about how much abuse we deal with…” ED Nurse at triage
“We respond to a Code Black and can never find anyone who knows
what is going on with the patient.” Security Officer
No formal training program for staff in dealing with aggression and violence
Difference in restraint technique training for Security and Mental Health
clinicians; nil restraint technique training provided to ED staff
Many staff reported feeling ill-equipped to deal with aggressive incidents
Code Black – Implementing a Team Approach
to Managing Violence and Aggression
The beginning…
Page 7
Code Black – Implementing a Team Approach
to Managing Violence and Aggression
Code Black – Implementing a Team Approach
to Managing Violence and Aggression
The beginning…
Page 8
Code Black – Implementing a Team Approach
to Managing Violence and Aggression
Page 9
Code Black – Implementing a Team Approach
to Managing Violence and Aggression
Code Black – Implementing a Team Approach
to Managing Violence and Aggression
The middle…
369 207
576465
369 207January 2013 – February 2014
Page 10
Code Black – Implementing a Team Approach
to Managing Violence and Aggression
Code Black – Implementing a Team Approach
to Managing Violence and Aggression
The end result…WEEKDAYS WEEKENDS AND PUBLIC
HOLIDAYS
AFTER HOURS / 7 DAYS
0800 – 1700* 0800 – 1700* 1700 – 0800*
ALL AREAS
Code Black Team Leader
Incident Response Manager
Aggression Manager
AND
Security
ALL AREAS
Code Black Team Leader
After Hours Nurse Manager
(AHNM)
AND
Security
ALL AREAS
Code Black Team Leader
After Hours Nurse Manager
(AHNM)
AND
Security
MEDICAL RESPONSE MEDICAL RESPONSE MEDICAL RESPONSE
INPATIENT WARDS
Clinical Pharmacology
Registrar
INPATIENT WARDS
Senior on Wards
Medical registrar
INPATIENT WARDS
Senior on Wards
Medical registrar
EMERGENCY DEPARTMENT
Emergency Department
White Team Consultant
*0800 – 1700
Grey Team Consultant
*1700 - 2400
EMERGENCY DEPARTMENT
Emergency Department
White Team Consultant
*0800 – 1700
Grey Team Consultant
*1700 - 2400
EMERGENCY DEPARTMENT
Emergency Department
Black Team Registrar
*2400 – 0800
CARITAS INPATIENT
Psychiatric Registrar
CARITAS INPATIENT
Psychiatric Registrar
CARITAS INPATIENT
Psychiatric Registrar
Page 11
Code Black – Implementing a Team Approach
to Managing Violence and Aggression
Code Black – Implementing a Team Approach
to Managing Violence and Aggression
The end result…
General Adult Patient Elderly or frail Adult
Moderate Level of Agitation
Lorazepam 1 mg to 2mg PO
(Minimum Dosage Interval 2 hours, up
to 8mg every 24 hours)
AND/OR
Olanzapine 5mg to 10mg PO
(Minimum Dosage Interval 2 hours,
up to 30mg every 24 hours)
Haloperidol 0.5mg to 2mg PO
(Minimum Dosage Interval 1 hour, up to
6 mg in 24 hours)
OR
Olanzapine 2.5mg to 5mg PO
(Minimum Dosage Interval 1 hour,
up to 10mg in 24 hours)
High Level of agitation and
aggression and unwilling to take oral
medication.
Option 1:
Midazolam 5mg to 10mg IM
(Minimum Dosage Interval 4 hours,
up to 30mg every 24 hours)
AND/OR
Haloperidol 5mg to 10mg IM
(Minimum Dosage Interval 2 hours,
up to 30mg every 24 hours)
Option 1:
Haloperidol 0.5mg to 2mg IM
(Minimum Dosage Interval 1 hour,
up to 6mg in 24 hours)
Page 12
Code Black – Implementing a Team Approach
to Managing Violence and Aggression
Code Black – Implementing a Team Approach
to Managing Violence and Aggression
The end result…
High Level of agitation and aggression
and unwilling to take oral medication.
Option 2:
Olanzapine 5mg to 10mg IM
(Minimum Dosage Interval 2 hours,
up to 30mg every 24 hours)
DO NOT GIVE WITHIN 60 MINUTES OF
IM MIDAZOLAM
Option 2:
Olanzapine 2.5mg to 5mg IM
(Minimum Dosage Interval 1 hour,
up to 10mg in 24 hours)
Option 3:
Haloperidol 0.5mg to 2mg IV
(Minimum Dosage Interval 1 hour,
up to 6mg in 24 hours)
NB: In case of Dystonic Reaction use Benztropine 1mg to 2mg PO or IM dependent on the severity of symptoms.
(Minimum 2 hour dosage interval, up to 6mg every 24 hours)
General Adult Patient Elderly or frail Adult
Page 13
Code Black – Implementing a Team Approach
to Managing Violence and Aggression
Code Black – Implementing a Team Approach
to Managing Violence and Aggression
The end result…
The ultimate goal for the Code Black Plan is to provide a safe work environment for all
staff. To provide a safe place for consumers to seek expert medical care and for visitors
to feel safe when inside the St Vincent’s Hospital Campus.
To enable and support staff to respond
effectively to aggressive, intimidating,
threatening or violent behaviour.
Page 14
Code Black – Implementing a Team Approach
to Managing Violence and Aggression
Code Black – Implementing a Team Approach
to Managing Violence and Aggression
Duty Of Care, Consent and DAMA
• Understanding scope of practice
• Understanding of duty of care within professional discipline
• If deciding between flight or fight, duty of care starts with
personal safety
If a patient has capacity to consent to Medical treatment, that
patient can consent or refuse to consent to any Medical
treatment even if that choice may risk harm to themselves.
A person forcing a patient to undergo treatment who has not
consented to that treatment and who has capacity may be
committing assault and battery and (in some instances) may
be charged with assault under criminal legislation.
Page 15
Code Black – Implementing a Team Approach
to Managing Violence and Aggression
Code Black – Implementing a Team Approach
to Managing Violence and Aggression
Duty Of Care, Consent and DAMA
• To save the persons life;
• To prevent serious damage to the
patient’s health;
or
• To prevent the patient from suffering or
continuing to suffer pain or distress.
or
Whether the requirements are satisfied will be a
matter of clinical judgement based on the
assessment of each patient.
Page 16
Code Black – Implementing a Team Approach
to Managing Violence and Aggression
Code Black – Implementing a Team Approach
to Managing Violence and Aggression
Duty Of Care, Consent and DAMA
The decision to use restraint is a clinical
decision that must only be made where a
patient’s disturbed behaviour simultaneously
satisfies four conditions:
1. The person has a Medical or Psychiatric condition
requiring care AND
2. The person is at the time incapable of responding to
reasonable requests from health staff to cooperate and
measures promoting self control are impractical or have failed
AND
3. The persons behaviour is putting themselves or others
at serious risk AND
4. Less restrictive alternatives are not appropriate
Page 17
Code Black – Implementing a Team Approach
to Managing Violence and Aggression
Code Black – Implementing a Team Approach
to Managing Violence and Aggression
Duty Of Care, Consent and DAMA
Page 18
Code Black – Implementing a Team Approach
to Managing Violence and Aggression
Code Black – Implementing a Team Approach
to Managing Violence and Aggression
Our Next Challenge
1• Identify patients at high risk of violence and aggression
2• Assess current risk and document in the patient’s clinical notes
3
• Review and/or develop behaviour management plans
• Implement behavioural contracts (as required)
• Request additional resources as required
4Effectively communicate risk and plan/s to all staff involved in the patient’s care
5• Monitor and review
Page 19
Code Black – Implementing a Team Approach
to Managing Violence and Aggression
Code Black – Implementing a Team Approach
to Managing Violence and Aggression
Our Next Challenge
1• Identify patients at high risk of violence and aggression
2• Assess current risk and document in the patient’s clinical notes
3
• Review and/or develop behaviour management plans
• Implement behavioural contracts (as required)
• Request additional resources as required
4Effectively communicate risk and plan/s to all staff involved in the patient’s care
5• Monitor and review
Page 20
Code Black – Implementing a Team Approach
to Managing Violence and Aggression
Code Black – Implementing a Team Approach
to Managing Violence and Aggression
Our Next Challenge
1• Identify patients at high risk of violence and aggression
2• Assess current risk and document in the patient’s clinical notes
3
• Review and/or develop behaviour management plans
• Implement behavioural contracts (as required)
• Request additional resources as required
4Effectively communicate risk and plan/s to all staff involved in the patient’s care
5• Monitor and review
Page 20
Page 21
Code Black – Implementing a Team Approach
to Managing Violence and Aggression
Code Black – Implementing a Team Approach
to Managing Violence and Aggression
Our Next Challenge
1• Identify patients at high risk of violence and aggression
2• Assess current risk and document in the patient’s clinical notes
3
• Review and/or develop behaviour management plans
• Implement behavioural contracts (as required)
• Request additional resources as required
4Effectively communicate risk and plan/s to all staff involved in the patient’s care
5• Monitor and review
Page 22
Code Black – Implementing a Team Approach
to Managing Violence and Aggression
Code Black – Implementing a Team Approach
to Managing Violence and Aggression
Our Next Challenge
1• Identify patients at high risk of violence and aggression
2• Assess current risk and document in the patient’s clinical notes
3
• Review and/or develop behaviour management plans
• Implement behavioural contracts (as required)
• Request additional resources as required
4Effectively communicate risk and plan/s to all staff involved in the patient’s care
5• Monitor and review
Page 23
Code Black – Implementing a Team Approach
to Managing Violence and Aggression
Code Black – Implementing a Team Approach
to Managing Violence and Aggression
Police
Page 24
Code Black – Implementing a Team Approach
to Managing Violence and Aggression
Code Black – Implementing a Team Approach
to Managing Violence and Aggression
ED Enhancement Project
Page 25
Code Black – Implementing a Team Approach
to Managing Violence and Aggression
Code Black – Implementing a Team Approach
to Managing Violence and Aggression
What comes next….
Page 26
Code Black – Implementing a Team Approach
to Managing Violence and Aggression
Code Black – Implementing a Team Approach
to Managing Violence and Aggression
Questions?