dr andrew walby - st vincent's hospital melbourne - fifty shades of code grey
TRANSCRIPT
Fifty Shades of Code GreyA clinical team response to acute
behavioural disturbance
Dr Andrew Walby
Request to speak today…
17 July 2015
“Mental Health has become a big issue with increasing
presentations to ED and length of stay. It would be
interesting to see what other EDs are doing to manage
them”.
“I came across an article in my research about the
management of aggression and violence at your
hospital/ED, and some important issues below, that I
believe would be of interest at the conference”.
6 October 2014 : State Election
17 July 2015
"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
17 July 2015
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."
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Summary
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• 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
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• 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
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• 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”…
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The fish pond…
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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
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Geography
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Geography
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EDMH : Contacts
Mental Health Catchment Areas
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Inner Urban East vs Inner West
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Section 351 (formerly section 10)
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History of Code Grey
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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
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7 May 2002 : Code Ivory
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Behavioural Assessment Room
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2002 : Funding obtained to re-develop the triage area,
including ambulance reception.
2003 : Behavioural Assessment Room (BAR) opened.
Safety and Quality Framework
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BAR
Code Grey Clinical Team
Response
Training Multi Disciplinary
Team
Policies Internal
and External
Partnerships
Police
Ambulance
“RAS Syndrome”
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“PIN Number”
“ATM Machine”
“HIV Virus”
“VIN Number”
“DC Comics”
“NEAT Target”
“BAR Room”
Development of Code Grey
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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
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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)
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Positive Outcomes
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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 34
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 35
Day/Month/Year Footnote to go here Page 38
May 2007
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May 2007 : AoD
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May 2007 : Restraint
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July 2011
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July 2012
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18 February 2014
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6 October 2014 : State Election
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October 2014
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SOOTHE
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14 May 2015
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Code Greys : growth over six years (WoH)
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Code Grey in ED : 2014
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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
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May 2015
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May 2015
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Other Strategies to Improve Safety
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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”…
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A “patient of interest”…
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The Future : PECC
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The Future : PAPU
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Acknowledgements
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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?
17 July 2015