andrew walby - st vincent's hospital, melbourne - fifty shades of code grey
TRANSCRIPT
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?