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Preventing & Managing Clinical
Aggression in a Children’s Hospital
Emergency Department Peter Sloman – Associate Nurse Unit Manager, Emergency Department Charlie Bowes – Clinical Nurse Consultant Aggression Management (Code Grey)
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About RCH
• International centre of excellence in child and youth
health
• Operating for over 140 years
• Brand new facility opened in 2011
• 330+ Beds
• Victoria’s only Paediatric Trauma Centre
• National Paediatric Cardiac & Liver Transplant centre
• Campus Partners include the University of Melbourne
& the Murdoch Children’s Research Institute
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About RCH Emergency
• 20x Bays, 4x Resus Bays, 8x Observation Beds
• We see over 83,000 patients annually
• Up to 350 patients a day during winter
• Waiting times up to 6hrs
• 70+ staff working over a 24hr period
• Approx 200 Code Greys a year in ED
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Presentation Outline
• Practice Development
• Innovation in Education
• Emergency Team Response
• The patient, the parent, and the
clinician: Key stakeholders in clinical
aggression management
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Why do we need Aggression Management:
• 2005 Report from the Victorian Violence in
Nursing Taskforce detailed 29
recommendations endorsed by the
Government of the day
• 2011 Report from the Victorian Parliamentary
inquiry into Violence and Security
Arrangements in Victorian Hospitals
• An increase of security activities and actions,
and well as a recorded increase in Violence &
Aggression in key area’s of our health service
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How does violence and aggression present
at the RCH
• Emergency Department • 50:50 Split between Parent/Family vs. Patient
• Adolescent Medicine • ED, Medically unstable Psychiatric DDx
• Adolescent Mental Health • BPD, Acute Psychosis
• Traumatic/Acquired Brain Injury • Young children through to older Adolescents
• Developmental Disability • ASD, Asperger's, GDD, Pradae Willi Sx
• Family/Parental Conflict • AVO, Court Ordered Restrictions
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What we did at the RCH
• Formed the Committee for Aggression
and Security Management
• Piloted a nurse led project in the ED
around aggression and violence
• Practice Development model
(Benchmarking & Needs analysis)
• Engaged training (NWMH – MOCA)
• Team selection & formation
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Policy Development
• Guided by the Taskforce
recommendations and by DHS/Dept. of
Health templates RCH developed a
Policy for the Code Grey: Management
of Aggressive Behaviour, and in line
with this a Code of Behaviour for
consumers, and a Code of Conduct for
Staff
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Procedure Building
• To support policy the committee and
project staff built procedures around
managing clinical aggression,
emergency team response, and the use
of restraint
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Guideline Implementation
• Clinical Practice Guidelines were
implemented for emergency restraint and
sedation, as well as the use of an Emergency
Behavioural Assessment Room or Safe Room
in the emergency department
• Within the RCH mental health services the
development of patient search guidelines
were adopted in response to evolving risk
identification
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What we continue to do
• Aggression & Violence Prevention Committee
(Executive Chair & Sponsorship)
• Appointment of a full-time clinical lead
• Victoria’s new Mental Health Act & Reducing
Restrictive Interventions Project
• Review of model – ED training resources
(with potential for hospital wide application)
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Education & Training • RCH MOCA (based on the NWMH MOCA
Model, altered to suit the child and youth
setting)
• Annual MOCA Competency within the mental
health division
• Regular in-service education and rehearsal
• Delivery of Verbal De-escalation & Crisis
intervention training sessions to both clinical
and non-clinical staff
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Principles of our training
• Early identification and intervention
approach
• The risk assessment framework of ESP (Environment, Self/Staff, Patients/People)
• Clinical Leadership model
• Harm minimisation approach
• Application of a least restrictive
intervention possible
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Innovation in Education: Making
training tangible for the busy ED
team
• Several barriers to ED staff being able
to undertake MOCA training. • 140 nursing, 50 medical, 30 clerical, 15 clinical
services, 8 allied health.
• Of this up to 80 staff rotating 3 monthly to annually,
making education and training very difficult
• Reduced ability over winter months to provide
training due to high department workload
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MOCA training
• Currently an 8 hour study day
• Identified a need to divide the training
into smaller components to maximise
the number of staff receiving training
• Idea of 4 modules that could be each
complete in a 1 to 2 hour timeframe
(during orientation, double staffing)
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Funding Grant
• RCH ED received ongoing support from
the DoH to develop aggression
management & violence prevention
resources for ED staff
• Giving us the ability to look at different
mediums – online, video, interactive
scenarios
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Staff Surveyed
• MOCA originally designed for any
clinician
• ED staff surveyed to identify their area
specific learning needs around
aggression management
• Compared this to the current training
content
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Results
• ED learning needs and current MOCA
training very similar
• Small modifications made to tailor it for
ED specific staff.
• Larger emphasis on verbal de-
escalation
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Process
• Met with:
• Nursing Education
• Workforce Development
• Corporate Communications
• Consultation took place with key
stakeholders during the design and
development stages
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Modules
• Four modules:
• Modules 1 & 2 - online learning package
• Video and scenario based with interactive
components
• Modules 3 & 4 – Face to face presentation
with aggression management trainers
delivered to small groups, hands on
approach
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Implementation Phase
Trial education package with an emphasis
on comprehensive feedback and
evaluation
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Emergency Team Response
• The who what when and why of the
RCH emergency response team!
• Who is on the team
• What does the team bring
• When does the team mobilise
• Why a multi-disciplinary team response
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Who is on the Team
Our team is made up of 7-10 members • Clinically led team-
• Team Leader (1-2 Senior Clinicians)
• Area Specific & Hospital Wide
• Nurses (3 staff)
• Adolescent Medicine/Neuroscience/Paediatric
Medicine (Developmental Medicine)
• Security Officers (2-3 staff)
• Experienced operators trained with Clinicians
• Medical Staff (1-2 staff)
• Utilising the treating Doctors
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What the team brings:
• Human Resources
• Clinical Knowledge
• Experience
• Idea’s
• Presence
• Strength
• Material Resources
• PPE
• Medication
• Documentation
• Treatment equipment
• Mechanical Restraints
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When does the team mobilise
• Planned Code Grey
• A planned code grey is
utilised when
aggression and
violence can be
accurately predicted
and managed with a
highly organised and
coordinated response
• Code Grey
• Occurs in a crisis
incident of violence
and aggression, while
still an organised
response, these team
responses are more
rapid in escalation,
and often require a
higher degree of
intervention
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Why such a large team
• Multi-disciplinary approach to care
• Broader skill base
• Presence/Shepherding/Crowd Control
• Procedurally driven for physical intervention
• Ability to observe/relieve
• Simultaneous incident management
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The patient, the parent, and the
clinician: Key stakeholders in
clinical aggression management
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Patient Factors
• A recent incident: • A 15yo male patient with a complex history of
psychosocial risk factors presents to the
emergency department unescorted with
evidence of self harm. After initial assessment
the patient begins to refuse treatment and
intervention, and becomes combative and
aggressive towards staff, he eventually
attempts to leave against medical advice!
• What is causing the patient to be aggressive?
• Applying ESP to this scenario!
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RCH Patient Priorities
• Patient centred care
• Targeted action plans
• Behavioural Management Plans
• Partnership in care
• Ownership of behaviours and condition
• Y@K
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Parent Factors
• A recent incident: • The father of a 6 month old infant has
presented with a respiratory illness. His
child has been triaged as a cat 4 and has
been waiting in the waiting room for 3 hours.
He presents as aggressive and abusive
and has made threats to staff.
• What was causing the parents
aggression?
• Applying ESP to this scenario!
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RCH Parent Priorities
• Family centred care
• Improved communication
• Membership in the treating “team”
• Encourage separation of situational
crisis and crisis of disease/condition
• Family Advisory Council
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Clinician Factors
• The clinicians perspective • Ability to work in a safe and supported
environment
• Zero tolerance to occupational violence and
aggression
• The rights & responsibilities to access and
attend training
• Support and Praise for improved practice
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Summary • We are proud of our achievements to date around
policy, procedure & guideline development & believe
that it makes the RCH a great place to work
• We are also proud of our clinical leadership model
and believe that it makes RCH a great place to be
cared for as a patient
• We acknowledge the ongoing nature of quality
improvement in this area
• We are excited by the opportunities that are ahead of
us in regards to change and improvement, We
believe this will help us be a great Children’s
Hospital!
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Acknowledgements
From the Royal Children’s Hospital:
• Dr Sandy Hopper – Emergency Paediatrician
• Ms Nadine Stacey – Clinical Lead, Quality &
Safety
• Marianne Hunter – Director, Workforce
Development
• Melody Trueman – Director, Nursing Education