ClinicalReducing Violence in the Emergency Department: A Rapid Response Team Approach
Section snippets
Background
This project was implemented in a 240-bed community hospital with an emergency center (EC) with more than 90,000 patient visits annually. Patients seeking care for mental illness and substance abuse stay, on average, between 15 and 17 hours while awaiting inpatient placement, and because of their long duration of stay, these patients represent approximately 25% of the EC patient population at any given time. In December 2009, the hospital formed a “De-escalation Team” consisting of physicians,
Code S Process
During the Code S response, the attending physician and the primary nurse perform the clinical assessment, making decisions to meet the patient's needs for safety and control. Sometimes these decisions entail medication (eg, anxiolytic or antipsychotic agents), restraint, or seclusion; however, in more than 70% of the Code S responses at our hospital, no invasive or restrictive interventions were required (E. Kelley, unpublished data, 2009-2011).
During a Code S, the clinical staff remains in
Results
As of this writing, Code S has been used at our facility more than 650 times in the EC. The primary goal of the Code S team is to provide the best possible care of the escalating individual at an early stage of escalation, using verbal de-escalation techniques. The desired outcome is to reduce the use of restraint and locked seclusion and ultimately reduce injuries to patients and staff. Because, according to the ENA survey, more than 50% of staff injuries are not reported,1 the team decided to
Case Study
Since the introduction of the Code S protocol, take-downs, locked observation, and patient and staff injuries have been reduced dramatically. The following case study is a description of the actual outcome in the case of “Don” and shows how the Code S protocol was implemented.
Linda, a 20-year veteran of emergency nursing, reported to work at 11 am. She got “that sinking feeling” when she learned that she was assigned to the red team, a low-acuity area in the EC that was a catch-all for belly
Conclusion
The Code S protocol was developed to fulfill the mission of the De-Escalation Team at my hospital to provide the best possible care of behavioral health patients. Before the introduction of the Code S protocol, an interaction such as the one previously described often would progress to further escalation of the patient, verbal and even physical assault on the nurse and/or sitter, and a take-down by security, which usually ended in restraint or seclusion. During such an intervention, the patient
Elizabeth C. Kelley, Member, Mayflower Chapter, is Nurse Manager, Emergency Center, Cape Cod Hospital, Hyannis, MA.
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Managing alcohol related aggression in the emergency department
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(2008) Emergency department violence surveillance study
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Cited by (22)
Code De-Escalation: Decreasing restraint use during agitation management in a community hospital emergency department
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2022, International Journal of Africa Nursing SciencesDevelopment and Implementation of an Emergent Documentation Aggression Rating Tool: Quality Improvement
2021, Journal of Emergency NursingCitation Excerpt :Level 1 interventions included verbal de-escalation20 by explaining what to expect during the ED visit, silent observation by nursing staff, attempt to distract or redirect,20 and increase frequency of staff rounds. Level 2 interventions included establishing a verbal behavioral agreement with the patient regarding the behavior; increasing the frequency of nursing rounds; orienting or redirecting the patient to reality20; reassigning the room for optimal observation20; informing the physician/licensed independent provider (LIP), charge nurse, and supervisor of patient's escalating behavior; contacting security5,21 to wand with a portable metal detector and/or search the patient for weapons in accordance with internal hospital policy and secure belongings as needed; and crisis intervention response team (CIRT) presence when appropriate.21 Level 3 interventions included using security/supervisor/charge nurse and/or CIRT21 as mediators, modifying the patient's environment, and consulting the physician/LIP who may order close observation.20
The consequences of violence against nurses working in the emergency department: A qualitative study
2018, International Emergency NursingCitation Excerpt :Healthcare work environments with the highest risk for WPV are emergency departments (EDs), psychiatric and intensive care units [1]. Many recent studies reported that the incidence of violence in EDs is growing increasingly around the world, including in Iran [14–17]. A recent survey conducted in Iran reported that 91.6% of nurses in teaching hospitals experienced verbal assault and 19.7% experienced physical violence during a one-year period [15].
Elizabeth C. Kelley, Member, Mayflower Chapter, is Nurse Manager, Emergency Center, Cape Cod Hospital, Hyannis, MA.