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)

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

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

Presentation Outline

• Practice Development

• Innovation in Education

• Emergency Team Response

• The patient, the parent, and the

clinician: Key stakeholders in clinical

aggression management

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

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

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

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

Procedure Building

• To support policy the committee and

project staff built procedures around

managing clinical aggression,

emergency team response, and the use

of restraint

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

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)

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

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

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

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)

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

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

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

Process

• Met with:

• Nursing Education

• Workforce Development

• Corporate Communications

• Consultation took place with key

stakeholders during the design and

development stages

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

Implementation Phase

Trial education package with an emphasis

on comprehensive feedback and

evaluation

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

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

What the team brings:

• Human Resources

• Clinical Knowledge

• Experience

• Idea’s

• Presence

• Strength

• Material Resources

• PPE

• Medication

• Documentation

• Treatment equipment

• Mechanical Restraints

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

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

The patient, the parent, and the

clinician: Key stakeholders in

clinical aggression management

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!

RCH Patient Priorities

• Patient centred care

• Targeted action plans

• Behavioural Management Plans

• Partnership in care

• Ownership of behaviours and condition

• Y@K

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!

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

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

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!

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