Issue 6 / 20 February 2012

NEW research published in the MJA appears to confirm that a proactive approach to dealing with aggressive patients is more likely to reduce the risk of events escalating and make staff feel safer.

The prospective audit, conducted over 14 months at the Royal Children’s Hospital Melbourne, followed the implementation of a formal system of management through establishment of a multidisciplinary “code grey” team to respond to patient and visitor aggression, including verbal abuse. (1)

The eight-person team included two security officers, a senior emergency department doctor (as team leader), four nurses from different wards and a member of the hospital administration.

The team could be activated by any staff member facing a perceived or actual threat to themselves or others where attempts at “verbal de-escalation” had failed.

“The prime method [to control aggressive behaviour] is continued verbal de-escalation coupled with the physical appearance of eight staff gathering at the site”, the researchers said. As a last resort, five-person physical restraint and chemical restraint could be used to manage the patient.

Over the 14 months of the study, data were gathered for 104 incidents, including 75 cases involving 40 different patients aged between 6 and 24 years, and 29 involving visitors. Of the 40 patients, 24 were female and 16 male, with a third the subject of more than one “code grey” event.

Aggressive patients were more likely to have pre-existing psychiatric or developmental problems, with self-harm and absconding threats usually accompanied by other forms of aggression. Verbal de-escalation alone was sufficient in 22 of the 75 patient cases or simply the presence of the team in three cases.

The lack of data and literature about aggression in the paediatric setting had been an impediment to establishing a system to manage aggression in the hospital.

“Initial challenges to the formation of our code grey response teams included the lack of pre-existing paediatric models, insufficient security support and the absence of staff able to provide physical support. Balanced against this was the recognition by all stakeholders of the need for cooperation with nursing and medical staff volunteering to participate in the teams”, the researchers said.

The program is still operating at the hospital and has been subject to only minor changes.

A similar formal program to manage aggressive patients was established at the Austin Hospital, Melbourne, in 2000, and it continues to help staff feel safer in the work environment, according to one of the staff involved in the program. (2)

Mr John Forster, a mental health nurse at the Austin who coauthored the research into the program, told MJA InSight that proactive measures helped to prevent the escalation of aggression as well as reducing the number of incidents.

The key components of the Austin’s program included staff education and training, risk assessment and management practices, the use of patient contracts and policy development. It integrated and balanced occupational health and safety obligations to staff with the duty of care to patients

Mr Forster said having a program in place meant an organisation was sending a clear message to patients, visitors and staff that aggression was unacceptable. The flow-on from having clear policies was that staff felt safe.

“Our aim was to give a clear undertaking on staff and patient safety.”.

He said further research into reducing aggressive behaviour was needed, particularly on whether the lessons learnt in a major hospital like the Austin could be used in a smaller health setting.

Dr Michael Fasher, a member of the Royal Australian College of General Practitioners National Faculty of Specific Interests, Child and Young Persons Health Network, said aggression from children and adolescents was not a common problem in general practice.

“The nature of general practice in the community means that this is an issue that doesn’t normally come up”, Dr Fasher said.

For GPs, the threat of aggressive behaviour was most likely to come from drug-seeking patients.

– Kath Ryan

1. MJA 2012; 196:198-201
2. MJA 2005; 183: 357-361

Posted 20 February 2012

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