Jonathan Knott, Royal Melbourne Hospital: Case Study: Prevention and Management of Clinical Aggression - Making Hospitals Safer


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Assoc Prof Jonathan Knott, Head of Emergency Research, Royal Melbourne Hospital; Clinical Sub-Dean for Emergency Medicine, University of Melbourne delivered this presentation at the 2013 Safe and Secure Hospital Conference. The comprehensive program addressed the following issues:

Early intervention via early reporting of disruptive, aggressive, and bullying behaviour to minimise work place violence
An innovative training model to help clinicians, security and policy makers respond to the problems of challenging behaviours
Therapeutic sedation in the Emergency Department: Best practice in managing the highly agitated patient
A systems approach to the prevention of Occupational Violence and Aggression (OVA)
Contract management security: The change from in-house security to contract security
Role of the Risk Based Approach throughout the design process
Preventing and managing clinical aggression in the paediatric and youth health setting
The roles, functions and training provided by the Mental Health Intervention Team (MHIT), New South Wales Police Force
Interactions between Police, Health staff, Ambulance and Hospital Security and future directions
A Legal Perspective: Prevention and management of violence in hospitals
Code Grey responses - Are they legal?

For more information about the annual event, please visit the conference website:

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Jonathan Knott, Royal Melbourne Hospital: Case Study: Prevention and Management of Clinical Aggression - Making Hospitals Safer

  1. 1. Prevention and Management of Clinical Aggression – Making Hospitals Safer A Prof Jonathan Knott Royal Melbourne Hospital University of Melbourne
  2. 2. “Majority of staff have an expectation of (violence). It sounds really horrible this, that something like this will happen, high expectation… I’m going to learn how to run quick… do become hard to violence and aggression… ...verbal abuse we ignore… just becomes natural” EMJ Nov 2013
  3. 3. Eighty participants reported being verbally abused at least once a month, and 39 reported this as a daily occurrence. Twenty-three staff had experienced physical assault at least once a month. Alcohol was the most commonly listed factor contributing to the violence and aggression. Staff suggestions for how to manage alcoholrelated violence included the provision of more security staff and better training. AEMJ 2011
  4. 4. The study shows 71% of medical practitioners experienced verbal or written aggression and 32% experienced physical aggression from one or more sources in the previous 12 months. MJA 2012
  5. 5. “Nurses are reporting hundreds of attacks in Brisbane's emergency departments as they struggle with violent patients” Channel 7 2013
  6. 6. What is clinical aggression?
  7. 7. Aims Patient education Zero tolerance Staff training Who gets trained what and how Emergency response Code Black is the National standard
  8. 8. Violence prevention and management Standards for development of training and organisational response in Victorian Health services Not finalised
  9. 9. Methods Extensive consultation Literature reviews Current practice and policies Recommendations Evidence base?
  10. 10. Training All staff should have basic training in management of clinical aggression • Orientation • Medico legal principles • Mental Health literacy • Recognition of early signs • Introduction to de-escalation techniques Training should be tailored to risk and types of exposure
  11. 11. Other modules Leadership Conflict resolution Obstetrics and adolescents Breakaway techniques
  12. 12. Training for Security Officers • • • • • • Health literacy, especially for mental health Conflict resolution Communication Medico-legal framework Safer restraint techniques In conjunction with clinical staff
  13. 13. Training • Evidence based (as far as practicable) • Clearly defined goals and measurable outcomes • Consider what can be given on-line • Who gives it - credentialing
  14. 14. Code Grey • • • • • Organisational response and responsibility Appropriate data collection Review by cross section of staff Policies adapted by reviews KPIs set for organisation
  15. 15. Code Grey Recognition that staff safety has a very high priority even whilst caring for our patients Standard must recognise this tension and accommodate it
  16. 16. Code Grey Combination of security and trained clinical staff – But clinically led Minimum numbers required for safe care
  17. 17. Code Grey Consideration of a tiered response – Code Black – Code Grey – Variations on Code Grey cf. Code Blue / Met call
  18. 18. Recommendations Standardisation – Of training – Of Emergency response National Standard – Agreement across jurisdictions
  19. 19. Conclusion Need to give the staff the skills they require to care for patients safely in a modern hospital Need to give the organisation the response to safely provide for their staff Need to ensure patients get the best care in the least restrictive manner