Preventing & Managing Clinical
Aggression in a Children’s Hospital
Emergency Department
Peter Sloman – Associate Nurse Uni...
About RCH
• International centre of excellence in child and youth
health
• Operating for over 140 years
• Brand new facili...
About RCH Emergency
• 20x Bays, 4x Resus Bays, 8x Observation Beds
• We see over 83,000 patients annually
• Up to 350 pati...
Presentation Outline
• Practice Development
• Innovation in Education
• Emergency Team Response
• The patient, the parent,...
Why do we need Aggression Management:
• 2005 Report from the Victorian Violence in
Nursing Taskforce detailed 29
recommend...
How does violence and aggression present
at the RCH
• Emergency Department
• 50:50 Split between Parent/Family vs. Patient...
What we did at the RCH
• Formed the Committee for Aggression
and Security Management
• Piloted a nurse led project in the ...
Policy Development
• Guided by the Taskforce
recommendations and by DHS/Dept. of
Health templates RCH developed a
Policy f...
Procedure Building
• To support policy the committee and
project staff built procedures around
managing clinical aggressio...
Guideline Implementation
• Clinical Practice Guidelines were
implemented for emergency restraint and
sedation, as well as ...
What we continue to do
• Aggression & Violence Prevention Committee
(Executive Chair & Sponsorship)
• Appointment of a ful...
Education & Training
• RCH MOCA (based on the NWMH MOCA
Model, altered to suit the child and youth
setting)
• Annual MOCA ...
Principles of our training
• Early identification and intervention
approach
• The risk assessment framework of ESP
(Enviro...
Innovation in Education: Making
training tangible for the busy ED
team
• Several barriers to ED staff being able
to undert...
MOCA training
• Currently an 8 hour study day
• Identified a need to divide the training
into smaller components to maximi...
Funding Grant
• RCH ED received ongoing support from
the DoH to develop aggression
management & violence prevention
resour...
Staff Surveyed
• MOCA originally designed for any
clinician
• ED staff surveyed to identify their area
specific learning n...
Results
• ED learning needs and current MOCA
training very similar
• Small modifications made to tailor it for
ED specific...
Process
• Met with:
• Nursing Education
• Workforce Development
• Corporate Communications
• Consultation took place with ...
Modules
• Four modules:
• Modules 1 & 2 - online learning package
• Video and scenario based with interactive
components
•...
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 t...
Who is on the Team
Our team is made up of 7-10 members
• Clinically led team-
• Team Leader (1-2 Senior Clinicians)
• Area...
What the team brings:
• Human Resources
• Clinical Knowledge
• Experience
• Idea’s
• Presence
• Strength
• Material Resour...
When does the team mobilise
• Planned Code Grey
• A planned code grey is
utilised when
aggression and
violence can be
accu...
Why such a large team
• Multi-disciplinary approach to care
• Broader skill base
• Presence/Shepherding/Crowd Control
• Pr...
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...
RCH Patient Priorities
• Patient centred care
• Targeted action plans
• Behavioural Management Plans
• Partnership in care...
Parent Factors
• A recent incident:
• The father of a 6 month old infant has
presented with a respiratory illness. His
chi...
RCH Parent Priorities
• Family centred care
• Improved communication
• Membership in the treating “team”
• Encourage separ...
Clinician Factors
• The clinicians perspective
• Ability to work in a safe and supported
environment
• Zero tolerance to o...
Summary
• We are proud of our achievements to date around
policy, procedure & guideline development & believe
that it make...
Acknowledgements
From the Royal Children’s Hospital:
• Dr Sandy Hopper – Emergency Paediatrician
• Ms Nadine Stacey – Clin...
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Peter Sloman & Charlie Bowes, The Royal Childrens Hospital Melbourne - Preventing & Managing Clinical Aggression in a Children’s Hospital Emergency Department

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Peter Sloman & Charlie Bowes delivered the presentation at the 2014 Emergency Department Management Conference.

The 2014 Emergency Department Management Conference explored areas such as how to improve access to care, clinical redesign, NEAT compliance, patient flow, point of care testing, geriatric care, and enhance the performance of Emergency Department.

For more information about the event, please visit: http://bit.ly/edmanagement14

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Peter Sloman & Charlie Bowes, The Royal Childrens Hospital Melbourne - Preventing & Managing Clinical Aggression in a Children’s Hospital Emergency Department

  1. 1. 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)
  2. 2. 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
  3. 3. 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
  4. 4. Presentation Outline • Practice Development • Innovation in Education • Emergency Team Response • The patient, the parent, and the clinician: Key stakeholders in clinical aggression management
  5. 5. 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
  6. 6. 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
  7. 7. 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
  8. 8. 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
  9. 9. Procedure Building • To support policy the committee and project staff built procedures around managing clinical aggression, emergency team response, and the use of restraint
  10. 10. 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
  11. 11. 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)
  12. 12. 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
  13. 13. 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
  14. 14. 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
  15. 15. 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)
  16. 16. 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
  17. 17. 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
  18. 18. 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
  19. 19. Process • Met with: • Nursing Education • Workforce Development • Corporate Communications • Consultation took place with key stakeholders during the design and development stages
  20. 20. 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
  21. 21. Implementation Phase Trial education package with an emphasis on comprehensive feedback and evaluation
  22. 22. 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
  23. 23. 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
  24. 24. What the team brings: • Human Resources • Clinical Knowledge • Experience • Idea’s • Presence • Strength • Material Resources • PPE • Medication • Documentation • Treatment equipment • Mechanical Restraints
  25. 25. 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
  26. 26. 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
  27. 27. The patient, the parent, and the clinician: Key stakeholders in clinical aggression management
  28. 28. 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!
  29. 29. RCH Patient Priorities • Patient centred care • Targeted action plans • Behavioural Management Plans • Partnership in care • Ownership of behaviours and condition • Y@K
  30. 30. 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!
  31. 31. 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
  32. 32. 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
  33. 33. 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!
  34. 34. 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
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