Dial 7788 “Code Grey— Pip3—Male Side” “This Is The Head Nurse”

By Janet Ferguson, PMHCNS-BC, Associate Director Behavioral Health Nursing, and Donna Leno-Gordon, RNMS, MPA, Director Behavioral Health Nursing

The title of this article contains status, may have been evident Please see “About the Authors” a series of actions that activate prior to the explosion, or may have on page 15. a procedure that summons staff been undetected or ignored due to through individual pagers and staff’s fear or lack of training. The an overhead announcement to staff who deal with the explosive respond to one of two acute patient are primarily nurses, but behavioral health inpatient the psychiatrist and, if necessary, units to assist in preventing or the police are brought de-escalating a crisis. The criteria in to resolve the “explosion.” This for activation of this team can be, practice of reacting to a crisis is but are not limited to, a patient no longer acceptable. Rather, the exhibiting severe agitation, yelling, emphasis is on how we can prevent threats, exhibiting violence, and/ these situations from occurring. or displaying any acute change in mental status. The trend in our Behavioral Health on acute inpatient units in recent Psychiatric inpatient units provide years has been to encourage a acute care for patients that have culture that is therapeutic, and that been admitted involuntarily, who uses fewer invasive interventions, often present with histories of such as restraints, seclusion, violence and/or suicide attempts, and intramuscular medication. and who are identified as at a Historically, patients on psychiatric high risk for becoming severely inpatient units would frequently agitated and possibly violent during exhibit agitation that would be their hospital stay, which could allowed to escalate to levels that result in the use of restraints and/ resulted in the use of restraints or seclusion. Patients treated on and/or seclusion. Not only would inpatient units exhibit a range this invasive method to control of fluctuations in their mental the patient be utilized, but the status that reflect the progress in length of time these forms of their recovery and psychosocial intervention were used could be influences. However, a common excessive. Nursing staff assumed scenario often reported is that a the lead role in attempting to patient “exploded without warning defuse the situation; however, the and required intramuscular behavior was often already at a medication and restraints.” The crisis level. This results in not only signs and symptoms of increasing hospital police presence, but their anxiety, or subtle changes in mental assistance in the actual physical

© 2010 CPI. 11 of Behavioral Health was to move forward toward changing the culture on the inpatient units to discourage the use of invasive means of controlling behavior such as restraints or seclusion.

Coney Island Hospital, located in , is one of eleven affiliated with City Health and Hospital Corporation. It is a 371-bed community hospital that provides service to southern Brooklyn residents. The Behavioral Health Department includes a psychiatric emergency department intervention toward the patient. The Our Behavioral Health Department within the medical emergency psychiatrist’s role would include decided it was time to create department, two 32-bed psychiatric evaluation of the patient, resulting in a climate that would influence inpatient units, psychiatric orders for intramuscular medication the entire staff on our inpatient outpatient programs, and a with restraints or seclusion due to units to participate in a proactive chemical dependency program the dangerousness of the situation. approach to intervening with (outpatient and inpatient). Frequent scenarios would have potentially escalating dangerous In early 2007, a multidisciplinary staff, including hospital police and situations before crises could committee was formed with the nursing staff, physically restraining erupt. Inpatient staff agreed that mission to develop a program an agitated patient in a highly tense perhaps with early intervention that would provide an approach and dangerous situation while a and preventative strategies, many that would be more therapeutic, nurse administered intramuscular of these events might be avoided, compassionate, and safe in medication. The staff would place resulting in a more compassionate preventing incidents of escalating the same patient in restraints and therapeutic milieu for the agitated behavior that culminates or seclusion. The risk for injury in crisis and often violence. The was always high during these committee included clinicians encounters. The signs and symptoms of and administrators as well as increasing anxiety, or subtle Today the use of restraint and representatives from hospital police seclusion is considered only as changes in mental status, and the information technology a last resort to be used only if may have been evident (IT) department. The vision of this all other options fail. The use of prior to the explosion or committee was to provide the best practice in the prevention intramuscular medication has also undetected and ignored been under scrutiny regarding aspects of escalated behaviors its therapeutic effect versus its due to staff’s lack of which included recognition of the invasive aspect. The practice of training or fear. early symptoms often exhibited by intramuscular medication and patients. The committee collected physical intervention can be data regarding how other hospitals patients. In addition, the idea to dangerous and places patients were handling these incidents and incorporate other disciplines into and staff in unsafe situations also conducted an employee survey being proactive and part of a team that may have been avoided. In of all the inpatient staff on all tours would help avoid invasive means of today’s world, the practice of these of duty regarding their attitudes controlling behavior. Current teams modalities is often viewed as an related to safety. The overall theme on our inpatient units were limited to actual treatment failure. This is that this survey revealed was that shift, unit, and discipline (generally particularly true if these modalities staff often felt afraid and that they nursing staff, a psychiatrist, and off- are viewed as a form of trauma not did not work as an effective team unit hospital police). The decision at only to the patients but to staff in crisis situations. Many staff Hospital Department as well. identified that they did not feel

12 Journal of Safe Management of Disruptive and Assaultive Behavior, September 2010 Crisis Intervention® techniques and rotational basis would participate as Inpatient staff agreed would be available to respond when a team member during their shift or that perhaps with a code was activated. assignment. early intervention and The Code Grey Team evolved over The Code Grey Team is comprised preventative strategies several months of meetings whose predominantly of inpatient nursing many of these events might agenda included but was not staff; however other key members be avoided, resulting in a limited to the following: include clinical administrators, inpatient therapists, psychiatrists, more compassionate and First, the development of a policy and procedure reflective and hospital police. During the therapeutic milieu for of our philosophy to avoid the planning phase of this initiative, a the patients. use of restraints and seclusion number of staff were selected to through early intervention by the attend CPI’s four-day certification they had adequate training in provision of a trained team of program to become Nonviolent ® symptom recognition and staff to assist in de-escalating Crisis Intervention Certified de-escalation strategies that used potentially dangerous psychiatric Instructors. To date we have 19 verbal means to intervene, rather emergencies in a safe, Instructors that are utilized to than physical force. The committee compassionate, and respectful provide training on all shifts on a also investigated what actually was manner. monthly basis. All staff assigned reported to be occurring prior to to the team have received formal ® the actual use of restraints—not Second, the identification of the Nonviolent Crisis Intervention only the patient’s behavior but the learning needs and necessary training by attending an eight- staff’s behavior as well. Identified training for all clinical staff and hour program conducted here at leaders and cohesive working hospital police to be able to Coney Island Hospital by one of teams were described as ineffective intervene at the initial signs of our Certified Instructors. Initially, and inadequate due to confusion, increasing anxiety or agitation. the training was targeted at staff poor communication, and, primarily, working in the acute psychiatric failure to respond to early warning Third, the coordination of care areas, which was only the signs of increasing anxiety exhibited services pertaining to staffing, staff assigned to the Code Grey by the patient. communication (written and Team. Presently, all staff working in verbal), and evaluation. the Behavioral Health Department The development of the psychiatric are expected to attend training at crisis prevention team called The inpatient staff, including many least annually, and the acute care Code Grey on the Coney Island of our administrators and hospital area (inpatient and psychiatric Behavioral Health Inpatient Units police officers, was trained in this emergency) staff attend more was our response to wanting to new initiative and in the expectation frequently. change the old culture. We wanted that each one of them on a to handle violence, potential violence, escalating behavior, and/or aggression through the safest, least restrictive means possible. We wanted our staff to have the knowledge and skills to move from a reactive to a primarily preventative practice. The goal is to provide assistance to the patient in regaining control of his/her behavior through the best possible Care, Welfare, Safety, and SecuritySM not only for the identified patient, but for other patients and staff as well. The Code Grey Team was defined as an interdisciplinary team that has received training in Nonviolent

© 2010 CPI. 13 The leader during these codes is that this new team is a means referred to as the team leader. The To sustain this proactive that enhances shared governance team leader is usually the nurse, preventive initiative, (team building) at the grassroots although this can change during the ongoing CPI education level across the entire inpatient actual code depending on how the staff, including hospital police patient responds. The team leader programs, monthly meetings and clinical administrators. In the is often the staff member who for critique and data past, staff who were reluctant to directs another team member to call review, and daily inpatient share their opinions or who were for a code and continues to interact treatment team meetings adversarial have now become with the patient. Team leaders active participants in this process. generally have the best rapport that address the symptoms Finally, this model resulted in the with the patient, the confidence of potentially escalating empowerment of staff and patients, to de-escalate the situation, and behaviors and/or high risk a greater collaboration, and overall are aware of the events leading improvement for patient and staff up to the behavior change that patients have become a satisfaction relating to treatment. In necessitates the code. The team is central part of our culture. addition to the individual debriefing alerted when a member dials a four- following each Code Grey, there is digit code that activates not only a monthly meeting to review difficult individual pagers carried by team staff motivation to attend trainings cases and share performance data members, but also an overhead not only as students, but also as related to crisis prevention. intercom announcement. The instructors. Many of our newer team uses the SBAR (Situation, instructors have reported positive We have been very excited by Background, Assessment, and feedback in their own skills to the results of Code Grey. Code Recommendation) system to quickly effectively intervene in potentially Grey was introduced to the units communicate key information volatile situations in their clinical in December 2008. The number about the incident to arriving team areas, including in the team of episodes of restraints and members, including whether the leader role. seclusion averaged 8.3 per quarter patient has a history of violent in January through November behavior or other pertinent factors. Learning is ongoing and occurs 2008. There was an immediate with each code, after which there improvement in decreasing the A number of positive trends have is a debriefing that focuses on the use of restraints and seclusion as emerged over the past year since patient and staff responses. This evidenced by the quarterly average introducing Code Grey. We have debriefing provides an opportunity being reduced to 2.5 per quarter of seen interest on the part of our staff for the exchange of a great deal of 2009. Similarly, the total number of to continue to learn about crisis information, and learning from each patient/staff injuries resulting from prevention, and we have observed other as well. We also discovered agitation-related incidents on the inpatient units decreased from 0.1 per month in 2008 to 0.016 per month in 2009. The Code Grey 2009 data has indicated a trend for staff intervention to occur prior to the patient exhibiting dangerous behavior. This is supported by the total number of Code Greys (136), resulting in only 10 episodes of restraints or seclusion for this year.

The plans for the future include continuing to reduce the use of restraints and seclusion. In the spirit to provide the least restrictive and safest intervention possible, this also includes reducing the use of intramuscular medication. To

14 Journal of Safe Management of Disruptive and Assaultive Behavior, September 2010 sustain this proactive preventive initiative, ongoing CPI education About the Authors: programs, monthly meetings for Janet Ferguson, RN, is the Associate Director critique and data review, and daily of Behavioral Health Nursing at Coney Island inpatient treatment team meetings Hospital. Ms. Ferguson holds a degree from Downstate College of Nursing and a Master that address the symptoms of of Science in Nursing from Hunter Bellevue potentially escalating behaviors College of Nursing. She is board certified and/or high risk patients have as an ANA Clinical Nurse Specialist in become a central part of our culture. Adult Psychiatric and Mental Health. Ms. Ferguson is certified as a Nonviolent Crisis Intervention® Instructor through Beginning in 2010 we have started (from left to right) Donna Leno Gordon and CPI and a Basic Life Support Instructor Janet Ferguson to have unannounced behavioral through the American Heart Association. mock codes in which staff are Ms. Ferguson has an extensive professional expected to respond as if the mock background that includes a broad portfolio of programs. She has participated codes were actual incidents. The as administrator, educator, and practitioner across a wide range of health care settings including Acute Care Psychiatry, Partial Hospitalization Program, Mental drills provide excellent teaching Health, Homecare, and Medical Surgical Nursing. In addition to her Coney Island opportunities, and they assist staf responsibilities, Ms. Ferguson has been and continues to remain involved with fin practicing what they learn in educating nursing students regarding Behavioral Health through her adjunct role Nonviolent Crisis Intervention® at several local colleges. Ms. Ferguson’s primary focus throughout her career has trainings in a controlled situation. been the care of the acutely mentally ill patients in the inpatient and psychiatric emergency department. These mock codes also serve to raise staff sensitivity to how patients Donna Leno Gordon, RN, is the Director of Behavioral Health Nursing and Palliative may feel resulting from feedback Care at Coney Island Hospital. Ms. Leno Gordon holds a degree in nursing from from staff who assumed the role Pace University, a Master of Science in Family Counseling from Iona College and an of the agitated patient during Executive Masters in Public Administration from Baruch College. Ms. Leno Gordon has extensive experience and a broad portfolio of programs she has designed and these teaching experiences. Staff administered across a wide range of care settings including Rehabilitation, Critical enthusiasm during the debriefings, Care, Hospice & Palliative Care, Homecare, Mental Health, Consultation Liaison following both mock codes and Psychiatry, and Chemical Dependency. true codes, continues to encourage Ms. Leno Gordon is currently co-chair of the Corporate Wide Palliative Care Council as dialogue that builds a stronger and well as the Nursing Director for Behavioral Health where she and the behavioral health more cohesive team. team earned the 2009 Patient Safety Champion Award for Coney Island Hospital for their “Code Grey” Psychiatric Crisis Prevention Team and the 2009 Annual Behavioral The impact of our initiative Health Best Practice Award for their “Agitated Patient Management Team,” assessing outside of our Behavioral Health and treating acutely agitated patients immediately entering the Emergency Department. Department has also been evident in our hospital. Staff from Medicine, the Emergency Department, and Pediatrics have requested to participate in our programs in order to be better able to intervene in a positive, proactive approach with their patients. The role of patient, whether in Behavioral Health or Medicine, remains a role that is stressful, and, as a result, can escalate to crisis situations that result in violence. Discussions to explore and perhaps create a team to assist or serve as consults in these potentially volatile situations are beginning to be considered for these areas outside of our Behavioral Health Department. n Staff at Coney Island Hospital

© 2010 CPI. 15