SACRED HEART HEALTHCARE SYSTEM
SACRED HEARTHOSPITAL
421 CHEW STREET
ALLENTOWN, PA 18102-3490
GENERAL POLICY AND PROCEDURE MANUAL
Subject:Crisis Assessment, Intervention, Policy #:GEN_679
Recovery (C.A.I.R.) Program and Code GreyInitial Effective Date: 8/06
Most Recent Revision:7/14
Approval:______Page 1 of 7
- PURPOSE:
A.To provide a safe environment through a cooperative effort of hospital staff during events where an individual(s) displays aggressive or assaultive behavior that could present a clear and present danger to patients, visitors, and/or staff.
B. To provide education on the causation of agitation and aggressive behavior to
potentiallyprevent the risk of threatening behavior.
C. To provide guidelines for identifying and preventing behaviors which are assaultive
toward others, or which are violently destructive of property.
D.To protect the health and safety of individuals, preserve their rights and dignity, and promote well being.
E. To provide uniform guidelines for the safe management of potential or actual
verbal or physical aggression.
- SCOPE:
This policy applies to all personnel that work in the Sacred Heart Hospital.
III.RESPONSIBILITY:
A.Employees that are in non-clinicalareas are responsible for being aware that there is a process for handling individuals that become aggressive/assaultive.
B.The Administrative Supervisors, Personnel in Behavioral Health, Emergency, Med/Surg, ICU,and Security Departments will remain competent in the techniques accepted by SacredHeartHospital and Health System for handling individuals that become aggressive/ assaultive.
C.Administrative (Nursing) Supervisor will be in charge of logistics
D.It is the responsibility of the department manager to assure compliance with this policy. The Restraint Committee/ Code Grey Committee will monitor the program
and provide reports to hospital Safety and Quality Improvement.
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IV. REFERENCES
CMS 482.13(e &f) (reviewed 7/14)
PA Code, Title 55, Chapter 13 (reviewed 7/14)
Psychiatric Emergency Assistance Team Program, Veterans Administration, 2010
Psychiatric Mental Health Nursing Scope and Standards of Practice American Nurses
Association 2007.
Sacred Heart Human Resources policy 1101-C: Reporting Work-Related Illnesses and
Injuries
TJC E-dition (July 2014) HR.01.04.01, PC.01.03.03, PC.03.05.01, PC.03.05.03, PC. 03.05.07, PC.03.05.09, PC. 03.05.11, PC.03.05.15, PC.03.05.17, PC.03.05.19
V. POLICY/ PROCESSES:
A.It is the policy of SacredHeartHospital (SHH) to create a safe environment where
behaviors that are potentially violent/aggressive can be quickly identified and treated.
This will be accomplished using the Sacred Heart’s Crisis Assessment, Intervention, and Recovery (C.A.I.R.) Program which is evidence-based. Topics included in the course include but are not limited to the following:
1.Attitudes toward behavioral health issues
2. Assessment of risk of aggression, potential triggers for aggressive/violent behavior
3.Suicidality
4. Recognition of signs of escalation
5. Verbal de-escalation(therapeutic communication)skills
6. Self-protective techniques
7. Team techniques to help the patient gain controlincluding the safe application of restraints
8. Mental health basics
B.The C.A.I.R. program is a three tiered training system
1. All employees will be made aware of the C.A.I.R. program and process and annual online training will be completed.
2.In addition, all persons hired in Security and Nursing will attend the C.A.I.R. Course during their orientation or as soon to their hire date as feasible.
Clinical staff in departments that have a high risk for behaviors that involve physical acting out and those persons that are part of the response team (The Administrative Supervisors, Personnel in Behavioral Health, Emergency, MED/Surg, ICU, and Security Departments) require that the staff is able to
recognize, de-escalate, and manage behaviors that lead to assaultive behavior and therefore the staff must attend the C.A.I.R. Course
3.Clinical staff in areas where there is less risk for behaviors that involve physical
acting out (Birthplace, TCF) and non-clinical staff (Cashier, Admissionoffice) that directly serve populations with potential for agitation orloss of emotionalcontrol require and that the staff is able to recognize and behaviors that are increasing and may become out of control. Staff inthese areas will receive training oncauses of aggressive/ assaultive behavior.
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C. Practicing the skills necessary for safe delivery of crisis management is important and will be accomplished through Mock Code Grey Drillsthrough actual Code Grey events, and annual review referred to as ReC.A.I.R .
1. Persons that respond to Code Grey events must be involved in at least one actual or mock Code Grey event every year. Employees will retake the C.A.I.R. course when necessary for remediation based on performance issues identified by the Restraint/Code Grey Committee or the employee’s manager.
2. The employee will be responsible for compliance and the manager will confirm attendance with the annual performance evaluation.
3. ReC.A.I.R. class will focus on review of recognition of behaviors indicating escalation, verbal de-escalation techniques, self-protection and team techniques including application of restraints, implementation of seclusion, monitoring, assessment and providing care .
4. Nurses will also review documentation of restraints.
D.Staff will assess patients and others within their environment for behaviors which may indicate that the individual is becoming increasingly agitated.
1.Allpatient care staff on behavior health units will have access to supervised transmitters which they may wear on their person during the shift and understand their use in an emergency. Transmitters will be checked periodically for function
2. If a staff member is alone in the communitywhile escorting patients duringtherapeutic leave andsomeone is demonstrating behaviors placing themselves or others at risk, the staff member should remove themselves from the situation and call 911 if possible.
E. The staff will utilize verbal and other non-physical interventions to de-escalate/
defusepotentially aggressive/ violent situations whenever possible.
1. The defensive techniques are designed to decrease risk of harm to the aggressor
a. Calm crisis situations at the first opportunity, there by modeling
good self control skills for the patients as well as allowing the patient
to " drop" their aggressive stance. Provide less stimulating/more quiet
environment.
b Provide contact, establish rapport and treat patients with respect and
dignity, while at all times taking care to keep a safe distance from any
potential assaultive patient.
- Inform patients that SHH staff will assist them to maintain or regain
self control.
d. When appropriate, the staff will remind patient regarding rules and
laws; that violence is unacceptable, and to be responsible for his/her
actions.
e. When appropriate the staff will provide patients will prompt and
adequate medical care and therapeutic intervention early.
i. Positive reinforcement
ii. Provide a place to walk.
- Engage patient in meaningful activity
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- Provide a safe area to express their concerns and emotions
v. Provide medications (anxiolytics, antipsychotics) when
necessary as per physician order
F. Physical interventions will be implemented only when a person is an immediate threat to self or others, and non-physical interventions have been ineffective.
G. Code Grey
1. The need for Code Grey, which is here defined as a team approach to control aggressive/assaultive behavior, may be called by any staff member at the hospitalwhen an individual/patient is escalating and there to likelihood or violence or aggression.
a. In the event that an individual (patient, visitor, etc.) is demonstrating behavior could escalate to be a danger of inflicting harm or injury to himself/herself or another individual, staff should call a “Code Grey” by dialing “3333”.
b. The Telecommunications Operator will announce “Code Grey + location” 3 times and then initiate alpha page.
2. Staff shall not actively intervene to physically restrain a person without assistance.
a. Techniques should be implemented only by staff trained in the techniques.
b.During a Code Grey, responding staff will use holds and maneuvers that decrease the risk of harm. One member of the team will be an observer and monitor the patient for distress and the techniques for potential harm. Special attention should be focused on prevention of respiratory compromise and joint injury.
c. Approved defensive techniques should be utilized for self-protection in the event ofimmediate threat of injury.
i. Wrist release – one hand grab
ii. Two hand grab - one wrist
iii. Two hand grab - one each wrist
iv. Arm bar choke/maintain airway
v. Choking against a wall
vi. Release from hair pull
vii. Bite avoidance
viii. Release from bite
ix. Punch blocking
3.The following active team interventions may be utilized as warranted by the situation and as instructed upon per Sacred Heart C.A.I.R. training manual to
prevent injury to aggressor or others. In all of the following maneuvers,
good communication among team members is essential in executing the
procedure safely and effectively.
a.Two person escort
b.Two person escort - removal from wall
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c. Team take-over:
i.to sitting
ii.to wheelchair
d. Application of restraints:
i.soft limb
ii.neoprene locked
iii.wrist-waist
e. Two persons fighting one another
4.The person initiating Code Grey will coordinate team efforts to maintain patient/staff/visitor safety until the arrival of the Administrative Supervisor or Psychiatric Nurse.
a.The person assuming the role of team leader will have received training in crisis intervention and restraint use.
b.Unit personnel will assist in maintaining order and patient safety of environment, patients, and personnel.
5.Patient safety is the primary concern throughout the Code Grey. Though efforts will be made to be least restrictive, restraints may be necessary to ensure individual safety and should be applied if the patient’s condition warrants it.
6.The following staff should respond to a “Code Grey”. When there is one
licensed staff member on the patient unit or the circumstances on the patient care area would be unsafe, staff from the patient care area is exempt from attendance. (See Appendix 1)
a. Administrative Supervisor or Clinical Nurse Manager of the unit that called the Code Grey
b. Psychiatric Units – 1 RN and 1 MHT
c. Security Team
f. One staff person from each of the following units: TCF, 5 T,
6T, PCU, ICU and ED.
7.The Code Grey is to be terminated by the Team Leader or Administrative
Supervisor/ Clinical Nurse Manager.
8. Following a Code Grey
a. Debriefing
i. The patient may be debriefed when appropriate and will include:
- What occurred during the Code Grey
- Behavior that lead to the Code Grey
- Alternatives for addressing the behavior if the behavior if it should re-occur.
ii. The staff will be given the opportunity for debriefing whether formally or informally.
iii.Referrals for post-traumatic stress counseling may be made as appropriate.
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9. Code Grey Critique
a. A Code Grey Critique (Form # 19680) will be completed at the termination of each Code Grey.The Critique provides an opportunity to report positive and negative evaluation points and provide suggestions for process improvement.
b. The Critique will be forwarded to the Director of Staff Developmentlogging and when appropriate reviewed by the Restraint/Code Grey Committee.
c. The Restraint/Code Grey Committee will report concerns/issues to the Patient Safety Committee.
10.An incident report must be completed whenever a Code Grey has been called.
H.If the situation is one that would need additional intervention or when a weapon (gun, knife) is involved the Allentown Police Department can be called at (9-911).
1. The determination if the Allentown Police Department is to be called to respond will be made under the direction of the Department/Unit Manager or Administrative Supervisor.
2. In the absence of the Department/Unit Manager or Administrative Supervisor the supervisor of security will make the call and notify the Administrative Supervisor of the action.
3.Until the police arrive, efforts will be made to secure the area and minimize risk to the individuals in the Code Grey area.
I. Documentation
1. C.A.I.R. Training records which will be placed in the employee’s file in Human Resources Department
.a. Liability Statement
b. Skills Completion
c. Post-test
2. Incident report (I.R.I.S.) whenever a Code Grey is initiatedand results in injury/issues.
3.Employee injury report, as applicable.
4.Code Grey Critique (Form #19680) will be completed following all Code
Greys.
5.Debriefing form (Form # 17630) will be completed whenever a person has been placed in behavioral restraints.
6.The staff will note the behaviors leading to the Code Grey, intra-code events,
and post-event assessment either electronically or on paper as part of the downtime process
J.Quality Improvement:
The individuals present at the Code Grey event will review the Code Grey and note issues and concerns on the critique which will be reviewed and reported at the Restraint/Code Grey Committee. Periodic outcome reports will be made to the Sacred Heart Patient Safety Committee and the Sacred Heart Quality Improvement Team.
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Disclaimer Statement
This policy and the implementing procedures are intended to provide a description of recommended courses of action to comply with statutory or regulatory requirements and/ or operational standards. It is recognized that there may be specific circumstances not contemplated by laws or regulatory requirements that make compliance inappropriate. For advice in these circumstances, please consult with Risk Management/Patient Safety and/or Legal Services.
Revised Date: 11/06; 10/07 Reviewed Date: 6/08 Typist: Donna Schiavone
679 crisis assessment