SummaryConey Island Hospital developed a trained crisis prevention and response team known as "Code Grey" to calm agitated patients in its psychiatric inpatient unit through the safest and least restrictive means possible. Key components include an activation system initiated by the designated team leader, use of a standardized communication system to quickly inform arriving team members of the situation, an emphasis on resolving incidents through nonphysical means, postincident debriefings, and monthly meetings and data sharing. The program has led to significantly less use of restraints and seclusion and to fewer injuries to staff and patients. Anecdotal reports suggest that staff have become very comfortable with the program and that it has improved their morale and perceptions of safety.Moderate: The evidence consists of pre- and post-implementation comparisons of restraint/seclusion use and injuries resulting from agitation-related patient incidents on two psychiatric units, along with post-implementation feedback from staff.
Developing OrganizationsConey Island Hospital
Date First Implemented2008
Vulnerable Populations > Mentally ill
Problem AddressedInpatient psychiatric patients can become agitated and, at times, may represent a threat to their own safety and that of other patients and hospital staff. Although use of verbal "de-escalation" strategies can often minimize injuries and distress by preventing or defusing major incidents, many staff lack the training and access to formal response systems that enable such an approach. Instead, they often resort to more invasive interventions, such as restraints, seclusion, or intramuscular injections.
- Agitated behavior, threatening safety of patients and staff: Patients hospitalized for acute mental health services can exhibit agitation that could quickly escalate to the level of violent, acting-out behavior. These highly agitated patients have the potential to assault others and/or harm themselves.1 Staff responding to an agitated patient may be unaware of the patient's recent history, making it more difficult to assess the best strategy to defuse the situation safely.
- Lack of training and formal response systems: Although de-escalation strategies that seek to calm patients through verbal means often allow successful resolution without use of restraints and seclusion,2 most staff receive minimal training on how to use such strategies effectively. Additionally, many hospitals lack a formal system for responding to agitated psychiatric inpatients. For example, at Coney Island Hospital, before implementation of this program, a small informal team (usually a nearby nurse, psychiatric technicians, a physician, if available, and one or more hospital police) typically responded to such incidents.
- Leading to more invasive interventions: The lack of training and formal systems to respond to escalating patient behavior cause staff to rely heavily on hospital police to physically intercede in response to an incident and can lead to more invasive interventions such as restraints, seclusion, or intramuscular injections. For example, before the formation of the Code Grey team at Coney Island, levels of patient agitation would often escalate to levels that resulted in the use of invasive interventions, with hospital police and/or nurses holding the patient down while a nurse administered a sedative or placed the patient in restraints or seclusion.
Description of the Innovative ActivityConey Island Hospital developed a trained crisis prevention and response team known as "Code Grey" to calm agitated patients in its psychiatric inpatient unit through the safest and least restrictive means possible. Key components include an activation system initiated by the designated team leader, use of a standardized communication system to quickly inform arriving team members of the situation, an emphasis on resolving incidents through nonphysical means, postincident debriefings, and monthly meetings and data sharing. Key program elements include the following:
- Formal activation of trained team: When a patient exhibits severe agitation, such as yelling, making threats, or harming himself or herself or another person, the individual who observes the incident (in most cases, a nurse) alerts the identified Code Grey team members assigned for that particular shift by dialing a four-digit pager code and making a brief announcement about the incident's location over the intercom system. The team consists of nurses, psychiatric technicians, physicians, administrators, therapists from the hospital's two psychiatric inpatient units, clinical administrators, and three behavioral health associates, former hospital police who have received specific crisis prevention training (updated November 2011).
- Rapid team response: For a typical incident, approximately 5 to 8 team members respond. If an abundance of members respond, the team leader dismisses extra staff to return to their responsibilities. If additional staff are needed, other clinicians may be summoned and hospital police may call for backup. The person who activates Code Grey serves as the team leader during the incident. In most cases, the leader remains constant throughout the intervention; however, if the patient seems to be more responsive to another staff member (e.g., one who has already established a good rapport with the patient), the current team leader can transition the leadership role to that individual.
- Standardized communication: The team uses the SBAR (situation, background, assessment, recommendation) system to quickly communicate basic information about the incident to arriving team members, including whether the patient has a history of violent behavior. SBAR, initially used by the military and in aviation, has been adopted by a growing number of health care organizations for handoff communications between staff.
- Emphasis on nonphysical resolution: The team considers physical restraints and seclusion to be last-resort strategies to be used only if other options fail. The team leader and clinical staff first use de-escalation strategies, such as recommended nonverbal and verbal interventions, recognition of cultural/gender differences in communication styles, and building a rapport with the patient. Hospital police play a secondary role, observing from a short distance or under the guidance of the team leader who communicates directly with the patient. If the patient becomes severely agitated, presenting a danger to him/herself or others, the team leader will instruct the hospital police to take a more direct (perhaps physical) role. Information provided in November 2011 indicates that the role of the hospital police has been minimized even further since the addition of behavioral health associates to the team.
- Postincident debriefing, monthly review, and data sharing: Team members hold a short debriefing immediately following an incident's resolution to discuss what worked and what might have been done differently. All Code Grey incidents are reviewed in the treatment planning conferences that occur daily on each unit. The team also holds a monthly meeting to review difficult incidents and share performance data related to crisis prevention, such as the number of incidents and injuries and use of restraints and seclusion. These data are then posted on an employee bulletin board.
References/Related ArticlesFerguson J. Coney Island reduces restraint use in behavioral health patients. Nurse.com. March 8, 2010. Available at: http://news.nurse.com/article/20100308/NY02/103080017
Contact the InnovatorJanet Ferguson, PMHCNS-BC
Associate Director, Behavioral Health Nursing
Coney Island Hospital
2601 Ocean Parkway Hammett 132
Brooklyn, NY 11235
Donna Leno-Gordon, RNMS, MPA
Director, Behavioral Health Nursing
Coney Island Hospital
2601 Ocean Parkway Hammett 138
Brooklyn, NY 11235
Innovator DisclosuresMs. Ferguson and Ms. Leno-Gordon have not indicated whether they have financial interests or business/professional affiliations relevant to the work described in this profile; however, information on funders is available in the Funding Sources section.
ResultsThe program has led to significantly less use of restraints and seclusion and to fewer injuries to staff and patients. Anecdotal reports suggest that staff have become very comfortable with the program and that it has improved their morale and perceptions of safety.
Moderate: The evidence consists of pre- and post-implementation comparisons of restraint/seclusion use and injuries resulting from agitation-related patient incidents on two psychiatric units, along with post-implementation feedback from staff.
- Less reliance on restraint and seclusion: In 2008 (before program implementation), the two inpatient behavioral health units averaged 8.3 episodes per quarter where staff used restraints and/or seclusion to calm an agitated patient. In 2009 (after implementation), that figure decreased to two episodes per quarter. Similarly, the percentage of total monthly incidents in which staff used restraints and/or seclusion fell from 10 percent in 2008 to less than 1 percent in 2009, and has remained at that level since this time (updated November 2011).
- Fewer injuries to patients and staff: The total number of patient/staff injuries resulting from agitation-related incidents on the two units fell from 1 per month in 2008 to 0.16 per month in 2009.
- Improved staff comfort, morale, and perceptions of safety: The number of Code Grey activations has steadily increased, from an average of 11 per quarter in 2009 to 28 per quarter in 2011. Program developers believe this trend demonstrates that staff are comfortable with the system and find it to be a valuable resource. In addition, anecdotal feedback suggests that the program has improved staff morale and perceptions of safety (updated November 2011).
Context of the InnovationConey Island Hospital, located in Brooklyn, NY, is a 371-bed community hospital with a large emergency department and two 32-bed psychiatric inpatient units for adults with primary major psychiatric disorders. The psychiatric units provide multidisciplinary assessment, individual and group therapy, pharmacotherapy, medical assessment and treatment, and aftercare. Many patients are admitted involuntarily and have histories of violence or suicide attempts, with incidents of severe agitation being common (typically occurring 10 to 20 times per month). The Code Grey team developed from awareness among administrators and clinicians that best practice in acute care psychiatry does not include restraints and seclusion to resolve incidents of agitation, and that an alternative approach could be safer and beneficial for patients and staff. National trends also promoted a more therapeutic and compassionate approach to crisis resolution involving psychiatric patients.
Planning and Development ProcessKey steps included the following:
- Committee formation: In early 2007, the Behavioral Health Department formed a committee to develop an alternative approach to preventing and resolving agitation-related incidents involving psychiatric patients. The behavioral health nursing administrators chaired the multidisciplinary committee, which included clinicians, administrators, and representatives from hospital police and the information technology (IT) department.
- Research: The committee collected information about how other hospitals handled these incidents and conducted a survey regarding staff attitudes related to patient safety (which revealed that staff often felt afraid and did not work as an effective team in crisis situations).
- Setting priorities: The committee identified several priorities that should be included in the new approach: make use of restraints/seclusion a last resort; use larger, interdisciplinary teams to respond to incidents; provide effective training for all staff; and create procedures for communication during and after incidents.
- Team recruitment: The committee decided that all inpatient clinical staff (nurses, psychiatric technicians, therapists, and psychiatrists) on the two psychiatric units would be trained and assigned to participate in Code Grey. Hospital police and clinical administrators were also trained and assigned to participate.
- Initial and ongoing training: In mid-2008, select nurses attended a 4-day training program offered by the Crisis Prevention Institute to become certified as crisis prevention instructors. While attending the program, they learned de-escalation strategies, symptoms of agitation, how to work as a team, and other important skills. To date, 20 nurses have completed the instructor program. On an ongoing basis, all inpatient and outpatient behavioral health staff periodically attend in-house, 8-hour refresher training sessions; staff sign up for these courses, which are offered on a monthly basis, several times a year.
- Program launch: After enough staff received training and the committee finished developing procedures for crisis response, Code Grey launched in December 2008.
Resources Used and Skills Needed
- Staffing: The program initially required no new staff, as existing staff incorporate it into their daily routines. As noted previously, information provided in November 2011 indicates that the hospital added three behavioral health associates to the team. These associates were former hospital police who received specific crisis prevention training and were reassigned to the Code Grey team. As of November 2011, the associates participate in the Code Gray team only during day-time hours, but the hospital plans to expand the number of positions to provide behavioral health associate coverage 24 hours a day, 7 days a week.
- Costs: Training represents the primary program expense; the 4-day institute costs approximately $1,500 per staff member. Other costs include the purchase of beepers for assigned Code Grey team members that are shared across shifts.
Funding SourcesThe New York City Health and Hospitals Corporation, of which Coney Island Hospital is a part, funded the cost of training.
Tools and Other ResourcesInformation about the Crisis Prevention Institute and its training courses is available at http://www.crisisprevention.com/.
Getting Started with This Innovation
- Include interdisciplinary staff: To gain broad support for this new approach to crisis resolution, include representatives from throughout the hospital, including administrators, physicians, hospital police, IT staff, and others.
- Encourage participation across shifts: To the extent possible, include night-shift employees in recruitment efforts and training, which should be offered during the afternoon and evening.
Sustaining This Innovation
- Maintain training: Have staff attend refresher training classes at least once a year so that they stay focused on key crisis resolution principles and abreast of any new developments in the field. Also, conduct occasional mock Code Grey team activation drills for team members to practice these principles and skills.
- Leverage administrators: Behavioral health administrators should be continuously involved in the program and committed to educating staff, providing resources, and assisting with troubleshooting problems when needed.
- Share results: Hold monthly meetings to review performance data so that team members can appreciate their tangible effect on patient care and periodically post this data in a location where it can easily be seen, such as an employee bulletin board.
Donat D. An analysis of successful efforts to reduce the use of seclusion and restraint at a public psychiatric hospital. Psychiatr Serv. 2003;54:1119-23. [PubMed]
Jonikas JA, Cook JA, Rosen C, et al. A program to reduce use of physical restraint in psychiatric inpatient facilities. Psychiatr Serv. 2004;55:818-820. [PubMed]
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Service Delivery Innovation Profile
Original publication: August 04, 2010.
Original publication indicates the date the profile was first posted to the Innovations Exchange.
Last updated: January 09, 2013.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.
Date verified by innovator: December 11, 2012.
Date verified by innovator indicates the most recent date the innovator provided feedback during the annual review process. The innovator is invited to review, update, and verify the profile annually.