Aggression management in a children’s hospital setting

Violence and aggression are significant problems in health care. Up to 85% of nurses have reported verbal abuse.1,2 Consequences include injury,3 post-traumatic stress disorder and decreased morale and motivation.4-6 Adolescents who present with aggression have a high risk of subsequent mortality.5

Although aggression has been described in adult,4,6,7 adolescent mental health and forensic settings,7-10 literature is scant regarding aggression in the general paediatric setting.

Behavioural disturbances arise from various factors11,12 including medical conditions (primarily neurological), intoxication, psychiatric and neurodevelopmental disorders and environmentally derived issues (fear, frustration and anxiety). Management of these disturbances involves prevention, early recognition and verbal de-escalation, but may require more forceful measures such as physical or chemical restraint. Management of aggression involves a dynamic set of events, with simultaneous evolving priorities requiring rapidly changing actions. A preplanned, systematic team approach is ideal to manage this kind of event.9,13 Reports regarding the organisational structure of a violence management team in emergency departments (EDs) and general hospitals are scarce.13,14

Although aggression is less frequent in children’s hospitals than in adult hospitals, it does occur. In response to the recognition of aggression as a problem,15 and to some sentinel events, a formal system of aggression management was implemented to improve clinical risk, staff safety and patient care. We describe the system’s development, structure and implementation, and present utilisation data from the first year of its operation.

Over 14 months, 135 separate code grey incidents were recorded on switchboard and security reports. For 31 incidents, no further information was available from secondary sources. Thus descriptive data were available for 104 incidents. Incidents occurred at almost equal frequency on wards (41; 39.4%) and in the ED (39; 37.5%). The remainder occurred in corridors, stairways, operating theatres, clinics, lifts, garden and medical imaging areas (Box 1). Half of all incidents occurred after hours. While patient incidents were more likely to occur out of hours and in the ED, visitor incidents were more likely to occur in hours and on the wards.

Incidents involved patients in 75 cases (involving 40 different patients) and visitors in 29 cases. Of the 40 patients, there were 16 males and 24 females. One-third of patients were the subject of more than one code grey event. The age range for patients was 6–24 years (median, 15 years). Three patients were aged over 18 years and were long-term RCH patients who had not yet been transferred to adult care. These patients had a long history of psychiatric disorders and all required the use of physical restraint.

The condition of the aggressor is listed in Box 2. Patients were more likely to have pre-existing psychiatric or developmental problems, whereas for visitors, frustration was the most frequently recorded issue. A small number of visitors were mentally unwell or affected by drugs or alcohol.

While verbal aggression was extremely common in both groups, physical violence was uncommonly displayed by visitors. Self-harm and risk of absconding in patients (Box 2) were usually accompanied by other forms of aggression.

Verbal de-escalation alone (in 22 of 75 cases) or simply the presence of the team (in three cases) was sometimes sufficient. However, over half the patients were restrained and most underwent more than one type of restraint (Box 3). Confinement in the ED safe room was used 11 times, mostly in conjunction with restraint. Of the three patients who departed voluntarily, one left with her parents after an outburst of anger, and two stable adolescents left after aggression directed at staff.

For visitors, verbal de-escalation was most frequently used. Ten of 29 events resulted in the aggressor leaving the hospital: four voluntarily, five with a security escort, and one apparently mentally unwell parent was restrained by police and escorted from the hospital by a crisis assessment and treatment team (Box 3). A second visitor was physically restrained from striking a patient.

In 90 incidents, the presence or absence of adverse outcomes was documented. Overall, two team members were struck by patients and one member of the team was spat on. Two other staff members were struck by patients, but it is unclear from the reports whether this was before the arrival of the aggression management team or during the code grey event. No serious injuries resulted to staff. Two patients sustained self-inflicted minor injuries (head bruising and cuts to the hands). One visitor inflicted facial fractures on another visitor, also before arrival of the aggression management team. No patient suffered an adverse event as a result of physical or chemical restraint.

To our knowledge this is the first report of a systematic approach that a general children’s hospital has taken to manage violence and aggression. This prospective series shows some findings that are relevant to other children’s hospitals. Aggression which is refractory to de-escalation by general clinical staff, while proportionately infrequent (135 incidents from 260 000 total episodes of care hospital-wide), is seen in patients and visitors and is common enough to warrant a specific and well designed response. In looking at the code grey incidents, verbal aggression is prevalent and physical aggression and self-harm is frequent. Even when stipulated as a last resort, restraint is used in over half of cases involving patients, and a substantial proportion of visitors (over one-third) were either escorted from the hospital or left voluntarily.

Self-harm and the risk of absconding may not appear to constitute frank aggression, but we believe the response to such behaviour best sits within an aggression management team framework.

Aggression management in a general paediatric setting differs from that in the adult ED or inpatient mental health setting.4,13,17-19 Aggression is much less frequent. Substance misuse is a frequent contributor to violence in adult EDs but was less frequently seen as a contributor in the paediatric setting. In our series, intoxication was more common in visitors than patients.

As expected, medical conditions were more prominent in our study than in mental health areas. Females were more likely to be aggressors than males; this was possibly related to the higher incidence of self-harm, depression and anxiety in females than males.20,21 Reports from both adult and combined adult and paediatric health care settings describe about twice as many incidents in the ED as in wards13 but the majority of incidents occurred outside the ED. This is an important consideration when planning the reach and composition of a hospital-wide aggression response team.

Parents and carers, to whom the hospital owes no medical duty of care, account for a higher number of incidents than in adult EDs.4 The aetiology of this aggression is commonly frustration, and management relies on verbal de-escalation and removal of the aggressor from the hospital. In such cases, the hospital management representative became the team leader, rather than a clinical staff member. Restraint was only applied in the extreme circumstances of a mentally unwell parent or a relative perpetrating actual interpersonal violence.

In aggression management, patients and staff are potentially at risk of physical22 or emotional harm and possible legal action. In this series, no patient was injured during physical or chemical restraint. Training of staff involved in the code grey teams needs to reflect that restraint use is a matter of last resort, and close patient monitoring of sedated patients is critical to avoid adverse events.23

Initial challenges to the formation of our code grey response teams included the lack of pre-existing paediatric models, insufficient security support and the absence of staff able to provide physical support. Balanced against this was the recognition by all stakeholders of the need for cooperation with nursing and medical staff volunteering to participate in the teams. The program continues to operate and has been subject to only minor changes. Like many new projects, continued efforts are required to maintain hospital management engagement.

Many elements of this program, such as policy and procedure development, team organisation, education and ongoing evaluation can be adapted by other institutions. Key factors to be considered in a modified model are the age range of patients cared for by the institution, the presence or absence of adult patients, the quality, presence and availability of on-site mental health services and the incidence of drug and alcohol-related presentations. Compared with many adult hospital models, the RCH team is predominantly comprised of clinical staff. While this facilitates a focus on care and compassion for behaviourally disturbed adolescents (with a high proportion of females, intellectually disabled and at-risk young people), this structure may be understrength to manage large, strong or particularly violent patients.