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Appendix 6: Sample Policies adapted from the Austin Hospital (NSW) Policies

Admission Guidelines for the Management of Aggressive Patients

Overview

These Guidelines should be read in conjunction with the Aggression Management Policies and Procedures in the Occupational Health and Safety Section, Human Resource Department on the intranet.

The major obligation for the employer under the Occupational Health and Safety Act^[1] is to ensure patient, visitor and staff safety by providing a safe work environment. The employer also promotes and fosters a culture where violence and aggression toward patients, visitors or staff is unacceptable.

Scope

Occupational aggression is defined as any incident where a patient, visitor or staff member (including agency and temporary staff) is abused, threatened or assaulted in circumstances arising out of, or in the course of their employment.

Aggressive behaviour, causing occupational aggression may include:

• Verbal, physical or psychological abuse (including bullying)
• Threats or other intimidating behaviours (e.g. spitting, gesticulating)
• Intentional physical attack (e.g. hitting, pinching, biting or scratching)
• Threats or attacks with weapons or objects
• Any form of indecent physical contact, including sexual harassment or sexual assault.

Objective

To provide a procedure for the management of patients demonstrating aggressive behaviour on presentation to the Emergency Department and/or requiring a ward admission.

References

Developed by the Occupational Health & Safety Unit in consultation with the Aggression Management Committee. Details of legislation, Codes of Practice and guidelines referred to are listed at the end of the document.

Policy

1. The employer is committed to preventing and managing risks associated with aggression to ensure a safe environment for staff, patients and visitors.
2. No aggressive behaviour or behaviour provoking aggression will be tolerated.
3. All managers, staff, patients and visitors must meet their responsibilities towards the prevention and management of aggression.

Process

The employer will attempt to achieve acceptable behaviour through a staged process of behaviour management, except in emergency situation such as a physical assault. Each step of the process should be recorded in the patient’s file and in the incident reports. This will ensure that all staff are aware of previous incidents and that further responses are based on evidence.

The process will involve moving through the following steps as required. Each step must be recorded in the patient file and/or incident reports.

1. Verbal requests to the patient/visitor to modify their behaviour;
2. Development of a patient care plan if appropriate;
3. Development of a patient/visitor contract;
4. Not Welcome Notice/Eviction from premises;

The Police may be contacted at any point during this process if it is determined that an external emergency response is required or assistance is necessary in escorting a person from the premises.

The following three references detail the processes for managing aggression and should be referred to. They are:

• Emergency Procedures Manual, Section B6 Pro-Active Management Strategies: Unacceptable Patient or Visitor Behaviour, pages 11- 23.
• Protocol for Early Intervention in Complex/Difficult Cases (Dec 02).
• Nursing Standard, Mechanical and Manual Patient Restraint.

In the circumstances where the safety of staff, patients and/or visitors is at risk, patient or visitor restraint may be exercised to provide a safe environment.

When a patient demonstrates behaviour which is threatening, aggressive or abusive, and a staged process of behaviour management has been unsuccessful, and it is necessary to restrain a patient, “The Standard for Mechanical & Manual Patient Restraint” is implemented.

Where physical or mechanical restraint of a visitor has been required to provide a safe environment, it is necessary to:

• Explain the reasons for the restraint
• Ensure that the person’s physical, comfort and emotional needs are observed and monitored whilst being mechanically restrained
• Ensure any adverse effects or complications are detected and acted upon immediately
• Ensure the use of restraint is reviewed and processes, which require attention or modification, are identified
• Request Police attendance.

In all cases, a documented patient care plan incorporating patient, visitor and staff safety considerations should be developed with reference to the team involved with the care of that patient. The plan should be reviewed every 24 hours or more frequently as required. Any changes should be documented on the plan.

Whilst the patient is demonstrating unacceptable behaviour, the initial focus of medical/surgical treatment will be to address potentially life threatening or permanently health threatening conditions, including psychiatric illness. Further treatment will be determined after taking into consideration the patient’s competency and ability to exercise cooperation with the treatment required.

Where a competent patient:

• Expresses that they do not wish to participate in further treatment, or
• Refuses to modify non cooperative behaviour to an acceptable standard which allows staff to provide care,

They will be deemed to have self discharged.

Request from the Police OR Mental Assessment Service (MAS) to Bring a Patient Requiring a Psychiatric Assessment to the Emergency Department

Where Police or MAS contact The employer to request an assessment for a person who is acting in a way, which warrants a psychiatric assessment, and they have no other injury or evident illness requiring medical assessment, they shall be referred to the CAT unit for assessment on site (i.e. their residence or other appropriate location) or at a convenient Police Station.

Emergency Department Management of Aggressive Patients

Staff will attempt to achieve acceptable behaviour through a staged process of behaviour management:

• requesting cooperative behaviour
• discussion and counselling
• explaining consequences of non cooperative behaviour with patient care

In emergency situations where a staged process does not work or is impractical to follow and it is necessary to ensure patient, visitor or staff safety, the following procedure is applicable. Note that a verbal request to modify behaviour must be tried in all circumstances.

1. Any patient who is assaulting, or attempting to assault patients, visitors or staff, (unless there is a medical reason for the behaviour) should be manually restrained and then mechanically restrained, (consistent with Nursing Standard, Mechanical and Manual Patient Restraint) to facilitate medical assessment. A medical assessment should be performed, including competency status, and then develop a patient care plan regarding further management. Consideration should be given to administering appropriate medication.
2. Patients who have assaulted or attempted to assault staff or others should be treated with caution, that is:
   • At least 2 staff members should attend the patient at all times
   • When attending these patients maintain an avenue of escape (i.e. do not allow the patient to obstruct the doorway).
3. Notify and consult with ED Director or Deputy as well as NUM regarding the patient’s care plan.
4. Where a patient is competent and has committed an assault and the staged process has not worked, place an alert on the patient’s medical record and make a note that readmission is to be only on the basis of the patient requiring urgent medical treatment. The CSU Director (or AHSM if out of hours) must be notified to endorse this action and discuss with the relevant Executive Director. If there is agreement that this is the appropriate course of action, the CSU Director or AHSM is responsible for ensuring that the patient is served with a Not Welcome Notice in accordance with the employer’s Aggression Management Procedures. They are also responsible for ensuring the patient is informed of this decision.
5. If the Executive Director, CSU Director or AHSM does not endorse this action, the alert must be removed and the documentation in the medical recorded is amended. The CSU Director, in conjunction with other relevant staff, will develop a patient care plan to provide a safe environment, and which will manage either their behaviour or the risks arising form their behaviour to staff, visitors and other patients
6. Should the patient require admission to a ward and/or is being transferred to the Operating Theatre, the Nurse in charge must discuss the patient’s behaviour and care plan with the Nurse in charge of the receiving area.

Management of Aggressive Competent Patients Requiring Hospital Admission

1. Patients who exhibit behaviour that is threatening to the physical well being of other patients, visitors or staff should only initially be treated for the presenting life threatening or permanently health threatening condition, including any psychiatric illness. Note that a verbal request to modify behaviour must be tried in all circumstances.

2. Any patient who has assaulted or attempted to assault patients, visitors or staff, (unless there is a medical reason for the behaviour) should be manually restrained and then mechanically restrained, (consistent with Nursing Standard, Mechanical and Manual Patient Restraint) to facilitate medical assessment. A medical assessment must be performed, including competency status, and also development of a patient care plan regarding further management. Consideration should be given to administering appropriate medication.

3. While the patient continues to exhibit behaviour which is, threatening, aggressive and/or abusive they:
   • Should be accommodated in a single room, even if this means that an intra-ward or inter-ward patient transfers are required at the time of admission,
   • Should be admitted to the ward which has their specialty unit. If this cannot occur at the time of admission, the patient should be transferred to the appropriate ward as soon as possible.
4. Where patients cannot be accommodated in the ward allocated for their specialty, they remain the responsibility of that medical/surgical unit and must be reviewed by the medical staff every 24 hours or more frequently as required.

5. As part of the admission process, the Aggression Risk Assessment and Management form must be completed, including the development of a patient care plan.

6. Psychiatric assessments of patients posing a significant risk of aggressive behaviour are considered high priority and require the Psychiatric Registrar to review the patient within 4 hours following admission.

7. If a safe management plan cannot be provided by the unit’s registrar, the patient’s medical/surgical consultant should be contacted by the NUM/ANUM

8. When assessed as competent, the patient must be requested to modify their behaviour according to the staged process outlined above. It must be explained to the patient that if they remain non-cooperative with aggressive behaviour, they may be deemed non-compliant with their treatment plan and eligible for self-discharge.

9. Where a patient has assaulted a person (staff member or otherwise) and/or has demonstrated aggressive behaviour that has not been modified despite being requested to conform with the staged process, place an alert on their medical record and where a sanction has been implemented, record that readmission is to only be on the basis that the patient requires urgent medical treatment for a life threatening or permanently health threatening condition. The CSU Director or AHSM must be notified to endorse this action and discuss with the relevant Executive Director. If there is agreement that this is the appropriate course of action, the CSU Director or AHSM are responsible for ensuring that the patient is served with a Not Welcome Notice in accordance with the employer’s Aggression Management Procedures. They are also responsible for ensuring the patient is informed of this decision.

10. If the Executive Director, CSU Director or AHSM does not endorse this action, the alert must be removed and the documentation in the medical record amended. The CSU Director, in conjunction with other relevant staff, will develop a patient care plan to contain their behaviour which must provide a safe environment.
11. Where a patient discharge becomes problematic because they have no discharge destination and it is considered inappropriate to discharge the patient in these circumstances, referral should be made in the first instance to the CSU Director or AHSM if after hours. The matter may be referred to the Executive Director Acute Operations or Chief Medical Officer if necessary.

Management of Aggressive Non-Competent Patients Requiring Hospital Admission

This section does not cover Patients being treated under the Mental Health Act 1986. Patients being treated under coverage of the Mental Health Act 1986 are to be treated in accordance with the provisions of that Act.

1. The treatment of non competent patients who exhibit behaviour that is threatening to the physical well being of staff should be aimed at containing the patient’s aggressive behaviour to other patients, visitors or staff and/or preventing self harm. Any patient who has assaulted or attempted to assault patients, visitors or staff and where there is a continuing unavoidable risk of further assault of patients, visitors or staff, unless the patient is manually restrained, the patient should be manually restrained, to facilitate medical assessment and or relocation. A medical assessment must be performed, including competency status, and also development of a patient care plan regarding further management. Consideration should be given to administering appropriate medication (Guidelines for the Pharmacological Management of Behavioural Disturbance).
2. While the patient continues to exhibit behaviour which is, threatening, aggressive and or abusive they:
   • Should be accommodated in a single room, even if this means that an intra-ward or inter-ward patient transfers are required at the time of admission,
   • Should be admitted to the ward, which has their specialty unit. If this cannot occur at the time of admission, the patient should be transferred to the appropriate ward as soon as possible.
3. Where patients cannot be accommodated in the ward allocated for their specialty, they remain the responsibility of that medical/surgical unit and must be reviewed by the medical staff every 24 hours or more frequently as required.
4. As part of the admission process, an Aggressive Risk Assessment form must be completed, including development of a patient care plan
5. Psychiatric assessments of patients posing a significant risk of aggressive behaviour are considered high priority and require the Psychiatric Registrar to review the patient within 4 hours following admission.
6. If a safe management plan cannot be provided by the unit’s registrar, the patient’s medical/surgical consultant should be contacted by the NUM/ANUM
7. Where a patient has assaulted a person (staff member or otherwise) and /or has demonstrated aggressive behaviour that has not been modified despite being requested to conform with the staged process, place an alert on their medical record. Where a sanction has been implemented, record that readmission is to be only on the basis of the patient requiring urgent medical treatment for a life threatening or permanently health threatening condition The CSU Director or AHSM should be notified to endorse this action and discuss with the relevant Executive Director. If there is agreement that this is the appropriate course of action, the CSU Director or AHSM are responsible for ensuring the patient is served with a Not Welcome Notice in accordance with the employer’s aggression management procedures. They are also responsible for ensuring the patient is informed of this decision.
8. If the CSU Director or AHSM does not endorse this action, the alert must be removed and the documentation in the medical record is amended. The CSU Director, in conjunction with other relevant staff, will develop a patient care plan to contain their behaviour which must provide a safe environment.
9. Where a patient discharge becomes problematic because they have no discharge destination and it is considered inappropriate to discharge the patient in these circumstances, referral should be made in the first instance to the CSU Director or to the AHSM if after hours. The matter may be referred to the Executive Director Acute Operations or Chief Medical Officer if necessary.

References

Legislation

Occupational Health and Safety Act 2001^[2].

Information

• Guidelines for the Prevention of Workplace Bullying and Occupational Violence, WorkSafe
• The New Zealand 2003 Zero Tolerance (Occupational Violence & Aggression): Policy and Interim Guidelines, Australian Nursing Federation (The New Zealand Branch), 2002
• Framework Guidelines for addressing Workplace Violence in the Health Sector, International Labour Office, World Health Organisation, 2002

Related Employer Policies

• Occupational Health and Safety Policy and Procedures Manual
• Emergency Procedures Manual
• Protocol for Early Intervention in Complex Difficult Cases (Dec 02)
• Home Visit Risk Assessment Policy (April 02)
• Staff Incident Report Form (reviewed Mar 02)
• Support for Staff Injured at Work (May 02)
• Support for Staff who wish to report assaults to Police after being assaulted at Work (August 02)
• Risk Assessment for Patient Admission (Nov 02)
• Terms of Reference, Aggression Management Committee
• Patient & Visitor Aggression Response Protocol (Nov 2002)

Employee Relations

• Bullying (Prevention of in the Workplace): A&RMC Policy No: 75/02
• Discrimination and Harassment Prevention Policy: A&RMC Policy No: 48/00
• Visitor Access (Employee Invited): A&RMC Policy No: 45/02
• Equal Employee Opportunity, A&RMC Policy No: 47/98
• E-mail and intranet Equal Opportunity Policy, A&RMC Policy No: 71/02

Nursing

Mechanical and Manual Restraint No 77/03

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Footnotes:

[1] Health and Safety in Employment Act 1992 in New Zealand (return to text)

[2] Health and Safety in Employment Act 1992 in New Zealand (return to text)

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