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Behaviours of Concern Spaces in Western Health Emergency Departments

This document is a summarised version of  OP-RS5-Search of Patient or Visitor and DP-EP4-Prevention and Management of Patients with Behaviours of Concern in the Emergency Department. The summary has been created to be Emergency Department specific, and has been endorsed by the ED Leadership Team. Staff should review the full document if they require further information.

Overview

This QRG outlines the behavioural assessment spaces called Behavioural Assessment Rooms (BAR’s), available within the Emergency Department (ED) at both Footscray and Sunshine Hospital.

The purpose of a Behavioural Assessment Space is to promote safety, dignity and privacy of staff, patients and visitors during the management of behaviours of concern (BOC).

Applicability

This procedure relates to all staff working within the Western Health Emergency Departments.

Responsibility

The Division of Emergency, Medicine & Access Divisional Director and Clinical Services Director and the Director and Nurse Unit Manager for the Emergency Department(s).

Guideline/Process Details

BAR Overarching principles

  • The principles of least restrictive environment are employed and the room is used as a therapeutic strategy within a management plan
  • Patient welfare and right to privacy, dignity and confidentiality are paramount
  • Specific gender and cultural issues to be observed at all times, wherever possible
  • Whilst there are no age restrictions to using the BAR, all other options need to be explored prior to use of the BAR for children under 18 years of age
  • Relatives and visitors are not allowed in the BAR

The BAR’s are intended to be used on a short-term (< 30 minutes) basis only for the rapid assessment and initial management of patients who:

  • Exhibit behaviours of concern on arrival to ED, including but not limited to Section 351 patients brought in by Police
  • Are considered high-risk due to a strong history of BOC on prior ED presentations
  • Have a management plan which stipulates assessment in the BAR
  • Develop significant behaviours of concern during their stay in ED and for whom management in a cubicle does not meet the criteria of safety, dignity and privacy as above

The following activities may occur or be commenced within the BAR:

  • Verbal de-escalation
  • Search in accordance with policy
  • Physical, mechanical and/or chemical restraint

The BAR is NOT to be used for continued patient care, seclusion or ongoing restraint unless there are no safer alternatives.

Notification

  • ‘BOC Alert’: pre-warning of the need for use of the BAR either due to:
    • Pre-notification by Police and Ambulance Services
    • Planned Code Grey
  • ‘BOC Call’: indicates the immediate requirement to manage a patient in the BAR.
  • Both should be announced over the intercom and trigger assembly of the team.
  • An accompanying group page is sent to the BOC Team and a phone call is made to the EMH team at Sunshine ED. The NIC is responsible for this.

Team Assembly

  • Triggered by announcement of BOC Alert or BOC Call.
  • Comprises at a minimum:
    • 1 nursing
    • 1 senior medical (EP or registrar)
    • 2 security
    • 1 EMH
    • Mental Health Nurse Navigator (when available)
  • Additional clinical and non-clinical (police, security) as required.
  • All members are not required in the room at the same time.
  • Staff should stand between the patient and the available exit/s.

Room Preparation

  • Remove unnecessary equipment.
  • At Footscray ED:
    • Turn on light switch to activate the external ‘Room-in-Use’ sign
    • Clear staff courtyard through direct communication via external BAR door or the tea-room
    • The BAR door must not be closed whilst the room is occupied
  • At Sunshine ED:
    • BOTH doors MUST remain OPEN at all times whilst the room is
    • Security to prepare path to BAR and activate ESCORT mode procedure to prevent public access during escort
      • Includes management of secondary egress / AV wait path of egress
  • At least two staff must be present at all times, one of which must be clinical.
  • For patients undergoing restraint at least one registered nurse must be present.
  • Patient belongings must not be brought inside the BAR.
  • WAVIRS should be activated in accordance with local procedure.

Patient assessment and/ or management

  • Management should be guided by:
    • BOC management matrix in the ED Nursing Observation Chart
    • Individual management plans
  • Verbal de-escalation and oral medication are preferred where possible and safe.
  • Physical, mechanical and chemical restraint may be used where other strategies have failed or were unsafe to attempt.
  • Full medical and nursing assessment to be performed as soon as safe to do so.
  • An immediate treatment plan should be devised as soon as possible.

Disposition of patient

  • Early decision should be made about disposition.
  • Options are resus, acute cubicle, BAU, The Hub, discharged home or discharged with police.
  • Until patient transfer, the requirements are:
    • The patient cannot be left alone
    • At least two staff are present, one clinical
    • At least one RN if the patient is restrained
    • The BAR is only used for a maximum of 30 minutes

BOC Stand-down

  • Decided by clinical lead
  • The following should be done on leaving the BAR:
    • Close and lock the equipment cupboard
    • Reposition the trolley
    • Turn off the light-switch
    • Close the door

Documentation

  • Timely and accurate documentation of events is essential including:
    • Assessment and interventions
    • Belongings
    • Code-Greys incident
    • Mechanical Restraint legally required documentations
  • A security alert should be added to EDIS if appropriate.

Debrief & Support

  • Post-incident debrief should be offered to staff and patients by the clinical lead on stand-down.
  • Managers must support staff affected from OVA incidents by offering:
    • supports relating to the EAP and critical incident stress management
    • OV Staff Support Packs about police reporting, legal process and support.

Reporting & Governance

  • All BAR use will be via a security incident and thus entered into Riskman by security and investigated by the NUM and/or ED Director.
  • Use will be reported and discussed at the ED OVA WG meetings, and escalated to the Hospital OVA Committee as required.
  • The BAR will be subject to usual work area audits.

Supporting Documents

Document Governance

Title: Behaviours of Concern Spaces in Western Health Emergency Departments
Version: 2.0
Date Published: May, 2022
Date of scheduled review: 01/05/2023
Author:  Approver: 
ED Leadership Team ED Leadership Team