By Dorothy Brooks
Anyone working in emergency medicine understands the importance of teamwork in a busy ED. Such cooperation is especially important when responding to cases of trauma, cardiac arrest, strokes and other high-acuity, time-sensitive conditions. Why not leverage teamwork to manage mental health crises and improve workplace safety?
That was the thinking in the ED at Yale-New Haven Hospital in Connecticut, where staff designed a protocol to quickly respond to cases involving patients who exhibit signs of agitation that may be accelerating. In such instances, emergency personnel can trigger a response by an agitation code response team (ACT).
While many EDs have instituted mechanisms to quickly trigger security staff, the ACT approach is unique in that the team includes security and clinicians. ACT staff work together in a prescribed manner to protect staff and prevent the need for restraints, sedatives, or other potentially harmful interventions. After three years, staff report they feel safer, and new data show the ACT approach is associated with a lower rate of physical restraint use.1
Ambrose Wong, MD, MSEd, MHS, director of simulation research at Yale School of Medicine, worked with colleagues to develop the ACT approach. Although many hospitals provide emergency staff with education on de-escalation, primarily through Crisis Prevention Institute training, Wong and colleagues noted the teamwork element is missing. “It doesn’t do anything to bring team members together. It is focused on one-on-one de-escalation,” he says. “In the ED, we are working in this fast-paced environment where all of us work very closely together. We are making decisions together.”
Thus, when responding to an agitated patient, Wong says teamwork should be coordinated, too. However, he acknowledges there are complexities he describes as the “patient care paradox.”
“It is really more of a moral dilemma because [clinicians] want to keep themselves and, of course, the patients safe,” Wong says. “But they know when they apply restraints or sedatives to get a patient to quickly calm down or de-escalate, some of those [interventions] can be harmful to patients.”
Further, even if providing sedatives or placing restraints is deemed the best approach under the specific circumstances, such interventions can be difficult to accomplish if the clinician is working one on one with an agitated patient. The ACT protocol anticipates such difficulties. “We are balancing what the security officers might see as a security threat with what we are trying to do clinically, which is to care about patients, first and foremost,” Wong explains.
Each ACT team includes a clinical lead who makes the decision about how to manage a patient, usually an attending or senior staffer. This person considers the opinions of security, along with junior staff, nurses, and techs.
When managing an agitated patient, it is important to consider the underlying clinical reasons. “We need to recognize that at certain times, that patient could potentially be perpetrating violence. That can happen very quickly,” Wong says. “The security staff members are there to recognize that and to support us, but we want, first and foremost, for the response to be clinical.”
When the ACT protocol was unveiled, there was organizational readiness for action on workplace violence. Part of this readiness was driven by a rise in hospital-based violence, as well as more patients presenting with mental health or substance use issues. “Traditionally, protective services staff and clinical staff ... don’t train together, and we don’t operate together, and the way that we think about patient care and work is so different,” Wong says. “There has never been a chance to overlap those worlds together.”
There was evidence of good synergy between clinicians and security staff when they gathered for a session in the clinical simulation center. “We had a standardized actor who acted as an agitated patient, we went through a scenario, and then we spent about 45 minutes just debriefing that,” Wong recalls.
As the participants began talking through the issues, light bulbs were going off on both sides. For example, security staff started to appreciate some of the clinical reasons why physicians might want to delay restraining a patient who the officers perceived as a security threat. Conversely, physicians began to appreciate some of the things security knows to observe, such as certain non-verbal cues or tip-offs that law enforcement personnel are trained to recognize. “It was really exciting for people to have a chance to share how they view [such a scenario] and try to frame it together to create consensus,” Wong notes.
Lt. Donald Costa, evening shift supervisor for protective services at Yale-New Haven, says security officers were completely on board with ACT from the start. Over time, he says their performance working together has improved steadily. “We train often together, and we do simulation work together to make us better working as a team,” Costa says. “The medical staff respects our opinions, thoughts, what we see, and the way we have been trained.”
In the early days, there were some ED personnel who were concerned the ACT alert might be activated too often, but Wong notes that issue is not a primary focus. “When an ACT team is successful, we actually are not restraining the patient or needing to do things that are coercive,” Wong says. “That means there was agitation, but we were able to apply things that we think are patient-centered — de-escalation, trying to talk to the patients, determine why they are agitated, and connect with them.”
Staff also may employ environmental modifications, such as turning down the lights and reducing noise levels, steps that can tamp down agitation. While such techniques do not always work, Wong says ACT developers believe it is important to try such measures first. “When any staff member feels like there is imminent danger to themselves or others, and that one or two people cannot handle the situation safely, that meets the criteria to call an ACT alert,” Wong explains.
On every shift, there are designated physicians, nurses, techs, and security personnel who will respond to an ACT alert, even when the ED is bustling. “We treat the ACT alert just like any other code,” Wong says. “If a stroke comes in or a trauma comes in, we are obviously seeing patients, but then we drop everything, and we respond to that first to make sure that situation is safe. We wanted to elevate a mental health or a psychiatric crisis to the same level.”
It took some time to make this a priority. Today, when someone triggers an ACT alert, everyone on that team for that shift responds immediately, just as clinicians designated to respond to more traditional codes would respond. “We all have portable radios, and they announce the ACT alert wherever it is,” Costa says. “We have three officers who are assigned to the ED. Once they have received notification, they let our main dispatcher know, and we bring additional resources to stand by in case the situation escalates.”
By protocol, each ACT team member knows where to position in relation to the patient, what role to play, and how to contribute. “We probably do two or three ACT alerts per shift, on average,” Costa says. “We all think this has made everybody safer.”
However, the process requires continual nurturing. For instance, in the early days of implementation, the ACT team participants would meet twice a month to compare notes and review the alerts that stood out. Now, the group meets once a month to debrief. “It takes training, and we are constantly re-evaluating,” Costa adds.
“We are very lucky that our security staff understands and values safety in the ED,” Wong observes. “They have given us statistics showing that the ED [is responsible] for the overwhelming number of calls for security responses; we get the highest number.”
For this reason, extra security officers always are stationed in the ED. This presence expanded over the course of the COVID-19 pandemic because mental health crises skyrocketed. However, Wong recognizes other institutions that treat different patient populations or operate with fewer resources may choose to respond to patient agitation differently.
The Yale-New Haven ED just completed its third year with the ACT alert. Investigators are planning to study longer-term outcomes. For example, they want to examine the well-being of patients who were the subjects of ACT alerts.
Elsewhere, ACT alert protocol has been put in place at Mayfield Hospital, a smaller community hospital in New Haven. Further expansion is planned.
The idea is to foster a more balanced approach. Traditionally, hospitals have employed triggers that only prompt a security response for patient agitation. “We are hoping to change that mentality so that both clinical and security respond together,” Wong says.
REFERENCE
1. Wong AH, Ray JM, Cramer LD, et al. Design and implementation of an agitation code response team in the emergency department. Ann Emerg Med 2022;79:453-464.
While many EDs have instituted mechanisms to quickly trigger security staff, a Connecticut hospital created a unique team-based protocol that includes security and clinicians. Everyone works together to protect staff and prevent the need for restraints, sedatives, or other potentially harmful interventions. After three years, staff report they feel safer, and new data show the approach is associated with a lower rate of physical restraint use.
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