Kudos to Liberty Hospital – the Orange Door is Working!

July 21, 2015    |   By: Calevir

All healthcare providers are committed to providing the highest quality, safest care possible for their patients. Yet this commitment often causorange doores them to endure violent or aggressive behavior from patients. They traditionally have accepted this as simply “part of the job.” Their reluctance to speak up or report incidents puts employees, patients and visitors at risk. As with many safety and performance improvement efforts, a strong safety culture must be at the foundation in order to change this thinking. Staff must recognize that aggressive and violent behavior by patients does not have to be tolerated, and they must feel that the hospital will support them in putting their own safety first. During the past few years this cultural problem has increased with the growing presence of gangs and use of street drugs and alcohol, and decreased availability of medical care and facilities for individuals suffering mental or behavioral illnesses.

This was the challenge for Liberty Hospital, a 250-bed medical center north of Kansas City. Their situation was heightened as they do not offer behavioral medicine services, but that did not stop the hospital from taking action. In 2012 they partnered with the “Handle with Care” (HWC) Behavior Management program, which traditionally has provided de-escalation training to prevent actions that reduce the need for restraints at schools, behavioral medicine units and emergency departments. With the increasing incidence of violent patients, it was decided to bring this training to Liberty Hospital for all staff that cares for patients.

Code White
A small multi-disciplinary team took on the project, first revisiting their process for getting additional security personnel to the scene of the disruptive behavior. This team realized that sometimes a person in uniform can escalate tension rather than de-escalate. It also was determined that a “show of force/support” can deter some from becoming aggressive when faced with more than one staff member. It was determined that a multi-disciplinary approach could be used for this process instead of just using security officers. A new process “Code White” was developed, which alerts the crisis intervention response team that additional assistance is needed to handle a violent patient, family member or visitor. While Liberty had enough security staff members assigned to the Code White team, they did not have adequate, consistent de-escalation training for the new members of the team. HWC provided a train-the-trainer program for ten instructors at Liberty Hospital. These trainers teach the one-day class for staff that will respond to Code White calls.

These trainers also streamlined the one-day training to two hours with intense focus on verbal de-escalation skills, how to recognize escalating tension and general awareness of potential violence. By the end of 2012 the trainers had provided education for all clinical employees who care for patients (nurses and CNAs). Additionally, this training became part of new employee orientation to ensure future consistency. Liberty generously has shared their “Code White” policy so others can replicate this process.

The “Orange Door”
After the staff training was hard-wired, the team brainstormed how to better communicate which patients are at risk for violent behavior. The “Orange Door” was initiated, which includes:

  • A placard placed on the door of any patient at risk for violent behavior to self or others;
  • Revision of the communication board at the nursing stations so the patient’s name is highlighted in light orange for all staff to be alerted of potential violence;
  • Additional training for staff to understand and identify suicide-imminent risk to self and others (See policy with definitions and procedures);
  • Communication with the patient, family member and/or visitors regarding expectations as defined in the Suicide- Imminent Risk to Self or Others policy; and
  • Sitter program that currently is undergoing improvement processes to ensure sitters appropriately and consistently are educated before being assigned to an “Orange Door” room.

Include community first responders
Liberty recently has begun to work c o o p e r a t i v e l y with the Liberty police force and fire department, explaining what happens when a non-medical patient with violent behavior is brought to Liberty Hospital’s Emergency Department (ED). Since there are no inpatient behavioral medicine beds, the patient must be assessed in the ED and be held until staff can arrange a safe transfer to a facility that provides mental healthcare. These first responders are learning how to identify the need for behavioral care so patients can be taken to the appropriate facilities whenever possible.

The Results
Although this new and improved program is less than two years old, Liberty Hospital has seen solid results. In 2012, more than $300,000 was paid for workers’ compensation claims relative to violent patient behavior. In 2013, that payout was reduced to $75,000. The team will continue to improve the “Orange Door” program until there are no injuries!

Changing the hospital’s approach to managing aggressive behavior is difficult because it requires a change in mindset that any patient can pose a risk. Caregivers are trained to give care, not to think of patients as potential risk for aggressive behavior, violence and harm. Liberty Hospital continues to change that mindset as the bedside caregivers, medical staff members and first responders work together to mitigate the risks of this issue. “The innovative steps, including developing a responsive team, have enhanced quality and safe care for our patients,” said Shirley Heintz, R.N., Chief Nursing Officer at Liberty Hospital. Additional information on implementing the Orange Door process may be obtained from [email protected].org.


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