24 Apr 2019

Middlemore Hospital seeks to stop rising violence in emergency department

10:46 am on 24 April 2019

Middlemore Hospital in South Auckland says it's committed to helping staff in its busy emergency department to manage rising violence and aggression.

Middlemore Hospital

Photo: RNZ / Cole Eastham-Farrelly

A new reporting system for violence and other issues in the emergency department (ED), known as Code Orange Calls, reveals there have been 256 such incidents there since the system began last May.

The Counties Manukau District Health Board defines these incidents as including aggressive, intoxicated or suicidal patients or visitors; events or behaviours in which staff feel uncomfortable or compromised; unwelcome visitors and patients or others who refuse to be sensitive to the right of others to privacy.

Middlemore Hospital also has a separate Staff Incident Reporting System for physical violence, under which 18 incidents of physical assault and 20 other related incidents were reported in the ED between January 2017 and May last year.

But the district health board told RNZ there were concerns that these numbers "do not adequately reflect the anecdotal reports and surveys of the emergency department staff of these type of experiences in their workplace, and that other issues leading to escalation in the emergency context were not being captured", such as aggressive, manipulative or intoxicated behaviours.

So, from June last year the ED moved to the Code Orange Calls system instead, as a pilot. The DHB said it does not specifically capture any injuries occurring to staff or other patients in the ED but is now providing "a more accurate basis on which remedial action can be taken".

Mental health and long waiting times increase tensions

Of the 256 calls since May last year, the most - 73 - concerned the ED waiting room and triage area, 34 were unknown, and 34 involved medical assessment. October last year was the month with the highest number of the calls, at 50, with 44 in September and 46 in November. January this year there were 27 but just one in February.

The ED clinical head, Vanessa Thornton, said mental health and long waiting times were among many reasons for rising tensions.

Asked if there were any trends in the data yet, she said: "We've got more mental health presentations and drug and alcohol presentations and that's across all [hospital] emergency departments. And ... unfortunately, we have longer waiting times at the moment in our emergency department, and that increases the frustration of patients." She added the hospital is always working hard to offer a faster service in the ED.

The system was "a way of documenting more of the lower-level aggression that occurs in the ED, particularly intimidating behaviour from patients or their whānau."

Dr Thornton said such outbursts by patients and others lowered the morale of staff.

"It can be very stressful for staff, which is why we're trying to sort of empathise..."

Dr Thornton said the situation was not unique to Middlemore.

"It's a problem that everybody is facing across all emergency departments, and it's always been there a bit but it's becoming more I guess and less tolerated.

"We're always trying to assist the staff to manage this. We put effort into our pastoral care to assist ... staff to manage. And we're also assisting them with the training on how to manage the situations," she added.

Multiple measures needed to deal with aggressive behaviour

Security staff were always present in the ED, but good documentation was needed and training focussed on helping staff handle aggression.

The DHB is also working on improving waiting times in the ED, which are currently about three hours on average for those of lower acuity and not in an emergency.

"We are restrained in this environment but we are actively thinking of ways to improve and every week we're trying new ways to improve the way patients are cared for at Middlemore and reduce some aspects of the ... wait times," Dr Thornton said.

The DHB also had mental health staff based in the ED to assist and had issued personal safety alarms to nurses.

It was also talking to police about patients who were brought into the ED under Section 109 of the Mental Health Act for assessment, in the expectation that police would stay in the ED until the patient had been medically assessed.

A different process was under discussion regarding other "badly behaved" patients with an identified potential for violence who were brought in to the ED by police.

The district health board's chief executive, Margie Apa, told RNZ in response to an Official Information Act request that: "There are instances where NZ Police frontline priorities mean that our DHB security staff members are asked to assist with the care of these patients, and we have a joint working group with NZ Police to address issues as they arise."

She added that in December, the DHB joined with front-line agencies, including the police, St John and Fire and Emergency NZ to develop a video to encourage people in the community to treat first responders, including in the hospital ED, with respect.

There are typically more than 118,000 presentations to the Middlemore Hospital ED in a typical year, and it grows every year.

RNZ requests to the DHB and to unions to speak to ED staff were declined.

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