Aggression management in a children's hospital setting

To describe the development, structure and implementation of a formal system of aggression management, and to document its utilisation during the first year of operation.

A prospective audit at the Royal Children's Hospital, a major children's hospital in Melbourne.

Analysis of utilisation patterns from prospective data forms augmented by retrospective review of security logs and medical records for 14 months from launch in December 2006.

Staff from four different clinical areas, led by an emergency consultant and a hospital administrator, made up the rostered multidisciplinary "code grey" team. Over 14 months, there were 104 incidents when the team was activated, involving patients in 75 cases and visitors in 29 cases. Incidents occurred at equal frequency on wards and in the emergency department. Patients involved were most commonly affected by a mental disorder, frustration and/or a developmental disability. The apparent cause of visitor aggression was mainly frustration and occasionally drugs. The majority of patient aggressors showed physical aggression towards people or objects or self-harming behaviour. Visitor aggressors were mostly verbally aggressive (and occasionally physically violent). For patients, the team used verbal de-escalation (56/75 events), physical restraint (34/75), sedation (23/75) and mechanical restraint (15/75). For visitors, verbal de-escalation occurred in 17/29 cases and 10/29 visitors left or were removed. Several patient and staff injuries were documented.

An aggression management team can be established in a children's hospital setting. This team structure provides a useful response to concerns about staff safety and optimal patient care.