Violence in the Emergency Department: Code Black Audit

Experiencing violence at work is one of the most problematic issues faced by emergency department (ED) staff. Rates of violence are increasing and this, combined with the increased incidence of people presenting with mental illness and drug and alcohol use, makes the ED a dangerous and volatile workplace. When an individual’s behaviour escalates to behaviour that threatens staff, patients, visitors or property, a code black alert (CBA) is called. However, there is limited evidence regarding the factors that lead to this escalation in behaviour and this makes it difficult to implement strategies that are effective in reducing violence. This study aimed to explore the organisational and individual characteristics associated with CBAs in one northern Tasmanian hospital.
We undertook a retrospective chart audit of all CBAs occurring in the ED at the LGH (treatment areas, triage area/waiting room and ambulance bay) during a 12 month period (July 2015 – June 2016). Organisational factors were obtained from security reports and individual characteristics were obtained from individual medical records.
There were 73 CBAs during the study period, the majority occurring after-hours (48% between 2200 and 0700). Injury to staff or patient occurred in 12% of CBAs. Mental health was the underlying reason for ED presentation in more than half of all CBAs and 53% of patients had a previously recorded mental health diagnosis. The impact of drugs or alcohol was difficult to determine due to limited testing for these substances.
This study provides preliminary data about organisational and individual factors associated with CBAs in one Tasmanian hospital. The study is being replicated in a regional Victorian hospital, hopefully leading to increased understanding about key triggers involved in CBAs in the ED. Incorporating improved mental health approaches may be an important factor in future strategies aimed at reducing ED violence.


Dr Damhnat McCann

Damhnat McCann is a Senior Lecturer in the School of Health Sciences at the University of Tasmania. Her research and clinical interests focus primarily on the care of children with complex needs and health service improvement in the acute care setting. Recent projects have focused on the emergency setting as part of the LGH ED/UTAS research collaboration. Damhnat particularly enjoys mentoring nurses undertaking research that is focused on improving clinical practice and patient outcomes.