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Coney Island Reduces Restraint Use in Behavioral Health Patients


To change the culture of aggressive physical interventions when patients act out, staff in the behavioral health inpatient unit at Coney Island Hospital developed a psychiatric crisis prevention team called Code Grey. The team focuses on handling violence, potential violence, escalating behavior and aggression through the safest, least restrictive means possible. The goal is to help patients regain control of their behavior while also creating a safe environment for the patient acting out, other patients and staff.

The Code Grey Team is predominantly inpatient nursing staff, however, other key members include clinical administrators, inpatient therapists, psychiatrists and hospital police. The team leader during the actual code is usually the nurse who has the best rapport with the patient. This gives the leader the confidence to try to de-escalate the situation and awareness of the events leading up to the behavior change necessitating the code.

The criteria for activation of this team can be a patient exhibiting severe agitation, yelling, threats, incidence of violence or any acute change in mental status. When put into action, Code Grey summons staff through individual pagers and an overhead announcement to respond to one of two acute behavioral health inpatient units to assist in preventing or de-escalating a crisis.

While developing the procedure, staff created a policy that avoided the use of restraints and seclusion through early intervention, addressed related training needs of staff and coordinated written and verbal services pertaining to staffing and communication.

The inpatient staff, including many of our administrators and hospital police officers, was trained about this new initiative and the expectation that each one of them on a rotational basis would participate as a team member during their shift or assignment.

A number of positive trends have emerged since introducing Code Grey in December 2008. The nursing staff has shown interest and growth in continuing to learn about crisis prevention. During the past year, more nurses have attended a four-day training program to become certified as instructors in crisis prevention. The number of certified instructors has increased to more than 20 and includes nurses on the off tours, as well. All nursing staff is expected to attend a one-day training session annually, although some have requested to attend more frequently as a refresher. All training programs are interdisciplinary, including clinical and non-clinical staff. In addition, learning occurs after each code during a debriefing that focuses on the patient and staff response. The Code Grey team also enhanced shared governance at the grassroots level across the entire inpatient staff, including hospital police and clinical administrators. Staff members who were once reluctant to share their opinions became active in the process. This model resulted in the empowerment of staff and patients, a greater collaboration and overall improvement for patient and staff satisfaction relating to treatment.

Code Grey continues to be challenging but rewarding. The number of episodes of restraints and seclusion averaged 8.3 per quarter in 2008 before implementation. There was an immediate decrease in the use of restraints and seclusion as evidenced by the quarterly average being reduced to two for the first two quarters of 2009 and continues to be the trend. Restraints and seclusion percentages decreased from an average of 10% per month in 2008 to between 0% to 1% in 2009 after the implementation of Code Grey.

As a result of the policy’s success, staff plan to continue to reduce the use of restraints and seclusion and use the least invasive means to prevent violence by providing education programs, mock codes and ongoing dialogue to maintain a strong and cohesive team.


About Author

Janet Ferguson, RN, PMHCNS-BC, is associate director of behavioral health nursing at Coney Island Hospital in Brooklyn, N.Y. Send letters to the editor to or comment below.

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