Practice Matters

What works: Code green prevents workplace violence

Over the public-announcement system at our inner-city, 500-bed hospital you hear, “Code Green, Main 5, Room 506.” That’s probably not a code you’ve heard before. A Code Green tells the team that an agitated individual needs help de-escalating. It sets into motion a rapid intervention to address violent situations and offers assistance and expertise in de-escalating a potentially dangerous encounter.

Our hospital started a Code Green Response Team in April 2013 to provide early intervention, protect hospital employees from potential violence, and contribute to a safe work environment. The story of our program may offer some insights into how you can work toward implementing strategies in your healthcare setting to successfully reduce workplace violence. (See Workplace violence and healthcare settings.)

Evidence based

Verbal de-escalation forms the foundation of our Code Green Response Team, which evidence supports as the most effective intervention in preventing violent behaviors. It shifts the focus from the traditional approach of calming the patient to a more collaborative method that builds trust with the caregiver and helps the patient regain control and calm himself. Often, the process is successful within 5 minutes, results in reduced use of restraints, and improves patient safety and satisfaction.

How it works

Our intermediate care unit (IMCU) provides an example of how the Code Green team works. As part of the only inpatient toxicology unit in the United States, the IMCU nurses had years of experience recognizing signs of agitation, managing volatile situations, and addressing violent behavior, but they realized that a specialized team could provide added value. The Code Green Response Team for this unit includes the IMCU charge nurse, the nursing supervisor, security personnel, the primary physician and nurse, the unit charge nurse, and others involved in the patient’s direct care. All members of the team completed specialized training in verbal de-escalation offered by the Crisis Prevention Institute (CPI).

Typically the IMCU charge nurse is the leader of the Code Green Response Team, but if another member of the staff is successfully engaged in de-escalating the situation when the team arrives, the leader positions him- or herself as a support person, controlling bystanders, assessing for safety concerns, monitoring the environment for potential hazards, and supporting a dialogue to determine the cause of the escalated behavior. The IMCU staff, who have specific toxicological experience and can recognize the symptoms of withdrawal, empower the nursing staff to advocate for appropriate treatment with reversal or sedative agents as appropriate.

If necessary, the team leader sets limits and directs the team to control the patient, reminding the patient that violence is not tolerated. After the situation is resolved, the leader debriefs the team and, if appropriate, the patient. (See Code Green in action.)


Return on investment

Employee injury rates directly affect staff job satisfaction, retention, and costs associated with medical treatment and days away from work. From April 2013, when the health system started the Code Green Response Team program, to September 2015, the organization saved $23,425 in costs related to employee injury. And because on-duty staff took on the role of Code Green responders, there were no staffing costs associated with activating the program. The only investment was providing education to staff during the 8-hour CPI training.

From the beginning, the Code Green process has improved patient outcomes. Between April 2013 and September 2015, 240 patients were assisted by de-escalation. Only 26 of the 240 required restraints. The remaining 214 were successfully de-escalated, leading to a 28% reduction in restraint use, which contributed to patient safety. During that same time, employee injuries on inpatient units decreased by 47%. In addition, nursing staff acknowledged feeling more supported during episodes of patient violence.

Creating a program

Many resources exist to help you build your own Code Green program. (See Valuable resources.)

One key point regarding staff education about the program: We found that delayed activation of the response team when a potentially violent situation is first suspected results in increased injuries and injury severity, making early activation of the Code Green Response Team essential.

Although creating a Code Green program takes time, the rewards—improved safety for staff and patients—are well worth the effort.

Yana Dilman is IMCU clinical manager and Faye Gardner is director of nursing education, practice, and research at PinnacleHealth System in Harrisburg, Pennsylvania.

Selected references

American Nurses Association. Incivility, bullying, and workplace violence. American Nurses Association. July 22, 2015.

Lipscomb J, London M. Not Part of the Job: How to Take a Stand against Violence in the Work Setting. Silver Spring, MD: American Nurses Association; 2015.

Richmond JS, Berlin JS, Fishkind AB, et al. Verbal de-escalation of the agitated patient: consensus statement of the American Association for Emergency Psychiatry Project BETA De-escalation Workgroup. West J Emerg Med. 2012;13(1);17-25.

U.S. Department of Labor, Bureau of Labor Statistics. State occupational injuries, illnesses, and fatalities. Updated April 21, 2016.

U.S. Department of Labor, Occupational Safety and Health Administration. Guidelines for preventing workplace violence for healthcare and social service workers. OSHA 3148-04R. 2015.

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