Better responses, safer hospitals

Standards for Code Grey responses

Purpose
The implementation of a standardised response to incidents of violence and aggression (Code Grey) in
Victorian public hospitals is a recommendation from the Inquiry into Violence and Security Arrangements in
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Victorian Hospitals.
This document outlines the standards required for an organisational response to the prevention and
management of clinical aggression. These standards may also inform responses for the prevention and
management of non-clinical aggression, such as that associated with visitors.
Managing clinical aggression is a broader organisational response that begins with prevention and extends to
post-incident management. This document articulates the Department of Healths expectation that all public
health services:

have a policy or procedure that defines the organisational Code Grey response (whilst local arrangements
will vary, the policy is to align with the principles and minimum practice standards in this document)

have an emergency alert of Code Grey that is separate from Code Black.2
These standards recognise that responses to clinical aggression are different from those to an armed threat.
While this differentiation of emergency codes is a change for some health services, it is necessary to have
consistent critical emergency response codes across health services state-wide.

Background
Health services have overarching policies outlining their accountability for providing a safe workplace. These
policies are underpinned by the principles of occupational health and safety and risk management. Building on
that foundation, this document describes, for incorporation into health services policies and procedures, a set of
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evidence-based principles and minimum practice standards for managing incidents of clinical aggression.
Code Grey procedures that are based on the best available evidence:

ensure patients are treated safely, with dignity and with clinical needs met
reduce the risk of serious injury to patients and staff, and
ensure staff implement a standard escalation process to a potential threat.
Establishing Code Grey standards raises awareness of the issue while providing support for our valuable staff.
Increases in the use of Code Grey alerts are considered a measure of success, reflecting the implementation of
good practice and thus safer and more secure workplaces.

The Inquiry into Violence and Security Arrangements in Victorian Hospitals can be found at
http://www.parliament.vic.gov.au/component/content/article/307-inquiry-into-violence-and-security-arrangements-in-victorianhospitals/1528-report .

Code Black is defined under ASA 4083. Code Grey is not recognised under the current ASA Standard.

These principles are based on a review of the literature, an exploration of current practice in Victoria, consultation and expert opinion.
A full report of the research can be found under Standardising Code Grey responses across all health services at
http://health.vic.gov.au/emergency-care/hospital-safety.htm .

Department of Health

Definitions
Clinical aggression: Aggression arising from the health condition and which occurs between a health
professional and a patient (or visitor).

Code Black: A hospital-wide internal security response to actual or potential aggression involving a weapon
or a serious threat to personal safety (ASA 4083).

Code Grey: A hospital-wide coordinated clinical and security response to actual or potential aggression or
violence (unarmed threat). Code Grey activates an internal alert or emergency response.

System level guidance

Principle 1: Standardised Code Grey responses support quality care across the Victorian health system.
Description

Minimum practice standards

A Code Grey response

based on practical,
evidence-based
guidance supports
consistent, safe and
effective practice.

1.1 All Victorian health services have an operational Code Grey response.
1.2 Local Code Grey responses align with the set of evidence-based principles and standards
outlined in this document.
1.3 The term Code Grey is used as the emergency code designated for unarmed, clinical
aggression across the Victorian health sector.

Health service level guidance

Principle 2: A Code Grey response is a whole-of-health-service responsibility.
Description

Minimum practice standards

All staff have a role in

ensuring effective and
safe Code Grey
response procedures.

2.1 A Code Grey policy and procedure is in place and has executive sign-off and support.
2.2 Factors that support sustainable Code Grey policy are in place including ongoing training.
2.3 The organisational strategy includes a clear governance structure for:
data collection and monitoring
evaluating outcomes
a defined review period.
2.4 The organisational procedure for Code Grey:
includes triggers and mechanisms for activation
defines the roles of team members
prescribes mechanisms for escalation
outlines post-incident procedures
includes guidance for involving or engaging police.
2.5 Policies that complement an effective Code Grey response are in place, including policies
regarding the management of weapons, restraining or secluding patients and search
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criteria .
2.6 Environmental factors that may lead to aggression (such as environmental design, security
systems and risk assessment) and interventions focused on individuals (such as training)
are considered.
2.7 Staff are trained to prevent and manage clinical aggression.
2.8 Carers and consumers are consulted when developing clinical aggression policies and
communication plans, including those representing vulnerable groups such as children,
older people, patients with disabilities, persons experiencing an episode of acute mental
illness and patients from culturally and linguistically diverse backgrounds.
2.9 Policies outlining acceptable behaviour are clearly visible to patients and visitors, and
provided in a format that will increase and enable comprehension.

4 Department of Health guidance on:

Preventing occupational violence: A policy framework including principles for managing weapons in Victorian health services, at
<http://www.health.vic.gov.au/__data/assets/pdf_file/0006/680937/Preventing-occupational-violence.pdf>
Criteria for searches in mental health inpatient services can be found at <http://docs.health.vic.gov.au/docs/doc/Criteria-forsearches-to-maintain-safety-in-an-inpatient-unit--for-patients-visitors-and-staff>
Providing a safe environment for all: Framework for reducing restrictive interventions can be found at
<http://docs.health.vic.gov.au/docs/doc/1020E7C38806095DCA257C380011BA55/$FILE/Framework%20for%20reducing%20rest
rictive%20interventions%20FINAL.pdf>

Department of Health

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Principle 3: Code Grey strategies consist of a dual clinical and security response that is clinically led.
Description

Minimum practice standards

Code Grey responses

3.1 A Code Grey response is led by senior clinical staff from the area in which the incident
require different
occurs.
management skills. In a 3.2 Agreed operational protocols are in place outlining how the team comes together during an
setting of ongoing clinical
incident and the roles and responsibilities of all team members.
care, the response team 3.3 The size of the hospital may dictate the number and type of staff involved. With the
is led by a clinician who
exception of minimum practice standards 3.1 and 3.2, best efforts are to be made to adapt
prioritises patient care
and reflect the standards 3.4 and 3.5.
and staff safety.
3.4 The composition of the response team includes: trained staff from the local clinical area;
security staff trained in delivering services in healthcare settings; and additional trained
staff from the wider hospital and/or emergency services as required. Responses in high-risk
areas such as mental health and emergency departments require locally-based teams that
are supplemented by security.
3.5 Where the use of restraint is indicated, the team consists of a minimum of five people: three
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to manage the limbs, one to manage the head and a team leader to monitor the patient .

Principle 4: Code Grey responses maintain a patient focus while ensuring safety for staff and visitors.
Description

Minimum practice standards

Code Grey responses

4.1 Code Grey procedures are:
reflect the individualised
established across areas, clinical and public within a health service
and multifactorial nature
modified for levels of staff training and local risk profile
of clinical aggression
inclusive of post-incident support mechanisms for all staff, such as counselling.
and take into account the
risk to staff and visitors. 4.2 Supervisors are competent in conducting an environmental hazard assessment and have
sufficient authority to implement changes to address identified risks and issues.
4.3 A tiered response framework is in place to appropriately address the range of possible
clinical aggression presentation.
4.4 Code Grey responses are primarily based on the clinical presentation of the patient along
with gender, ethnicity, age and cultural diversity.
4.5 Patients are managed using the least restrictive intervention.

Restraint (particularly prone restraint) has been identified as a significant risk,

http://docs.health.vic.gov.au/docs/doc/A3D7E24D93C07554CA257C0F0008A0B7/$FILE/Practice%20of%20Prone%20Restraint.pdf .
The use of restrictive interventions is directed by the provisions of the Mental Health Act 2014.

Department of Health

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