Editor’s Note: This blog was originally published in March 2015. But as incidents of hospital workplace violence continue to fill our daily news feeds, we felt it was important to re- share.
The Emergency Department (ED) at St. David’s South Austin Medical Center was full to bursting. Each day, 150 new people were moving to the Austin area, and the Texas capitol city was struggling to accommodate them. Dr. Sally Gillam, Chief Nursing Officer at the hospital, felt the change.
More traffic in an ED that already serviced 75,000 visitors a year was sure to mean more stress and an increase in violent patient episodes. And into the swelling demographic came a change in regional police department procedure.
As Dr. Gillam explains in a 2015 CPI podcast interview: “So at the same time that we saw growth like that, we also had some changes with our local law enforcement. We saw local law enforcement actually introducing their efforts to increase their drop off of psychiatric cases at our facility, when a lot of these patients were, believe it or not, deemed too unpredictable for a standard incarceration environment such as jail or some type of holding cell. . . [I] was actually told, ‘Dr. Gillam, these patients are too violent to go to jail. So therefore, we need them to either decompress, or we need them to rehab themselves long enough in your emergency department prior to us returning to see if we are going to take them to jail or not.
Training Investment, Code Purples, and a Quality Improvement Study
As these changes bred deep concerns about a potential increase in hospital workplace violence and its impact on quality of care, Dr. Gillam decided to invest in Nonviolent Crisis Intervention® training. All ED employees were eligible to attend the training. At the same time, Dr. Gillam decided to measure the effectiveness of the training through a quantitative quality improvement (QI) study.
When hospital workplace violence appears imminent, staff declares a code purple via the public address system, initiating urgent security team responses. It was the incidence of code purples in the ED that Dr. Gillam chose as the focus of her study.
The goal of the one-year QI study was to see if Nonviolent Crisis Intervention® training would effectively reduce monthly code purples. The variables analyzed were the percentage of cumulative staff trained monthly, the percentage of staff completing the training, and the number of code purple events per ED visit per month. To make sure the study was internally consistent, several confounding factors were addressed, including psychiatric patient mix, staff turnover/experience, gender mix, and ED wait times.
Code Purple Incidence vs. Nonviolent Crisis Intervention® Training
Initial code purples were expected to decrease in response to progressively higher percentages of trained staff. However, a simple look at the code purple incidence per 1000 visits showed the trend line increasing, counter-intuitive to the expected influence. Further study was needed, so analysis was refined by adding the additional variable of percentage of staff trained in 60-, 90-, 120-, and 150-day periods. The additional analysis yielded a strong, negative, and highly significant correlation between monthly code purple incidence and the percentage of staff trained within the current 90-day period. Correlations for the 120- and 150-day were nearly as strong.
However, after 150 days, no correlation was found between the training and a reduction in code purples. Dr. Gillam explains: “So I started looking at 90 days, because I had it monthly, and it was just kind of not telling the story. Then cumulatively it didn't tell the story at all. But then, if you massage and look at your numbers enough, numbers really do tell a story. You just have to have the patience to listen to them. So, what emerged from this was that, in 90-day blocks, you could really see what was going on. What was happening was, people who were trained, it really took the first 90 days for them to actually see some tremendous decreases in code purples after their training. . . what my study shows is that at 90 days, the benefit of education began to really pay off.
Reducing Hospital Workplace Violence by a Factor of 10
The conclusion of the study is that the benefits justified the training costs. Based on the results of the study, a 1% increase in >Nonviolent Crisis Intervention® training within the current 90-day period mapped to 0.0452 code purple events per 1,000 ED visits. In aggregate, the Nonviolent Crisis Intervention® training avoided 33.7 code purples, a 23% decrease from the projected number of code purples had training not occurred.
The cost of training versus benefit realized was significant, according to Dr. Gillam:
“What I essentially did was I adopted a 180-day window as the maximum period of time for the effectiveness of initial Nonviolent Crisis Intervention® training to remain in force. I wanted to do what my study said. So at six months, I felt like that was the right time to utilize, because I would like to see every-six-month training, based on this study. Okay? And I assumed that there would be two 8-hour sessions per year.
I assigned 16 hours of employee time at their salary cost, and then I also looked at instructor time and their cost, and I arrived at a figure that was essentially 2% of payroll per year. That's what the cost was. That's very low. So we used percents. I didn't use gross numbers, because that changes, depending on what your average salary costs are, and that doesn't change a lot. So I arrived at a figure that was 2% of payroll per year is used to achieve a benefit that was able to mitigate 23% of violence-related risk.”
“So if someone needed to utilize or reflect on a study to help ascertain whether or not they wanted to invest in Nonviolent Crisis Intervention® training for their staff, this study is actually what can prove that 2% of payroll reduces 23% of hospital workplace violence.” – Dr. Sally Gillam
Nonviolent Crisis Intervention® Training appeared to lower the incidence of code purples during the study period at St. David’s. Some latency seems to occur before the effects of the training are visible, and the effects of the training do not appear to persist or accumulate over intervals of six months or longer.
Dr. Sally Gillam retired in 2019 after 30 years of service as Chief Nursing Officer (CNO) at St. David’s South Austin Medical Center in Austin, Texas. She currently is a Regional CNO/VP for Baylor Scott & White Healthcare, where she leads the professional practice of nursing and the delivery of safe, efficient, and effective care across seven hospitals in the Austin, Round Rock, and Hill Country regions.