How this hospital halved its code blacks

It used to be a familiar scene for Emergency Department Director Prof. Paul Preisz. A psychiatric or drug-affected patient being ferried to and from departments. Too behaviour-disturbed to be treated by medics. Too physically unwell to be in the sole care of psychiatrists. Often left to sit for hours in a crowded waiting room, or in the back of a police wagon, the patient’s condition would worsen, agitation would breed and violence would typically ensue.

In fact, scenarios like this are said to account for a large portion of Australia’s hospital violence statistics. In some metropolitan hospitals, up to 10,000 code blacks are reported every year; and across the sector, up to 38% of workers have experienced physical assault at least once in their careers.

Witnessing too many patients with comorbidities falling through the cracks in the system, Prof. Preisz founded Australia’s first ever PANDA (Psychiatric, Alcohol and Non-prescription Drug Assessment) unit at St. Vincent’s Hospital in November 2020 — a holistic pit stop where people could have their complex needs addressed at once. Never turned away, patients presenting at the PANDA unit are immediately granted a quiet personal space where a team of toxicologists, psychiatrists, doctors and other specialists provide a unique blend of acute and social care.

The result: a 50% reduction in ‘code blacks’ since the unit’s inception, amongst a cohort that would typically present the highest risk group for security threats.

Today, Prof. Preisz — whose unit has treated upwards of 3000 people to date — spends more of his time poring over thank you cards from patients, than security incidents from staff.

“The reduction in patient violence is quite a remarkable side effect of the PANDA initiative,” he told Hospital + Healthcare. “With our main goal to adequately treat complex comorbidities, it wasn’t what we set out to achieve. However, given the current rates of violence among this patient cohort, it is certainly something to be celebrated.”

In fact, Preisz recalls receiving a heartfelt thank you note from one of his most challenging patients. Recently out of jail, the man was homeless, had a significant drug history and was experiencing methamphetamine-induced psychosis when he presented at the PANDA unit. In a traditional healthcare setting, he would likely have become aggressive or violent. At PANDA, he remained cooperative and amenable to treatment.

“The man was immediately given a private bed away from the commotion of the emergency department, where staff were able to diffuse his temperament and provide tailored care. Shortly after admitting him, we placed him on a fairly strong detox program and provided the necessary social supports. It turned out the patient had a significant background of post-traumatic stress disorder and a range of medical issues, including high blood lipids and prediabetes. We arranged housing for him and enrolled him as an outpatient to provide longer-term medical care,” Preisz said.

Not long after his admission, Preisz and team were surprised to receive the man’s letter in the mail — a level of gratitude not often seen amongst people presenting to ED in such circumstances.

“It’s quite different to how things could have unfolded in a traditional healthcare setting. I recall seeing patients of a similar nature being sent to and from the very same wards in an ambulance because none of the staff felt they had the right specialty to take care of the person. When they are finally admitted, the patient is rightly frustrated and often becomes threatening towards staff, or physically lashes out. Providing tailored care and placing them in a low stimulation environment sees patients with complex comorbidities behaving quite differently,” Preisz said.

Staff experiences on the PANDA ward are positive too, with many relishing the experience they gain at the facility.

“A junior doctor of mine once said something lovely,” Preisz recalled. “He told me the experience of working at the PANDA unit had made him not only a better doctor, but a better person. It’s wonderful to hear feedback like that, because it shows harmony between people’s expectations and the reality of working in health care. People often go into the field because they want to help people and have a rewarding experience in doing so. In traditional wards, workers can grow disheartened when they don’t get the appreciation they deserve — or are met with violence instead. At PANDA, the environment fosters better patient/staff relationships, giving workers a better sense of having made a meaningful difference.”

The PANDA model is already being considered in other major hospitals and there is increasing talk about expanding the model, in light of its success. Preisz hopes it will be the start of a growing trend — for the sake of patients and staff.

“Every patient has the right to receive the care they need; and every healthcare worker has the right to a safe working environment. Thankfully the PANDA unit provides both.”

Image credit: ©stock.adobe.com/au/Khunatorn