Emergency response team

I work in a psychiatric emergency department. We don't typically call codes in our department. As soon as people start escalating the team in the department is great at responding. Other inpatient units in our building call code whites by pressing the code white button on their name tags or pressing the code white buttons on the walls. Usually one RN from the ED responds to codes in our building and one RN from each floor responds as well. The ED RN is designated code manager. Security and the duty doc respond as well.

At our 240 bed hospital we have CODE STARR paged overhead for verbal aggression/ combative pt. We use a program called STARR by a company named Mitigation Dynamics. A good amount of our floor staff and all of ER takes the 2 day course. There is a refresher 4 hour course every 2 years. STARR focuses on and prefers verbal de-escalation of the situation. But several hours are spent learning hands on physical manipulation of pts using a team approach for safety. It is a great program and we have used it for about 8 years. The techniques used have even saved one of our female ER techs from a male assaulter outside of work. She had a guy appear behind her in the parking lot wanting to cause harm and she was able to bring him to the ground and hold him until police arrived. (Using a move called the Clamp). Its not a martial arts class, but the information learned is excellent. We show up to CODE STARR calls in numbers (4-6 typically with one lead). Safety in numbers and the pt doesn't typically want to fight a whole crew. I worked ER for 10.5 of those 8 years and pts very rarely were hurt when take down methods had to be used.

I work in a large  (600+ bed) inpatient psych hospital. Units try to manage crisis on their own as much as possible and not all acute behaviors (or medical issues) result in a code being called all staff are trained in de-escalation techniques and challenging patients often have specific behavioral plans created to help avoid behaviors becoming code situations.  (for example my unit may only call a behavioral code for one out of every 10 behavioral emergencies because we are able to manage the others with out extra staff).  If it does move to a seclusion/restraint situation ALL staff are trained in what we call "safe containment" and physical restraint techniques with clearly designated roles. Typically lead RN will lead these situations, but we do allow flexibility such that if another staff has rapport and is primary engaged with patient they lead if need be. 

We have the ability to directly ask security for a "walk through" (1-2 staff casually walk through the unit) or a "show" (2-4 come prepared to deescalate) if things are escalating and we just want some extra people on the unit to potentially help manage milieu while unit staff are engaged with the emergency but are hopefully not going to escalate to code situation. 

To call a code you can radio in a code, call security/dispatch on phone for code, or hit a personal monitoring device we each wear -- the prior two are preferable as then you can provided more detail on what is needed, but the monitoring device is good because not only can you activate it by pushing the button, but it also will trigger security if there is sudden change in motion (e.g. if you go from upright to laying down with in a certain number of seconds and then don't move it will also send an alert and security will look a cameras in your area and call code if needed - of if you've just dropped the device will call the unit to confirm no code and not call).  Although it is much more rare - if security monitoring cameras sees something that looks dangerous (e.g. patient appearing to charge staff running down the hallway) they will also independently call a code. 

When a code is called (Green = psych, blue = medical) Program manager, attending psychiatry staff, RN managers from all "sister" units, and at least one staff from each of the program "sister" units respond to other codes in the program along with security staff.  (who responds to codes is assigned each shift). For some units/situation the code will be called "Code Green X units and security only" -- this is usually more common for our specialized units (e.g. medical-psych).   

Code blue summons rapid response team, program manager, RN managers, and medical staff but usually gets a HUGE response because they aren't as common (and if there has been a "code green" followed by a "code blue" people tend to assume the worst and you get more than enough staff to manage both situations). 

Many times we get almost too many people and it is important for whomever is in charge of the code to direct staff to roles and ask excess staff to leave.  You almost never want more than 4-8 people directly involved with the patient for restraint or medical and want the rest being utilized to manage milieu and do things like bring supplies or open doors, make phone calls etc.  It can be useful to have some of the responding staff stick around to help staff anteroom and manage milieu while the unit debriefs after the incident.