Yellow Does NOT Mean Proceed with Caution

Aim: : The purpose of implementing “Code Yellow” in the Emergency Department (ED) was to standardize the response for behavioral events, provide a mechanism for tracking these events, and provide early recognition and awareness of patients who have had prior behavioral health needs.

Framework:: A formal framework was not utilized for this project, however, the PDSA cycle most closely coincides with the process used during the development of this project.

Setting:: We are a busy, teaching, urban Level I trauma center located in the Midwest.

Stakeholder Team:: Bedside nursing identified a problem and created a project with subsequent education of the project and data analysis. The physician team educated our provider colleagues and were consulted during project planning for input on how to best facilitate communication between staff during a response. Our Clinical Nurse Specialist was the liaison between bedside staff, physician staff, and assisted with brainstorming and problem solving. Our Psychiatric Liaison Services Manger assisted with educating the psychiatric staff.

Methods: : Our goal was to create a program that streamlined the process of notification to the interprofessional team that assistance is needed in relation to a behavioral event. Initially, there was no process in place that easily and quickly notified staff of a need for help, requiring bedside staff to notify each team member individually. This was a time-consuming process that compromised staff safety. Therefore, a modified version of this facility’s inpatient behavioral response team (BRT) was created for the ED. This approach allows bedside staff to initiate a Code Yellow when a patient is exhibiting unsafe behaviors toward themselves or others, for example: attempting to elope, verbal or physical threats, or any other form of escalating behavior. This promotes rapid evaluation by the interprofessional team followed by individualized interventions to ensure staff and patient safety. This project was led by an ED bedside nurse in collaboration with ED and psychiatric leadership. Education was then provided to all stakeholders including nursing, providers, psychiatry, pharmacy, and police. Data is analyzed monthly with findings disseminated to the Behavioral Response Team Committee and Workplace Violence Prevention Committee.

Outcomes:: Beginning in August 2022, findings demonstrate that 64.1% of patients who present to the ED and meet requirements for a Code Yellow receive medication to assist with behavior management, 25.6% require restraint application, 48.7% are discharged from the ED, 20.5% are admitted to inpatient psychiatric care or sent to rehab, 30.7% are admitted for acute medical treatment, and 7.6% require more than one Code Yellow activation while in the ED. We continue to educate staff regarding utilization and documentation of Code Yellow criteria and interventions.

Implications:: Code Yellow is a no-cost, easily adaptable program that allows for various interventions to increase staff and patient safety in real-time while also capturing data on individuals who may require behavioral intervention in the future. We plan to expand this project to create criteria for placement of an identifier within the patient chart that alerts staff to the potential of behavioral events.