The patient at Singapore General Hospital’s (SGH) emergency department (ED) was becoming increasingly agitated and aggressive. He began shouting and threatened to kill himself. Assistant Nurse Clinician Mohamed Ridzuan Sulaiman tried to calm him down, but the patient suddenly picked up a glass bottle of cough syrup.

Mr Ridzuan knew it was time to trigger the hospital’s Code White.

Like the more well-known Code Blue (for a sudden cardiac arrest), Code White is an emergency signal to alert the hospital’s team of four male nurses and two security officers that a colleague needs support in a potentially dangerous situation. “The objective is to de-escalate violent cases. If our security officers are not able to resolve the issue, the situation may then have to involve the police,” Mr Ridzuan said, adding that staff can text or use the public address system to call for the Code White team when faced with verbal, physical or sexual abuse.

Abusive incidents are not uncommon in hospitals, but the number of cases appeared to have increased during the COVID-19 pandemic, especially at the ED, where tempers tend to run high due to the usually crowded room and long wait time. It is also common for staff to have to deal with patients who are drunk, raise their voices hurl vulgarities, throw things at people around them, threaten other patients and demand food or immediate medical attention. Some refuse to be examined and are uncooperative during consultation, while others touch nurses inappropriately.

Between January and August 2022, 48 verbal and physical abuse cases were reported at the ED, compared to 55 between 2019 and 2021. In 2019, a team of ED nurses came together to work on the Code White project, which won the Singapore Health Quality Service Best Team Award for 2022. The Code White framework sets out clearly what constitutes abuse, and how to handle and de-escalate violence in a quick and safe manner. “Patients raising their voices, using vulgarities or creating a commotion are early signs of aggression. If they are not addressed promptly, the situation can escalate quickly and result in physical injuries,” Mr Ridzuan said. He has been punched in the stomach by a patient, while a colleague was hit so hard in the face that his spectacles and face shield broke.

To empower and give nurses and staff at SGH’s ED confidence in managing abusive situations, they are encouraged to attend an hour-long Code White training session to assess, prevent and manage violent and aggressive situations. Being able to manage such situations ensures the safety and respectful treatment of staff and patients alike.

In the past, most of the staff were reluctant to report abuse, citing reasons such as accepting violence and abuse as part of the job. “When a patient hits them, many staff just let it pass,” said Mr Ridzuan, adding that they also feared getting reprimanded, not getting support or not knowing how to report abuse. The reporting process has been simplified and takes less time, thus encouraging more to report abuse. Having this data provides the hospital with a more accurate picture of what is happening on the ground.

“Abuse makes healthcare work more physically and mentally exhausting. It also affects the quality of care for other patients. The Code White initiative creates a more conducive environment, boosts morale, reduces burnout among healthcare workers and improves patient well-being,” said Mr Ridzuan.

Besides Mr Ridzuan, the Code White team includes Senior Staff Nurses Seah Hwee Ling, Maureen Lee Kai Yi, Nurul Iffah Mansor, Tay Kok How, Siti Nurhalizah Kamis and Lee Guan Teck; Principal Enrolled Nurse Anthony Chandren; Senior Patient Care Assistant Ariss Selamat; and the Security Department’s Senior Associate Executive Muhammad Fadhil Mohamed Zin. Nowretired Nurse Clinician Norizan Jaafar led the team on the project.

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