LIBERTY HOSPITAL
Liberty, Missouri
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I.
GUIDELINE: “Code White” - Crisis Intervention Response
Team
EFFECTIVE DATE:
DEPARTMENT: All
REPLACES: NEW
10/29/2012
PURPOSE:
A. To ensure that staff and patient safety is maintained when responding to / intervening with anyone who is
demonstrating physically aggressive behavior or threatening physically aggressive behavior that would
undermine Liberty Hospital’s (LH) culture of safety.
B. To provide instructions/guidelines for the Crisis Intervention Response Team (CIRT) members in order to
manage the situation in a professional manner and so that a therapeutic resolution can be established.
II. DEFINITIONS:
A. Code White – an emergency response term used to describe the method for summoning the Crisis
Intervention Response Team members.
B. Crisis Intervention Response Team (CIRT) – identified staff members who are trained and certified in an
approved crisis intervention program who are to respond, upon request, when an individual is demonstrating
physically aggressive behavior or threatening physically aggressive behavior.
C. Crisis Response Coordinator – an individual trained/certified in an approved crisis intervention program that
directs other CIRT members.
D. Show of Force/Support – term used to describe an operation intended to warn or influence individuals
exhibiting threatening behavior, of the capability to act or intervene if necessary.
E. Verbal Intervention Techniques – active listening, setting limits, support techniques, and other problem
solving methods.
F. Physical Intervention Techniques – physical supportive holds and/or restraint techniques used to manage
dangerous behavior. (These techniques will only be used as a last resort in providing for the safety of the
patients and others. Reminder: the hospital’s restraint policy must be followed whenever restraint
techniques are utilized.)
III. RESPONSIBILITY:
The management of the CIRT will be the responsibility of the Safety Officer. The Safety Officer will work with
the Organizational Development Department to evaluate and monitor the program (including training and
efficiency).
IV. POLICY:
A. All Staff have a responsibility in the identification, and pro-active prevention of behaviors that threaten a
safe patient care environment. Liberty Hospital will implement and utilize intervention program techniques
that treat(s) all parties involved with respect, dignity and courtesy. The ultimate goal is to support the parties
involved, and/or to deescalate the situation in a manner that provides for the safety, security and welfare of
all.
B. There are times in which the boundaries of socially acceptable behavior are extended due to unusual
circumstances. For example, if a patient is newly diagnosed with a serious/fatal illness, it is anticipated that
the patient and/or family may experience and express anger. In these situations, evaluation, support and
intervention by licensed clinical social workers, psychologists, chaplains or other psychosocial disciplines
may be appropriate to support the family.
C. The following behaviors are considered unacceptable and CIRT should be notified immediately:
1. Behavior that interferes with or presents a danger of interfering with patient care, or other business at
Liberty Hospital.
Administrative
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LIBERTY HOSPITAL
Liberty, Missouri
Guideline: Code White
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2. Threats of violence or use of unlawful force against anyone on LH property.
3. Behavior that is abusive, verbally offensive or hostile.
4. Behavior that creates fear and/or apprehension on the part of other patients, family members, staff
and/or visitors at LH.
5. Additional unacceptable behaviors include threats, harassment, bullying, coercion, intimidation,
cursing, body language/posturing, sexual overtones, aggressive gestures, aggressive language,
racial slurs or inappropriate physical contact.
D. Crisis intervention program training will include the use of verbal de-escalation skills, physical intervention
techniques, and role playing designed to reduce the risk of physical and emotional injury to all parties
involved.
E. A “Code White” will be activated when a show of support is determined necessary to de-escalate a
threatening situation.
F. CIRT response coverage will be 24 hours a day every day.
V. PROCEDURE:
Initial Incident Response
A. When an individual is demonstrating physically aggressive behavior or threatening physically aggressive
behavior, staff should notify the hospital operator, by dialing 7555 and request the CIRT to their location.
B. Upon notification, the operator will contact the Security Officers by radio; utilize the overhead paging system
and announce “Code White”, location. Repeat three times; and page the CIRT group.
C. Upon announcement of a “Code White” the following steps should be taken:
 CIRT members:
1. Respond to the location and evaluate situation.
2. Determine and identify a CIRT Coordinator, based upon the particular situation and/or the other
members who have responded.
3. Follow the directions and/or recommendations of the Coordinator.
4. Other positions can include:
a. PRT – Assigned to execute the Primary Restraint Technique
b. Arm Passer – Assists the PRT in escorting, then passing for PRT
c. Leg Person – Watch the legs and hug the knees when assigned
d. Scribe – Complete the CIRT IC Structure form and assist with debriefing. Send out a
follow-up e-mail to CIRT members on lessons learned, etc.
e. Liaison – Work with the Coordinator to keep other unassigned CIRT members, that have
arrived at the scene, informed of situation
f. Safety – Assesses safety concerns in the environment, and in conjunction with other team
members, addresses those concerns
g. Talker – Focus on the patient/visitor and create a therapeutic relationship to help address
their concerns and work to reduce tension
 CIRT Coordinator:
1. Assess the situation, nature of the behavior and identify resources available/needed.
2. Develop a plan of action to de-escalate the individual’s behavior based upon crisis intervention
program training/techniques:
a. Initially utilize verbal intervention techniques and/or all non-physical options available
b. Utilize physical intervention techniques only as a last resort.
3. Supervise and/or direct the other CIRT members
4. Act as the person in charge
5. In collaboration with other CIRT members, determine when the threatening situation is no longer
manageable and contact local police
6. In collaboration with other CIRT members, determine when the threatening situation has been
resolved and/or no longer exists
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LIBERTY HOSPITAL
Liberty, Missouri
Guideline: Code White

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If the individual is a patient:
1. Charge Nurse, Clinical Resource Leader, Supervisor and/or Department Director:
a. Assist with managing situation utilizing de-escalation techniques until CIRT members
arrive
b. Brief the CIRT members of the circumstances and/or any special needs/precautions.
2. Primary R.N.:
a. Update CIRT Coordinator of any significant information about the patient to assist with
developing a plan of action such as pertinent medical information that may/may not affect
mood or behavior, etc.
b. Notify the patient’s attending physician and communicate any suggested interventions to
the CIRT Coordinator
c. Document an event note in SCM, and any other department-specific documentation
required.
Post Incident Response
A. Individuals who responded:
1. Will meet briefly upon completion of the situation to critique the event.
2. The CIRT Coordinator/designee will be responsible for completing a CIRT Event Evaluation and
forwarding it to the Safety Officer.
3. Will be responsible for completing any other documentation, as required, by either department-specific
or house wide guidelines. (i.e., Event Report, Employee Injury Report, Security Report, etc.)
Performance Improvement
A. CIRT calls will be reviewed monthly and analyzed for trending and pertinent actions, which may be
required.
1. Actions to improve performance are determined based on trends and/or analysis.
2. Based on evaluation of CIRT calls, the Safety Committee will meet quarterly and determine if
revisions to policies and procedures governing the CIRT are needed.
Quality Performance Improvement (QPI) receives a summary report from Safety Committee quarterly
VI. EDUCATION/TRAINING:
A. Members of the CIRT will complete an approved crisis intervention program training before they are
assigned to the team, and will complete a refresher class every 2 years.
B. Training will be conducted by a certified trainer.
VII. DOCUMENTATION:
Staff Satisfaction Survey
CIRT Team Satisfaction Survey
CIRT Incident Command Structure Form
Event Report (Quantros)
Security Report
VIII. REFERENCES:
Handle With Care Behavior Management System
Sentinel Event Alert, TJC issue # 45, June 2010
E.N.A. Workplace Violence Summit 2012
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LIBERTY HOSPITAL
Liberty, Missouri
Guideline: Code White
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IX. HISTORY:
10/2012
New
R Dailey/Safety Committee/CIRT Task Force/Service Council
X. APPROVAL:
DATE:
David H. Feess, President and CEO
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