Introducing routine risk assessment for occupational violence and aggression in the Emergency Department

Ms Elisa Ilarda1, Dr Ainslie Senz1
1Western Health, Footscray, Australia

Violence in health care settings ia significant problem world-wide.  Emergency Departments are considered high risk areas with the number of incidents of staff exposure to violence ranging from 60 to 90%. Most research around violence in EDs relates to the management of behavioural crises once they occur. Early identification of risk and proactive intervention has the potential to reduce the incidence of crises, reduce the use of restrictive practices, improve overall quality of care and safety.  Review of several violent incidents at Western Health EDs indicated a failure of both objectivity around violence risk and lack of early intervention.

An evidence based tool (the Broset Violence Checklist) was introduced to identify patients with higher likelihood for violence. The BVC uses the presence or absence of six behaviours to predict the potential for violence. The tool was integrated into the Nursing Observation Chart and co-located with a matrix of strategies for various staff disciplines. Together this is locally known as the Behaviours of Concern (BOC) chart.  The BOC chart was implemented in January 2019 along with education.  All patients have the chart commenced on arrival and completed at least hourly along with other observations.  The score is then linked to an escalation and intervention plan.  To our knowledge, this is the first implementation of the tool in an ED.

There was a statistically significant improvement in the performance of violence risk assessments from 30% to 82% (p<0.001), with regular audits now indicating near 100% compliance.  There has also been a significant move from reactive to proactive management of violence (increase in Planned Code Greys of 65%, reduction in Unplanned Code Greys by 11%.)  In addition, mechanical restraint use has reduced by 21%.  Most importantly, we have seen a 100% reduction in Worksafe notifiable injuries with zero significant injuries affecting our workforce.


Elisa Ilarda is a registered Psychologist with a background in forensic, clinical and organisational psychology.  She is currently employed for Western Health managing the occupational violence portfolio in the safety, risk and improvement unit. She has gained prior experience as a Senior Psychologist in correctional centres, hospitals, and Universities. Her prior experience involved providing specialist clinical assessment and treatment to offenders.

Elisa also has a background in organisational psychology where issues such as workplace aggression, violence and bullying may affect the psychological well-being of staff. She has also been a clinical teacher for Melbourne and Monash University and provides expert opinions to Courts in this area and to the Department of Health and Human Services in the prediction of violent and sexual offending.

Ainslie Senz is an Emergency Physician with more than 20 years’ experience across various disciplines in the health industry.  Having trained in Queensland, she moved to Western Health in Victoria 7 years ago, and soon after took on a secondment in Alcohol and Other Drugs within the Emergency Department.  She is currently the Director of the Emergency Department at Footscray Hospital, a metropolitan hospital in the western suburbs of Melbourne.

Her interests lie in creating sustainable and continuous quality improvement practices and developing collaborative multi-disciplinary work relationships.  Along with her management responsibilities, she holds the occupational violence portfolio and chairs a group responsible for the successful implementation of a risk-screening tool for violence and aggression in the ED.

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