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When the sound of silence means danger

Concerns from CNAs about inaudible duress tones result in systemwide change.


These scenes are all too familiar:

It was the last day of orientation for one of our new hires at ATRMC’s A/B unit. She was collecting a urine sample from a patient while her preceptor watched to review her skill.

Suddenly, they heard screaming. As they listened, they realized a person was shouting “code gray” from an adjacent room. They were right next door, but the cry was barely audible.

The preceptor rushed to help her fellow CNA in the next room. The patient — who was on a hold — was rushing the door in an attempt to elope. Together, the two CNAs tried to deescalate, but ultimately had to use hands-on tactics to secure the patient.

When the CNAs got the patient back in the room, they attempted to back out and notify the provider, but the patient again became aggressive and grabbed the CNA’s hair.

An after-action review of the event revealed that the CNA had hit the duress button on the CenTrak badge at the start of the incident. Yet no one could hear the distress call from the Hill-Rom GRS-10, so additional staff members did not quickly recognize there was a situation which needed additional help.

This isn’t an isolated incident. In another, a nurse working a night shift was assisting a patient who became violent. The patient weaponized a telemetry box and tried to sling it into several staff members’ heads. When the RN pushed the duress button on the CenTrak badge, it was reported to alarm for 15 minutes before others noticed.

The staff involved in these incidents reached out to voice their concerns. These CNAs and nurses took action to obtain approval from leaders and staff at all three facilities since the Hill-Rom tone is a systemwide setting.

The issue was taken to the Asante Nurse Advisory Council for leadership approval and then routed to Asante’s nursing key user group to select and approve a louder, more urgent tone.

That group, along with the nursing informatics team, integration services analysts, and Nursing Professional Development worked through the technical aspects and change-management processes to make a systemwide change that would ensure a safer environment for all staff.

toneOn April 14, the staff duress tone was changed as a direct result of ATRMC A/B team’s advocacy and engagement. The new alert uses a new audible tone which creates a greater sense of urgency. This is a Hill-Rom global setting change that was applied at all three Asante hospital facilities.

More work to be done

While the tone has been changed, ongoing research around duress call functionality shows:

  • Only the dome lights above the room sound staff duress calls.
  • Changing the configuration to include zone lights will not help all units hear staff duress calls because some units don’t have zone lights in their area. Zone lights are in various areas and hallways on units and emit tones and calls for designated rooms in the area.
  • Units having trouble hearing duress tones may want to review and raise the volume on the GRS-10 consoles within their unit. For areas that were experiencing this most often, staff had manually overridden the system and turned the GRS-10 volume down.

Assessment of options and next steps related to dome and zone light tones is ongoing.

To learn more about CenTrak duress badges, check out the badge operation tip sheet. Visit the Behavioral Safety Management and Crisis Prevention page for training resources. For additional Workplace Violence Prevention resources, visit the WPV page on myAsanteNET.

Thank you to the ATRMC A/B unit, crisis intervention, key user group, nursing informatics, integration services analysts and NPD teams for working diligently to bring about this positive change!

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1 Comment. Leave new

  • Robert White
    May 9, 2023 9:06 am

    I am so proud to see these types of system improvements coming out of our shared governance structure. Strong work AB Unit Council!!

    And thank you!!


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