Code Violet: What should doctors do? Here's what the latest Govt Guidelines say

New Delhi: After the recent directive issued by the Union Health Ministry to ensure the safety of doctors, the Delhi Government has also issued an advisory to all Medical Directors/Medical Superintendents.

Taking Suo Moto cognizance of the "apathy and dilapidated plight of the doctors in the light of the recent shameful events which has shook the nation", the Director General Health Services, GNCTD has asked the heads of medical institutes to set up a Committee to formulate a security plan including "Code Violet" to promptly take action against threat or act of violence within a healthcare facility.

As per the release, this committee shall be constituted under the chairmanship of the Medical Directors/Medical Superintendents and Head of Office as Member Secretary. Further, Senior Doctors (preferably HODs) of the Hospital and representatives of the Resident Doctors and Nurses will also be included in the committee to prepare the security plan of the Hospital.

Such plans will include "Code Violet"- an emergency where there is an immediate threat or act of violence within the healthcare facility. The DGHS has specified the different steps of Code Violet- identification, activation, response, post-incident actions, etc.

The Delhi government's release comes on the same day when the Supreme Court bench comprising the Chief Justice of India DY Chandrachud constituted a National Task Force, composed of nine senior doctors and several ex-officio government officials, to develop safety protocols for healthcare professionals across India.

Supreme Court issued this direction while taking suo-motu cognisance of the recent brutal incident of rape and murder of a PG medical trainee doctor at Kolkata-based RG Kar Medical College and Hospital.

In the release, the DGHS, Government of NCT of Delhi mentioned, "Director General Health Services, Government of NCT of Delhi has taken Sou Moto cognizance of the apathy and dilapidated plight of the Doctors in the light of the recent shameful events which has shook the nation."

Therefore, the DGHS, GNCTD issued the following advisory to all the Medical Directors/Medical Superintendents:

"1. Kindly make a committee under the chairmanship of the Medical Directors / Medical Superintendents and Head of Office as Member Secretary. The Committee must consist of the Senior Doctors (preferably HODs) of the Hospital and representative of the Residents Doctors and Nurses for preparation of the security plan of the Hospital. The security plan must include "Code Violet" and potential preparation and training for all the doctors and peripheral staff.

2. The security plan of the Hospital must be shared with Deputy Commissioner of the Police of the concerned district and Station House Office of the Police Station with a copy to the Director General Health Services, Government of NCT of Delhi.

3. Special Provision for safety of the Doctors at the Casualty and Emergency Services from the attendants and family of the patients. It is one of the key vulnerable area of the, hospitals where the security of the Doctors can be easily compromised. The security plan must make provision of the security arrangements and protocols for the Access Control to the Doctors by the attendants and family of the patients.

4. Medical Directors / Medical Superintendents and Head of Office of the Hospitals must make Police Complaint under aegis of Section 6 of the Delhi Medicare Service Personnel and Medicare Service Institutions. (Prevention of Violence and Damage to Property) Act, 2008 within 6 Hours of receiving complaints from the Doctors. A copy of the complaint must be sent to Deputy Commissioner of Police of the district concerned along with a copy to the Director General Health Services, Government of NCT ofDelhi.

5. Any Medical Directors / Medical Superintendents and Head ot Oftiee of the Hospitals who do not make Police Complaint under aegis of Section 6 of the Delhi Medicare Service Personnel and Medicare Service Institutions. (Prevention of Violence and Damage to Property) Ac, 2008 within 6 Hours of receiving complaints trom the Doctors must provide justification for their inaction to the Director General Health Services, Government of NCT of Delhi."

The release also includes Code Violet: Management of Violence in Healthcare Facilities Standard Operating Procedures (SOPs) for Code Violet:

What is Code Violet?

Code Violet Definition:

Code Violet refers to an emergency situation where there is an immediate threat or act of violence within the healthcare facility.

Purpose:

To establish a clear and effective response to incidents of violence or threats of violence within the healthcare facility, ensuring the safety

Scope:

This policy applies to all healthcare staff, including medical, administrative and support personnel as well as patients and visitors within the healthcare facility.

Policy Statement:

The healthcare facility is committed to maintaining a safe environment. Any acts of violence, whether physical or verbal will not be tolerated. The facility will take immediate and appropriate action to manage and mitigate such incidents.

Step 1: Identification of Code Violet Objective:

Ensure all staff can recognize and promptly respond to potential or actual violent incidents.

Procedure:

Assessment:

 Observe for signs of escalating tension, such as raised voices, aggressive body language, or physical confrontation.

 Listen for verbal threats, abusive language, or indications that someone is feeling threatened or distressed.

 Be aware of environmental cues, such as the presence of weapons or objects that could be used to inflict harm.

Decision-Making:

 Determine the severity of the situation. If there is an immediate threat to safety, proceed to activate Code Violet.

 If uncertain about the severity, err on the side of caution and seek advice from a supervisor or security personnel. 

Examples of Situations Triggering Code Violet:

 Physical assaults between patients, staff, or visitors.

 Threatening behavior with or without a weapon.

 Verbal threats or severe intimidation directed towards staff or patients.

 Uncontrolled, aggressive behavior that poses a danger.

Step 2: Activation of Code Violet Objective:

Ensure a swift and coordinated response to violent incidents.

Procedure:

Immediate Action:

 Call the designated emergency number (e.g., internal extension or direct line) to report the situation.

 Clearly communicate the following:

Location: Exact area within the facility (e.g., ward, department, room number).

Nature of the Incident: Brief description (e.g., “Physical altercation between two patients,” “Visitor brandishing a weapon,” etc.).

Details: Number of individuals involved, any visible weapons, and any immediate dangers. Notification:

 Notify nearby colleagues to either assist or move to a safe location.

 If safe, close doors to contain the situation and prevent others from entering the area.

Step 3: Response to Code Violet Objective:

Safeguard individuals and manage the situation effectively.

Procedure:

For Staff:

Evacuation:

 Move non-involved patients, visitors, and staff to a secure area away from the incident.

 Use a calm and firm tone to direct people, emphasizing their safety.

Containment:

 Lock or barricade doors if the situation involves a confined space.

 Avoid physically confronting the aggressor unless trained and it is necessary to protect others.

Communication:

 Keep communication lines open with security and administration.

 Provide updates if the situation changes (e.g., if the aggressor moves to another area).

For Security Personnel:

Immediate Response:

 Arrive at the scene as quickly as possible while assessing risks (e.g., potential weapons).

 Identify the aggressor(s) and attempt to de-escalate verbally by maintaining a calm demeanor, using clear and non-threatening language.

Physical Intervention:

 If verbal de-escalation fails, use approved physical restraint techniques.

 Ensure the safety of all parties, applying the minimum force necessary to control the situation.

Coordination with Law Enforcement:

 If the situation involves weapons or severe threat, request assistance from law enforcement.

 Ensure a seamless handover of the situation to the authorities if necessary.

For Administration:

Support:

 Monitor the situation from a command center or designated safe area.

 Coordinate with security and law enforcement, providing necessary resources.

Documentation:

Assign a staff member to document the incident in real-time, noting actions taken, timings, and any injuries.

Step 4: Post-Incident Actions:

Objective:

Provide support, review the incident, and implement preventive measures.

Procedure:

Regular Training:

 Provide all staff with regular training sessions on recognizing and responding to violent incidents.

 Include role-playing exercises to simulate real-life scenarios.

Scheduled Drills:

 Conduct Code Violet drills at least twice a year to test the effectiveness of the SOPs.

 Review drill outcomes to improve response procedures.

Evaluation and Feedback:

 After each drill or incident, gather feedback from participants to refine the SOPs.

 Update training materials to reflect any changes in procedures.

Critical Points for consideration:

 Hospitals to make a committee under the Chairmanship of the Medical Director/Medical Superintendent and Head of Office as member Secretary. The Committee must consist of the senior doctors (preferably HODs) of the hospital and representatives of the Residents Doctors and Nurses for preparation of the security plan of the Hospital. The security plan must include “Code Violet” and potential preparation and training for all the doctors and staff.

 The security plan of the hospital must be shared with the Deputy Commissioner of the Police of the concerned district and station house office of the Police Station with a copy to the Director General Health Services, Government of NCT of Delhi.

 Medical Directors/Medical Superintendents and Head of Office of the Hospitals must make Police Complaint under aegis of Section 6 of the Delhi Medicare Service Personnel and Medicare Service Institutions. (Prevention of Violence and Damage to Property) Act, 2008 within 6 Hours of receiving complaints from the Doctors. A copy of the complaint must be sent to Deputy Commissioner of Police of the district concerned along with a copy to the Director General Health Services, Government of NCT of Delhi. If any Medical Directors/ Medical Superintendents do not make Police Complaint within 6 Hours of receiving complaints from the doctors must provide justification for their inaction to the Director General Health Services, Government of NCT of Delhi.

 Proper Display of relevant penal provisions of the State legislation to prevent violence against health care workers in Hospital premises

 Sufficient number of High-resolution CCTV cameras to be installed at strategic locations including entrances, exits, corridors, dark spots and sensitive areas. A control room should be setup in the Institute for quick response to an emergent situation. In the Control Room one admin staff should always be stationed along with security persons.

 Employment of adequate number of well trained security guards for proper monitoring / patrolling/surveillance of the premises. The security of Hospital should be strengthened and the security personnel should be directed not to allow entry of any unauthorized person inside Hospital. There should be absolute weapons prohibition inside premises of hospital.

 Entry and exist should be strictly monitored to allow entry to authorized personnel only. Identification badges for staff, patients, and visitors may be issued for easy identification of authorized personnel. Display of I Card by all Hospital Staff while on duty be made mandatory. Appropriate arrangements be made to ensure that all visitors are monitored.

 The visitor time should be specified and restricted and only limited and valid visitors one or two should be allowed by turn during visiting time and with an attendant pass only. Restricted access to certain areas may be devised.

 Comprehensive plans may be drawn for tackling various types of emergencies. These Plans should be regularly updated and rehearsed including conduct of periodic mock drills to train staff and security personnel for effective responses in emergency scenarios.

 All hospital staff, including doctors, nurses, and administrative personnel should be trained in recognizing and responding to security threats. They should equip with appropriate skills to handle emergency situations effectively.

 Public address systems should be devised to quickly disseminate information during emergencies.

 Dark spots in the campus should be mapped and adequate lighting in the premises should be ensured particularly in the duty areas of the lady health care staff, parking lots, entryways etc.

 Adequate number of well secured duty rooms with basic amenities should be provided for female health professionals. Deployment of lady health professionals at night should be preferably done in more than one number. They should be escorted in premises while on duty and proper arrangement of secured transport should be made for them for any movement at night.

 Posters depicting legal liability and consequences of Assault and vandalism against medical professionals should be displayed at prominent places in hospital premises.

 Relations sitting area should be far away from the critical area and the dead body whenever shifted should never be shifted from the area where the relations of the patient are sitting.

 Create a safety culture.

 Create a crisis Intervention Team.

 Be proactive and take threats seriously.

 Management should have regular safety dialogue with staff.

Also Read: Breaking News on RG Kar Case: Supreme Court Constitutes National Task Force to draft Action plan for Safety of Doctors