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Spot the signs that can lead to ED violence


March 1, 2015

Spot the signs that can lead to ED violence

Experts explain origins of violence and suggest tips for helping to prepare your facility


Understanding the origins of patient violence, setting up your facility's environment properly, and getting both your staff and administration's support are all key elements to making your ED a safer and less violent place.

That's the message delivered from hospital safety experts during a recent HCPro webcast, "Preventing Violence in the ED: Designing an Effective Violence Prevention Program."

In the 90-minute program, Lisa Pryse Terry, CHPA, CPP, director of Hospital Police & Transportation at the University of North Carolina Hospitals in Chapel Hill, and Tony York, CPP, CHPA, MBA, CEO and senior vice president of security for HSS in Denver, led a lively discussion about how hospitals can prepare for patient violence, as well as active shooters and other violent incidents.

"Just look at the amount of physical violence that our care providers are being exposed to, whether they're being grabbed or pulled or hit, spit on or pushed, kicked or scratched," said York, adding that nurses are a large population in hospitals that tend to take the brunt of patient violence.

"This is an issue of what I like to refer to as patient-generated violence, a concern that we all have to be aware of that when our care providers in that one-on-one situation, working with someone who may not yet be classified as high-risk, how do we help them understand that the concerns that they have typically are being driven from the individuals that we're all charged to care for?"

While patient violence is unfortunately an "accepted" hazard of the healthcare industry, a growing number of active shooter incidents in hospitals have led to concern in the healthcare industry and a drive to train staff members to faster de-escalate potentially violent situations, and to better design ERs to help contain violent intruders and protect staff members.

Terry, who wrote the HCPro book, Preventing Violence in the Emergency Department, pointed to a recent incident at Winter Park (Florida) Memorial Hospital. A patient brought in by law enforcement handcuffed, she said, had to go to the restroom and had the handcuffs removed. While he was there, he stole the officer's gun, threatened the officer and a nurse with the gun, attacked an 83-year-old man and stole his car, and then led police on a high-speed chase. He was later apprehended after causing a traffic accident.

Terry said the problem of patient violence has many origins that stem from the changing face of healthcare in the United States. The American College of Emergency Physicians says that decentralization and defunding has led to unstable behavioral health patients being boarded 79% longer than ever before, she added.

"Sometimes they will come in suicidal or self-destructive and many are substance abusers," she said. "They can be easily agitated or frustrated, and they will endure long wait times. Of course, many of these patients come in with medical issues, and those have to be treated and be able to be boarded for a period of time until they can get those under control. So these are cases that are probably the most difficult to treat. They may endure some assaultive behavior and frustration all the way around."


Recognizing signs of violence

Both Terry and York agree that the best way to reduce violence is for staff and facility management personnel to get better at patient engagement, and to learn telltale signs that a person is likely to become violent.

A nationwide debate has ignited about whether the ER should be a place where weapons are introduced to help defend against violence. While that's not likely to happen, much of staff training has centers around verbal de-escalation and other tactics designed to stop aggressive people before they get to a violent place. For this to work properly, however, busy staff need to know how to spot these "behaviors of concern," said Terry.

"You've got to be able to recognize them and have early intervention," she said. "Typically, the perpetrators will first consider. They may be sitting there for hours, and they may be making a plan. Then they're going to prepare how they're going to walk out those doors. They see who goes out those double exit doors, when someone takes a patient to the bathroom. They may actually say 'I'm going to leave,' or 'I'm going to kill myself.' Then you might as well know that once you've gotten to this point, they will act out."

Terry said that things like body language and environment need to be taken into consideration when deciding what to do next. For example, is the person clenching his or her fists? This can be a sign that the person is about to act out. Is the ER very busy? Sometimes, offering a cup of coffee or to move an anxious person to a private room can be enough to help defuse an escalating situation. But the decision has to be made carefully.

"I think that's going to have [to] end up being a determination that every one of you will have to make based on the available resources within your organization," said York. "Is there another room that could be used? Is there a place to overflow into that we would have to give that consideration when you're faced with this type of situation? I know it's not easy, and that's something that is not a comfortable situation. Obviously, we know that to ask the individual to leave?if it's a visitor maybe?but if it's a patient, we're probably not going to be given that opportunity."


Tips to reduce violence

Terry and York suggested several tips for participants to take back to their facilities to help make them prepare for violent incidents:

Plan an escape route. Much of York's career centers around helping hospitals build patient treatment areas that are safer, and when it comes to violent-prone patients he preaches the importance of isolation. If you can isolate problem patients, there is less of a chance they will be able to harm other patients and staff members. Where staff often fail to protect themselves, he says, is to have an escape plan.

"Do you have a safe room for your staff members to be able to retreat to in the event of an active shooter or an individual who is absolutely acting out so bad that now we have to give a place for folks to retreat?" he said.

For the most part, as long as there is not a critical need for patient engagement, letting patients calm down in a room is a safe option as long as they are being monitored and there is nothing they can use as a weapon to harm themselves or a staff member. York even showed examples of a treatment room that was built with doors that can be closed quickly to cut off access to oxygen tanks, treatment carts, and other items in the room to prevent them from becoming weapons.

Work on your delivery. It's hard to tell a bunch of overworked, stressed, and tired nurses and healthcare workers that they need to be nicer. But most experts agree that many violent incidents could be de-escalated with simple verbal and nonverbal communication. Think about it: how many times have you mistook the meaning of someone's message simply because of the look on the person's face? Now, put yourself in the shoes of an anxious, non-English-speaking man worried that his wife is waiting too long to be seen by a doctor. Instead of telling him for the 15th time to wait, a hot cup of tea and a smile, as well as slowing your pace of speech, could be all that's needed to keep him from becoming your next violence episode.

"We need to be approachable and interact positively, and I would add to that interact energetically," Terry said.

"Ensure that they know we're there to help them. Provide a sincere greeting and communicate clearly. Literally listen to what is said, and try to understand, and watch for behaviors of concern. There may be individuals [whose] first language is not English. So ensure that we have the right types of individuals working with those patients."

Drill for the real thing. It's been said many times: when a patient becomes violent, the response from staff needs to be second nature to keep it from escalating. Unfortunately, drills and staff education often go to the bottom of the list when it comes to budget priorities.

Facilities on the forefront of preventing violence always make time to train their employees in de-escalation tactics and how to handle violent patients. In extreme cases, many are trained in "run-hide-fight" tactics that teach them to run to a safe spot to protect themselves and patients and to only fight back in a last-resort situation.

These plans may look great on paper, but unless your staff has practiced doing it, there's a good chance they won't know how to do it when the real thing occurs. Drills and training are a great way to develop relationships with local law enforcement by giving them a chance to come in and develop their own skills along with your staff.

Weapons should be carefully considered. With more active shooter incidents being reported in the nation's hospitals, a lively debate has arisen over whether hospitals should use guns and other weapons to help protect against violent intruders bent on causing death in a healthcare setting. While you shouldn't hold your breath waiting for the days of physicians carrying guns, some hospitals have begun looking into creating and arming police forces, and others have looked into less-lethal solutions such as Tasers™.

"Every use-of-force tool and piece of defensive equipment [decision] that's used in healthcare should never be made in a vacuum," York said. "It should be done with all members of the care team as well as the hospital administration, and we should also have very clear guidance on what training is being provided and of course when it would ever be utilized. I've asked this question of many hospital CEOs and administers, and that is this: When would you ever want to see that firearm discharged in your healthcare facility? As a result, what many organizations have done, and I've seen this over the course of my 20-plus-year career, is we're seeing a reduction in the number of firearms that are being used inside of healthcare today."

That, of course, does not mean that a security officer guarding the front of the building should not carry a weapon, he says, but a hospital is a place where generally people come to get better and you don't want to turn it into a police state. Less lethal measures can be just as efficient a deterrent.

"You'll see that the Taser™ weapons are being used not so much to basically be used against a patient, but it does create an additional tool that now allows people to be able to change the behavior of the patient. There is what is called in our industry the 'red dot syndrome,' and that is the compliance that we're seeing based on if someone does see that we have that device."

Invest in and rely on technology. You're only human. To think you can rely on your staff to take care of all your security needs is unrealistic. That's why many security experts encourage hospitals to take advantage of new technology.

At the very least, security cameras can help monitor patients and provide a video record of any incidents that occur. But to provide a truly safe facility, investment in other security features may be necessary.

"We need to be able to control access," York said. "So having the appropriate locking mechanisms, to be able to hopefully have a sophisticated access platform that would allow us to be able to secure that environment with a single push of a button, but most importantly, be able to know that the care providers and everyone working in the emergency department can have the ability to restrict who they allow in and that the folks can't just come in uninhibited."

Some facilities, he said, have gone a step further and started to rethink the design of the ER to slow intruders down and provide safety for frontline staff. Safe rooms, front desks that are too high for someone to jump over, angling entrances to prevent someone from driving a car into the building, and even eliminating front-facing windows that allow someone to shoot into a patient's room are all things that hospitals are now considering in their safety plans.

"Ten years ago, there were still quite a few organizations out there who did not have a secured emergency department/medical treatment area," York said. "Today, you would be the exception. So the industry standard is you have a locked emergency department. Efficiency directly correlates to tension levels. So the faster that you can get them out of the chairs and inside the medical treatment area, it's been proven that we're reducing tension levels and we're getting people to not be as acting out."

Get support from physicians and administration. It starts from the top and trickles down. That's a message we hear often, but too often we also hear that the CEO or upper management of a hospital is more interested in the latest diagnostic equipment or research initiative that makes the local papers rather than making security a first priority.

"Make sure you've got effective planning, maintain persistence, and protect yourself and others, always a safe environment," Terry said. "Assume a proactive stance. Don't wait until we have to react."

Both Terry and York said getting administrative support can be a tightrope act in some places, and it starts with having strong support from other staff members, a good relationship and regular meetings with administration, and evidence. Being armed with the latest worker's comp statistics for your facility, for instance, can help you make a case for investing in a security force or technology.

"I think one of the first things is to have a very specific but concise master security plan, and make sure that that plan goes along with the hospital's strategic plan," Terry said.

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