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Avoid violence in the emergency department

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January 1, 2009

Avoid violence in the emergency department

Ask any hospital safety director and they will tell you violence in the ED is becoming an increasingly larger problem. The reason behind this is simple. The combination of long waits, a large population of uninsured patients, and the extreme stress that often accompanies ED visits creates a pressure cooker of high anxiety. Tempers flare and violence or threatening behavior ensues.

“Let me put it this way,” says Anthony N. Potter, CHE, CHPA-F, CPP, FAAFS, director of public safety at Forsyth Medical Center in Winston-Salem, NC. “Every officer that I have had injured since I have been here—and that’s five years—has been injured in the ED.”

A survey conducted in 2007 by the Emergency Nurses Association found that 86% of emergency nurses have been the victim of violence by a patient or a patient’s family member. In 2005, the Annals of Emergency Medicine published a study evaluating emergency physicians in Michigan. The surveys found that 74.9% of participants indicated at least one verbal threat in the previous 12 months, 28.1% reported they were victims of physical assault, and 11.7% were confronted outside the ED.

“People who are sick or people who have a family member who is sick frequently don’t act rationally,” Potter says. “If I applied the same rules of behavior in the emergency department waiting room that I applied on the street, we’d be locking up people left and right.”

But the ED isn’t the streets, and the same rules don’t apply. A security director’s job has become proactive rather than reactive, so you need to implement preventive measures before anxiety escalates to violence.

Training in groups

Training security officers to recognize signs and anticipate violence before it happens is a crucial step in keeping the ED safe.

Potter says public safety officers at Forsyth undergo 216 hours of basic training, which includes a nonviolent crisis intervention training program that teaches officers to recognize and then neutralize a situation in which a patient or family member is losing control. Forsyth uses a training program designed by the Crisis Prevention Institute. You can find information about it at www.crisisprevention.com.

Hospitals have a limited number of security officers, and they can’t be everywhere at once.

Bonnie Michelman, CPP, CHPA, president of the International Association for Healthcare Security and Safety and director of police and security at Massachusetts General Hospital in Boston, advises facilities to include ED staff members in a similar training regimen so they can recognize a situation before it gets out of hand.

“EDs tend to be large, and there are not a lot of security people in most of them, so you need to have everybody trained on awareness education,” Michelman says. “And when you train people together—the ED staff and security—they learn it together, they bond, they work together, and they understand how it’s going to work so when the problem comes in, there is usually a seamless reaction.”

Michelman recommends implementing a training program called Management of Aggressive Behavior that teaches verbal and nonverbal de-escalation techniques to use before physical restraint becomes needed (www.personalsafetytraining.com/moab.php).

Even if training is too expensive, simply bringing the ED and security staff together to hash out problems and responsibilities can help establish straightforward guidelines.

Barbara Bisset, PhD, MPH, MS, RN, executive director of the Emergency Services Institute at WakeMed Health & Hospitals in Raleigh, NC, did just that. During 2008, Bisset observed varying expectations regarding what security officers could and should do. She brought together her frontline staff and security department and made lists of fears and perceptions, as well as a list of what measures the hospital had in place.

This meeting was “a real eye-opener” for staff members, says Bisset. Many doctors and nurses were not fully aware of the extensive camera use and officer training provided by the hospital.

You’re on candid camera

Video surveillance is an obvious deterrent for criminal behavior, but in a hospital, the placement of cameras makes all the difference. George Patak, operations manager at the Detroit area office of the Wackenhut Corporation, says security cameras are helpful in deterring violence only if their presence is known.

“They are important if the potential criminal knows he is being watched,” Patak says. “So if you have a covert camera and nobody knows they are being watched, they are going to be useless to you.”

Patak advises placing a monitor at the ED receptionist’s desk that rotates through the various camera feeds.

Bisset describes this as the “Wal-Mart greeter effect.”

“In other words, somebody has eye contact with you or you have these cameras very open, or you have signage that this area is under continuous monitoring. It won’t prevent everything, but sometimes it will give people pause,” Bisset says.

Cameras also give patients in the waiting room a sense of security in what, for some, can be a frightening environment.

Strapped for cash

It’s no secret hospitals are cutting back because of economic constraints. So the idea of purchasing thousands of dollars of surveillance equipment might not sit well with your administration.

If that’s the case, there are several steps you can take to secure your ED without emptying your wallet:

  • Maintain your lighting system. Since hospitals are required to regularly maintain their lighting system, it makes sense to keep security measures in mind, Patak says. Ensuring that areas such as the parking garage and the entrance are well lit will produce a safer feel.
  • Trim bushes. When the landscaping crew comes to cut the grass, have them trim down shrubs or bushes to eliminate hiding areas for assailants, Patak says. Keeping a clear sight line in all areas will help security officers identify potential threats.
  • Scrub graffiti. Make it part of your safety protocol to immediately eliminate any graffiti on the premises. “The theory behind this is after a while, the gangbangers get tired of their art getting erased and they will go somewhere else,” says Potter.
  • Create a clear policy. Sitting down to clearly spell out procedures and policy in the event of any violence will ensure that everyone is on the same page.

Gang culture

The beauty of the ED is that it accepts and treats everyone who comes through the doors.

But that acceptance also exposes the hospital to potentially dangerous situations, since injured gang members seeking treatment might bring with them the threat of violence.

Patak and Michelman have spoken extensively on the threat of gang violence and have coauthored an article in The Journal of Healthcare Protection Management titled “Gang Culture from the Streets to the Emergency Department.” Both experts encourage security directors to have procedures in place if there is an injured gang member in your ED.

Patak describes this as a “perfect storm” scenario. “You are dealing with a criminal and he may be armed, and he also has cohorts who might offer protection and they could be armed,” he says. “You also might have the opposing gang come in and try and finish the job.”

This creates a danger not only for the patient and staff members, but also for those in the waiting room. Patak and Michelman suggest restricted visitation for that patient, having a security guard accompany the victim or registering the patient under an assumed name. Training all staff members to recognize gang clothing, tattoos, colors, and signs will help them spot a potential problem.

Market safety

Although there are certainly some low-budget changes you can make to your ED to create a safer environment, it’s no secret some of the large implementations (e.g., officers, technology, and training) require time and money. For that, you are going to need your hospital administration’s support.

“You have got to establish that very close relationship, where if the CEO feels there is a problem someplace, they’ll pick up the phone and call you and expect you to solve it,” Potter says. “And you’ve got to work very hard on that all the time.”

Potter uses the hospital’s marketing department to help create a positive image for the security staff. Whenever he gets a note from a patient complimenting his staff, he sends it to the marketing department to publish in the hospital’s newsletter.

“We’re in there every other issue,” Potter says. “Because of that, people look at us in a slightly different way. We are the problem solvers. You don’t know who else to call, you call public safety.”

Keep updating

The truth is, working toward a safer ED is never-ending. New changes can always be made, more people can always be trained, and technology is constantly expanding. Therefore, annual evaluations are crucial to protecting your ED. Gathering opinions from ED staff members and security officers will allow you to pinpoint problems and address them. This will also allow doctors and nurses to feel safer in their work environment and more confident in a violent situation.

Hospitals are also using different approaches to prevent ED violence. For example, Beverly (MA) Hospital added a specialist in the ED in the past year who is available around the clock to listen to agitated patients’ concerns.

“The number of episodes happening in the emergency department have decreased dramatically despite the [patient] volume going up,” Michael Tarmey, RN, Beverly’s director of clinical operations, told The Boston Globe in a November 2008 story on the growing problem of violence in emergency rooms.

However, there is no easy answer.

“I think that it’s a matter of really being conscientious and sitting down and performing an assessment and, based on that assessment, prioritizing,” Bisset says. “And then my suggestion is every year, trying to put in things to strengthen the program, because this is a very long process. It’s not something that can be fixed quickly.”

Train your staff to spot gang symbols, concealed weapons

Gang members can commit violence right in your hospital’s ED. Even the most basic knowledge of gangs can help staff members in the ED spot a potential problem, such as recognizing concealed weapons.

Below are some tips from George Patak, operations manager at the Detroit area office of the Wackenhut Corporation and coauthor of “Gang Culture from the Streets to the Emergency Department.”

Gang symbols

  • Pay attention to colors. Members of the Bloods will wear primarily red colors, whereas members of the Crips will primarily wear blue. Contact your local police department for the most recent information on gang members in your area and then share that information with your ED staff.
  • Check for certain clothing. Look for one pant leg rolled up, one shoelace untied, or a hat tilted to the right or left. If someone wears their clothing all three of these ways—especially on only one side of their body—they are likely a gang member.
  • Recognize tattoos and graffiti. Five- or six-pointed stars, pitchforks, crowns, flames, the devil’s tail and horns, a pyramid, a staff or cane, or a sword and top hat are all red flags for gang membership.
  • Watch out for sports jerseys. Gang members adopt sports teams as their colors to better blend in. Some hospitals have gone so far as to ban people from wearing jerseys from certain teams.

Concealed weapons

Wearing heavy clothing during the summer should raise suspicion. If someone wears a jacket on a hot day, they may be doing so to conceal a weapon.

Assailants may provide unwitting tip-offs that they are carrying weapons when they rise from a chair. You won’t see the weapon, but a gang member will grab their waistband through their jacket to secure a weapon they have concealed there.

In the winter, look for someone wearing one glove. An armed assailant will have one hand bare to keep their shooting hand unencumbered.

Dress for success

When violence breaks out in a hospital, ED staff members are often roped in. However, some simple advice can keep staff members safe should they find themselves in a violent situation.

The trick is all in what you wear, says Barbara Bisset, PhD, MPH, MS, RN, executive director of the Emergency Services Institute at WakeMed Health & Hospitals in Raleigh, NC.

Below are a few suggestions staff members can take:

  • Use your pockets. For your stethoscope, that is. Although it’s traditional to see doctors and nurses with a stethoscope slung around their neck, it can become a choking device if the wrong patient gets their hands on it.
  • Protect your ears. Don’t wear dangling earrings; a violent or confused patient might cause injury by pulling on them.
  • Same goes for hair. Wear long hair up or pulled back. “It’s long and flowing, it looks beautiful, but working in the ED, it’s not appropriate from an infection control perspective and from a safety perspective,” Bisset says.
  • Don’t wear ties. Sure, you might look professional, but do you want to do so at the risk of getting choked? Bisset recommends clip-ons if staff members feel a necktie is needed.
  • Wear a breakaway lanyard. Several ED staff members wear a cord around their neck to display their ID badge. If this is the case, make sure they are breakaway so they can’t be used as a weapon to strangle a staff member.



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