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How to know ED violence is imminent


January 1, 2016

How to know ED violence is imminent

For the most part, healthcare facilities are safe places. Healthcare itself can be a very rewarding profession. But that reward doesn't come without risk. Unfortunately, patient violence in the healthcare workplace is becoming more commonplace. According to The American College of Emergency Physicians (ACEP), approximately 60% of all workplace assaults and violent acts occur in the healthcare and social assistance industries.

According to the Online Journal of Issues in Nursing, "Workplace violence is one of the most complex and dangerous occupational hazards facing nurses working in today's health care environment."

More than 53% of about 7,000 emergency room nurses surveyed reported experiencing verbal abuse at work. Thirteen percent reported experiencing physical violence in the past seven days.

And violence isn't just directed at nurses. In November 2013, a nurse at a Texas surgical clinic was killed when she tried to help victims of a man who went on a stabbing spree with a knife. In January 2015, a renowned cardiologist at Brigham and Women's Hospital in Boston was shot and killed by a man who had an issue with his mother's treatment. The man was able to walk into the hospital and ask for the doctor by name, and killed himself after shooting the physician.

Unfortunately, many healthcare workers sense that violence in the workplace is an accepted occupational hazard. They perceive the industry is tolerant of violent individuals. But it doesn't need to be this way. You can make a difference while being safe doing your job.

Many patients in healthcare facilities experience heightened emotions, ranging from fear to anger and even mental health issues. For this reason, a certain amount of patient aggression is commonly accepted by many in the healthcare field as "part of the job," and many incidents go unreported.

Violence in healthcare often results in injuries and even death for both patients and caregivers. Sadly, many healthcare workers believe that violence is to be tolerated as a hazard of the profession. Some have put up with dysfunctional behavior for so long that they do not even recognize it as workplace violence.


Put yourself in their shoes

Waits in the hospital can be long, and people don't always understand the concept of triage?no one wants to endure a five-hour wait to get a loved one help. But people are generally reasonable, and keeping them calm could be as simple as recognizing their frustrations. If waiting times are long, perhaps it's time to get out and greet people, apologize, explain the reason for the delay, and maybe offer some coffee or pizza for those waiting.

Something as simple as providing a brief update on the status of a loved one or giving a person a reassuring smile and greeting can be enough to defuse an escalating situation. Eye contact can also indicate genuine concern and alleviate anxiety. In an overcrowded ED, speaking to an agitated person with a calm voice and offering to help him or her find a more comfortable place to wait can be a welcome gesture.

Sometimes these measures don't work, though. If that's the case, it's time to put your security department on alert. Extra patrols from uniformed officers could send the message that violence won't be tolerated, but you also don't want to create the illusion of a police state. At the very least, having a security officer present can help reassure people.


Verbal and nonverbal signs

As much as 70% of communication is nonverbal, so there's a good chance that if someone is going to get aggressive, you'll see it in his or her actions first.

The pathway to violence begins with so-called "behaviors of concern," which may be obvious but can sometimes be very subtle.

For the untrained individual, these signs of pending violence can go unnoticed, especially in the busy healthcare environment. In most cases of imminent violence, though, there are plenty of warning signs. Look for some of the following:

  • Rapid, uneasy eye movements that dart back and forth, or a wide-open, focused stare.
  • Constant questioning. This is often an attempt to gain understanding of the situation.
  • Pacing in the hallway. This can be a way to work off anxiety.
  • Rapid breathing?usually a reaction to stress.
  • Clenching of jaws and fists, another common stress reaction.
  • Verbalized threats of aggression. These should never be ignored, as verbal threats can be the last sign that physical violence is about to occur.

Different kinds of patients

Hospitals are a microcosm of society, and people of all ages and walks of life are found there. It's important to recognize who they are, their special needs, and the chance that they will act out. But always remember that patients are human beings who deserve to be treated with respect, dignity, and privacy. Here are some examples of patient types, followed by things to look out for when dealing with them:

  • Forensic patients (prisoners). Most hospitals have protocols that help them handle forensic patients, and they usually start with making sure that the police or sheriff's department gives the security department a heads up about who is coming through the doors. In addition to the usual signs of impending violence, it's a good idea to have security check the patient for signs of intoxication and weapons?there have been many instances where a patient brought a knife or gun into the ER that a police officer never found. In extreme cases, ask security to use handcuffs, ankle restraints, or other methods of restraint, especially if the patient is entering the hospital already agitated. Depending on their risk assessment, officers may choose to ensure a safe and secure environment by deploying law enforcement officers to guard the patient's room.
  • Intoxicated patients. These patients either show up at the hospital drunk and looking for a place to sleep it off, or are looking for a hit of their favorite drug?usually painkillers?and posing as a patient to get it. Substance abuse?particularly of heroin and other opiates?has become such a problem in some states that hospitals have started to form in-hospital "intervention teams" designed to identify substance abuse problems in patients and get them to treatment quicker.
  • Behavioral health patients. Some patients enter the hospital following suicide attempts, or at the urging of family and friends due to suicidal thoughts. But many patients who attempt suicide in the hospital do not have a known history of suicidal tendencies. Unfortunately, the increased number of behavioral health patients creates a dilemma for clinical staff when they can't attend to patients quickly enough?often leaving these patients alone and afraid?and as such, healthcare security officers may be the first to observe behaviors of concern. Behavioral health patients should be treated just like any other patient when it comes to their clinical team, but they may require additional security support and management.


While it's not always easy to spot someone who is addicted to drugs, there are plenty of signs to look for in intoxicated patients. First of all, many people under the influence get brought in through the ambulance bays, and returning patients may already be known to hospital staff to have an addiction. Look for people who are either combative or withdrawn and have trouble focusing, standing, or sitting up straight. You may also detect an odor of alcohol or slurring of speech. Also, patients who insist on being prescribed a certain drug?OxyContin, for instance?may be there just in the hopes of getting more of that drug. Think de-escalation and isolation. It's often impossible to reason with an intoxicated individual, so approaching him or her in a threatening way can escalate the situation.

Establish a separate room or area within the ED for treatment of behavioral health patients. The area should be clearly visible to staff, including security. All items that could be used as weapons should be removed or carefully secured. This includes any items that could be used for self-injury. Never allow a potentially violent patient to get between you and a door, to ensure you have an escape route from the situation.


Editor's note: The preceding was an excerpt from HCPro's Preventing Workplace Violence: Handbook for Healthcare Workers, published in March 2015. Reviewed by ­Tony York, CPP, CHPA, MBA, CEO and senior vice president of security for HSS in Denver, the handbook explores the causes of violence in the healthcare environment and offers techniques to help workers reduce violence and keep themselves safe at work. For more information or to order the book, please visit www.hcmarketplace.com.


How to handle angry situations

Don't waste time, emotion, and energy trying to solve a problem that's not solvable. If a problem is not solvable, admit it. Say something like, "This situation is out of our control. What we can control is ..." Then, offer something that you can do to help the situation, even if only indirectly.

Do not allow yourself to get into a heated battle with the person. There are many tricks to this. One way is to speak softly and slowly. Patients often quiet down because they want to hear how you might be able to help them.

Avoid saying things like "calm down," and avoid touching the person. These things often make a situation worse rather than better.

Avoid escalating the situation?go one down, not one up. Going one up means that you try to outmaneuver the patient. Then, the patient tries to one-up you, and the situation just escalates higher and higher. To stop the conflict from escalating, go one down, or make a conciliatory remark. You can say something like, "You are right. It is extremely noisy in here. No wonder you can't rest." Or, "Gee, I am late (even if you are only one minute later than the patient expected you). But I am here now." A bit of levity, but not flippancy, and being patient focused might turn things around quickly.

Avoid excuses or explanations, such as "Everyone is so busy," "We don't have enough staff members," or "There are sicker patients than you." No one really wants to hear that. They just want to know when their needs are going to be addressed.

Avoid threatening behaviors. They may increase fear or prompt assault.

Avoid shouting. If the person is not listening to you, raising your voice may worsen the situation. A person with schizophrenia, for instance, may be preoccupied with inner voices (auditory hallucinations).

Avoid criticizing. This might escalate the situation.

Avoid baiting the patient. Don't do anything to encourage wild or impulsive behavior.

Avoid standing over the patient. Keep a comfortable distance and put yourself at the same level as the patient. If he or she is seated, seat yourself.

Avoid eye contact or touching. This might be perceived as threatening.

Give the patient some sense of control combined with a sense of safety. Often, the presence of others is reassuring.

Don't back yourself or the person into a corner.


Training scenario

A young man brings his wife, who is complaining of severe abdominal pain, to the ED. His anxiety is obvious as he bursts through the entrance with a panicked look on his face. After a quick assessment, the triage nurse determines that there is nothing life-threatening that requires emergency response. She moves the young woman to a bed in a patient waiting area for further assessment and treatment.

Within minutes, the ED becomes a chaotic scene. A three-car collision results in serious injuries for multiple patients who are brought to the ED by ambulance. Some patients are critically ill, requiring urgent response and treatment. Hospital staff spring into action and deploy policies and procedures to manage patients according to acuity and severity of injuries. Not understanding the ED protocol and wanting his wife to be seen immediately, the young man becomes agitated and frustrated.

His eyes dart around the ED taking in what's happening. He stops every person he sees to ask when a doctor will see his wife. The young man then begins to breathe rapidly, pacing around his wife's bed and back into the hallway. Without warning, he begins shouting at nurses and threatens physical violence if someone does not see his wife immediately. He grabs a nurse in the hallway, demanding she attend to his wife.

What would you do? What are your hospital's protocols for dealing with this man? What are the warning signs of violence that you recognize? How could this situation have been prevented?

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