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10 tactics to Reduce Violence in the Emergency Department

Posted on Tue, Aug 19, 2014
10 tactics to Reduce Violence in the Emergency Department

According to a survey by the International Association for Healthcare Security & Safety, the number of violent incidents involving hospital workers jumped 37 percent in the past three years. In this 3 part series, two EmCare-affiliated Divisional Directors of Clinical Services, share the details of their first-hand experience with violence in the ED and they reveal the improvements that need to be made within ER departments to reduce acts of violence in the hospital.

By Ginger Wirth, RN and Denise Sexton, RN, BSN, Divisional Directors of Clinical Services, EmCare

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I was a victim of violence in the E.D. Here's my story. Pt. 1

I was a victim of violence in the E.D. Here's my story. Pt. 2 

  1. Teach staff to recognize aggressive and escalating behaviors early.  Be able to anticipate potential violent situations or patients/families that exhibit signs of increased stress, dissatisfaction or agitation.  Remember that overcrowding of ED’s, increased wait times and the ED’s being used as primary care clinics can have significant potential on increasing stress on patients, families or visitors.
  2. It is imperative that we provide education on how to deescalate aggressive or potentially violent customers.  This has to be real time training-- hands on, not the computer- based modules that we so often see on an annual basis in healthcare.  This training needs to be shown to all staff with a focus on the Emergency Department team, and should include drills or exercises to practice putting this training into action.  I understand that in other countries this happens on a regular basis.  We have disaster drills, fire drills, code blue drills, why are we not drilling on how to protect the staff, other patients and visitors in the hospitals?
  3. We need to educate the staff that there are Federal Laws in place to protect and prosecute those that do harm against healthcare workers.  This should be a zero tolerance initiative and treated as such in healthcare.  Staff should be encouraged to report any incidents-- small or large-- to administration and those incidents should be investigated and dealt with strictly and severely.  No longer should there be a stigma or fear or retribution for reporting incidents of violence.  This will take away the power from those assailants and give it back to the staff.
  4. Signs should be clearly posted in the Emergency Departments that any acts of aggression, disrespect or violence in the ED will not be tolerated and could result in law enforcement action.  I have seen these signs in a couple ED’s and I believe that informing the patients, families and visitors right in the beginning and reinforcing that with signs could help to deter events.
  5. Hospitals need to perform a root cause analysis of any and all incidents that occur in the facility.  In healthcare, we do these on all medical events that have adverse outcomes quickly and effectively.  Any type of violence needs to be treated the same and given the same attention.  The areas for improvement will show during these events and they demonstrate to any staff involved that these are serious events, and they will be investigated and addressed as such.
  6. ED team members need to treat all patients and their family members as if they have the potential to become violent. Never drop your guard with any of them.
  7. Be sure to undress the patients, put them in a hospital gown, and search for weapons. With most states adopting open carry laws for concealed weapons, you never know who may have a gun. We’ve removed many weapons over the years from patients,  most of which have been knives or other sharp objects. Clear the room of anything that they can use to harm you or themselves.
  8. Make sure that you have a code that you can call that will bring all available personnel to the ED. There is strength in numbers. I have seen many psych patients and irate family members become more cooperative with just a show of staff.
  9. Always position yourself with a way out of a room so you cannot be cornered by the patient. Never let a patient come between you and the door. Even a small patient can become unbelievably strong when adrenaline kicks in.
  10. Administration needs to be supportive and prosecute to the fullest extent of the law on any threats to healthcare workers. I have seen many patients and family members verbally abuse staff and think that they should take it.
 
What tips do you have for preventing violent episodes in your ED? Tell us in the comments. 

RELATED ARTICLES

I was a victim of violence in the E.D. Here's my story. Pt. 1

I was a victim of violence in the E.D. Here's my story. Pt. 2 

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I was a victim of violence in the E.D. Here's my story. Pt. 2

Posted on Tue, Aug 12, 2014
I was a victim of violence in the E.D. Here's my story. Pt. 2

According to a survey by the International Association for Healthcare Security & Safety, the number of violent incidents involving hospital workers jumped 37 percent in the past three years. In this 3 part series, two EmCare-affiliated Divisional Directors of Clinical Services, share the details of their first-hand experience with violence in the ED and they reveal the improvements that need to be made within ER departments to reduce acts of violence in the hospital.

By Ginger Wirth, RN, Divisional Director of Clinical Services, South Division

I have actually been a “victim” twice in my career while in the ED.  Both involved patients who had some mental/psychiatric etiology.  The first time was in 1990 while my team was providing a female patient with discharge instructions and calling her significant other for a ride home, she became agitated and punched me in the face.  This resulted in some pretty substantial bruising and some neck strain after I hit the floor. The facility fully supported me and charges were brought against the patient. She was found guilty of assault and received probation. 

The other time was also by a psych patient who became combative when he was told that he was going to be committed.  He began screaming and yelling at the staff and cornered me in the room and punched and kicked while trying to elope.

I don’t think there’s a lack of support from hospital administration, as I have had great support in both incidences.  I think the problem stems from the growing lack of treatment options throughout the country for mental health patients. Consequently, they are being dumped in the emergency departments.  No longer will the correctional system keep patients that have mental illnesses without medical clearance, causing these patients to clog and remain in the ED’s.  If police apprehend a person with any hint of a history of mental illness, they come to the ED for evaluation.  When they arrive in most ED’s, the providers are not comfortable initiating treatment for the mental illness even if there is a long history. 

For example, if a patient goes off their regular medications for depression and is picked up by law enforcement they are brought to the ED for clearance.  The ED providers may not be willing to shoulder the responsibility of restarting medications or discharging the patient without a psychiatric evaluation.  So, these patients remain in the ED until they can be stabilized.  Getting them into the mental health system can take days, weeks or sometimes months.  Also of note: many of these patients are self-pay and have a lack of resources to begin with, which hampers their entry into the overcrowded mental health system of many states. 

There has been some relief and “light at the end of the tunnel” for some areas with the increased usage of telemedicine.  In South Carolina, there is a fairly robust use of telepsychiatry; however, this has quickly succumbed to overuse and capacity issues.  The limited number of inpatient beds is a problem for patients with insurance, as well as the uninsured.  We have an opportunity to continue with training in our EDs to recognize aggressive situations, provide support for our ED providers in the care of the mental health patients in the community and what resources are available and how to access these resources easily and timely. 

All staff in the ED must know that violence against healthcare providers should NEVER be tolerated, expected or dismissed.  All cases should be reported to the facility administration and law enforcement when appropriate.  Abuse is just as unacceptable for someone that cares for patients, as it is for the patients themselves.

ABOUT THE AUTHOR 

Ginger joined EmCare in 2013 as a Divisional Director of Clinical Services for the South Division with the strong belief that she could continue to make positive changes within healthcare by helping others focus on quality, excellence and the overall patient experience. Ginger Wirth regards her role as Director of Clinical Services as the ideal opportunity to partner with nursing, physician and facility leaders to make positive changes to the entire patient care experience. Her 20+ year nursing career has been dedicated to quality and excellence, promoting overall positive outcomes and safety for patients. 

RELATED ARTICLES

I was a victim of violence in the E.D. Here's my story. Pt. 1
 

Have you witnessed violence in your ED? What steps can staff take to protect themselves and the other patients in their care? Tell us about it in the comments. Next week: In part 3 of this 3-part series, Ginger Wirth and Denise Sexton provide tips to  reduce instances of ED violence in hospitals.  

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