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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


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. 


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 


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.


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. 


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.  


EmCare’s Genesis Cup Honors Innovation, Creativity in Health Care

Posted on Sat, Apr 13, 2013

Medical Directors, EmCare Executives Recognized for “Making Health Care Work Better™”


EmCare’s Genesis Cup program was designed to recognize and celebrate the creativity and innovation of everyday physicians as part of the company’s never-ending pursuit to improve the delivery of patient care.

Each year, EmCare selects a Genesis Cup winner and runners-up to reward innovation and improvement in health care. The three honoree teams presented their prize-winning projects to their peers at EmCare’s 26th Annual Leadership Conference.

This year’s Genesis Cup contenders explored topics including the effectiveness of medical scribes, the improvement of trauma and blood transfusion services and a new emergency department optimization model.

Here’s a summary of the winners and runners-up.

Genesis Cup Winner: “Are Scribes Worth It?” (pictured)

A study gauging the pros and cons of employing medical scribes has earned The Genesis Cup award for 2013.  The scribe project was produced by Dr. Tanveer Gaibi, medical director for Northwest Hospital in Randallstown, Md., Dr. Michael Hochberg, medical director for Saint Peter’s University Hospital in New Brunswick, N.J., Dr. Daria Starosta, EmCare director of practice development, and Mark Switaj, EmCare client administrator. Their landmark project, titled “Are Scribes Worth It?,” concluded that scribe programs can greatly assist higher acuity E.D.s that are experiencing long patient stays, reduce the incidence of patients leaving without treatment, and expedite data entry into challenging electronic medical record (E.M.R.) systems.  Some scribe programs can even pay for themselves.

Genesis Cup Runner-Up: “E.D. Optimization Model”

A new Emergency Department (E.D.) Optimization Model earned a Genesis Cup runner-up recognition for Andy Mulvey, M.D. and Richele Wright, M.S.N, F.N.P, B.C. Dr. Mulvey and Wright developed the new operational plan implemented at Community Hospital South (CHS) in Indianapolis. Their program improved overall quality of care and quality metrics while also building an increase in E.D. patient volume.  All of this occurred during a major rollout of a new electronic medical record (E.M.R.) system.

Inside of six months during 2012, Mulvey, Wright and others used the award-winning model to reduce Left Without Being Seen rates from 3.8 percent to 0.24 percent. The average Length of Stay fell from 351 minutes to 281 minutes. And the E.D. volume grew to more than 42,000 visits, with a roughly 25% increase in total patient visits since 2011.

Genesis Cup Runner-Up: “Lean Processes to Improve E.D. Trauma Care”

The effective implementation of Lean processes to improve both emergency trauma care and urgent blood release has earned Genesis Cup honors for a medical director from John Peter Smith Hospital (JPS) in Fort Worth, Tex. The second 2013 Genesis Cup runner-up is Carrie de Moor, M.D., F.A.C.E.P., who acts as EmCare’s emergency medical director for JPS.

Dr. de Moor came up with a new, Lean system for urgent blood release. Under the new JPS guidelines, patients receive urgent blood off of clinical appearance and vital signs rather than the previous required lab results. The new clinical appearance/vital signs criteria are determined by the treating physician and include:

  • Systolic blood pressure of less than 90 (indicating hemorrhagic shock)
  • Acute ischemic electrocardiogram (E.K.G.) changes or chest pain due to anemia
  • Any other clinical appearance suggesting that the patient’s current illness, traumatic or medical, may result in imminent death without immediate transfusion.

By changing the way urgent blood is requested, Dr. de Moor and JPS saw some impressive year-to-year improvements, including:
  • 2,784 fewer units of P.R.B.C.s transfused
  • 2,200 fewer units of F.F.P. transfused
  • Overall savings of $945,035 for the hospital
  • Decline in blood utilization occurring along with increase in volume from 100,000 patients per year to more than 120,000 patients per year in the same time span.

Dr. de Moor also used Lean process improvements to improve care for trauma patients at JPS. The new, Lean program Dr. de Moor designed is mechanism-based, activated internally and mimics trauma activation flow. The implementation of the new trauma model had a dramatic impact:

  • The average time to Level 3 Trauma Activation/Consult fell from two hours five minutes to one hour and 20 minutes.
  • An hour and a half of average patient wait time was eliminated
  • The trauma area now processes 2.125 patients in the time it previously took to process one patient.

Genesis Cup Runner-Up: Enticing the Best Performance from Physicians

Timothy R. Jones, M.D., associate director at Baylor All Saints Medical Center in Fort Worth, TX, earned Genesis Cup accolades for his submission, “Enticing Best Performance from Physicians.”

“Physicians are naturally hard workers,” says Dr. Jones. “Every physician thinks he or she is above average, that they all bring their ‘A-Game’ to each shift, but the truth is that most physicians are anonymous in terms of hospital data, and anonymity can create inertia.  By empowering physicians with detailed, unblinded monthly performance data that reveals how each physician in a group performs compares to the average and to his/her named peers, performance in all measured metrics improves across the board.  It’s direct feedback physicians can use to improve their practice, and they love it.”

Dr. Jones examined Relative Value Units (RVU) generated per hour, patients seen per hour, RVUs generated per patient, Press-Ganey scores, and coding trends for level 3, 4, 5, and critical care charts over a 13- month period within his ED group.  The results were dramatic.

  • RVU/hr (physician) increase – 27.2%
  • RVU/hr (midlevel) increase – 29.1%
  • Patients/hr (physician) increase – 14.7%
  • Patients/hr (midlevel) increase – 16.7%
  • RVU/pt (physician) increase – 10.2%
  • RVU/pt (midlevel) increase – 11.4%
  • Net Charges increase – 28.6%
  • Collections increase – 19.0%

“Knowledge really is power,” says Dr. Jones. “By simply empowering physicians and midlevels with unblinded performance data, a healthy sense of competition is established and practice excellence becomes the status quo.”

“Three clear winners emerge,” concludes Dr. Jones.  ”The physician with increased take-home pay and a true understanding of his/her practice pattern, the group with increased revenue and, most importantly, the patient who is met by a physician primed to optimize the customer experience.”

In addition to recognizing the inventor/innovator, The Genesis Cup recognizes those involved in the initiative, including the emergency department, radiology department, hospitalist team, anesthesia team and the regional office in supporting such endeavors.