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The Locked Fortress: Are We Afraid of Our Patients?

Bukata, W. Richard MD

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Dr. Bukata is the medical director of the emergency department at San Gabriel Valley Medical Center in San Gabriel, CA, a clinical professor in the department of emergency medicine at Los Angeles County/USC Medical Center, and the editor of Emergency Medical Abstracts.

I became the medical director of our ED in 1985 when plans were under way to build a new department. Unfortunately, the ED was going to be just a bigger version of the 1960s ED that preceded it. One key problem was the registration window. It was a counter along the main hall into the building. Patients had to walk up and ask to be seen in the ED; there was no place to sit down and no privacy. To make matters worse, the plans called for a two-inch-thick Lucite window to separate patients from the registrars.

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I was able to prevent the Lucite window from being installed (that is, until about two years ago). But for about 15 years, patients talked directly to the registrars. Because we still weren't conveying the message we wanted, something good happened. We abandoned registering patients at the window, we stopped doing triage (a total waste of time when beds are open in the ED), and did an end-run around the process by registering patients at the bedside. You would think we were doing surgery without anesthesia; the staff envisioned chaos, but we reminded them of how they would like to be treated in the ED.

Unfortunately, it only took a couple of registrars to say they felt unsafe to get the Lucite installed and a “security analysis” of the ED done by some “experts.” What resulted is what seems to be happening to all EDs: There is closed circuit TV, everyone has to be “buzzed” into the department, and there is lots of bulletproof Lucite (patients have to talk through an intercom).

I very much resented the message that all of this “security” was sending to our patients: You are the enemy, you may be here to hurt us, we are afraid of you. Yet, there is no Lucite in the main lobby of the hospital. The main lobby has nice upholstered chairs and “pink ladies” to attend to patients' needs and answer questions. In the registration area off the main lobby, patients sit in little cubicles and are registered in privacy for their elective surgeries. In the ED, the patients are “different.”

Were we really any safer in the ED now that we had all of the new “security?” The closed circuit TVs might briefly deter entrance if someone were waving an Uzi around, but most people who want to harm ED staff are probably smarter than that. And all of the doors can be pushed open if pushed on hard enough (or a would-be attacker could just wait for someone else to enter or leave through the door). Anyone can easily gain access into the inner sanctum as long as he doesn't act like a raving maniac at the registration window or in front of the security cameras. Once in the ED, that's the end of the charade of security. A gunman could take out the entire department in a matter of seconds. We have had people carrying concealed weapons come into the ED without a second look.

And if you really annoy a patient or a family member, remember that the staff has to leave the department some time. Assailants don't have to enter the department; they just have to be patient and greet you in the parking lot when you leave.

In the meantime, the 99.99 percent of our patients who are good, honest people coming for medical care are given the impression that we are afraid of them. I think most EDs make bad first impressions on their customers. And the driver is always the same: the perception that the ED staff is somehow in danger.

I've worked in two community EDs for 30 years in Los Angeles. I saw one act of violence that was of consequence. A patient for some inexplicable reason suddenly rose from his gurney and stabbed the patient in the next gurney, a total stranger to him. All the security in the world would not have prevented the incident. Sure, there have been some angry patients and some mean drunks, but nothing of consequence. Yet the fear persists.

Clearly, not every hospital is the same, but once a person enters the ED core, he can have his way with the staff. Most of the “security” is around the periphery: doors, cameras, Lucite. But none of these can effectively prevent someone clever from getting into the department, but meanwhile we create a very bad message for all of the other patients.

Remember, you never get a second chance to make a first impression (Head & Shoulders shampoo), and that bad impression starts with the way we initially treat our patients. They go to the bulletproof window and indicate they want to be seen, wait for the triage nurse to get around to seeing them, then once it's clear that they are going to live, they sit in the waiting room until called into the back. Then a technician takes them to a room and asks the same questions as the triage nurse, gets them into gowns, and then another nurse takes over, asking those same questions while assessing nutritional status, barriers to learning, immunization status, and a number of other irrelevant items. Finally, the patient sees a doctor. That makes the doctor the fifth person to see the patient; no wonder it takes forever to provide even the most basic of services for our patients.

What triggered this rant? The following paper says doctors in Michigan are afraid of the potential for workplace violence and 28 percent of the respondents said they were subjected to a physical assault in the prior year. They all can't be working in Detroit. My plea is don't paint all EDs with the same brush. Random acts of violence occur all the time in the United States; we've even coined the term “going postal.” This does not mean that every post office needs to be converted into an armed camp. Remember, 99.99 percent of patients are good people who, if we treat them with respect, value their time, and don't treat them as if we are doing them a favor, will respond in kind.

Workplace Violence: A Survey of Emergency Physicians in the State of Michigan Kowalenko T, et al Ann Emerg Med 2005;46(2):142

BACKGROUND: Few studies have focused on the specific experience of emergency physicians with violence in the ED.

METHODS: The authors from the Emergency Physicians Workplace Violence Task Force of the Michigan chapter of ACEP surveyed a random sample of 250 attending-level Michigan American College of Emergency Physicians members concerning their personal experience with workplace violence.

RESULTS: Analyzable responses were received from 171 subjects (68.4%). More than three-fourths (76%) reported at least one violent episode during the previous year (verbal assault, 74.9%; physical assault, 28.1% [89% from a patient, 9% from a family member, 2% from a patient's friend]; confrontation outside the ED, 11.7%; stalking, 3.5%).

An urban hospital location was not significantly associated with workplace violence. Most physicians (81.9%) stated they were occasionally fearful of workplace violence (9.4% were frequently fearful, 1.2% were constantly fearful), and 42 percent had sought various forms of protection, including guns and knives. About one-fourth (27%) reported that security officers were permanently assigned to their ED, and 24 percent reported that general hospital security staff made rounds in the ED, while five percent (all in rural locations) stated that there were no security measures in their ED. A subset (16%) stated that they had considered leaving their particular hospital as a result of violence, and one percent did leave to practice in another location.

CONCLUSIONS: Violence in the ED is reportedly common, with some type of physical assault within the previous year reported by more than one of every four responding emergency physicians in this series.

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Mandatory Reporting

I live in California, and the law requires all ED patients to be screened for domestic violence, and if she is positive, it is mandatory that it be reported. The following paper addresses mandatory reporting and examines the pros and cons. I must say I find myself on largely the con side because of my libertarian leanings.

Patients should be advised in advance that reporting is mandatory if they divulge current abuse

But the thought that I would, despite the wishes of a patient, report something that was told to me in confidence just doesn't sit right with me. Talk about treating someone in a condescending manner! It would appear beneficial that patients be advised in advance that reporting is mandatory if they divulge current abuse. I like the conclusion of this paper; it calls for a moratorium on such laws until we better understand their consequences. I also like the position of the American Medical Association that says competent patients should be able to opt out of being reported.

Mandatory Reporting of Domestic Violence: The Law, Friend or Foe? Iavicoli, LG, et al Mt Sinai J Med 2005;72(4):228

Domestic violence affects two million to six million adults a year, with injuries to 500,000 each year. The author from the Mt. Sinai School of Medicine in New York comments on laws mandating domestic violence reports (currently, California, Colorado, Kentucky, New Hampshire, Rhode Island, and New Mexico). HIPAA mandates medical privacy (www.aspe.hhs.gov/admnsimp) with the caveat that privacy regulations in domestic violence do not preempt state laws. Advocates of mandatory reporting feel that it sends a clear message that such acts will not be tolerated, that the onus of reporting is removed from the victim, and that patient safety is enhanced. Some studies have reported that most victims of domestic violence support mandatory reporting and would not be deterred from seeking medical care in such circumstances. Those who oppose mandatory reporting feel it diminishes patient autonomy, compromises confidentiality, can place patients at increased risk, and might deter patients from seeking medical care for injuries. Some studies have found that mandatory reporting would decrease the likelihood of disclosure and place the patient in jeopardy, and that female victims of domestic violence were fearful of increased violence and family separation. There is clearly a need for objective and definitive assessment of the risks and benefits of mandatory reporting before further laws are enacted. The AMA has proposed that existing laws include measures to protect patient identity, an opt-out clause for competent adults, and periodic reevaluation of the effects of existing laws.

© 2006 Lippincott Williams & Wilkins, Inc.

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