Last April two people died and one was critically injured in a shooting involving two hospital employees at Long Beach (CA) Memorial Medical Center. (www.usatoday.com/news/nation/2009-04-16-hospital-shooting_N.htm?csp=34) The shootings were deemed part of a national trend “because of the tension that's going on in our society today,” according to the police chief in Long Beach.
The emergency medicine literature warns us of impostors claiming to be accreditation surveyors, health care professionals, or government agents. We are told to be alert to vehicles loitering near the entrance to the hospital or slowly driving around it. Experts caution that EDs are prime targets for terrorist attack. (ED Management 2005;17:61.) But ask a friend to make a late-night visit to see how easy it is to access your emergency department.
While I discussed the current state of violence in EDs last month, we should be grateful we're not living just a couple of decades ago. A 1988 survey of 127 U.S. teaching hospital ED directors found that one-third reported at least one verbal threat each day, and 23 reported at least one threat with a weapon each month. Seventeen reported having significantly injured a patient during restraint, and 20 reported litigation related to restraint usage, including one death. At that time, only 79 institutions had security personnel present in the ED 24 hours a day. (Ann Emerg Med 1988;17:1227.)
When I was working at a Level I trauma center in the 1980s, the chief of security assured me that hospitals were neutral territory for violent criminal types; they would leave their weapons in the car when they came to the ED, and declare a temporary truce from their daily business of gang violence and mayhem. Curiously, the Annals survey reported one program using metal detectors that confiscated more than 300 weapons a month. Of course, the fact that four to eight percent of psychiatric patients have been found to have weapons (Hosp Community Psychiatry 1986;37:837) is even less reassuring to us.
Even more significantly, more than half of the EDs back then who reported at least one patient a month displaying a weapon as a threat did not have 24-hour security in the ED. Of the 55 respondents reporting a physical attack at least once a month, less than a third had 24-hour ED security. Of the nine who reported violent ED death within the past five years, most did not use 24-hour ED security personnel. (Ann Emerg Med 1988;17:1227.)
And those findings were before the threat of terrorism. Since September 11, hospitals realize they could be the target of terrorist attacks. “Reactionary” security, such as adding metal detectors to an ED after a shooting or putting cameras in a storage area after thefts, has been criticized as a concept whose day has come and gone. (Health Facil Manage 2003; 16:16.)
While the potential for gang violence is undoubtedly greater than the likelihood of a terrorist attack on the ED at least for now, the future may well entail barriers to prevent vehicles from coming too close, bullet-resistant film on windows, explosion-proof walls, air intakes for ventilation located 40 feet above the ground, and covered structures in which sprinklers and power could be mustered to decontaminate large numbers of people.
The concept is called Crime Prevention through Environmental Design (CPTED), and the idea is to look at the overall design of a facility and use that design as a security tool. Already this concept has taken hold in at least one South Central Los Angeles facility in which ambulances must go through a secure gated entry to get to the hospital. (Health Facil Manage 2003;16:16.)
It was inevitable that September 11 would trigger screening mandates for hospitals. Before then, the trend was toward hospitals offering unrestricted access to the public. The 2003 Homeland Security publication, “The National Strategy for the Physical Protection of Critical Infrastructures and Key Assets,” identified hospitals as key in defending against terrorism. (J Healthc Prot Manage 2004;20:44.) Most of us have card access, door alarm contacts, various locking systems, and security cameras, and our institutions must be in compliance with Homeland Security mandates.
Because the rate of gunshot wounds is at least eight times higher in the United States as any other industrialized country, one might suppose that ED violence is less of a concern in other English-speaking countries. Interestingly, violence against staff in accident and emergency departments in the United Kingdom and Ireland has been fairly common historically. Of 273 consultants in charge of 310 departments, 233 reported that patients were the chief assailants and nurses were the most common victims of verbal abuse and physical violence. Staff reported 10 fractures, 42 lacerations, and 505 soft tissue injuries annually. (J Accid Emerg Med 1998;15:262.) Alcohol, recreational drug usage, waiting times, and unmet expectations were listed as the chief causes of violence. Police made 298 arrests, but there were only 101 court appearances and even fewer (76) convictions. No gunshot wounds or homicides were reported; the intent to harm is there in the United Kingdom, just not the means to be lethal.
We are allowed to restrain patients and to use our professional judgment about when it is safe to do that for the sake of patients and others. In the classic 1981 case, Youngsberg v. Romeo, the U.S. Supreme Court decided that professional judgment should be exercised. (Int J Law Psychiatry 1982;5[3–4]:285.) We can be and have been sued for failure to restrain or detain a violent patient, injury to a patient resulting from his physical restraint, and for restraint or detention of a patient that didn't result in injury. (Ann Emerg Med 1988; 17:1227.)
Although we are all aware of Joint Commission guidelines on restraints, colleagues have told me they simply are not going to restrain patients anymore. This seems to them the easiest way to comply with JC guidelines. But it is easier to defend a suit for false imprisonment (restraint), assault, and battery than to defend a wrongful death as a result of failure to restrain.