March 2018: An emergency physician at a British Columbia hospital is punched in the face by a patient.
January 2018: A patient at a Cleveland hospital pins an ED nurse against the wall and sexually assaults her, groping her chest and buttocks while thrusting and rubbing his genitals on her.
December 2017: An ED nurse in Oklahoma City is choked and sexually assaulted by a patient.
October 2017: A patient in a Davenport, IA, ED grabs his physician by the throat.
June 2017: An ED nurse in Boston is stabbed multiple times in the head and neck by a patient with paranoid schizophrenia.
June 2017: A patient in a Lancaster County, PA, ED attacks three members of the hospital staff, including an emergency physician and a nurse.
March 2017: Two men attack doctors in an ED in Kingman, AZ, punching one in the face and trying to choke the other. They also threatened to kill an ED nurse and her family.
If it's a day ending in y, there's an emergency physician or nurse being targeted for violence or aggression at a hospital somewhere. This comes as no surprise to anyone who has ever worked in an emergency department, and it's hardly unique to the United States. One of the most recent studies on the topic, an 18-country review published in International Emergency Nursing, found that one in four emergency department staff members has experienced violence and aggression in the workplace, most commonly from patients. (8 Jan 2018; http://bit.ly/2DNBfyP.) “ED staff experienced violence and aggression as an inevitable part of the job,” the authors wrote. And that one in four number probably sounds low to many people; other studies have suggested that experiencing violence from patients or visitors is a virtually universal experience for ED staff.
Despite decades of studies documenting the problem, along with various proposed interventions, there's still not much in the way of solid, research-based evidence about which strategies to combat violence in the ED are actually effective.
“I'm sorry to say that there has been a paucity of new research documenting good new interventions that have really worked,” said American Board of Emergency Medicine President Terry Kowalenko, MD, a professor and the chair of emergency medicine at the Oakland University William Beaumont School of Medicine in Rochester, MI, who in 2012 wrote a review of current evidence on violence recognition, management, and prevention in the ED. (J Emerg Med 2012; 43:523.) Little new data on what strategies might be effective have been released in the intervening six years, he said. “It's an area of research that really hasn't been tapped into fully.”
That doesn't mean that hospitals and EDs aren't trying various strategies, just that it's difficult to know exactly how effective they are.
Stopping Violence Before It Starts
“Ideally, hospital security and violence prevention need to be multifactorial and multidisciplinary. First and foremost, all health care workers need to have ongoing training on how to recognize potentially violent patients and de-escalate the situation,” Dr. Kowalenko said. “A lot of the education health care workers get in this area is about what to do with a patient who already is violent—things like physical or chemical restraints—but we could do more by preventing it all together. That requires training in identifying the person who could become violent and then utilizing conflict resolution and de-escalation techniques.”
Pinnacle Health System in Pennsylvania has what it calls a “Code Green Response Team,” led by the charge nurse from its Intermediate Care Unit, an inpatient toxicology unit treats large volumes of behaviorally challenging and violent patients. Physicians or nurses on any unit can page the “Code Green” team, which also includes supervisors, security, physicians, charge nurses, and bedside staff, all with special de-escalation training, if a potentially violent situation arises. (See adjacent article.)
Writing in American Nurse Today in February 2017, Pinnacle nurses Yana Dilman, RN, and Faye Gardner, RN, reported that the organization saved $23,425 in employee injury costs between the program's adoption in 2013 and September 2015, with the only cost of the program being the eight-hour training. “Between April 2013 and September 2015, 240 patients were assisted by de-escalation. Only 26 of the 240 required restraints,” they wrote. “The remaining 214 were successfully de-escalated, leading to a 28% reduction in restraint use, which contributed to patient safety. During that same time, employee injuries on inpatient units decreased by 47%.”
The University of San Diego, which provides violence prevention training to all employees who provide direct patient care and additional training in high-risk departments like the ED, has been piloting a system in which violent or potentially violent incidents are recorded in a “staff safety alert” in the electronic medical record. The alert includes whether the patient's behavior is isolated or part of a pattern, what caused it (drug-induced, psychiatric, or dementia), and recommended strategies to reduce future violence and injury.
Jeffrey Ho, a professor of emergency medicine at the University of Minnesota and the chief medical director for Hennepin EMS, is also a deputy sheriff who was asked by his institution to serve as medical director of the security department, a novel approach. “Most hospitals with large security forces look at them as an institutional enterprise that is not part of clinical service,” he said. “Health care security professionals often don't feel like they have a clinical mission, but it became clear to me that's not true.
“Clinicians call security when things get out of control in a clinical area.... But that's the last thing you want to have happen. That's a failure to identify a potential problem, to appropriately de-escalate, or to use medication. What used to happen after such an incident is that clinicians would do an after-action review and point fingers at security. We brought to the table a root-cause analysis of what led to the behavior, and more often than not, we found clinical reasons for what happened. Patients who hadn't been fed for several hours, or who wanted a blanket and the call button was being ignored, or who couldn't get to the bathroom. By the time we're calling security, that's often a failure of the clinical service line.”
Security: Who and What?
But even the best violence prevention and de-escalation strategies are not effective 100 percent of the time. “There are times when people are so out of control that typical de-escalation techniques do not work and people end up getting hurt,” Dr. Ho said.
A recent survey by STAT News found that EDs rely on a combination of hospital security and local police to prevent and handle violence, and often hire retired police officers or former military police to serve on their security staff. Seventy-four percent of the hospitals surveyed called for outside help more than 50 times a year in 2013 (up from 62% in 2011), and 22 percent called more than 100 times per year (up from 14%).
Large metropolitan hospitals with significant volume and more resources can afford to have better-trained security forces, and, in some cases, virtually their own police departments.
“More and more hospitals are going to their own security forces that are employed by the hospital itself,” Dr. Kowalenko said. “But there are some places where they have to rely on the local police to be their security. Some hospitals, depending on how small the facility is, may not even have someone stationed in the ED directly; they may have just one security person for the whole hospital.”
In places like that, Dr. Ho said, “security may well be ‘we dial 911.’ When 70 to 80 percent of the country is rural by geography, many small hospitals can't afford a full-time, well-trained security staff. I have a friend who was an emergency physician who was assaulted by a patient, and it turned out to be a career-ending injury. He filed a complaint, and the administration's kneejerk reaction was to hire a security officer. But it was a single guard sitting in the waiting room 16 hours a day, and on the day I visited, it was a 70-year-old guy who walks with a cane.”
The body of evidence on the best way to arm security personnel is limited, Dr. Kowalenko said. “When you look across hospitals, there is a wide spectrum of choices, from a tear gas type of substance to TASER weapons to actual firearms,” he said. “A couple of years ago, our hospital changed over from no firearms to having select individuals on campus—usually a supervisor and one other individual somewhere within the hospital—having firearms. That was a big deal, and not everyone was comfortable with it, but my personal feeling is that any guard who meets the criteria for training and certification should be able to carry.”
Dr. Ho began consulting early on with the manufacturer of TASER conducted electrical weapons, now known as Axon Enterprise. He has also been Axon's medical director since 2004, in a carefully managed contractual arrangement in which Axon contracts with Hennepin Health System for his time.
TASERs and De-Escalation
Dr. Ho said he is convinced that TASERs are particularly useful for hospital security after more than a decade of researching their impact on human physiology. “Our research group has been the world's experts on what these things do to the human body, and we haven't found anything that is dangerous or damaging enough that it is not worth the benefit that these tools have brought to health care security,” he said. “We have a real problem with violence in hospitals, particularly in the ED and psychiatric treatment areas, and while the goal is always de-escalation, there are sometimes circumstances when security needs to incapacitate people to prevent violence. They need a tool that will do that without the excessive, unforeseeable risk of injuring or killing them.”
Pepper spray or foam used in a confined space, he noted, requires decontamination and the potential shutdown of a clinical unit. Those sprays also can take time to incapacitate the subject, and violence can escalate in the meantime. “You'll have people who are even angrier after application, throwing objects and attacking staff,” he said. “Some security staff also have collapsible batons, but imagine what it looks like when security comes in and starts striking people with what's basically a club. And guns, of course, carry significant risk.”
Other institutions have used dogs, said Dr. Kowalenko, including his own hospital at one point. “I had a patient once who was becoming violent and security showed up with a dog. The patient said, ‘You're not going to let that dog loose on me.’ He was drunk and escalating, but he was still making sense. He said, ‘You're not letting that dog go until I assault somebody, and I got a 50-50 chance the dog doesn't know who's attacking and who's trying to protect himself.’ That made sense. How much training do these dogs have?”
TASERs, on the other hand, incapacitate the subject within seconds if used correctly. “No clinical data show that they cause physiological harm when used as intended,” said Dr. Ho.
Hennepin County Medical Center began equipping its civilian medical center protection officers (MCPOs) with TASERs in 2008. Guards “deployed” TASERs a total of 27 times during the first year after they were introduced. But deployment can mean anything from removing the TASER from its holster to aiming it at the subject to actually deploying the probe that causes the incapacitation. Dr. Ho and his colleagues reported only three cases of actual probe deployment in their study. (J Emerg Med 2011;41:317.) The display or aiming of the TASER alone was enough to de-escalate the situation in the other cases.
“In each reported case, there were suspects, victims, or witnesses that reported it to be their perception that injuries were likely avoided in each incident because the CEW [conducted electrical weapon] prevented further behavior escalation,” Dr. Ho wrote. “These reports were supported by similar reports from the MCPOs at the incident. In a single case of PD [probe deployment], the agitated male subject later told the MCPOs that he was prepared and desiring to injure several hospital employees during the incident until the CEW was used on him, at which point he changed his mind due to the discomfort he experienced. In a separate incident, RD [red dot] display was credited with aborting one patient's suicide attempt (sharp object held to the throat). The patient in this suicide attempt was not injured.”
Dr. Ho reported that he has consulted with many hospitals interested in adopting a TASER program since the study was published. “In my state alone, every major hospital and health system has since adopted TASER weapons for their security staff,” he said.
Whenever Dr. Ho consults with a hospital, he cautions them that the use of a weapon such as a TASER must be a single tool in a comprehensive plan for violence prevention and use of force. “It's not the holy grail,” he said. “You have to fill your gaps first with a solid de-escalation and security program. Nurses and physicians, particularly in the emergency department, have become all too accustomed to thinking that dealing with violence is ‘part of my job’ or ‘just what I have to deal with.’ That should not be the way we have to think.”