Toward a safer Emergency Department Environment
It’s About Time

   Our hospital Emergency Departments are busier and more chaotic than ever, and that trend will only continue. In addition to the rise in medical patients, as mental health funding continues to be inadequate, more and more mentally ill patients will be coming to the Emergency Department for primary treatment and exacerbation of their illness. It is not uncommon for some of these patients to have to stay in the facility 48 hours or more while awaiting psychiatric disposition, many times acutely agitated or even violent. The Emergency Department is the recipient of violent crime victims brought in by police or EMS, so it has the potential to receive the families or gang members of these patients bent on retribution. Given this crucible of volatile, high stress ingredients, it should not be surprising that violent and “near-violent” episodes occur on a regular basis in our facilities, especially in our Emergency Departments, and some studies show it may be on the rise.

What are we doing about this rising threat?

I’ve been an Emergency Physician. Over the years, many Emergency Department physicians and nurses have developed a “MASH” mentality, where violent encounters are to be expected and dealt with internally almost on a routine basis. Having to restrain or talk down a disturbed patient is commonplace. Avoiding an aggressive encounter or dealing with insulting or cursing language from an intoxicated patient is part of the job. Some staff consider it a “badge of honor” to be able to quickly subdue an agitated patient. Many can talk about an event where they took a knife from a patient or confiscated a weapon. Hardly a week goes by when an ED staff person has not been spit upon or had something thrown at them. Many of the staff are on first name basis with the local law enforcement personnel. There has been a mentality to “take care of it ourselves”. But is the threat too great?

In January, a cardiac surgeon was shot in Boston by the son of a patient who had died after that physician had performed a procedure on her. This incident and others across the country have called to question whether our Emergency Departments are safe enough. Do we need to do more to recognize and avoid potentially violent situations? Are we protecting our patients, our physicians and our staff…. and our reputations as a safe haven for those who are ill?

The issue of violence in our hospitals is not new. In 2004, the Occupational Safety and Health Administration (OSHA) reported that healthcare and social service workers account for nearly half (48%) of all nonfatal injuries reported in the U.S. from workplace violence and assaults.

It is doubtful that the Emergency Department will become less stressful. It remains a high volume, high acuity and high anxiety environment. But it is also the portal where many of our patients pass through. For these patients the Emergency Department is the first encounter with the hospital. And by the way, how about those HCAHPS scores? We cannot let our patients be at a minimum “grossed out” or at a maximum at physical risk when they visit the ED for their acute and sometimes life-threatening illness.

We clearly need to do more, but to what extent? To become more like our airports with metal detectors, and other high security measures is simply not practical. What measures can we do to better insure safety, yet preserve our role as a peaceful place to provide healing for our community?

Here are a few measures we could consider for the entire facility, but especially for the

Emergency Department:

1. Develop a culture of increased awareness of the potential of violence throughout the health care facility, but especially in the Emergency Department. The concept of having the ED staff handle these situations themselves is simply not appropriate.

2. Increase education and training of medical staff, including physicians, for earlier recognition and management of potentially violent situations…. emphasizing the adage of “SAFETY FIRST !!” for our employees, patients and families.

3. Increase surveillance in the areas of entrance and egress for the Department. In some cases this may entail increasing staff and increasing police protection.

4. Develop programs such as Code NORA — short for “Need an Officer Right Away” , as was recently done in a Massachusetts hospital with good results.

5. Better arming ED police officers with weapons and TASERS could be considered, but has had mixed results in the literature.

6. Develop a system to “flag” patients in the medical records who have a history of violence or aggressive behavior so that the staff can be alerted in advance.

7. Consider additional surveillance such as body cameras for key front line ED personnel such as is suggested by physician Jeremy Brown, M.D., in this month’s Emergency Physicians Monthly

We owe it to ourselves as providers and to our patients and their families to make their encounter with our hospital and Emergency Department as safe as possible.

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