Protecting Emergency Room Staff

Emergency departments, whether part of a hospital, stand-alone or even sometimes urgent care, are typically the front line when it comes to patient, family or visitor aggression and violence. When I write my security and violence management assessment reports, the ER is usually the first topic discussed.

According to a 2011 study by the Emergency Nurses Association (ENA), “54.5 percent out of 6,504 emergency nurses experienced physical violence and/or verbal abuse from a patient and/or visitor during the past week. The actual rate of incidences of violence is much higher as many incidents go unreported, due in part to the perception that assaults are ‘part of the job’.” There is little doubt that these numbers have worsened since 2011.

ER’s, including treatment spaces, waiting areas, triage rooms, admitting/patient access counters and offices, overflow and fast track areas, receptionists and other related spaces, are understandably places of stress, fear and concern. They are typically where patients and their families first encounter healthcare support when they are at their most vulnerable and on edge. To compound risks arising from those stresses, ER’s are facing increasing incidence of mental health admittances, aggressive drug seekers, gangs, shooting victims and their colleagues, criminal patients, domestic violence spill-over, weapons, disrespectful and entitled patients and families, and even the threat of domestic terrorism.

I’ve interviewed thousands of ER staff and find an admirable dedication to the care of all their patients, an attraction to the hectic and caring atmosphere and an understanding that the environment brings with it some inherent risks. I was a rare adult victim of Reye’s Syndrome in 1983 and learned, after I woke from my coma, that I had struck an ER physician. I later returned and apologized to the doctor and told him I had no remembrance of my actions. He was forgiving and told me I clearly didn’t know what I was doing.

And yet, I hear more and more that ER staff are routinely experiencing volitional or purposeful harm. It is fairly common for them to tell me they get hit, threatened, spit at and slapped virtually every day. Too often they tell me it’s just, “part of the job.” Sometimes they don’t even report these assaults and threats because they don’t have the time to write reports, believe the Administration doesn’t care or listen, or believe that’s just what ER work is about. In recent years I more often hear they don’t report or press charges because of a hopefully incorrect perception that the Administration cares more about patient satisfaction scores than their safety.

Assaultive and threatening purposeful behavior should never be just "part of the job" and should never be tolerated. It should also be noted that such behavior, if not recognized and managed early on, could escalate to more extreme violence up to the active shooter or hostage taking.

So, what can be done to make ER staff and their patients safer? Following a serious violent incident in an ER or hospital, staff often demand metal detectors and armed police officers. While those measures may be appropriate, depending upon many factors, they are far from the ultimate answer. For example, much violence in ER’s is at an intimate level at bedside or over the counter, and even many security and police officers in the area cannot prevent every such attack.     

Protective measures could include:

·        Proactive team-based patient risk assessment and management processes to as early as possible identify patients (and family members) with a proclivity toward violence, assign a level of risk and make a plan for safe care, based on the risk level, as the patient moves through the hospital and system. These interdisciplinary teams are often made up of representatives of Security, Safety, Nursing, Human Resources, Risk/Legal, Behavioral Health/Psychiatric and de facto members from the department or unit affected.

·        Training of bedside and patient care staff on recognizing early indicators of potential violence, de-escalation techniques and safely managing threatening and violent behavior. Note that there should be similar training for at-risk front-line “Gatekeeper” staff such as Registration/Patient Access, Triage, Receptionists and Retail Pharmacists. I seldom see such training beyond traditionally high risk staff such as Security, ER treatment staff and Behavioral Health.

·        Commissioning independent and objective, interview intensive, security and violence management assessments to determine true and present risks and vulnerabilities and, in light of those, evaluate and recommend best and most cost effective procedural and physical protective measures based upon best practices and industry standards as well as the organization’s/facility’s particular culture, values, history, location, functions, layouts and budgets. Such assessments have the added benefit of demonstrating the Administration’s concern for the safety and welfare of its people as well as eliciting more buy-in for new measures and procedures.

·        Remember that the ER does not exist in a vacuum and the overall security of the hospital will affect the ER’s security and safety. For example, too often it’s too easy to “tailgate” into the ER from the hospital side behind staff or authorized visitors.

·        Related to the above, while most ER treatment areas are restricted to the public, it is a perennial problem that people will find ways in, often by “tailgating” behind employees or authorized visitors. Careful consideration should be given to overall unit access including from the Ambulance Entrance and Radiology.

·        Identification of especially vulnerable staff (e.g. younger and less experienced/seasoned nurses) and subsequent training, mentoring and shadowing

·        Unit and facility lockdown capabilities – how quickly and safely can you lock down your at-risk units or facilities?

·        Staff positioning and situational awareness – staff in patient rooms and offices often place themselves where they cannot avoid attack or effect an escape. Are there escape routes? What are their options? Do they know the signs of potential violence? Do they know when and how to escape? Are they protective of each other? Can they communicate duress?

·        Identification and equipping of safe rooms and shelters to "buy time" during threats as well as escape routes for exposed staff – most incidents of violence, including active shooters, in healthcare environments are over in less than five minutes, seldom more than ten. Therefore, if you can “buy” five to ten minutes of safety until law enforcement or security can respond you will likely be safe. Likewise, I often see “Gatekeepers” such as Registration/Patient Access or Reception in a location where they are fully exposed and have no escape options.

·        Patient safety associates and/or presence of mental health professionals. Adding even a basic mental health professional presence in the ER can help gauge the atmosphere (milieu), assist with de-escalation and intervene at an early and more easily manageable stage.

·        Likewise, including behavioral health staff in disruption and conflict response teams substantially enhances the capabilities of those teams.

·        Speaking of atmosphere, anyone who has worked in an ER will relate how there are times when all is peaceful and even boring and other times of almost continuous chaos, stress and conflict. A “traffic light” process could be implemented in which quantifiable indicators and measurements would designate the perceived level of risk in the area, along with pre-determined protective measures such as staff doubling up, increased security presence, higher level of access and egress control, screening for contraband, etc.

·        Clear and responsive reporting channels and processes – impediments to reporting, such as long and complex reporting forms or processes, will only discourage reporting and impede the Administration’s ability to protect their people.

·        Systems to internally and externally communicate and monitor duress along with proper and safe response protocols – portable or fixed panic or duress buttons can be great ways to covertly communicate duress but should be accompanied by a safe response protocol, training and regular testing. For example, placing video cameras viewing panic buttons areas allows for Dispatch, Switchboard or others to observe what is happening and communicate that to responding officers or staff in real time. 

·        Related policies, procedures and plans. I seldom see a comprehensive workplace violence program and plan compromising the essential four elements: Prevention, Mitigation/Threat Management, Response and Recovery. 

·        Placement of “crisis or observation units” to monitor, manage and care for mental health and other higher risk patients in ER’s. A nationwide trend in hospitals and especially emergency departments has been an increased influx of mental health patients, largely due to diminishing local and regional mental health resources, and the receiving hospital and unit may not be adequately trained nor equipped to safely manage this added burden and risk.

·        Clearly communicated and consistent support for employee safety and welfare by the Administration. The Administration cannot assume that their people know they care, but must take real actions, including their regular presence, to show their appreciation and support. Nothing casts more of a wet blanket and causes long-term dissatisfaction than invisible top administrators following a traumatic incident.

·        Keep in mind that a person becoming aggressive and loud negatively affects the satisfaction of all persons in earshot, especially in the relatively open and crowded spaces of the ER. There is much talk nowadays concerning what should be the tolerance level for bad behavior.

·        Fostering a nurturing culture of staff safety and security awareness, ownership, protectiveness, involvement and engagement by all. All employees should know they are active members of the Security and Safety Team. Often when security fails it was not because of a failing of security staff or systems but a failing of care providers and other employees.  Do your people prop doors, not wear their ID badges, fail to call Security or law enforcement in a timely manner, escalate rather then de-escalate, fail to positively engage, or allow strangers in or out of restricted doors (tailgating)? This awareness can be especially built upon a foundation and mission of strong customer service and engagement. Too often ER staff tell me that security and safety, “Isn’t my job.” Even many nearby security and police officers won’t see and hear everything.

·        Strategic deployment of security systems and tools including video, competent and visible security staff, access and egress control and monitoring, alarms, lighting, panic and duress systems, bollards and other barriers, intercoms, remote releases, screening for contraband and weapons, elopement and abduction monitoring, visitor management, worn identification, safe rooms and shelters, centralized system-wide security monitoring centers, law enforcement liaison and presence, background screening, etc.

·        Planning security and safety into the design of waiting rooms and ER treatment spaces including access and egress management, ambulance/EMS entrances, day and evening visitor access management, greeting and screening functions, treatment rooms, nursing stations, Registration and Triage desks and rooms, waiting areas, etc. Too often I see that Security and Safety were not considered during planning and the facility is later forced to retrofit and remodel at much more cost.

·        Encouraging clinical staff to call Security or other responders at an early stage when their mere presence might deter further escalation. Too often staff wait until fists and chairs are flying to call for assistance, and the application of force may be necessary and violence is more likely.

Dick Sem, CPP CSC of Sem Security Management has over 40 years’ security and violence management experience. He serves healthcare clients across North America in almost every state performing comprehensive security and violence management assessments, targeted assessments (of Security Department/Program, Workplace Violence Program, Accessibility, Outlying Facilities, critical departments, etc.), development of related policies and plans, expert witness service and training.

Call or write if you have questions, would like to discuss an issue or would like a proposal from us.  

Dick Sem, CPP – Sem Security Management        [email protected]          262-862-6786