Volunteer team cuts violence risk and liability
Security training uses real-case scenarios
When a newborn baby’s father is told that the mother has forbidden him to see his child, the situation can immediately become tense. When you add a bit of alcohol to the man’s system, a lonely nursery in the middle of the night, and a single hospital security guard who’s tied up in the emergency department, violence is a real possibility.
But suddenly, five hospital staffers appear in the nursery from different departments in the hospital, each trained in techniques to defuse potentially violent situations. And if necessary, they also are trained to handle physical confrontations.
The "Code Green" emergency response team at St. Agnes Hospital in Fond du Lac, WI, can often avoid having to physically restrain a patient or visitor. Their mere presence sometimes is enough to discourage any act of violence.
And in doing so, they have discouraged injuries, workers’ compensation payments, lawsuits alleging lax security, and lawsuits alleging an overzealous response by the hospital.
Team is ready to provide assistance
Security and risk management concerns are tightly interwoven in any health care facility, so improving security means improving risk management. The hospital’s innovative emergency response team demonstrates how the two departments can work cooperatively for the good of the entire hospital. The team grew out of administrators’ concerns that the facility was experiencing an upsurge in "disruptive person" incidents.
In 1995, the hospital logged 458 such incidents, a 30% increase over the steady rate of the previous two years. Safety and Security Coordinator John Gormican agreed with Cathie Aschenbrenner, RN, director of risk management, that a more formalized security response was necessary.
The hospital had long used an informal emergency response team to aid the hospital’s one uniformed guard per shift, but the increase in incidents suggested the need for specific training. The 250-bed hospital serves a small community, but it is located near a women’s prison and provides obstetrical and other care to the inmates. Patients being admitted to the nearby county mental health center also are taken to the hospital for medical clearance, so the hospital sees more than a typical number of patients with behavioral problems.
"Preventing violence is important from a risk management standpoint because we have an obligation to provide a safe facility for our employees, visitors, and patients," Aschenbrenner explains. "If an unfortunate injury occurs, this sort of preparation will make it harder to allege that the hospital did not take the necessary precautions to prevent it."
Members recruited from all over facility
Gormican and Aschenbrenner decided to have volunteer staffers trained by professionals in security and behavioral health. The local police department provided a training officer who used safety guidelines from the federal Occupational Safety and Health Administration (OSHA) to tailor a program for the hospital. The facility’s own behavioral health staff provided instruction on what types of disruptive people may be encountered, what motivates them, and the best way to defuse the situation.
Volunteers were recruited from various hospital departments, with an eye particularly toward people who could be more useful in a physical confrontation. Though the team members usually do not have to use force, the team is designed to handle violent people who are beyond the negotiating stage. They may try to defuse the problem without touching the person, but they are called because similar attempts by other staff members have failed.
Fifteen people, including two women, are trained as members of the Code Green Emergency Response Team, named after the code used to call security to a violent scene. Four or five members usually are available to respond to each incident.
The hospital’s uniformed security guards respond along with the team, but there usually is only one guard on duty per shift.
In addition to the emergency response team, other staff members at the hospital went through the three-hour training session. Departments that were seen as particularly vulnerable to violence the behavioral health, emergency, pharmacy, nursery, and cashier areas sent representatives to learn to handle disruptive people before having to call the emergency response team. Eventually, the hospital may send all staffers from those departments through the training.
All hospital staffers undergo general security training as part of the orientation process and ongoing inservices, but not as much as the training offered in this course.
Insurer offers additional training
The hospital’s insurer provided additional educational materials and a training film. (In addition to the security training, the hospital has trained staff members on how to deal with patients who have been subjected to "pepper sprays" by the police. See the story on p. 142 for more information.) Among the training regimens offered are analyses of actual incidents, such as the one with the newborn baby’s family described above.
The response team can be called out quickly in two ways. High-risk departments are equipped with Code Green emergency buttons that will silently initiate the call-out system in the communications department. If the button is not available, any staffer can dial "1234" on a hospital phone to get priority access to the communications department, which will then notify the team by radio, pagers, and a "Code green" message over the hospital public address system. When they get the call, team members immediately respond.
Once on the scene, the team members observe the situation and wait for the clinician in charge to say whether any physical restraint is necessary. Especially when the disruptive person is a patient, the nurse or doctor determines whether the team makes any physical contact. But if it is apparent that the person will injure himself or others, the team can act immediately.
In addition, there is a separate call-out system that allows the team to be called only as a precautionary measure. Buttons are provided in the same areas with Code Green buttons, but in a few additional areas such as the main lobby information desk. When these buttons are activated, team members are asked to report to the area and only observe in case a situation develops.
Team works together to best advantage
The team’s formal training allows the members to work as a unit, knowing how each will approach the situation, who will give instructions, and what should and should not be done. Other hospital staff understand that these are specially trained employees, so they do not interfere. The uniformed security guards appreciate knowing that others are present to help, but also that they know what they are doing.
"If one person has one way of doing something, and another person has another way, someone can get hurt," Gormican explains. "The team structure helps keep people from getting carried away. Without it, you might just have a well-intentioned bystander jump in to help and end up making the problem worse."
The emergency response team does not wear uniforms, special badges, or other identifiers. In fact, the members and uniformed guards remove all badges, ties, watches, and anything else that could be used as a weapon. Identifying the members is not a critical need because, when the situation has escalated to violence, the disruptive person is going to ignore symbols of authority. After each incident, hospital officials file reports on the incident and evaluate the response for any possible improvements. (See p. 141 for a sample form.)
The team is called out about 25 times per year, and most of those incidents do involve a physical confrontation. The formal training was first provided in April.
"It is too early to obtain numerical proof that the team response is yielding benefits, but we suspect we are achieving fewer injuries to patients and staff," Gormican notes. "We have had serious incidents in which we were pleased that there were no injuries, and we knew there could have been."
Aschenbrenner also says it is too soon to know if the emergency response program will lower hospital liability risks, insurance premiums, and workers’ compensation costs, but she suspects that all of those benefits will accrue with time. She also recalls incidents in which the team may have averted injuries that could have resulted in lawsuits against the hospital.
In one incident, a patient who was very ill decided that he was going home at 3 a.m. and attempted to walk out of the hospital. The man was not a psychiatric patient, but he was confused. Because he was large and strong, the clinical staff could not convince him to return to his room. The emergency response team was summoned and gently took the man back to his room.
Another incident involved a psychiatric patient who was found running through the halls. He then returned to his room and began assaulting his roommate. The response team was able to rescue the roommate and control the violent patient until the clinical staff could sedate him.
"We have responsibility to protect people in those situations, so we easily could have been sued if we didn’t have a way to respond," the risk manager says.
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