Here’s how to prevent assaults on staff
If a staff member is assaulted in your ED, it can have far-reaching effects long after the incident is over, warns Tracy G. Sanson, MD, FACEP, assistant medical director for the department of emergency medicine at Brandon (FL) Regional Medical Center. "A violent incident can change the way your ED operates for a long time," she says. "The memories of an event may last for months or years, affecting staff morale and retention rates. The stress of the threat of violence can affect productivity and employee health, including substance abuse and suicide."
Occupational health and safety laws say employees must be provided with a safe working environment and safe systems of work, Sanson notes. "Employers should prepare a plan to identify, assess, and control potentially threatening or violent situations and incidents at work," she adds. (See "Use this 'before and after' checklist," in this issue.)
ED personnel experience the majority of all hospital assaults, warns Tom Scaletta, MD, FAAEM, chairperson of the department of emergency medicine at West Suburban Hospital Medical Center in Oak Park, IL.1 In a national survey, 62% of residents admitted fearing assault in the ED, and 43% of university-based EDs report at least one physical assault of a staff member monthly, he adds.2,3 Here are effective strategies to prevent assaults on ED staff:
— Develop an ED security plan. Scaletta suggests developing an ED security plan that addresses the following issues:
- security personnel hiring, training/certification, weapons-carrying policy, and responsibilities;
- alerting/response protocols (i.e., hostage situation, overt violence, pre-violence);
- restraint techniques/participants;
- arrest vs. eviction rules for disruptive patients/ visitors;
- violence prevention means (i.e., zero tolerance for violence, checking IDs, metal detectors); and
- reporting requirements (form completion, committee review).
— Educate staff in violence-prevention techniques. Staff should be trained to identify predictors of violence in individuals, develop de-escalation skills, and "get out of the way of unstoppable trouble," says Scaletta. (See "Resources," at end of this article, for courses to take.) "Flagging violence-prone individuals on subsequent ED visits helps alert staff to be ready for anything," he says. "Of course, this information should not be used to mistreat the person in a retributive way."
— Avoid lack of communication and unprofessional behavior. Use patient liaisons in the waiting areas to explain how the system works, why waiting might be necessary, and what is happening in the clinical area, says Scaletta. He offers the following anecdote to illustrate the importance of avoiding behavior that can escalate violence: After a surgical resident was overtly rude to a patient in police custody, he repaired a laceration and did not immediately dispose of the suture kit. "The arrestee was able to use a free hand to grab a scalpel and threaten the resident during morning rounds," he says. Luckily, no one was hurt, and the staff learned an important lesson from the frightening incident, says Scaletta. "Treat patients and visitors with respect, and remain professional at all times," he underscores.
— Implement additional security measures. Safety measures to consider include portable panic buttons, visitor control policies, locked-entry and total lock-down capability, video cameras, and metal detectors, says Diane Presley, RN, MSN, director of nursing for emergency services/critical care at Seton Medical Center in Austin, TX. Seton’s ED recently installed doors with a lockdown capability, and most of the ED hallways are videotaped, Presley reports. "There is locked entry only, so there is ease of access for patients and visitors to come out of the department," she says. "The trauma center is always locked, and the ED locks down from 10 p.m. until 6 a.m. or if there is a incident such as a disaster of internal or external nature."
— Ensure adequate training of ED security. Your ED’s security guards might not be as effective as they could be if they haven’t been trained to work in hospitals, Presley cautions. "Training should include violence management, plus investigation and detection of uncommon weapons," she says. The Lombard, IL-based International Association of Hospital Security and Safety has a certification course for hospital security officers, she notes.
— Encourage staff to report all incidents. All involved staff should complete a report after an assault occurs, says Scaletta. (For a sample reporting form, click here.) He recommends reviewing security calls for violent or disruptive patients and visitors. "When there was a verbal threat of harm and certainly when there was an assault reported by security, the involved staff member should be asked to fill out a data collection form, even in retrospect," he says.
Tracking assaults helps because the process allows the reviewer (or review committee) to look for commonalities, says Scaletta. "Maybe a certain staff is always getting into it’ with difficult patients/visitors and this person needs some interpersonal skill building." You might discover there are opportunities to call security or the local police earlier, or learn about a security staffing problem that needs objective evidence to be overcome, says Scaletta.
References
1. Pane G, Winiarski A, Salness K. Aggression directed toward emergency department staff at a university teaching hospital. Ann Emerg Med 1991; 20:283-286.
2. Anglin D, Kyriacou D, Hutson HR. Residents’ perspectives on violence and personal safety in the emergency department. Ann Emerg Med 1994; 23:1,082-1,084.
3. Lavoie FW, Carter GL, Danzl DF, et al. Emergency department violence in United States teaching hospitals. Ann Emerg Med 1988; 17:1,227-1,233.
Sources
For more information on preventing assaults, contact:
• Diane Presley, RN, MSN, Emergency Services/Critical Care, Seton Medical Center, 1201 W. 38th St., Austin, TX 78705. Telephone: (512) 324-1013. Fax: (512) 324-1401. E-mail: [email protected].
• Tracy G. Sanson, MD, FACEP, Department of Emergency Medicine, Team Health, Brandon Regional Medical Center, 119 Oakfield Drive, Brandon, FL 33511. Telephone: (813) 948-6190. Fax: (813) 948-8477. E-mail: [email protected].
• Tom Scaletta, MD, FAAEM, Department of Emergency Medicine, West Suburban Health Care, 3 Erie Court, Oak Park, IL 60302. Telephone: (708) 763-2227. Fax: (708) 383-4422. E-mail: [email protected].
Resources
Crisis Prevention Institute (CPI) offers three levels of intervention training. For more information, contact: CPI, 3315-K N. 124th St., Brookfield, WI 53005. Telephone: (800) 558-8976 or (262) 783-5787. Fax: (262) 783-5906. E-mail: [email protected]. Web: www.crisisprevention.com.
REB Training International offers Management of Aggressive Behavior (MOAB) courses that provide skills training for management of violent behavior. For more information, contact: REB, P.O. Box 845, Stoddard, NH 03464. Telephone: (603) 446-9393. Fax: (603) 446-9394. E-mail: [email protected]. Web: www.rebtraining.com.
The Emergency Nurses Association (ENA) has a position statement titled Violence in the Emergency Care Setting. All ENA position statements can be accessed from the web site: www.ena.org. (Click on "Programs and Meetings" and then "Position Statements" then scroll down to "Violence in the Emergency Care Setting.") Single copies of position statements are available at no charge. To obtain copies, contact: ENA, 915 Lee St., Des Plaines, IL 60016. Telephone: (800) 243-8362 or (847) 460-4000. Fax: (847) 460-4001. Web: www.ena.org.
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