Safe Haven

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Every emergency department nurse has a story about being faced with violence at work, directed at them, their colleagues, the ED physician, techs and even other patients.

While violence has been increasing across the healthcare continuum, the ED seems to be at the epicenter, and no hospital, large or small, is immune.

Security First

Under terms of the Emergency Medical Treatment and Active Labor Act, any patient who comes to the ED seeking treatment must be given an appropriate medical exam to determine if an emergency medical condition exists.

In other words, anyone who presents to your ED requesting treatment must be seen.

A 2012 Agency for Healthcare Research and Quality study showed nearly 70 percent of weekend admissions and 40 percent of weekday admissions come through the ED.

Add the numbers of people who use the ED as their primary care provider and you have a potentially volatile situation, with overcrowding, long wait times and frustration in the mix.

That can lead to disaster, said Fredrick Roll, MA, CHPA-F, CPP, president of Healthcare Security Consultants, Frederick, CO.



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Roll, a leading expert on hospital security, said that, because most patients in the ED don’t want to be there, the environment is already primed for potential violence.

Additionally, patients with psychiatric co-morbidities also can contribute to the problem.


“The best case is that nothing will happen, but you can’t plan on that,” he said.

“Hospitals across the country are beginning to take the threat of violence against staff seriously, especially in the ED, because avoiding the situation could be much more costly to them in the long run.

“Good security is good customer service.”

The staff at Antelope Valley Hospital in Lancaster, CA, took that advice to heart after an armed man came to the ED looking for someone he had a grudge against.

Not finding him, the armed man left without firing a shot, but it was the tipping point for the hospital’s administration and security.

Now, the ED is staffed 24/7 with a company of nine security agents, and patients go through a metal detector before entering.

And, with gang activity in the region east of Los Angeles on the rise, a policy is in place to lock the entire facility down if a patient comes with gang-related injuries.

Be Prepared

Roll councils more than 200 hospitals nationally on security issues, starting with the ED.

He begins with a checklist hospitals can use to improve safety for workers, patients and visitors.

“Everything begins with common sense,” he said.

“ED managers must review security plans and incident reports at least annually, more often if there’s an issue. Next, follow the plan and make sure all employees – not just nurses and physicians – know what to do.”

First up on Roll’s list is access – make sure every entrance is secure.

This includes not only the main doors into the ED, but secondary entrances, treatment rooms, the reception/waiting area and outside doors.

Is the reception area safe? If not, consider putting up bulletproof glass walls or other barriers.


If a violent situation arises, does staff know how to respond?

Do you screen every person who comes to the ED, or look for people who seem dangerous?

Every hospital must have a lockdown protocol ready to go, with key staff in place to call it.

Don’t wait for a violent incident to talk about the possibility one might occur. Have processes in place for staff to talk about it should one happen, so security can be assessed and tightened, if need be.

All patients aren’t violent, but some might have the potential to become violent.

Train nurses and other ED staff to see that potential, and use the contact with first responders, EMTs and police officers to get a handle on patients who may have acted out on the way to the ED.

Warning signs can include pacing or restlessness, increasingly loud speech or insisting on being seen immediately.


“The question I always ask clients is, “What would you do differently tomorrow if you had an adverse incident today?” Roll said.


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“Hospitals need to have reasonable and appropriate security, based on their size, the number of ED visits they have annually, their patient mix, hospital services (are they a trauma center?), market demographics and local crime rates.

“They need to find the line between being wide open and totally secure to be able to both care for patients and protect their staff.”


Nursing Care

In a 2002 Emergency Nurses Association study, every nurse in the study said they had been verbally assaulted.

More than 80 percent said they also had been physically assaulted by patients or family members of patients. Unfortunately, those numbers have not gone down in the ensuing decade.

Within days of receiving a level III trauma designation in September 2011, NorthBay Medical Center in Fairfield, CA, found itself caring for gunshot victims, gang violence and a host of other cases that pushed their security system.

Daman Mott, MSN, RN, director of emergency services and trauma, said staff safety is always uppermost in his mind.

“Fairfield has experienced a declining economy and an increase of gang activity,” he said.

“As a result, we not only have to be prepared for anything here medically, but we have to be ready to protect our staff and anyone else who might be in danger.”

Despite the increase in violent crime, Mott said most ED visits are more low key.

“Outbursts are more likely to come from a patient or visitor who is overwhelmed than from a gun-carrying gang member.”

NorthBay has constant security on-site to ensure situations don’t get out of hand, but Mott and his team also use safe practices.

ED nurses have strong assessment skills, and are trained to use those skills to watch for situations that could become problems, Mott said.

“We use therapeutic diffusion to work with patients who are anxious or have run out of patience with us,” he said.

“We would rather stop a situation before it escalates than deal with it after it has.”

Candy Goulette

is a frequent contributor to ADVANCE.

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