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Tracy Sanson MD, FACEP

Violence in the Medical Setting 

Gangs tagging the ED ambulance entranceSubmitted by: Selim Suner, MD© 2004 EMedHome.com

Tracy Sanson MD, FACEP

Workplace Violence

The leading killer of working females (35% of fatal work injuries)

The second leading killer of males

Workplace Violence Rates Nearly Triple in Past Ten Years

Workplace homicides by clients has climbed 296% from 1997 to 2007

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Health care workers experience close to two fifths of non-fatal assaults on employees in the United States

Violent incidents are underreported due to multiple reasons

• Staff fear blame for incidents

• Reporting takes time

• Staff feel that reporting is unimportant

ENA survey 2009

50% of ED nurses had experienced violence by patients on the job

> 25% had experienced 20 or more violent incidents in the past three years

U.S. Department of Justice, >400,000 nurses and healthcare professionals are victims of violent crimes in the workplace/yr

Massachusetts Nurses Association

48% of all non-fatal assaults in the U.S. workplace are committed by health care patients

Health care workers suffer violent assaults at a rate 4 times higher than other industries; for nurses and other personal care workers, this rate jumps to 12 times higher than other industries

Emergency Physician study

75% threatened in the last year

28% experienced at least one assault

18% had obtained a gun

12% confronted outside the ED

4% experienced a stalking event

Only 33% had security personnel permanently assigned to ED

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Personalsafetyquestionsforyouremployer

Is there adequate security coverage?

Does the ED treatment area and hospital have secured exterior doors?

Are security assessments done to determine risks and vulnerabilities?

Are there training opportunities for staff?

Is the staff educated and equipped to deal with violent or disruptive behavior?

Does the administration support an aggressive stance against violence?

Hospital back to normal after shots fired in emergency

roomBy First Coast News Staff

JACKSONVILLE, Fl - Shands Jacksonville is back to normal after shots were fired in the emergency room late Wednesday evening.

The patient, a former police Sergeant who was arrested by police in a domestic battery case, apparently grabbed a security guard's gun

Threat or Verbal abuse

Harassing

Intimidating or bullying

Swearing/cursing

Stalking

Outward hostility and aggression is included, even without physical action

Physical Aggression

AssaultGrabbing or shovingKickingSlapping or hitting

Stabbing/ShootingSexual Assault

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Fine Line Factors in a Violent Episode

At risk individual

A perceived or

actual hostile

environment/situation

Triggering event

Patterns and Profiles

Look for patterns rather than individual warning signs

Profiles can help identify potential problems - HOWEVER - they are not all inclusive or exclusive

Causes of WPV

* Stress

* Frustration

* Low self-esteem

* Physical disorder

* Medication reaction

* Mental disorder

* Alcohol use

* Illicit drug use

* Retaliation / revenge

* Gang/social pressure

* Personal gain

* Poor coping skills

* Violation of personal space

* Family disputes

* Debts / gambling problems

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Violent Incidents

75% occur on the evening/night shift

77% of perpetrators are patients

> 20% of patients carry a weapon

Four types of WPV

* Violence by strangers* Violence by clients/patients* Violence by co-workers* Violence from personal relationships

Strangers

Assault, robbery

gang violence, rape

Difficult to prevent

Facilities dealing with money or drugs, trauma treatment, or violent neighborhoods

Can be very violent

Patients et al.

AggressiveAngryConfusedSexually aggressive

Most common type of healthcare violence

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Violence by coworker

Aggressive, intimidating (Bully)

Sexually aggressive

Angry, disciplined or discharged

* Supervisor: Unaware/fails to address

* May continue for extended time

Victims often reluctant to report

Personal relationships

IPV, Child custody

Stalking

Enemies

One’s personal life is private…except when it threatens to disrupt or endanger the work environment

WORKPLACE VIOLENCE

Is the second leading cause of death in the workplace overall

Is the leading cause of death in the workplace for females

1/20 women will be the victim of a stalker

Practice Universal Precautions

Most reliable predictor: history of violence

Anyone has potential for violent behavior

Elderly, demented

Sleeping addict

Ill diabetic

Head Trauma

Post ictal

Delusional

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Associated factors

Age

Injury/Illness

Drug use

SituationsTrauma, Delays, Gangs

Police custody, Death

Environmental

Physical Warning Signs

Gut feeling of fear or threat

Loud, pressured, threatening, profane speech

Increased muscle tension and hyperactivity

* Pacing

* Advancing / retreating

* Clenching fist

* Grimacing

* Frequent change of posture

* Easily startled

Emotional Warning Signs

* Disorientation* Excitability* Euphoria* Manic behavior* Extreme distrust / paranoia

The escalating individual may show some of these emotional signs

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Verbal Warning Signs

* Angry, loud, forceful speech* Fragmented sentences* Defensive, hostile reaction to inquiries* Claims of prior violent acts* Admit to “command hallucinations”

Intentional Escalation

* May be preplanned

* Little advance warning

* Difficult to prevent or to stop

May be trying to “pick a fight”

Less controllable

Not likely to easily de-escalate

Situational Escalation

Aggravating circumstances(delays, rude/condescending speech)* Individual unsuccessful in coping with

steady or escalating pressures Behavior gradually or rapidly escalates

from calm to acting out

Early intervention may prevent escalation Delayed will not

Situational Escalation

Anxiety - behavior is changingRespond supportively

Defensive - losing rationalitySet limits

Acting Out - loss of controlIntervene

Verbal vs VerbalPhysical vs Physical

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Preventing Violent Attacks

Minimize waiting Minimize direct eye contact Avoid direct confrontation Deal with threats by setting and enforcing

limits Avoid disagreements in front of agitated

patients Don’t invade personal space

• Zero Tolerance for Threats

• Required Reporting

• Identify Early Signs

• Provide Employee Assistance

• Be Open and Responsive

• Provide Stress Reduction

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Verbal De-escalation

Project calmness / confidence

Be an empathetic listener

Show interest in the person

Maintain a relaxed but attentive posture, stand at angle from person

When dealing with a violent person:

Assess the situation in your mind

•Project calmness

•Be patient, empathetic, encourage the person to talk

•Focus attention on the person so they feel you are interested in what they have to say

Maintain relaxed yet attentive posture, position yourself at a right angle instead of directly in front of the person

•Ask for small specific favors, such as if you could talk in a quieter area

•Reassure and point out choices

•Arrange yourself so your exit is not blocked

Acknowledge person’s feelings and being upset

Seek small favors

Offer food or drink

Move to quiet area

Set ground rules, consequences

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Reassure / point out choices

Break problems into smaller ones

Accept criticism positively

Avoid the facts

Avoid arguing or defending

Ask for and repeat back recommendations

Don’t make promises you cannot keep

Prepare in advance

Remove free objects

From room

From self

From the patient

Have an escape route

Maintain a safe distance

Appropriate stance

Non confrontational professional attitude

Restraints

Prevent imminent harm to patient or others

When other means of control are ineffective

or inappropriate

Prevent serious disruption of the medical

evaluation and treatment

Prevent significant damage to the physical area

To treat the patient’s medical symptoms

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Restraints

Once the decision has been made:

NO further discussions or negotiations

Clearly state the reason for the restraints and how they will be applied

Never use as a punitive measure or for convenience

•Aspiration•Suffocation•NV compromise•Skin breakdown•Rhabdomyolysis•Death

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Chemical Restraints

Treat the medical process

Use a familiar drug

Use IV if possible

Decrease the dose for elderly

Have resuscitation equipment and antidotes immediately available

Opiates

Pain is the major precipitating factor

Haldol Patient remains responsive

Reduces tension, anxiety, hyperactivity

Benzodiazepines

PO, IM and IV

PO

almost as quick as IM

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# of Security FTEs for ED

# of Other: off duty police, other security

Authorized weapons

Firearm

Baton

Mace/Pepper Spray/Foam

Handcuffs

Tasers

Body armor

Worksite Analysis

Analyzing and tracking records

Screening surveys

Analyzing workplace security

Employee questionnaire or survey: Employees' ideas on the potential for violent incidents, identify or confirm need for improved security measures

Closed-circuit video recording: high-risk areas 24/7

Public safety >than privacy in these situations

Curved mirrors at hallway intersections or concealed areas

Enclose nurses' stations

Install deep service counters or bullet-resistant, shatter-proof glass in reception, triage and admitting areas

Provide employee "safe rooms" for use during emergencies

“Time-out" or seclusion area High ceilings without grids

Minimal furniture in crisis rooms

Lightweight

No sharp corners/edges

Affixed to the floor, if possible

Limit # items that can be used as weapons

Separate rooms for criminal patients

Comfortable waiting rooms: minimize stress

Limit access, secure door access

Arrange room to prevent entrapment

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Engineering controls, workplace adaptations

Lock all unused doors to limit access

in accordance with local fire codes

Install bright, effective lighting, both indoors and outdoors

Replace burned-out lights and broken windows and locks

Metal detectors—installed or hand-held

Metal Detectors

2 security officers

Estimate 10 hrs per day would require 7 full time workers

Cost exceeding $150,000

Hand held wand

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Post incident response

Prompt tx and psychological evaluation regardless of its severity

In addition to actual physical injuries Possible Short & long-term psychological trauma

Fear of returning to work

Relationships change with coworkers & family

Feelings: incompetence, guilt, powerlessness

Fear of criticism by supervisors or managers

Controlled Access

Lockdown

Hostage

Weapon threat

Weapons Screening

Use of Taser or other security tool

Bomb threat

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Hazard Prevention and ControlEngineering Controls

Panic Buttons

Height Marker 

on Exit DoorVideo Surveillance Equipment

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Hazard Prevention and ControlAdministrative & Work Practice Controls

Admin and work practice controls affect the way workers perform jobs or specific tasks (establish a policy of when doors locked)

Prohibit transactions with large bills (over $20)

Increase staffing at past assault sites

Establish liaison with local police and state prosecutors

Lock delivery doors or rear doors

Sample Signage

People who work in this department

should be able

to carry out their work in safety

People demonstrating

violent or aggressive behavior

will be asked to leave

Rural ED’s

Limited resources- minimal security (if any)

Low volume

Many located near exits to major highways and interstates

Staffing – importance of minimum of 2 RNs

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General Awareness

Set up passive protection measures

Body position and distance

Find escape routes

Know where & when

to call for help

Trust your gut instincts

Medical Setting Violence

Significant threat to staff & patients

ED must be assessed and prepared

Staff must be trained

Identify state-specific laws related to health care worker assault

ED & hospital leadership essential

Death is too high a price to pay to practice one’s profession

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DrTracy@TracySansonMD.com

TracySansonMD.com

@TracySansonMD

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Sentinel Event Alert #59: Physical and verbal violence against health care workers

Joint Commission requirements relevant to physical and verbal violence against health care workers

Hospitals | Critical access hospitals | Ambulatory | Office-based surgery Behavioral health | Home care | Laboratory | Nursing care centers HOSPITALS

Environment of Care (EC)

EC.01.01.01 Element of Performance (EP) 4: The hospital has a written plan for managing the following: The environmental safety of patients and everyone else who enters the hospital’s facilities.

EC.01.01.01 EP 5: The hospital has a written plan for managing the following: The security of everyone who enters the hospital’s facilities.

EC.02.01.01 EP 1: The hospital implements its process to identify safety and security risks associated with the environment of care that could affect patients, staff, and other people coming to the hospital's facilities. Note: Risks are identified from internal sources such as ongoing monitoring of the environment, results of root cause analyses, results of proactive risk assessments of high-risk processes, and from credible external sources such as Sentinel Event Alerts.

EC.02.01.01 EP 3: The hospital takes action to minimize or eliminate identified safety and security risks in the physical environment.

EC.02.01.01 EP 7: The hospital identifies individuals entering its facilities. Note: The hospital determines which of those individuals require identification and how to do so.

EC.02.01.01 EP 8: The hospital controls access to and from areas it identifies as security sensitive.

EC.04.01.01 EP 1: The hospital establishes a process(es) for continually monitoring, internally reporting, and investigating the following: - Injuries to patients or others within the hospital’s facilities - Occupational illnesses and staff injuries - Incidents of damage to its property or the property of others - Security incidents involving patients, staff, or others within its facilities - Hazardous materials and waste spills and exposures - Fire safety management problems, deficiencies, and failures - Medical or laboratory equipment management problems, failures, and use errors - Utility systems management problems, failures, or use errors Note 1: All the incidents and issues listed above may be reported to staff in quality assessment, improvement, or other functions. A summary of such incidents may also be shared with the person designated to coordinate safety management activities. Note 2: Review of incident reports often requires that legal processes be followed to preserve confidentiality. Opportunities to improve care, treatment, or services, or to prevent similar incidents, are not lost as a result of following the legal process.

EC.04.01.01 EP 3: Based on its process(es), the hospital reports and investigates the following: Injuries to patients or others in the hospital’s facilities.

© 2018 The Joint Commission | Published by the Department of Corporate Communications jointcommission.org

What is workplace violence? The CDC National Institute for Occupational Safety and Health (NIOSH) defines workplace violence as “violent acts (including physical assaults and threats of assaults) directed toward persons at work or on duty.2 The U.S. Department of Labor defines workplace violence as an action (verbal, written, or physical aggression) which is intended to control or cause, or is capable of causing, death or serious bodily injury to oneself or others, or damage to property. Workplace violence includes abusive behavior toward authority, intimidating or harassing behavior, and threats.3

A complimentary publication of The Joint Commission Issue 59, April 17, 2018 Physical and verbal violence against health care workers

“I’ve been bitten, kicked, punched, pushed, pinched, shoved, scratched, and spat upon,” says Lisa Tenney, RN, of the Maryland Emergency Nurses Association. “I have been bullied and called very ugly names. I’ve had my life, the life of my unborn child, and of my other family members threatened, requiring security escort to my car.”1 Situations such as these describe some of the types of violence directed toward health care workers. Workplace violence is not merely the heinous, violent events that make the news; it is also the everyday occurrences, such as verbal abuse, that are often overlooked. While this Sentinel Event Alert focuses on physical and verbal violence, there is a whole spectrum of overlapping behaviors that undermine a culture of safety, addressed in Sentinel Event Alert issues 40 and 57;2,3 those types of behaviors will not be addressed in this alert. The focus of this alert is to help your organization recognize and acknowledge workplace violence directed against health care workers from patients and visitors, better prepare staff to handle violence, and more effectively address the aftermath.

Each episode of violence or credible threat to health care workers warrants notification to leadership, to internal security and, as needed, to law enforcement, as well as the creation of an incident report, which can be used to analyze what happened and to inform actions that need to be taken to minimize risk in the future. Under The Joint Commission’s Sentinel Event policy, rape, assault (leading to death, permanent harm, or severe temporary harm), or homicide of a patient, staff member, licensed independent practitioner, visitor, or vendor while on site at an organization is a sentinel event that warrants a comprehensive systematic analysis. While the policy does not include other forms of violence, it is up to every organization to specifically define acceptable and unacceptable behavior and the severity of harm that will trigger an investigation. The Centers for Disease Control and Prevention (CDC) National Institute for Occupational Safety

and Health (NIOSH) defines workplace violence as “violent acts (including physical assaults and threats of assaults) directed toward persons at work or on duty. 4 The U.S. Department of Labor defines workplace violence as an action (verbal, written, or physical aggression) which is intended to control or cause, or is capable of causing, death or serious bodily injury to oneself or others, or damage to property. Workplace violence includes abusive behavior toward authority, intimidating or harassing behavior, and threats.5

Published for Joint Commission accredited organizations and

interested health care professionals, Sentinel Event

Alert identifies specific types of sentinel and adverse events

and high risk conditions, describes their common

underlying causes, and recommends steps to reduce

risk and prevent future occurrences.

Accredited organizations should

consider information in a Sentinel Event Alert when

designing or redesigning processes and consider

implementing relevant suggestions contained in the

alert or reasonable alternatives.

Please route this issue to appropriate staff within your organization. Sentinel Event

Alert may be reproduced if credited to The Joint

Commission. To receive by email, or to view past issues,

visit www.jointcommission.org.

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From People in Crisis (6th ed.), by Lee Ann Hoff

ASSAULT & HOMICIDAL DANGER ASSESSMENT TOOL Key to Danger

Immediate Dangerousness to Others Typical Indicators

1 No predictable risk of assault or homicide

Has no assaultive or homicidal ideation, urges, or history of same; basically satisfactory support system; social drinker only

2 Low risk of assault or homicide

Has occasional assault or homicidal ideation (including paranoid ideas) with some urges to kill; no history of impulsive acts or homicidal attempts; occasional drinking bouts and angry verbal outbursts; basically satisfactory support system

3 Moderate risk of assault or homicide

Has frequent homicidal ideation and urges to kill but no specific plan; history of impulsive acting out and verbal outbursts while drinking, on other drugs, or otherwise; stormy relationship with significant others with periodic high-tension arguments

4 High risk of homicide Has homicidal plan; obtainable means; history of substance abuse; frequent acting out against others, but no homicide attempts; stormy relationships and much verbal fighting with significant others, with occasional assaults

5 Very high risk of homicide Has current high-lethal plan; available means; history of homicide attempts or impulsive acting out, plus feels a strong urge to control and “get even” with a significant other; history of serious substance abuse; also with possible high-lethal suicide risk