R E V I E W S & A N A LY S E S Survey of Emergency Department Practices in Pennsylvania Hospitals to Protect Patients and Staff Denise Martindell, RN, JD INTRODUCTION Senior Patient Safety Analyst Pennsylvania Patient Safety Authority The incidence of workplace violence experienced by emergency department (ED) staff is well documented. Reports indicate that nurses experience work-related crime at least twice as often as any other healthcare provider.1 An Emergency Nurses Associa- tion 2009 ED violence surveillance study showed that of 2,907 emergency nurses who reported a violent experience, 54.8% reported having experienced physical violence ABSTRACT or verbal abuse from a patient or visitor during a seven-day calendar period. More The incidence of workplace violence than half of those reported experiencing more than one incident of patient or visitor experienced by emergency department violence during this period.2 Physicians also experience a high rate of violence in the (ED) staff is well documented. Protect- ED. Behnam et al. estimated the rate of violence against ED physicians and residents ing ED staff from violent individuals will by surveying residents and faculty ED physicians of 65 randomly selected residency enable staff to provide safe and optimal programs nationwide.3 More than 75% of respondents experienced a violent act while care to patients. Equally important are working in the ED. The most common violent acts were verbal threats (75%) followed the safeguards that protect patients by physical assaults (21%), confrontations outside the workplace (5%), and stalking and visitors from violent acts from any (2%). One in 10 was threatened with a weapon (knives or guns). Full-time security was source in the ED. In June 2011, the available in most settings (98%), but was least likely to be physically present in patient Pennsylvania Patient Safety Authority care areas. The majority of respondent EDs did not screen for weapons (60%) or have conducted a survey to study violence metal detectors (62%). Only 16% of programs provided violence workshops, and fewer protection practices in Pennsylvania than 10% offered self-defense training. acute care hospitals. The survey also A considerable variability in ED security programs has been demonstrated in the examined potential barriers to compli- literature. A cross-sectional survey of security programs conducted among New Jersey ance. Survey findings showed potential hospitals from 2003 through 2005 examined ED security programs and employee gaps in violence protection practices. assault rates in EDs with different financial resources, sizes, and background community For example, mandatory violence crime rates.4 Small hospitals in towns with low community crime rates implemented prevention training for ED staff was the fewest security program elements and provided less funding for security programs, reported by only 36% of respondents. despite having the second highest rate of assault-related Occupation Safety and Health Eighty-seven percent of respondents Administration (OSHA) recordable injures among ED staff. Large hospitals had lower indicated that the ED did not have a employee assault rates irrespective of where they were located. The authors conclude designated area for holding prison- that due to the highly stressful workplace characteristics of EDs, the risk of employee ers. Thirty-four percent of respondents assault is likely to be universal among all hospital sizes in all types of communities; reported that hands-free personal therefore, a comprehensive security program is needed in all hospital EDs.4 communication devices and other communication equipment, such as Not only is ED staff exposed to violence, but patients are at risk. A 2010 Joint walkie-talkies, were used in the ED. Commission Sentinel Event Alert advises that patients are at risk from violence Ninety-three percent of respondents entering from outside the hospital.5 According to security consultant Russell Colling, reported that ED staff did not wear a MS, CHPA, “The most important factor in protecting patients from harm is the personal alarm. Gaps in violence pro- caregiver . . . ”5 Accordingly, ED staff must be educated and enabled to protect tection practices identified through the themselves in order to help ensure a safe environment for patients. survey suggest opportunities for improv- ing violence protection practices to REPORTS TO THE AUTHORITY increase the safety of both ED staff and A search of the Pennsylvania Patient Safety Authority reporting system database for patients. At the facility level, awareness reports from the ED using words related to violence showed that from 2006 through of knowledge gaps and/or compliance 2010, Pennsylvania healthcare facilities reported 384 events of violent acts or verbal gaps as compared to best practices abuse. This is no doubt an underestimate of the number of relevant reports actu- will also facilitate targeted allocation of ally submitted by Pennsylvania hospitals, because most assaults and other potentially resources. (Pa Patient Saf Advis 2011 criminal events are reported as Infrastructure Failures and are accessible only to the Dec;8[4]:126-130.) Pennsylvania Department of Health. The 384 events reported as Serious Events and Incidents include 266 (69%) cases of verbal abuse or threats. The remaining 188 events were cases of physical violence in the ED. Of the total events, 3% were reported as a Serious Event. In 85% of the reported Serious Events, the patient sustained an injury. Page 126 Pennsylvania Patient Safety Advisory Vol. 8, No. 4—December 2011 ©2011 Pennsylvania Patient Safety Authority Both patient and staff were reported Table. Response to Violent Events in the Emergency Department (N = 384), Reported to injured in three events. Respondents the Pennsylvania Patient Safety Authority, 2006 through 2010 reported that the ED staff responded to POLICE SECURITY these violent events in a number of ways, OFFICERS OFFICERS USE OF including summoning security staff or CALLED CALLED TO USE OF PEPPER USE OF the police department to the ED or using TO ED THE ED RESTRAINTS SPRAY A TASER® methods to help subdue a violent patient 34 (9%) 84 (22%) 32 (8%) 4 (1%) 2 (<1%) to protect the patient, the staff, and other patients. The Table shows those reported responses to violent events in the ED. side and also pulled out the [intrave- All results are published anonymously in The following are examples of reports nous line] in an arm. Security, the the aggregate. submitted to the Authority related to ED nursing supervisor, and the police violence. were called. Per the nurse, “I was Methods and Limitations kicked in the side and punched on The Authority distributed online surveys A safety security officer responded to side of the face by patient.” to acute care hospital patient safety officers the ED for a disorderly patient. Upon arrival, contact was made with ED Police officers brought a violent and (PSOs) in June 2011. Of 157 surveys sent doctor and nurse practitioner, who aggressive patient to the ED. The to Pennsylvania acute care hospitals, 94 reported the patient was at the ED patient was placed in the observation (60%) surveys were returned; of these, 71 seeking medications for his illness and room of the ED. The patient became (76%) of respondents were identified by a was threatening staff verbally and violent and punched the seclusion facility-specific numeric code for purposes yelling and screaming. The doctor room door. Following this, there was of analysis. The 71 identifiable individual reported that there was nothing else a scuffle between police officers, secu- respondents represent 65 hospitals, or 41% the doctor could do for the patient rity, and the patient. The patient was of all hospitals that received a survey. Not all and requested that man be removed Tasered once. . . respondents answered each survey question. from the ED. The man was noted to Response rates are based on actual responses be yelling, screaming, and using pro- AUTHORITY SURVEY OF ED for each individual question. fanity while sitting in the treatment VIOLENCE PROTECTION area. The man was asked several PRACTICES RESULTS times by the undersigned to calm After analysis of events reported to the down; however, he refused to do so. ED Volume Authority, the high incidence of violence The man refused any and all offers of Survey participants were asked about against ED staff, and the potential assistance from ED staff and doctors. the annual volume of patients treated in variability of security programs and The man was then escorted from the the ED. Of the 65 hospitals represented resources as reported in the literature, ED as well as from hospital property. in the survey, representatives of 58 the Authority elected to study the A patient became belligerent and implementation of ED violence protection responded to this question. The results loud with foul language after an offer best practices in Pennsylvania acute are shown in Figure 1. of prescription for a non-steroidal care hospitals. The Authority developed medication. Security was called, a survey based on the International Individual Participants and the patient demanded to leave Association for Healthcare Security Survey participants were asked to identify with narcotics, while acting violent and Safety (IAHSS) safety program in their job designation (e.g., title). Thirty- and swinging his arms at staff. [The healthcare, OSHA guidelines, and other nine percent of respondents identified patient was] escorted out of the ED current literature.3,4,6-8 Survey content themselves as an ED physician director by security while maintaining loud was also developed and reviewed in and 31% as the ED security director. The verbal abusive language toward staff collaboration with expert ED practitioners remaining 30% of respondents repre- in the waiting room. and security officers. To increase response sented diverse job titles, such as ED nurse A patient kicked and punched an rates, the survey was distributed online, manager, director of nursing, PSO, risk ED nurse while the patient was accompanied by a letter of endorsement manager, director of support services, or being restrained. The patient ripped by the Pennsylvania Chapter of the director of clinical operations. off the four-point restraints on one American College of Emergency Physicians. Vol. 8, No. 4—December 2011 Pennsylvania Patient Safety Advisory Page 127 ©2011 Pennsylvania Patient Safety Authority R E V I E W S & A N A LY S E S Figure 1. Average Annual Emergency Department Volume, According to Pennsylvania of respondents reported that the ED Patient Safety Authority Survey of Violence Prevention Practices, June 2011 had a policy and procedure to follow if a weapon was fired in the ED. NUMBER OF RESPONSES ED Monitoring and Access IN HOSPITALS 25 Survey participants were asked questions about monitoring of the ED, including 22 identification of visitors, access to the 20 ED, and the presence of security cameras. More than half of respondents reported 16 that visitors were required to check into 15 the ED (61%), and 23% required visitors to wear a visitor badge for identification. 11 The majority of respondents indicated 10 that access was restricted to the ED; 87% reported restricted access to the ED treat- ment area from the waiting room, and 5 74% reported restricted access from the 5 4 hospital into the ED (e.g., badge required for entrance to the ED from the hospital). MS11601 Of the respondents that reported the 0 <20,000 20,000 - 40,000 - 60,000 - >80,000 use of security cameras in the ED wait- 39,999 59,999 80,000 ing room (87%), more than half (53% ) reported the cameras were monitored 24 EMERGENCY DEPARTMENT VOLUME hours a day, 7 days a week. When security cameras are used in the ED treatment ED Security of respondents reported that security areas (31%), 40% of respondents reported To ensure security of patients and visi- officers did not carry firearms. Protec- that the cameras were monitored 24 hours tors, hospitals employ security personnel tive devices used by security officers were a day, 7 days a week. The lower percentage or hire outside security services. Survey pepper foam/spray (22%), batons (10%), of respondents that reported the presence respondents were asked about the type, conducted energy weapons (e.g., Taser®) and monitoring of security cameras in the availability, and training of security ser- (9%), and handcuffs (1%). The remainder ED treatment area compared to moni- vices available in the ED. Sixty (71%) of respondents (58%) reported either toring of the ED waiting room may be respondents have security officers that are “unknown” or “none of the above,” sug- related to patient privacy concerns. hospital employees; of those, 31% have gesting that more than half of security security officers that are hospital employ- officers may not use protective equipment ED Designated Areas ees who are available in the ED 24 hours in the ED. EDs may have a designated area or sepa- per day, 7 days per week, and more than Survey participants were asked about rate room for certain patient populations half (59%) have security officer employees screening practices in the ED for weapons to help ensure the safety of the patient, who are not stationed in the ED full time or other potentially dangerous items. The visitors, and staff. Of note, a majority of but are available to the ED full time. Fifty- majority of respondents reported that respondents (87%) indicated that the ED one percent of all respondents reported metal detectors (86%) or x-ray scanners did not have a designated area for prison- that ED security officers were required (100%) were not used to screen patients, ers. The 2010 IAHSS survey describes to complete a national training program, visitors, or belongings. However, 79% of the increasing number of forensic and such as Management of Aggressive respondents reported that the ED had psychiatric patients as a growing concern Behavior or Crisis Prevention Institute a written policy and procedure to follow among security professionals because programs. Survey participants were asked if a weapon or other potentially danger- these patients are considered high risk in about the use of protective equipment by ous item was found in the possession of terms of potential violence and danger ED security officers. Ninety-three percent a patient or visitor. Almost half (48%) to staff.8 Figure 2 depicts the availability Page 128 Pennsylvania Patient Safety Advisory Vol. 8, No. 4—December 2011 ©2011 Pennsylvania Patient Safety Authority of a designated area or separate room for Figure 2. Emergency Department Designated Patient Areas, According to Pennsylvania categories of patients that may pose a risk Patient Safety Authority Survey of Violence Prevention Practices, June 2011 to themselves or others. PERCENTAGE ED Staff Communication Devices 100 The survey included questions about the YES YES YES availability of personnel protection devices 69% 70% 13% and alarms in the ED. Almost three- NO quarters of respondents (71%) reported 80 87% that the ED had panic buttons placed throughout the ED. These devices may be used by ED staff to summon assistance in 60 a situation in which violence is threatened or occurring. Personal communication devices and alarms were generally not available. Only 34% reported that hands- 40 free personal communication devices and other communication equipment, such as walkie-talkies, were used in the ED. NO NO Ninety-three percent reported ED staff 20 31% 30% did not wear a personal alarm. YES MS11602 Self-Defense Training and ED 13% Violence Prevention Programs 0 BEHAVIORAL AGGRESSIVE PRISONERS According to Blando et al., a significant HEALTH PATIENTS PATIENTS degree of variability among hospital ED SEPARATE AREA FOR PATIENT security programs is thought to be due in part to absence of federal legislation requiring baseline security features. More- employees. Violence prevention training workplace (e.g., a defined approach to vio- over, nationally, OSHA guidelines for was reported to be mandatory for ED staff lent patient or visitor behavior, including the protection of healthcare workers are by 36% of respondents. steps to stop unacceptable behavior and voluntary.4 Similarly, results of a survey Participants were asked to choose all removal of the individual from the ED if of workplace violence across 65 U.S. EDs barriers to compliance with a violence required). Fifty-five percent of participants showed that fewer than half the EDs protection plan that applied. The respon- reported that the ED performed a safety had violence training programs for staff, dents could choose more than one answer assessment within the past year. although little data is available to prove and identified insufficient staff training that these programs actually reduce the (70%) and that the time required to RISK REDUCTION STRATEGIES number of events. The authors conclude comply with the program was prohibitive Survey findings show a number of poten- that the efficacy of violence prevention (70%) as the major barriers, followed by tial areas for improvement: programs needs further study.9 cost factors (65%) and lack of a perceived — Sixty-nine percent of respondents do Authority survey participants were asked need to comply due to low volume of vio- not have a security officer available about self-defense and violence preven- lent acts in the ED (48%). Other barriers in the ED 24 hours per day, 7 days tion training for hospital employees and entered in free-text fields by participants per week. ED staff. Similar to the aforementioned included failure to identify acts of vio- lence, high turnover of ED staff, and lack — The majority of respondents studies, fewer than half of respondents reported that metal detectors (86%) (32%) reported that their hospital offers of approval for the use of metal detectors. More than half of respondents (64%) or x-ray scanners (100%) were not self-defense training for employees, and used to screen patients, visitors, or 68% responded that their hospital offers reported that their hospital has a zero tolerance policy for violence in the ED belongings for weapons or other violence prevention training to hospital potentially dangerous items. Vol. 8, No. 4—December 2011 Pennsylvania Patient Safety Advisory Page 129 ©2011 Pennsylvania Patient Safety Authority R E V I E W S & A N A LY S E S — Personal communication devices [online]. Sentinel Event Alert CONCLUSION and alarms are generally not avail- 2010 Jun 3 [cited 2010 Nov 15]. Analysis of events reported to the Author- able to ED staff. Sixty-six percent of Available from Internet: http:// ity reporting system database showed that respondents reported that hands-free www.jointcommission.org/ from 2006 through 2010, Pennsylvania personal communication devices and sentinel_event_alert_issue_45_ healthcare facilities reported 384 events of other communication equipment, preventing_violence_in_the_health_ violent acts or verbal abuse. Although they such as walkie-talkies, were not used care_setting_/. represent an underestimated number of in the ED. Ninety-three percent — Occupational Safety and Health relevant events actually reported by Penn- reported ED staff did not wear a Administration (OSHA). Guidelines sylvania hospitals for reasons cited above, personal alarm. for preventing workplace violence for the event reports show that staff and — Eighty-seven percent of respondents health care & social service workers patients have been harmed. The Author- indicated that the ED did not [online]. [cited 2011 Aug 15]. Avail- ity’s survey was intended to study violence have a designated area for holding able from Internet: http://www. protection practices in Pennsylvania acute prisoners. osha.gov/Publications/OSHA3148/ care hospitals and has demonstrated — Thirty-nine percent of respondents osha3148.html . a number of potential gaps in those reported that violence prevention — Occupational Safety and Health practices that suggest opportunities for training was mandatory for ED staff. Administration (OSHA). Healthcare improving violence protection practices The following resources can provide guid- wide hazards: workplace violence [Hos- to increase the safety of both ED staff and ance and information on the development pital eTool online]. 2008 Mar 6 [cited patients. Identification of these gaps can of policies and procedures to prevent vio- 2011 Aug 18]. Available from Internet: also facilitate the development of train- lence in the ED: http://www.osha.gov/SLTC/etools/ ing programs on a statewide level. The hospital/hazards/workplaceviolence/ Authority will be publishing additional — Emergency Nurses Association guidance on gaps in ED violence preven- viol.html. Institute for Emergency Nursing tion practices identified by the survey in Research. Emergency department — International Association for Health- care Security and Safety. Healthcare a future issue of the Pennsylvania Patient violence surveillance study [online]. Safety Advisory. 2010 Aug [cited 2011 Aug 18]. Avail- security: basic industry guidelines able from Internet: http://www. [online]. [cited 2011 Aug 20]. ACKNOWLEDGMENTS ena.org/IENR/Documents/ Available from Internet: http:// John J. Kelly, DO, FACEP FAAEM, FCPP Albert , , ENAEDVSReportAugust2010.pdf. www.iahss.org/About/Guidelines- Einstein Medical Center, and AnnMarie Papa, Preview.asp. DNP RN, CEN, NE-BC, FAEN, Emergency , — Joint Commission. Preventing Nurses Association, contributed to the survey design for the data discussed in this article. violence in the health care setting NOTES 1. Gallant-Roman MA. Strategies and employee assaults. J Emerg Med 2009 7. Occupational Safety and Health Admin- tools to reduce workplace violence. Jan 2. istration. Guidelines for preventing AAOHN J. 2008 Nov;56(11):449-454. 5. Joint Commission. Sentinel Event workplace violence for health care & 2. Emergency Nurses Association. Emer- Alert. Issue 45. Preventing violence social service workers [online]. [cited gency department violence surveillance in the health care setting [online]. 2011 Aug 15]. Available from Internet: study [online]. 2010 Aug [cited 2011 2010 Jun 3 [cited 2011 Mar 29]. http://www.osha.gov/Publications/ March 28]. Available from Internet: Available from Internet: http://www. OSHA3148/osha3148.html. http://www.ena.org/IENR/Documents/ jointcommission.org/assets/1/18/ 8. Mikow Porto VA, Smith T. The IAHSS ENAEDVSReportAugust2010.pdf. SEA_45.PDF. 2010 crime and security trends survey. 3. Behnam M, Tillotson RD, Davis SM, 6. International Association for Health- J Healthc Prot Manage 2010;26(2):1-23. et al. Violence in the emergency depart- care Security and Safety. IAHSS 9. Kansagra SM, Rao SR, Sullivan AF, et al. ment: a national survey of emergency Guideline 02.07 Program Management. A survey of workplace violence across medicine residents and attending physi- Security and Deployment [online]. 2010 65 U.S. emergency departments. Acad cians. J Emerg Med 2011 May;40(5):565-79. Oct [cited 2011 Aug 16]. Available from Emerg Med 2008 Dec;15(12):1268-74. 4. Blando JD, McGreevy K, O’Hagan E. Internet: http://www.iahss.org/About/ Emergency department security Guidelines-Preview.asp. programs, community crime, and Page 130 Pennsylvania Patient Safety Advisory Vol. 8, No. 4—December 2011 ©2011 Pennsylvania Patient Safety Authority PENNSYLVANIA PATIENT SAFETY ADVISORY This article is reprinted from the Pennsylvania Patient Safety Advisory, Vol. 8, No. 4—December 2011. The Advisory is a publication of the Pennsylvania Patient Safety Authority, produced by ECRI Institute and ISMP under contract to the Authority. Copyright 2011 by the Pennsylvania Patient Safety Authority. This publication may be reprinted and distributed without restriction, provided it is printed or distributed in its entirety and without alteration. Individual articles may be reprinted in their entirety and without alteration provided the source is clearly attributed. This publication is disseminated via e-mail. To subscribe, go to http://visitor.constantcontact.com/ d.jsp?m=1103390819542&p=oi. 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