Violence in the ED Reaches a Crisis Point

The emergency department has always been a dangerous place, but a recent confluence of factors has combined to create a crisis of violence.

It seems that nearly every day there are reports of deaths by shootings. Last fall, we were horrified when two off-duty police offers shot the unarmed son of a Texas physician in a hospital behavioral unit. Virtually all emergency physicians have personally experienced or witnessed a violent incident in the ED. Hospital staff and physicians experience double the rate of work injuries when compared to all other occupations with the exception of police forces and the military. The next question, then, is this: Is ED violence getting worse, or is our perception warped by the media? Our research says it is actually getting worse [1-10]. Here’s why, and how we can begin to address the problem.

Changing Patient Populations
The ED patient population has changed over the years. We see far more violent and psychotic patients due to closures of state psychiatric and local mental health clinics and the reduction or elimination of psychiatric/behavioral hospital beds [12-13]. EDs have become the de facto first line of treatment for mental health patients. At the same time, designer drugs, cheaper heroin, methamphetamines, PCP, cocaine and prescription drug abuse all contribute to ever increasing drug and/or alcohol abusing population.

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A Supreme Court decision in 1976 (Estelle v Gamble 495 US 97) ruled that prisoners have a constitutional right to appropriate medical care. They are sent to EDs for diagnosis, treatment and referral. Numerous media reports show a high rate of violent incidents associated with inmate patients, including shootings and deaths. One study found that 1.9 attempted or completed escapes by prisoners from the ED or other hospital clinics transpire weekly [17]. Few EDs are adequately prepared to deal with prisoner patients.

On an already demanding Saturday night, you witness a disruption outside the entrance when a car pulls up. A couple of bleeding and non-responsive young men are pushed into the ED. Then another car arrives. Suddenly, the ED is filled with tension as taunts, threats and challenges are exchanged. Guns are drawn before security arrives, and the ED becomes a potentially deadly place. The growing number of gangs, found in nearly every community in the nation, has exponentially increased the likelihood of violence in the ED [18], since gang warfare often does not stop at the ED door.

We know that violence in the ED is not a new issue, but there is growing evidence suggesting that changing patient populations combined with increased access to weapons, both legal and illegal, have created an unprecedented crisis in EDs [19-21].

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Understanding
Violence Unfortunately, we have no definitive data on the actual number of violent incidents that take place in EDs. Hospitals are not required to report violent events to any national or state agency, with the recent exception of California (2016, State of California Department of Industrial Relations Labor Code, Section 6401.8). That is not to say that we don’t report incidents. In fact, most hospitals have policies encouraging or requiring internal reports.

The 2016 California legislation is unprecedented. The law requires that by January 1, 2017, all violent events that take place in hospitals or healthcare settings must be reported. The legislation also prohibits hospitals from taking punitive or retaliatory actions against employees who seek assistance and intervention when they are victims of violence. Furthermore, it requires that hospitals document and retain a written record of any violent incident against a hospital employee or other healthcare worker. The information will be made available on public websites beginning in 2018.

Why is this law crucial? All studies and reports on hospital violence currently rely on voluntarily reported data. When reported, ED violence is likely underreported: it happens so frequently, and busy staff members do not have the time to fill out incident reports [8,23].

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Hospital Security Staff
EDs rely on their hospital security staff to prevent and handle violence. What types of individuals are hired as hospital security staff? They are often retired police officers or former military police officers. Some come from private security staff. Our team surveyed U.S. hospitals to obtain focused data about hospital security [21]. Based upon survey responses, 82% of hospital security guards were unarmed. However, 62% of hospitals called for outside police assistance 150 times in 2011, while 14% of hospitals called for outside police assistance more than 100 times per year. By 2013, 74% of hospitals called for outside help more than 50 times per year and 22% called more than 100 times per year. The majority of EDs now rely on a combination of hospital security and local police. But do these practices make a difference in our safety?

We were unable to find many solid facts about this topic. What we do know is that hospital security staff is trained for work in a hospital setting, but we don’t know whether arming them reduces violence in the ED. Nor do we know how much their training focuses on effective methods for determining when situations require the use of weapons (tasers, batons, guns, etc.) or restraints (e.g., handcuffs, body holds). Relying on outside police professionals brings additional concerns. Police forces are trained to use weapons in violent situations, but we don’t know the extent to which they are trained to de-escalate highly volatile situations common to EDs.

Factors that Affect the Likelihood of Violence in the ED
EDs are the single portal of entry to medical treatment in an urgent situation. But the very design of EDs may contribute to its inherent risk for violence. With rare exceptions, our hospitals are spread over wide expanses and are open to the public twenty-four hours a day. But open access presents a dilemma: How do we maintain open public access while minimizing danger or preventing entry of those who constitute a security risk? Published studies and reports have additionally identified a couple of factors that are associated with ED violence, some of which are patient, personnel, and ED design factors.

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Violence and Hospital Administration
Probably one of the greatest nightmares for hospital administrators is a highly publicized report of a violent event in an ED, particularly when injury or death occurs. In the competitive contest for patients, administrators fear that a poor public image will result in patients seeking treatment from other hospitals or clinics. When patients go to competitors, the overall financial health of the hospital is impacted.

Administrators also fear litigation when violence occurs, even if hospitals are not found culpable. In the absence of reliable comparative information about hospital violence in their own and other hospitals, it is difficult for hospital administrators to gauge the extent to which their particular hospital or facility is safer or less safe than competing organizations. When officials don’t know the facts, they may postpone or eliminate resources needed to improve safety in the ED.

Solutions – Ways to decrease violence in the ED
While there is evidence to support the perception that violence is increasing in the ED, there is scant evidence in what constitutes the most efficient and validated ways to reduce it. We found a small number of studies30 showing that metal detectors or hand-held weapons scanners reduce the number of weapons brought into the ED, although the public and hospital administrators sometimes find such methods objectionable.

There is little evidence that arming more security staff is effective in reducing violence in the ED. In fact, a few studies have shown the opposite effect: more armed hospital security staff and the use of armed police forces result in more shootings [32-33]. Some states have made assaults on healthcare workers a felony crime. To date, however, little is known about the effectiveness of this method for deterring violence.

Other suggested solutions involve the use of video and body cameras. Video cameras that are continuously monitored both inside and outside the ED can help reduce violence by identifying suspicious, secretive, or angry individuals and preventing access. Some studies have shown that behavioral cues such as pacing, furtive looks and staring, demanding attention, cursing, aggressive statements and threats, resisting treatment, and clenched fists are precursors to violence [34-35].

Several hospitals, in areas with high gang activity, have experimented with the use of former gang members as consultants to reduce the threat of gang violence. Johns Hopkins and hospitals in Chicago, Philadelphia, Oakland, Los Angeles, and Portland found that former gang members, trained to convince gang and family members to declare the ED a safe zone will respond positively [36,37]. Gang members were more likely to be cooperative when coached by their peers, than when confronted by security or police personnel.

Other suggested solutions involve the use of curved mirrors and glass panels in doors for better monitoring, and placement of ED staff stations to allow for visual scanning in the ED. In some EDs, small and widely spread waiting areas help to limit the “contamination” effect of agitation from one group to another.

Some novel approaches have been suggested. One is the use of weapons-sniffing dogs. Used internationally in war situations and in drug-related crimes, sniffer dogs can be more effective than security staff and police professionals in identifying individuals who are carrying weapons, including bombs. Sniffer dogs are considered widely accepted by the public [38].

While training programs in techniques for handling and managing aggression have shown some results in de-escalating violence, ED physician and staff training tends to be sporadic, and may not focus on the early identification of behavioral cues which presage violence. Nurses are more likely to participate in training programs while ED physicians rarely train. On-going training will be necessary as more efficient methods for preventing violence are developed.

The problem with all violence prevention techniques and training programs is that they have been largely developed in an ad hoc manner, hospital by hospital. Few evaluation studies have been conducted and, unfortunately, many of those were done by companies offering training or devices. The Cochrane Collaboration is undertaking a systematic review of interventions that can prevent and minimize workplace aggression toward healthcare workers [39]. Reports such as these can help identify the most effective tools for reducing and managing ED violence.

Violence in the ED is not going away anytime in the near future. That’s why it’s critically important that our hospital administrators understand the prevalence and severity of violence. A number of studies have shown that the level of administrative support for violence reduction is essential to decreasing it.

ED physicians can influence hospital administrators through informal conversations and formal presentations, analysis of incident report data, personal experiences, or external materials describing the epidemic of violence in the ED. Inviting a hospital administrator to spend a Saturday night in the ED can also prove invaluable insight to the problem of ED violence.

REFERENCES

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