Post on 08-Oct-2020
1
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
2
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
3
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
4
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
5
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
6
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
7
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
8
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
9
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
10
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
11
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
12
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
13
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
14
# 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
15
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
16
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
64
Hazard Prevention and ControlEngineering Controls
Panic Buttons
Height Marker
on Exit DoorVideo Surveillance Equipment
17
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
18
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
19
DrTracy@TracySansonMD.com
TracySansonMD.com
@TracySansonMD
1
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.
20
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