Healthcare Lives Saving - saione.com · products catalog Los Angeles, CA 1984 Seoul, ... Healthcare...

SECURITY MANAGEMENT 59

Healthcare

MARY PAT MCKAY, a physician in the emergency depart-ment at The George Washington University Hospital in Washington,D.C., has been slapped, grabbed, spat on, and kicked—all while trying torender medical assistance to patients in the ER. She has narrowlyavoided taking some punches too. McKay’s experience is not unique foremergency department workers in the United States. She knows of col-leagues who have endured worse. According to the Emergency NursesAssociation (ENA), employees in the healthcare industry see four timesmore nonfatal assaults than those working elsewhere in the private sec-tor. One consultant interviewed for this story cited a case of a nursewhose jaw was broken by a patient. In addition, violent crime some-times follows patients to the ER. For example, when McKay worked inan emergency department in Pittsburgh, rival gang members showedup with guns because a prominent gang member had been brought tothe hospital.

Several factors contribute to danger in the emergency department, in-cluding the stress of the situation and the fact that people generally arestuck, sometimes for hours, in overcrowded waiting rooms. These con-ditions can cause tempers to flare.

Hospitals have a responsibility to staff and patients to mitigate emer-gency room violence. The key is to know how to evaluate the risk andthen develop a security program tailored to those findings.

Saving

SecurelyBY LAURA SPADANUTA

Lives

Risk AssessmentThe first step in developing an ER vio-lence prevention program is to assess theexisting risk, including current threatsand countermeasures.

The threat analysis should begin with areview of crime demographics and indica-tors in a given distance around the hospi-tal. The hospital can use analytic tools,such as those from CAP Index, says JeffAldridge, CPP, president of Security As-sessments International in Durham,North Carolina, who has performed riskassessments for hundreds of hospitals. ACAP Index report, based on data from lawenforcement, includes probability meas-ures on crimes such as homicides, larce-nies, and rapes.

The assessment progresses from theanalysis of the threats around the prop-erty to an analysis of the threats withinthe property. This analysis is carried outthrough an examination of the recordedviolent incidents within the hospital andespecially within the emergency depart-ment. This can be difficult, however, be-cause hospital record retention policies

vary widely. Hospitals retain records of vi-olent incidents anywhere from a fewmonths to upwards of 10 years.

Another problem in carrying out thisanalysis is that emergency department in-cidents are widely underreported. TheENA estimates that as many as half of theverbal and physical assaults that nursessuffer go unreported.

One reason that incidents are not re-ported is that medical professionals con-sider some level of abuse from patientsunderstandable given what the patientsare going through, and they take it instride. Another reason is that reportingtakes time, which already short-staffedemergency departments don’t have, saysJonathan Rosen, director of the occupa-

tional safety and health department forthe New York State Public Employees Fed-eration. Managers might discourage re-porting, arguing that the violence is not abig enough deal and that the employeesare needed in the emergency department,rather than in the employee health de-partment reporting an incident, saysRosen.

Whatever the reason, the fact is that indoing a risk assessment, security profes-sionals have to go beyond just looking atofficial reports and logs. They should in-terview staff to get a fuller picture of staffexperiences and the types and frequencyof incidents.

Existing security. The next aspect ofthe assessment is to examine the existing

security, including a completephysical analysis of every-thing from access controls tocameras to the location ofemergency call stations. Proto-cols and guidelines shouldalso be assessed, along withstaff education and trainingprograms. This analysis takesabout three days, saysAldridge.

Reducing RiskOnce the hospital has the com-plete picture of the existingthreats and countermeasures,it can work with its securityteam and consultants asneeded to determine wherethere is remaining risk that isnot countered by existingmeasures. They can then craftadjustments to the securityprogram to address that risk ifit exceeds the level deemed ac-ceptable by the administra-tion. The following measuresare among those that a hospi-

Healthcare

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60 SECURITY MANAGEMENT

Emergency rooms today use a hub-and-spoke design, with a nurse stationin the middle that lets staff see into allthe treatment rooms.

62 JUNE 2008 WWW.SECURITYMANAGEMENT.COM

tal may decide it needs to implement orenhance.

Training. Since most emergency roomviolence occurs between patient and care-giver, it is essential to train staff on how todetect and defuse potentially violent situ-ations. There are, however, no federalstandards for hospitals regarding vio-lence-prevention training for emergencyroom staff, and practices vary.

Some hospitals institute detailed train-ing regimens, while for others, it’s “catchas catch can,” according to McKay. Thisscattershot approach leaves many staffmembers vulnerable to attacks that couldbe avoided.

Ideally, hospitals will train staff to bealert to signs of trouble. When a patientshows signs of agitation, such as rocking,pacing, eyebrow furrowing, or a raised

voice, a trained staff member should beable to recognize those signs and to stepin to calm the person, says William H.Nesbitt, CPP, president of Security Man-agement Services International Inc.

Just speaking with the person can alle-viate tension. The conversation can be assimple as asking patients if they are all-right or need anything. This technique iscalled verbal de-escalation.

“It’s the most powerful tool that wehave,” says Tony York, CPP, CHPA, andsenior vice president for Hospital SharedServices, Inc., in Denver, Colorado, thestate’s largest hospital security contractor.

Just giving people the chance to verbal-ize frustrations can often calm themdown, because they no longer feel ig-nored, says York, who is also president ofthe International Association for Health-care Security and Safety (IAHSS).

Staff members also need training inhow to approach an agitated person. Theyneed to be able to do so in a way that min-imizes the risk to themselves while alsomaking sure not to appear confronta-tional. Some important tips to remember,according to Rosen, are: stand in an openstance, with legs apart, a safe distancefrom the patient; make short, simple, affir-mative statements; and speak in a calmvoice.

“Those who’ve gone through good,formal, aggression-management train-ing…understand that there is a way tomanage that type of behavior,” says York.

Assistance. Even with training, how-ever, staff will not be able to mitigateevery situation on their own. “The prob-lem is, somebody who wants to hurtthemselves or do something that’s poten-tially life-threatening may or may not beable to be talked out of it,” says McKay.

And sometimes, the individuals arementally unstable, disoriented, intoxi-cated, or on drugs. “You can’t have a ra-tional conversation with somebody who’swhacked out on PCP, for example,” saysMcKay.

Staff must know when to call for assis-tance, and the hospital should providethem with an easy means of doing so.Emergency areas should be equippedwith panic buttons, for example, so thatstaff can quickly summon security if a

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visitor or a patient cannot be calmed. If patients are causing the disruption,

then they may need to be restrained phys-ically or sedated before receiving medicalattention. The decision to use restraintsor to sedate a person should be carefullyconsidered, however, and well docu-mented, given that some patients havedied in restraints.

“It’s a risky activity, and for the most

part you do want to eliminate it,” saysRosen, adding, “but there are situationswhere prevention fails, and you have noother choice.”

York agrees. “The application of a re-straint…is typically a means of last re-sort.” He adds that the staff membersneed to document that they took othersteps to mitigate the aggressive behaviorbefore resorting to the restraints.

Not all problems arise from the pa-tient, however. If a family member orother visitor is causing any type of distur-bance, they should be asked to leave, saysAldridge. And anyone who is actuallycommitting a crime (such as an assault)should be detained by security and ar-rested by law enforcement.

Sometimes the violence stems from afight that participants have carried intothe hospital, as in cases where gang mem-bers continue their turf battles in the ER.In those situations, police should becalled immediately.

Reporting. As noted earlier, staff mem-bers do not always report incidents theyperceive as minor. Hospitals should workto change this attitude, says Aldridge.“There should be a zero tolerance levelfor violence. People [making] threats tostaff should not be tolerated,” he says.“This is what we write into our protocols,and then we educate the staff on the factthat if somebody says ‘if you touch meagain, I’ll kill you,’ then you need to callsecurity.”

Design. The design of the emergencyroom can also play a role in curtailing vio-lence. Design can allow staff members tokeep tabs on patients, visitors, and any po-tential problems brewing in the waitingroom or treatment areas. It can calmdown aggravated individuals. It can alsoprevent potentially dangerous individualsfrom even entering the department, whencoupled with proper door locking and ac-cess control mechanisms.

A key element of a good design is to en-sure that staff members have a way to ob-serve patients and anyone in the waitingareas. The shape and layout of the emer-gency department and its patient roomscan go a long way to improving observa-tion potential.

With that in mind, most emergency de-partments designed today are following atype of hub-and-spoke approach, accord-ing to William Heil, electrical engineer atHarriman Associates in Auburn, Maine.There is a nursing or administrative sta-tion in the middle of the room with abirds-eye view of all the treatment rooms.

“A nurse can sit and usually look 360degrees around them into each of the indi-vidual patient rooms to actually see what

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each patient is doing,” says Heil. Addition-ally, he says, the patient rooms are fittedwith full glass panels so that the nursescan see what’s going on inside.

If a patient becomes physically aggres-sive with a staff member or there is an al-tercation, someone from the nursing sta-tion should be able to see it and send help.

Secure room. The design may include apsychiatric observation room that can be

used to contain mentally unstable or in-toxicated patients who might otherwisebe harmful to themselves or others. Theseare rooms that are outfitted in such a waythat nothing in the interior of the roomcan be used by patients to harm them-selves or others.

“Frequently they’re prison-grade typefixtures in that type of a room,” says Heil.For example, if there is an air condition-

ing vent in the ceiling, it should be of a de-sign type that a patient would not be ableto loop a belt through the vent to hanghimself. Additionally, the room offers away to separate the troubled patientsfrom the general patient population.Larger hospitals may even have a secondgroup of observation rooms with theirown nursing stations so that those pa-tients can be treated in an area completelyseparated from the general ER area.

Light. Lighting has an impact on a per-son’s sense of well-being. Aldridge encour-ages the use of natural light in emergencydepartments so that patients feel lessclaustrophobic and depressed. However,windows—the source of natural light—can also create a security vulnerability,notes Ella Franklin, special projects direc-tor at Washington Hospital Center.

Franklin is involved in a project calledER One, which has developed a theoreti-cal design for an emergency room of thefuture, with the aim of withstanding amass casualty event. Washington HospitalCenter has implemented some of EROne’s innovations in an emergency de-partment extension as part of a “Bridge toER One” project. But the use of naturallight has proved to be a tension point be-tween architects and clinicians, saysFranklin.

Perpetrators can come up to the win-dows from outside, she notes. As a result,“we ended up with this hybrid designwhere we have the walls at about three-quarters height [from the street], and awindow at that level,” Franklin says.

A related question is whether to usebulletproof glass in windows. Aldridgerecommends that facilities with entrancesthat are all glass should have ballistic lam-inate over the windows. In the case of EROne, however, because the windows werehigh up, law enforcement said that therewas little risk of a direct shot in, and bul-letproof glass was not used.

Soothing distractions. Another additionto the environment that can relieve ten-sion is the availability of food and otherdistractions in the waiting area. That canbe achieved with vending machines andtelevisions. These help people take theirminds off the real reasons they are at theemergency room in the first place.

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Fast-track area. As waiting times inemergency departments increase, manyhospitals are also looking for creativeways to lessen the patient wait timethrough streamlining. For example, somehospitals now have adopted a fast-trackoption, where patients with simplerproblems can be seen more quickly, oftenin a separate section of the emergencydepartment.

However, the fast-track strategy is notwithout its critics. The ER One team toyedwith the idea of having a tiered systemwhere there would be fast-track roomswith fewer resources for some patientsand fully equipped rooms for patientswith more serious troubles. The teamchose not to do that, because they wantedall of the rooms to be capable of handlingany type of case in a mass casualty event.

There’s another issue with the segre-gated fast-track approach, according toMcKay: “One of the problems that hashappened in every hospital that I’veworked in that uses this technique is itdoes mean that sometimes, dependingupon the flow and who shows up when,the sickest people wait longest, which isreally counterintuitive.”

Access control. Access control is oneof the most important aspects of emer-gency department security. Experts agreethat all doors to the emergency depart-ment patient treatment location shouldbe locked and alarmed, and no one shouldbe able to get through without passing bysecurity.

Aldridge recommends that any doubleglass doors that can be pried apart be in-stalled with positive locking.

But it is not just a matter of limitingwho comes in. Access control in emer-gency departments must also includerules on who gets out. If individuals werepermitted easy exit from the emergencypatient treatment area, assailants wouldhave a better chance of getting away, saysAldridge.

Most hospitals have some access con-trols, but they do not always extend thatcontrol specifically to the ER, accordingto a survey released in 2007 by GE Secu-rity and IAHSS. The survey found thatwhile 81 percent of hospitals had imple-mented electronic access controls gener-ally, only 68 percent had access controltechnology of any kind in the emergencydepartment. And Aldridge points out thata weak point in many hospitals is thatthey do not keep all of the entrance doorslocked.

Nesbitt says that it’s important for ahospital to be able to place the emer-gency department in lockdown if needed.There should also be controls in place toprevent individuals from enteringthrough the ambulance area, he says.Hospitals can achieve this level of controlthrough some sort of garage door openeror key lock technology that only ambu-lance drivers can activate.

Only 11 percent of hospitals in theGE/IAHSS survey used electronic visitormanagement. Badging does not have tobe electronic to be adequate, however,

Health care



WWW.SECURITYMANAGEMENT.COM SECURITY MANAGEMENT 69

says Aldridge. He says visitors can be re-quired to trade valid government identifi-cation, such as a driver’s license, for a visi-tor’s pass. After the visit, the pass isretrieved in exchange for the return ofthe identification.

Visitors’ badges should include the fol-lowing information: name, picture, andexpiration date. Preferably, the badgesshould be sturdier than just stick-onpieces of paper.

To ensure that unauthorized visitorsdo not accidentally wander into restrictedspaces where visitors can sometimes go,an attendant, rather than a card swipe,should control entrance into the patienttreatment area, recommends Aldridge.The attendant would be responsible forbuzzing in only persons with valid accessto the area. Of course, this would requirean additional full-time employee.

By contrast, card access without an at-tendant can be used to protect rooms thatonly staff members are authorized toenter, says Aldridge.

Staff should also have to wear IDbadges, but Aldridge notes that it is diffi-cult to get doctors to comply.

Access control guidelines should al-ways be reasonable, says McKay. Sheknows of a situation in the emergencyroom where an individual came in be-cause of chest pains, but in his rush, heleft his identification at home. As a result,he was not permitted entry until he wenthome and retrieved it.

The incident led to a change in policy.Now, “If you’re a patient, you get to comein. It’s obviously the reasonable ap-proach,” says McKay.

Visitor protocol. Another aspect of accesscontrol is placing a limit on the numberof visitors who can enter the treatmentarea or even the waiting room with a pa-tient. Aldridge recommends two as an ac-ceptable number of visitors to allow atone time per patient in the treatmentarea.

Restricting the number of visitors inthe treatment area is clearly good for secu-rity. McKay points out another reason:They faint. “That just makes work foreverybody,” she says.

Metal detectors. Many ERs use metal de-tectors to provide an extra layer of secu-

rity aimed at ensuring that no weaponsget through the doors to the department.Aldridge highly recommends this type ofscreening for departments in high-crimeareas.

A county hospital that Aldridgeworked with in North Carolina was notconvinced of the need to screen forweapons, but it agreed to try a metal de-tector out since the manufacturer offered

it for free for 30 days. In those 30 days, thedepartment found 48 handguns and morethan 100 knives. The metal detector evencaught an elderly woman who tried tosneak into the emergency room with aconcealed meat cleaver.

The case illustrates the threats hospi-tals face. There are, however, several fac-tors to consider before installing a metaldetector in the ER.

Healthcare


The first factor to consider is the all-incost of such a system. Not only is there theup-front expense of the equipment and in-stallation, but there is also the ongoing ex-pense of staff to do the screening. Accord-ing to Nesbitt, one metal detector requiresthe “full-time equivalent” of 4.3 individu-als working during the week to staff it.

In analyzing the cost, the security teammust remember that in emergency de-

partments with more than one entrance,all entrances would need detectors. More-over, the detectors must be staffed aroundthe clock. This means that officers at themetal detector cannot leave their post toassist in the treatment area, where mostsecurity issues arise.

The second factor is a legal considera-tion: Once metal detectors are installed,removing them could create a liability.Imagine, says Nesbitt, that a hospital has ametal detector, removes it, and then some-one gets shot. “That makes [a legal] liabil-ity probably 10 times worse than it wouldhave been if you didn’t have the metal de-tector in the first place.” He also warnsthat saving money is not a strong argu-ment for removal of a metal detector.

That’s why Nesbitt suggests that insome cases it could be useful to employ amagnetometer wand instead of a metaldetector. The hospital should post signsthat state that no weapons are toleratedand that individuals are subject tosearches.

McKay points out that some patronsmay have a negative reaction to metal de-tectors. “There are some folks who believethat it is off-putting, meaning that it’s say-ing, we don’t want…your kind here.” Butshe adds, “My personal bias is that safetyoutweighs that problem.”

Surveillance. Experts advocate hav-ing surveillance cameras in place at eachdoor and at entrances and exits. Cur-rently, ongoing video surveillance is not

allowed in the patient care areas at Wash-ington Hospital Center, according toFranklin. However, she says that ER One is“futureproofing,” or preparing for what itsteam hopes occurs in the future—that thecameras will be allowed to tape patientcare areas. Their bridge emergency depart-ment has already installed cabling in theceiling in hopes that cameras can be con-nected one day.

Signage. Signage is an important as-pect of a security program, but its role isoften overlooked in the emergency de-partment. Signage is “50 percent of allhospital security, and it’s probably theleast used,” says Aldridge. It’s so impor-tant because half of the value of security isits deterrent effect, he explains.

Even just putting up a sign that saysweapons are prohibited and that individu-als are subject to search has an effect thatis visible from security cameras; peopleoften just turn away and leave. The effect,according to Aldridge, is analogous towhen burglars avoid homes with alarmsigns in the yard.

Guard presence. Another effectivemeasure is to have guards patrolling thewaiting room, rather than just sitting at asecurity station. Patients and visitors areless likely to be confrontational with eachother when an officer is present, saysYork.

Because the need for medical attentionis itself stressful and because hospitals areopen to the general public, includingcriminal elements, it’s inevitable thatproblems will arise. But by implementingstaff training, good design, access controls,and appropriate protocols, hospitals cango a long way toward preventing anyproblems from getting out of hand and re-sulting in injury or death. ■

Laura Spadanuta is an assistant editor at

Security Management.

Healthcare

Violent incidents are a normal

part of the job for many emer-

gency department workers, but

they often go unreported. Hospi-

tals can, however, take steps to

make the emergency department

and its staff members less vulner-

able to violence.

The first step is to conduct a

risk and security assessment. It

will reveal what countermeasures

are missing. Those vulnerabilities

can then be addressed within the

context of a comprehensive vio-

lence prevention program.

Another critical step is to train

staff and security members to

mitigate potentially violent situa-

tions. When staff knows how to

engage in verbal de-escalation

with those showing signs of agita-

tion, they can often prevent dan-

gerous situations. If talking does

not work, however, there should

be provisions to restrain patients

or to remove disruptive visitors.

Emergency room design also

plays a role in preventing vio-

lence. Newer ER departments are

being designed to provide maxi-

mum observation, enabling staff

members to catch problems at

early stages.

Access control and lockdown

mechanisms are essential aspects

of any emergency department se-

curity plan. There must be a way

to keep track of who is coming

into the patient treatment area,

including a badging and control

system for visitors.

Other physical security meas-

ures, such as metal detectors, can

help to prevent violence, but they

are a major resource commit-

ment, and the decision to imple-

ment them must be carefully

thought out.

By implementing a solid secu-

rity plan and providing essential

staff training, hospitals can help

make the emergency department

a safer place.

SYNOPSIS»

Most hospitals have some accesscontrol, but they do not always extendthat control specifically to theemergency room.


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