Shortly after 12:30 a.m. on Sept. 3, Darrell Garner walked into Baton Rouge (La.) General Medical Center with a gun. He entered the room where his teenage stepson was a patient and argued with his estranged wife, allegedly shooting her in the arm and shooting her boyfriend in the arm and head. Local police responded quickly, but Garner apparently left while doctors and nurses treated the victims. (Ten days later, the suspect turned himself in to local police where he remains in custody.) Authorities put the facility on lockdown, and for hours, most employees got either erroneous information or none at all.
"At that time, we had no way to alert people to what had really occurred," says Edgardo Tenreiro, Baton Rouge General's executive vice president and chief operating officer. "We also hadn't yet thought about having a command center outside the hospital, so when I arrived at 1 a.m., I spent valuable time driving around our campus, trying to find the center location."
After a three-hour sweep of the facility, the SWAT team gave the all-clear and the medical center returned to normal operations.
Hospital administrators recognized that their security policies needed an upgrade. For one thing, Code White—the emergency code Baton Rouge General uses to announce violent patients—was not only inaccurate, but in this case, with a gunman involved, it also could have put at risk employees who responded to assist colleagues. The following Monday, leaders instituted Code Silver to alert staff to the presence of an active shooter.
"With the Code Silver, we're able to tell everyone to get out of harm's way—close patient doors, close doors to the unit, and barricade themselves behind desks," Tenreiro says. "In these situations, we don't want any hospital employee trying to control the individual, and we want to keep others from walking into affected areas."
Traditionally, the public perceives hospitals as places of healing—environments that are antithetical to violence. But recent data reveal a different reality. Shootings at Baton Rouge General, Danbury (Conn.) Hospital, and Johns Hopkins Hospital in Baltimore this year have prompted the health care community to re-examine security policies and procedures.
According to the Joint Commission Sentinel Event Database, 256 assaults, homicides and rapes have occurred in hospitals since 1995. The June Sentinel Event Alert showed a marked spike in activity in the last three years—since 2007, 110 violent incidents have occurred. Joint Commission officials, however, believe hospital violence is significantly underreported.
"Hospital administration makes the decision whether to report incidents, and people don't like to report violence more than they have to," says Russell Colling, a health care security consultant who serves as an adviser to the Sentinel Event Alert. "Many incidents go unreported because they don't fall into the hospital's definition of 'violence,' but others are omitted because officials don't want them to reflect negatively on the hospital's image."
The 2010 International Association for Healthcare Security and Safety crime and safety survey of 212 hospitals found that hospital crime of all kinds is rising. There were 660 aggravated assaults and 2,720 simple assaults in 2009.
Changes in the ways patients and police use hospitals place the facilities at greater risk for violent activity. A 2004 Occupational Safety & Health Administration report for health care providers on preventing workplace violence identified three substantial risks to patient and employee safety: an increased number of mental health patients using hospitals for follow-up care because so many psychiatric facilities have closed or lost beds; a rise in police use of hospitals to hold aggressive and intoxicated individuals; and 24-hour public access to hospitals.
However, neither The Joint Commission nor the OSHA guidelines include a mandate to enact any changes in security.
Not all hospital units or employees are at equal risk, however. Heavy traffic, high stress levels and the types of cases that come in make emergency departments most susceptible to violence. Intensive care units are also vulnerable, Colling says, because of elevated stress levels among patients and their loved ones.
Nurses Bear Brunt
Overall, nurses are the most frequent targets of violence because they have the most direct patient contact. A 2009 study from The Journal of Nursing Administration found that in the past three years, 50 percent of ED nurses experienced some type of physical violence, from shoving, hitting, kicking to being spit upon, and 70 percent experienced verbal abuse. In addition to patient volume and stress levels, the study points to long wait times, a lack of privacy, and anger from patients and family members as contributing factors.
Nurses are not automatically inclined to report abuse, says Diane Gurney, R.N., president of the Emergency Nurses Association. "As nurses, we feel a responsibility to assist patients who need our help, and being involved in these violent incidents has generally been accepted as part of the job," Gurney says. "But this part of the health care and nursing culture must change."
The first step to reduce hospital violence is conducting a risk assessment, says Donna Gates, a nursing professor at the University of Cincinnati. Gates works with the federal government to identify strategies for reducing the number of violent acts in health care environments. As part of an assessment, The Joint Commission recommends hospitals review crime rate records and statistics for the area around the facility and survey employees about their perceptions of risk. All disciplines must be included to identify all areas that need more security.
"Nurses and doctors tell us they want to know what to do when, they want to know what the specific guidelines are, and they want to know when to call security," Gates says. "We have to use their input to move toward a culture of safety."
This type of plan is important because it gathers top-down support throughout the hospital, says Joe Bellino, IAHSS president. By bringing together security personnel, chief nursing officers, ED managers, chief operating officers and local police, hospitals can draft and implement zero-tolerance policies that encourage all staff to report actual and perceived threats.
Data from the Emergency Nurses Association shows that hospitals with zero-tolerance policies are 50 percent less likely than hospitals without one to experience a violent incident.
Hospitals can train their employees based on the results of the risk assessment, Bellino says. Depending on the facility's experience with violent events, employees may require extensive training or they may simply need a refresher course on recognizing initial violent signs or on physical techniques to restrain patients safely. Bellino also suggests allocating funds to have an ED nurse or security officer trained to be a certified safety instructor. He or she then can customize the security information for a specific hospital.
Training employees to de-escalate a potentially violent situation is a hospital's first line of defense, Colling says. Active listening and giving patients and their visitors space can help hospitals sidestep many problems. He suggests all staff uniformly enforce such policies as the number of visitors allowed per patient at any given time to avoid prompting anger or frustration. Hospitals also should reduce the number of access points through which the public can enter.
From Police to Panic Buttons
Bellino says local law enforcement agencies should be involved in planning. "I recommend that all hospitals sit down with their local police to discuss protocols and determine the processes to respond to violence in the hospital, as well as what works best for all involved," he says. "It's optimal to invite law enforcement to the training opportunities for your employees so they know how you respond to these situations, and they learn the layout of your facility."
Sandra Schneider, M.D., president of the American College of Emergency Physicians, says doctors and nurses should become comfortable with requesting a security presence with threatening patients before violence occurs. "It's proactive, if you have a violent patient, to arrive with security and to have the officer with you the entire time," says Schneider. "But make sure the officer knows where his or her resources are and that he or she is adequately trained to quickly subdue a dangerous person."
Hospitals also can use discreet tactics to identify volatile patients and alert staff to take precautions, she says, such as color-coding charts or supplying potentially violent patients with different colored socks. ACEP supports installing panic buttons in case of emergencies.
Technology is an effective tool to prevent violence or counteract an event should it occur. Jane Lipscomb, R.N., a professor at the University of Maryland School of Nursing and an expert in workplace violence prevention, says an architect with safety experience can analyze which hospital units need additional security. The IAHSS also recommended closed-circuit television monitoring of high-risk units, metal detectors at ED entrances and electronic access controls.
The OSHA guidelines endorsed giving staff who work with volatile patients hand-held alarms that can be activated in an emergency and installing shatterproof glass in reception, triage and admitting areas.
The confusion associated with having an active shooter on hospital grounds taught Baton Rouge General two valuable lessons, COO Tenreiro says. Hospitals should establish the location for a command center outside the hospital and ensure all personnel involved in managing a crisis know the location. In addition, hospital officials need a listing of all pertinent land line and cell phone numbers, and the command center should offer Internet access to allow administrators to use such social media sites as Facebook and Twitter to communicate messages to staff inside the facility.
"Most importantly, in a situation like ours where we had an armed person in the building, you must accept that you aren't in control. The cops take over immediately," Tenreiro says. "We served as support resources only."
After a patient shot a nurse at Danbury Hospital, now Western Connecticut Healthcare, in March, OSHA cited the hospital for violence-prevention deficiencies. The hospital has implemented new strategies to better protect staff and patients, says John Lucas, director of security, including a policy posted on the hospital's Intranet home page that outlines responsibilities for the CEO on down. The hospital hired six additional security officers, bringing the total to 34, and placed some of them in the ED that serves both medical and psychiatric patients. Visitors must register at the information desk when entering the hospital and must wear visitor passes.
If a patient begins to exhibit unruly behavior, providers at the bedside may request a security consultation to determine whether the patient poses a threat. If officers identify danger, a patient will undergo a safety assessment—a detailed search of personal effects for any weapons or dangerous items. For patient behavior beyond what hospital security can control, the ED attending physician can request a call to the police by asking for a consultation with "Dr. Blueman."
"In the three months after we implemented the new safety protocols, we've seen a 75 percent drop in reported incidents," Lucas says. "Nine out of 10 conflicts are resolved at the bedside through discussion."
Whitney L.J. Howell is a freelance writer in Durham, N.C.
Facts About Violence
A nationwide survey of emergency nurses between May 2009 and February 2010 found that in hospitals:
- 97.1% of physical violence was perpetrated by patients and their relatives.
- 80.6% of physical violence occurred in patients' rooms; 23.2% in corridors, hallways, stairs and elevators; and 14.7% at nurses' stations.
- 38.2% of physical violence against emergency nurses occurred while they were triaging patients, 33.8% while restraining or subduing patients, and 30.9% while they were performing invasive procedures.
- 15% of male nurses reported having been victims of physical violence compared with 10.3% of female nurses.
- 13.4% of violent acts occurred in large urban areas compared with 8.3% in rural areas.
Source: The Emergency Nurses Association's Emergency Department Violence Surveillance Study, 2010