Home On the Wards How violent is your hospital?

How violent is your hospital?

August 2015

Published in the August 2015 issue of Today’s Hospitalist

THE ER CALLS YOU to admit a drug overdose patient. The nurse is a bit apologetic, explaining that she is just covering for the one who first saw the patient. It turns out the first nurse is being evaluated for blunt trauma after the patient slugged her.

Or you’re about to make rounds on your sickest patient, but hear “Code Silver, MICU.” The TV news in another patient’s room explains that a family member pulled a gun on the nurses there and that law enforcement is on its way.

Spend a little time with the nurses at your hospital and you’ll hear more stories like this “or maybe you have some of your own. The fact that a surgeon was shot and killed in a Boston hospital earlier this year shows that doctors are not exempt from physical attacks.

Health care workers are particularly at risk for assault. In August 2010, the Bureau of Labor Statistics reported that between 58% and 67% of all workplace assaults between 2004 and 2007 occurred in health care and social service jobs.

And the almost 10,000 assaults tallied in 2007 were probably greatly under-reported. According to a study in the July 2014 issue of the Journal of Emergency Nursing, victims themselves may write off assaults as “part of the job.” Or they may be discouraged from pressing charges by administrators unwilling to make changes or by judges who figure that working around “those people” is asking for trouble.

A 2013 study of emergency-department violence found that in-house safety reports were filed only 42% of the time, and police reports only 5% of the time. As one ED nurse who’s experienced violence in a hospital first-hand put it to me, “Unless we’re bleeding or have a fracture, the cops don’t figure it’s worth the trouble of a report … and the hospital paperwork is just as big a pain.”

State legislators are beginning to take notice (no doubt realizing that they and all their constituents need health care some time) and violence against health care or emergency workers is now a felony in 32 states. Georgia and Minnesota have implemented zero-tolerance measures that take the decision out of the hands of hospital administrators. Hospitals in those states are required to post signs warning of the legal consequences of interfering with those who take care of patients.

We have the technology
Walk into a nice hotel and you’ll be given a keycard. It lets you into your room and facilities like the pool or exercise room, but not into the manager’s office or kitchen, because you have no reason to be there.

If you have jury duty or need to file some legal paperwork, you will almost certainly pass through a metal detector at the county courthouse, just like the one at the airport. And many amusement parks give you a bar-code bracelet that records your having paid for a ticket and which rides you’re allowed to enjoy.

Now compare that to the hospital outside Houston where a family member held the entire ICU at gunpoint earlier this year. There are at least 10 entrances, and safety precautions are limited to locking all but the main doors after dark.

The gunman went through doors without metal detectors, and once he was inside he could go anywhere he wanted. The ICU does require you to swipe your badge at the door, but once the guy was in the unit, he had free access.

An ounce or more of prevention
Some violence is easy to predict: verbal or physical threats, or a positive drug screen for PCP or meth. But warnings can sometimes be more subtle. The National Institute for Occupational Safety and Health offers an online course (for nurses, but it would apply to anyone working in a hospital “or working anywhere for that matter) that includes changes that can help make the workplace safer. The course is free and offers continuing education credit.

A hospital that cites cost or patient-satisfaction concerns when asked about safety precautions may want to consider the cost of not putting those in place. A Minnesota study published in the March-April 2011 issue of Nursing Economics found a huge loss of work hours and productivity when ED nurses “who are the highest-risk group “were subjected to physical assault. All the victims to some extent were affected by time off work and limited ability to relate to patients, not just the 17% of the group diagnosed with PTSD.

OSHA has issued recommendations for protecting health care and emergency workers; those range from identifying high-risk situations and patient populations to installing physical barriers and alarm systems. The agency also has the power to fine hospitals and clinics when there is evidence that risks to health care workers were ignored.

OSHA also outlines reporting methods so nurses or others who feel a dangerous situation is being ignored can report the problem to the agency without going through a hospital administrator. That appears to be more significant than you might think: Multiple surveys of emergency nurses indicate that victims fear administrative retaliation if they report crimes against them.

Those Joint Commission visits that have us all on edge every one to three years? The commission also has standards for hospitals’ response to intimidating situations and workplace violence, even when clinicians are the ones being intimidating, and a shrug of the administrative shoulders does not meet those standards. Enough reports reaching the Joint Commission or evidence during its visit that security is inadequate can cause big problems for administrators who didn’t want to spend the money to protect the people who work there.

And do I even need to mention lawsuits? Tort reform was never intended to protect organizations that neglect protective measures for an employee who was injured. A plaintiff’s attorney would have a very public field day if a nurse attacked by a muscular psychotic was disabled or killed in a situation that should have, through reasonable safety measures, been prevented.

Assessing your own risk
You’ve probably had cause to call security at your hospital, if only for a suicide watch or a confused patient with a tendency to wander. How long do your nurses say it takes security to answer a call? Are those security guards armed and, if not, does the hospital have an agreement with local law enforcement for a quick response? Maybe a taser would be safer for security to carry in a hospital, but having no trained security staff in a facility with more than 200 beds is inexcusable.

Open the issue of workplace safety with your nurse friends before you raise it at a medical staff meeting. Get an idea of how receptive administrators have been to warnings, and find out if employees are trained in defusing situations before they escalate. Remember, this is not strictly a nursing problem: X-ray techs, secretaries and even the cleaning staff can get in the way of a frustrated drug-seeker or angry visitor.

Review your own practice and make sure that emotional issues that can lead to violence are communicated clearly. A patient who wants a do-not-resuscitate order needs to advise her family of her wishes before she is intubated. Someone facing high-risk surgery should let you tell his or her next of kin just what the chances are of death or disability. A family that appears overly optimistic may feel betrayed when things gets worse, so be generous with your warnings.

Look at your high-risk groups of patients: drug and alcohol abusers, those with criminal records (how many prison tattoos have you seen in the last month?), people who have cognitive impairment or who are just plain angry. Other risky areas: places like stairwells where an unwanted visitor can hide, equipment that could be used as a weapon and, of course, absent or hard-to-find security guards. Other ways to reduce risk include being alert to behaviors that warn of impending violence, avoiding no-exit situations, and learning (and using) words and body language that reassure hostile or frustrated people.

Selling your hospital on safety
Rather than be the sole voice urging change, build support first. Your surgery and emergency medicine friends are the doctors most likely to have taken care of injured hospital personnel, and they may have some opinions (and case histories) to offer.

If the hospital has at least some decisions made by committees, see if the chairs of quality improvement and risk management can raise these kinds of issues. Get facility safety on the agenda for the next general hospital staff meeting; odds are good that somebody with a bad experience will jump on your bandwagon, and it may be someone the administration cannot ignore. If your hospital is putting a heavy emphasis on patient satisfaction, point out that patients rarely feel satisfied when dangerous situations are tolerated.

Doctors have far more freedom to speak out than hospital employees, most of whom have little or no union support. Hospitalists, who work in all parts of the facility, are in a good position to evaluate its problems and persuade people to make changes for the better.

These are the people who care for our patients. Shouldn’t we all have a safe place to work?

Stella Fitzgibbons, MD, has been in practice since 1984. She works as both a hospitalist and an ED doctor and as a medical expert witness in malpractice cases.