The emergency department (ED) is a high-volume traffic area where different, potentially volatile situations can arise daily. The lack of healthcare resources available at night and on weekends drive many people to the ED. But it’s not just nights and weekends when issues may arise in the ED — they can happen any time of day or night. The emergency department is the most challenging and stressful area in any hospital, where dramatic life-and-death cases come through the front door.
Nurses, physicians and other medical professionals are on the ED’s front lines and are at an increased risk for workplace violence. Most incidents in the ED occur under very specific conditions, and primarily emanate from identifiable individuals, including:
- Drug and alcohol-impaired patients and visitors
- Victims of gunshot wounds and the circumstances surrounding those situations
- “High acuity” behavioral health patients who perceive the ED as the only treatment option due to the elimination of or decrease of mental health inpatient and outpatient community treatment alternatives
- Perpetrators of domestic violence who may follow their victims through the ED doors
- Forensic patients entering the ED under the supervision of law enforcement or Department of Corrections officials.
The American College of Emergency Physicians (ACEP) believes that optimal patient care can be achieved only when patients, healthcare workers and all other persons in the ED are protected against violent acts occurring within the department. As such, ACEP advocates for increased awareness of violence against healthcare workers in the ED and for increased safety measures in all EDs.1
The International Association of Healthcare Security and Safety (IAHSS) Guidelines Council recently requested input from the Emergency Nurses Association (ENA) and the American Organization of Nursing Leaders (AONL) in the development and updating of several guidelines for healthcare security regarding violence. In addition to “Security in the Emergency Setting,” these guidelines include violence in healthcare, targeted violence, threat management and management of weapons.2
According to IAHSS, healthcare facilities (HCFs) that provide emergency care have special security needs and should have a security plan that incorporates additional safety and security enhancements applicable specifically to such areas. The plan should be based on identified risks for the ED, including trauma-level designation, volume, types of patients treated, incident activity and community demographics. The security administrator should be involved in the planning and building phases of ED construction and renovation as a resource relative to security design issues. Additionally, IAHSS recommends that the ED waiting area should be separated from the ED treatment area and be self-contained to include independent access to restrooms, telephones and vending machines. Seating and other furnishings should be fixed to mitigate the possibility of these items being used to harm persons.
The following considerations should be weighed in ED security planning:
- Access controls should be in place to control and limit access of ED visitors into the ED treatment area and into the main hospital. A room or area within the ED, separate from other patients, should be available for the treatment of behavioral/mental health or other high-risk patients. Consideration for this room should include visibility by staff and the removal or securing of items that could be used by patients to injure themselves or others.
- The ambulance entrance should be separate from the walk-in entrance and waiting room.
- Security staff provides support services in the care and control of ED. These services are to be provided at the request and under the direction and supervision of clinical staff unless circumstances require immediate action to prevent injury or destruction of property.
- Security equipment and systems to protect staff and patients should be in place. These may include electronic access control, video surveillance and duress alarms.
- The ED should be capable of being rapidly locked down in event of an emergency. Drills should be conducted to exercise the lockdown process. Physical measures and procedures should be in place to deter the elopement or removal of patients at risk to include those who could harm themselves, others or children who may be at risk for abduction or abuse.
- ED staff (including security) should receive ongoing training in workplace violence and aggressive/violent patient management to recognize, avoid, diffuse and respond to potentially violent situations. Periodic meetings, at a minimum annually, with multidisciplinary staff, should be conducted to review security protocols and resolve security issues within the emergency care setting. Policies, procedures and training programs should be established for security’s role in managing high-risk patients including patient watches, holds, searches and application of patient restraints.
- To respond to incidents more appropriately in the clinical environment, it is important to understand the nature of aggression. The violent behaviors displayed by a patient as a result of his/her clinical diagnosis should be differentiated from the violent behavior that is a criminal end unto itself. Clinical aggression can escalate into criminal aggression. However, a patient in a hospital setting (and especially an emergency setting) may often display aggressive behavior as a result of his or her clinical diagnosis or the environment. Behavioral health patients are typically at a higher risk of initiating violence, but any patient may display behaviors of concern that escalate into violent actions.
- It is crucial for all caregivers and assigned security professionals to be properly trained and keenly aware of the circumstances surrounding a potentially aggressive patient. This training equips professionals to successfully facilitate the most appropriate response to the behavior. It also provides a greater likelihood that warning signs will be identified for early intervention and de-escalation of the situation. Understanding the violent individual and the nature of aggression helps security professionals and clinicians respond most effectively and efficiently.
In addition to contributing to a safe environment, security professionals are also responsible for upholding the facility’s reputation, mission and values, while providing outstanding customer service for a positive patient experience. The ED is an environment where critically ill and high-risk individuals are gathered in a confined space. The risk of violence is much higher than other areas of the hospital. The security officers who are sensitive to the environment and the needs of patients and visitors achieve success. The officers who have been trained to identify potential signs of violence early, intervene quickly and mitigate risks are also effective in the ED. They are better able to mitigate threats, de-escalate violent situations and coordinate with a variety of resources internally and externally to facilitate a better outcome.
According to IAHSS, the quality of security officer training is critical to the overall success of the HCF’s security program. Individuals performing security services should be appropriately trained to meet any legally required training standards and healthcare security industry best practices. Examples of the training for the officers in the ED setting includes:
- Behavioral health/mental health patients
- Clinical aggression versus criminal aggression
- Centers for Medicare & Medicaid Services (CMS) Conditions of Participation (restraint/seclusion)
- Emergency Medical Treatment and Labor Act (EMTALA)
- Fire/Life Safety Code
- Infection Control/Standard Precautions.
Training is not a one-time event. Security professionals should receive ongoing training, including drills and exercises, to address changes in the environment, improve and further develop their skills and measure competencies.
It is critical that security professionals and clinical staff engage and work collaboratively to prevent and manage violent events as they occur in the ED setting. To better accomplish this goal, they should train together as much as possible.
Developing a violence prevention and response plan
An effective plan requires a multidisciplinary team approach that engages top leaders and key stakeholders. Representatives from human resources, security, risk management, public relations, legal counsel and other areas as needed should be involved in developing and reviewing the plan. Space is often limited, waiting areas are crowded, and patient treatment areas are filled with patients, staff and family members.
The primary objective is to avoid violence. When violence erupts, swift action is necessary to contain the situation and avoid threat to innocent bystanders. According to the Emergency Nurse’s Association (ENA), the response plan should address the following components:
- Prevention: Acknowledge intolerance of all workplace violence and necessity to put measures in place to prevent it from happening; raise awareness of the culture of acceptance and promote the importance of recognizing escalating situations and early intervention; and understand the barriers to an effective prevention program and remove as many as possible.
- Response: Identify the barriers to swift, effective and safe response to an occurrence; educate the ED staff (including management and administration, law enforcement, public safety and security) on appropriate response policies, procedures and skills to minimize the likelihood of harm to a patient or staff member.
- Reporting: Acknowledge that occurrence reports hold valuable information for future improvements and should never generate a punitive, retaliatory response; recognize that staff culture and attitudes have an impact on the generation of reports when a violent incident occurs; acknowledge that lack of reporting can impede an initiative to improve the safety of your ED for patients and staff.3
Threat Assessment Teams (TAT), Disruptive Patient Assessment Teams (DPAT) and the physical environment
HCFs should establish a process and a multidisciplinary team to identify, assess, validate, mitigate and respond to threats of violence or other behaviors of concern. Additionally, it is critical that the organization regularly assess and address security vulnerabilities and risks in the ED physical space.
The Threat Assessment Team (TAT) should, among other things, be a multidisciplinary team designated with responsibility for:
- Assessing formal or informal reports of behaviors of concern
- Addressing reported incidents or threats
- Alerting staff and others who are at risk
- Creating and monitoring safety plans
- Reviewing after-action debriefing sessions, evaluating and revising as needed, the actions taken to mitigate the threat
- Advocating, supporting and counseling for victims as necessary
- Regularly reviewing trends in threat management events
- Routinely reporting program status and recommended changes to leadership.
Disruptive Patient Assessment Teams (DPAT) are smaller groups focused on a daily assessment of patients at high risk for violence and may be responsible for responding to the increased number of healthcare assaults in the ED (and other areas of the hospital). A clinician with strong leadership skills and experience in de-escalation and management of violent individuals often leads this team. Individuals from various departments support the team leader, including security, human resources, social services or other relative specialties.
The DPAT is clinically driven, and the interval of assessment required is based on clinical discretion in most cases. Diagnosis, behavior patterns, medication issues, recognized threats and other factors may deem it appropriate to conduct 12-hour or 24-hour patient assessments to mitigate risk. It is important to ensure the assessment process does not give the patient a feeling of being policed or watched. The DPAT assessment team member can demonstrate concern for the patient and address him or her with compassion and caring, which alleviates concerns and contributes to a positive patient experience.
The role of team members is to assess and manage threats and threatening behavior, anticipating events before they occur when feasible. They succeed by carrying out their primary mission to assess the likelihood of violent events and to determine the best methods of intervention. Patient and staff safety are always key factors in their considerations and recommendations.
The importance of providing and maintaining a safe physical environment for the patient, visitors and staff cannot be overemphasized. The IAHSS Security Design Guidelines for Healthcare Facilities, 3rd Edition has been endorsed by the American Society of Healthcare Engineers (ASHE) and can assist security practitioners, design professionals, building owner representatives and planning leaders in helping them make informed decisions for effective security principles into each new construction and renovation project.4
Violence prevention requires hospitals to develop programs based on management commitment. The TAT and DPAT succeed with the support of hospital leadership. It is critical to have all parties fully engaged in the process. Assigning responsibility and ensuring that individual team members accept accountability leads to the highest levels of success. Threat assessment is a continuous process, and the teams require continuous support. The physical environment also contributes to the overall patient experience in the ED.
A calming and safe physical environment can reduce and mitigate violence. Healthcare organizations should continuously seek cost-effective methods that address the safety and security of new and renovated space.
- ACEP. “Violence in the Emergency Department: Resources for a Safer Workplace.” Available from: bit.ly/32oeJwC.
- IAHSS. Healthcare Security Industry Guidelines 2018. Available from: bit.ly/35mfTu4.
- ENA. “Workplace Violence.” Available from: bit.ly/2FphyUQ.
- IAHSS. Security Design Guidelines for Healthcare Facilities, 3rd Edition. 2020.