Mary Pat McKay, a physician in the emergency department at The George Washington University Hospital in Washington, D.C., has been slapped, grabbed, spat on, and kicked—all while trying to render medical assistance to patients in the ER. She has narrowly avoided taking some punches too. McKay’s experience is not unique for emergency department workers in the United States. She knows of colleagues who have endured worse. According to the Emergency Nurses Association (ENA), employees in the healthcare industry see four times more nonfatal assaults than those working elsewhere in the private sector. One consultant interviewed for this story cited a case of a nurse whose jaw was broken by a patient. In addition, violent crime sometimes follows patients to the ER. For example, when McKay worked in an emergency department in Pittsburgh, rival gang members showed up with guns because a prominent gang member had been brought to the hospital.
Several factors contribute to danger in the emergency department, including the stress of the situation and the fact that people generally are stuck, sometimes for hours, in overcrowded waiting rooms. These conditions can cause tempers to flare.
Hospitals have a responsibility to staff and patients to mitigate emergency room violence. The key is to know how to evaluate the risk and then develop a security program tailored to those findings.
The first step in developing an ER violence prevention program is to assess the existing risk, including current threats and countermeasures.
The threat analysis should begin with a review of crime demographics and indicators in a given distance around the hospital. The hospital can use analytic tools, such as those from CAP Index, says Jeff Aldridge, CPP, president of Security Assessments International in Durham, North Carolina, who has performed risk assessments for hundreds of hospitals. A CAP Index report, based on data from law enforcement, includes probability measures on crimes such as homicides, larcenies, and rapes.
The assessment progresses from the analysis of the threats around the property to an analysis of the threats within the property. This analysis is carried out through an examination of the recorded violent incidents within the hospital and especially within the emergency department. This can be difficult, however, because hospital record retention policies vary widely. Hospitals retain records of violent incidents anywhere from a few months to upwards of 10 years.
Another problem in carrying out this analysis is that emergency department incidents are widely underreported. The ENA estimates that as many as half of the verbal and physical assaults that nurses suffer go unreported.
One reason that incidents are not reported is that medical professionals consider some level of abuse from patients understandable given what the patients are going through, and they take it in stride. Another reason is that reporting takes time, which already short-staffed emergency departments don’t have, says Jonathan Rosen, director of the occupational safety and health department for the New York State Public Employees Federation. Managers might discourage reporting, arguing that the violence is not a big enough deal and that the employees are needed in the emergency department, rather than in the employee health department reporting an incident, says Rosen.
Whatever the reason, the fact is that in doing a risk assessment, security professionals have to go beyond just looking at official reports and logs. They should interview staff to get a fuller picture of staff experiences and the types and frequency of incidents.
Existing security. The next aspect of the assessment is to examine the existing security, including a complete physical analysis of everything from access controls to cameras to the location of emergency call stations. Protocols and guidelines should also be assessed, along with staff education and training programs. This analysis takes about three days, says Aldridge.