Though we certainly wish otherwise, these are dangerous times in healthcare due to escalating violent behavior toward healthcare workers and threats to patients.

For example, federal labor officials recently cited Bergen Regional Medical Center in Paramus, NJ, for allegedly failing to protect employees from violent patients. In a 3-month period this year, healthcare workers at Bergen were victims of violent patients in eight incidents, including one in which a nurse suffered a laceration and bruises attempting to stop an attack on a patient, the Occupational Safety and Health Administration reported on September 3, 2015.

Employees at Bergen reported incidents that involved patients barricading workers in a room, threatening them and exposing them to bloodborne pathogens. Several employees experienced being bit, punched, kicked, and threatened by patients, OSHA reported.

After the aforementioned nurse complained to OSHA, inspectors went on site and found evidence of eight incidents of workplace violence from Feb. 22 to June 12, 2015. OSHA cited the facility on August 18 for one general duty clause citation for failing to keep the workplace free of hazards. OSHA issued one repeated citation for incorrectly recording workplace injuries on the OSHA 300A illness and injury reporting form. Proposed penalties total $13,600. Bergen Regional requested an informal conference with OSHA’s area director after receiving the citations. The 1,070-bed facility provides long-term, behavioral health, and acute care.

Prepare to protect

Foreknowledge is power and training is essential to prevent and minimize violent threats, which include active shooter incidents and the occasional admission of an injured or sick criminal. It was this latter scenario that set off a dangerous series of events in March of this year at Inova Fairfax Hospital in Falls Church, VA. A convicted bank robber who was being treated at the hospital stole a guard’s gun. A shot was fired, and he held the guard hostage before fleeing. The prisoner is thought to have carjacked two vehicles after leaving the hospital, and he was captured in a Washington, DC, neighborhood after a nine-hour manhunt involving hundreds of officers.

The incident prompted a five-hour lockdown of the facility. The facility’s preparations for such an event helped minimize the impact, says Greg Brison, the hospital’s director of emergency management and security.

A key part of that preparation was that workplace violence training is required for employees at least once annually. That training includes information specific to responding to shots fired in the healthcare system. Inova Fairfax also works closely with local law enforcement and other emergency responders. In fact, it allowed them to use a new patient care center for training before the hospital moved in any patients, and they used a scenario very similar to what later happened.

The hospital had conducted full-scale drills as well as tabletop exercises to test its planning for an active shooter, including a meeting held just the day before the shot was fired. The Inova Fairfax incident illustrates how quickly a violent incident can put hundreds of people in jeopardy and disrupt a healthcare facility, Brison notes. No one was injured at the hospital during the incident, and patient care resumed as smoothly as could be expected after a long lockdown.

“There’s no question that our planning and the extensive training for our employees made a difference in the outcome,” Brison says. “This is the kind of thing you hope never happens, but if it does, you want your people to know what to do and how to stay safe.”

Employee health professionals can glean a strategy or two in reviewing some key aspects of Inova’s emergency planning. The prisoner incident affirmed the value of much of the facility’s planning, but it also highlighted some needs that had not been considered, Brison says. He offers this advice based on the facility’s experience and planning.

  • Provide access and information to local law enforcement ahead of time. During an emergency, it might be difficult for anyone to meet police officers at the front door, let them in, and then guide them through the facility. Provide a way for police to gain entry on their own, such as keys or key cards, along with detailed floor plans they can use on arrival.
  • Standardize names of entryways. Inova Fairfax has numbered all entry points, starting with the main entrance as Door 1 and then working around the building clockwise with sequential numbers. The number is marked prominently on the entryway. This system will improve communication with police who can be told to go to Door 5, for example, rather than having them struggle to find “the west wing entrance near radiology.”
  • Security should know where prisoner patients are at all times. It is not enough for security to know that an inmate is in a certain unit. Security should know exactly what room and staff members should notify security whenever the patient is moved somewhere else.
  • Serve only finger food to prisoners. Even plastic eating utensils can become effective weapons, so prisoner patients should be designated for only meals that require no utensils, such as a sandwich. Any staff members delivering meals should know of this restriction so they don’t routinely include a utensil packet or comply when the prisoner asks for one. If you decide to provide utensils, you must have a strict accounting of them afterward.
  • Use high-visibility clothing for prisoners. As a result of the prisoner escape, Inova Fairfax will no longer provide standard hospital gowns for anyone under police custody. Those patients now wear bright orange gowns to make them easier to spot if they escape and also to serve as a warning to staff that this person could be hostile.
  • Enable after-hours security officers to access security video. It is common for nighttime security officers to be limited in their access to security camera recordings, and it frequently requires a manager to come in to the facility obtain them. When a violent person still might be on the campus, security officers must be able to gain access to those recordings without delay so they and local police can identify and track the person.
  • Have backup command centers. For much of the lockdown, Inova Fairfax leaders could not get to their command center because it was in an area of the hospital not yet cleared by police. They now are establishing a backup command center on the opposite end of the building, with the same communication capabilities and resources such as job action sheets.
  • Arrange police escorts for necessary clinical care. Even in a lockdown, patients might have a clinical emergency. The staff members responsible for those patients cannot remain in place as they are supposed to during a lockdown, so police should be prepared to escort them and guard them as they work. This system is best accomplished by discussing the need with police ahead of time so they can have adequate personnel on hand.
  • Arrange for off-site parking. Parking might seem a mundane issue when people are in jeopardy, but it quickly became a problem that threatened to hinder the response of staff and local law enforcement. The Inova Fairfax shooting happened at 3 a.m., and the hospital’s shift change is 6:30 a.m. Additionally, outpatients begin arriving soon after, so about 2,000 people and cars were arriving while the hospital campus still was locked down. Inova Fairfax is developing a plan for designated parking areas in an emergency and a method for notifying those coming to the facility. The plan also will include a way to transport critical staff to the facility from those off-site parking areas.
  • Prepare for media arriving at your campus and other areas. The plan should call for public relations staff and security officers to be on hand, not just at the hospital campus, but also at any other area where staff members are likely to congregate after evacuation. Reporters will go to those areas to interview staff, so public relations representatives should be there also to help control the public message. Any designated off-site parking area for incoming staff and patients must have media relations and security present.