By Gary Evans, Medical Writer

In the increasing threat of violence in healthcare, the ED is ground zero.

Given the threat, it is time to start designing violence prevention in the ED structure, creating physical changes that direct traffic flow by car or on foot and putting barriers and checkpoints between the healthcare worker and the potentially violent patient, says Patricia A. Lenaghan, RN, MSN, NE-BC, FAAN, senior healthcare clinical and operations analyst at Leo A. Daly, an architectural firm in Omaha, NE, that designs violence prevention into new construction and renovations in healthcare.

“Twenty years ago when I remodeled my first ED, working with the architects and the engineers, I wanted to put in bulletproof glass and locked access doors,” she says. “It was not a popular decision. People tried to talk me out of it, but having been an ED staff nurse, I cared a lot about the staff. I insisted that those things happen.”

While some inner-city hospitals may use metal detectors and ask incoming patients to identify themselves, other hospitals perceive the risk of violence to be so low that people can easily gain access and move undeterred within the facility.

“In many suburban hospitals, basically you can still walk in kind of unannounced,” she says. “That is why I wrote the article. I just don’t think there is enough attention being paid to securing emergency departments and providing a safe environment. It is really not that hard.”

A paper written by Lenaghan and colleagues1 provides a review of design practices to help guide clinical user groups in meetings with hospital leaders, architects, and engineers. In general, environmental designs that influence ED safety and security are to be divided into key areas like parking, entry zone, care zones, and room clustering.

“Best practices to prevent or contain violence include methods to secure high-risk departments or areas, cordon off the ED entrance and access to the rest of the facility, create safe spaces for staff, and provide opportunities for rapid egress from secured spaces,” Lenaghan and colleagues noted. “Camera surveillance and intrusion alarms should be considered as standard features for all healthcare facilities.”

In trying to renovate existing facilities for violence prevention, a common approach is to create barriers between receiving staff and incoming patients and visitors.

“I think also stationing security at the front door,” she says. “If you don’t have an office, then just having their presence there [is a deterrent]. Those kinds of things do not require redesigning anything.”

Have increased awareness for people in and around the hospital, erring on the side of security, she says.

“I think it is perfectly fine for the front-end staff to stop people and ask them who they are there to see,” Lenaghan says. “Everybody has to be super aware of the comings and goings and the situations. You have to be proactive about that.”

It is becoming more common to require visitors to wear badges, particularly in pediatric hospitals where infant abduction also is an issue, she adds.

“They are requiring people to sign in and to get a badge with their picture on it,” she says. “Those are simple steps that are pretty easy to take, and will minimize people just wandering around.”

The emphasis on patient satisfaction and staff friendliness has led to some discouragement of these types of approaches, but Lenaghan makes a cogent point: “People can’t be friendly if they don’t feel safe.”

One way to feel safe in the ED is to have sight lines that afford viewing of other staff, open rows of seating with no bottlenecks, and use of mirrors to reveal blind hallways. Sequencing patients through the system into separate waiting areas can ease frustration of waiting and demonstrate equity in the flow toward care. Furnishings should be fixed to prevent objects from being used as weapons.

“Create waiting areas for patients after triage with distinct areas for fast-track, pediatric, and low- and high-acuity,” the authors noted. “These sub-waiting areas avoid the need for patients to return to a previous physical location. By having patients move in one direction during the entire process, emergency departments can reduce the perception that patients are being neglected or unfairly made to wait.”

As part of this, the triage and admitting staff should have clear egress to a safe fallback area. Security alert systems in the lobby and strategically located “duress alarms” can speed the response to an incident. Importantly, staff need clear lines of sight that leave no team member in a blind spot.

“Clinicians who cannot see each other cannot help each other, and, predictably, reduced visibility results in a sense of isolation,” the authors state. “Isolation is not good for staff morale, patient monitoring, or communication among caregivers. It also reduces safety for staff. To increase transparency, workstations can be strategically located to be within view of each other.”

If possible, design a “safe room” that can be locked down to protect staff, patients, and visitors during an incident. While design and renovation can keep violence at bay, it is still important to train workers to de-escalate situations, Lenaghan notes.

“When I ran emergency departments, we did de-escalation techniques as part of our annual reviews,” she says. “We made sure that the staff knew what to say and how to say it, and the body language to use to de-escalate a situation. Almost everyday nurses and doctors in the ED have to de-escalate some type of situation.”


1. Lenaghan PA, Cirrincione, NM, Henrich S. Preventing Emergency Department Violence through Design. Journal of Emergency Nursing 2018; (1)7-12.