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Hospitals are looking for new and better ways to protect staff and patients, both from intruders who mean harm, and patients or family members who become aggressive and agitated. However, defending against active assailants presents the greatest challenge, as hospitals and EDs strive to remain open and welcoming to the communities they serve.
In November, an emergency physician and a pharmacist were among four people shot and killed by an active assailant at Mercy Hospital & Medical Center in Chicago. On Dec. 1, deputies shot and killed a patient who was exhibiting threatening behavior at University Hospital in Tamarac, FL. Two days later, at the University of Kansas Medical Center in Kansas City, KS, a gunman injured at least two people before turning the gun on himself.
With incidents like these occurring on a more frequent basis, frontline providers have ample cause for concern. In fact, it is already quite clear that violence is hardly a rare occurrence in healthcare. In October, the American College of Emergency Physicians (ACEP) released the results of a survey showing that nearly half of more than 3,500 emergency physicians polled indicated that they had been physically attacked while on the job, and more than two-thirds of respondents agreed that violence in the ED has increased over the past five years. (Editor’s Note: Read much more about this ACEP poll at: .)
Hospitals are responding to the problem with tactics that include everything from de-escalation training to active shooter drills. While experts note there is no one-size-fits-all solution to keeping frontline providers safe, they concur that protective measures need to evolve continuously to meet the challenges posed by new threats and societal trends.
Mission Health, a system that includes several hospitals in western North Carolina, has instituted a multifaceted approach to safety that encompasses many different departments and layers of protective steps.
“We have teams on de-escalation, local law enforcement engagement, systems safety, and we have teams on assault data,” explains Robert Whiteside, CHPA, executive director of security for Mission Health. “It is a large elephant, and we look at it piece by piece.”
Like many systems, Mission Health keeps its procedures for responding to an active assailant largely under wraps so as not to tip off people with ill intent. Whiteside notes that staff members regularly engage in active shooter drills so they will be prepared in the event an attack occurs.
“We stay on top of every white paper, every new bit of literature that comes out, and every new bit of research that is available on the subject of active assailants,” he says.
Further, Whiteside emphasizes that while he oversees security, the work is very interdisciplinary, involving risk management, legal, and facility services. Likewise, given the vulnerability of hospital EDs to violent intruders, leaders from emergency services work alongside Whiteside to develop and implement security procedures and to ensure staff and patients are protected.
“The staff [members] are very engaged in education and training,” explains Richard Lee, MSN, RN, CEN, NE-BC, executive director of emergency services, who oversees operations at six EDs for Mission Health. “We invest in our teams.”
For example, Lee notes that the health system provides staff with training in crisis intervention techniques, which helps employees recognize when the behavior of a patient or family member starts to become agitated. Further, staff members learn how to de-escalate these situations.
“We have care process models for agitation, anxiety, and how to manage patients who may be out of control,” says Lee, noting that such training also includes equipping physicians and advanced practice providers with education on medications that may be clinically appropriate in some circumstances. “We drill constantly, whether it is a code blue drill or it’s a mass casualty drill or an active assailant drill ... the more you drill staff, the more comfortable you get with your processes, and the more comfortable [staff members] get with whatever the routine is for when we go on any type of lockdown or restricted access.”
Lee says this training is essential for staffers who have to continue operating the ED and keep patient flow moving when there is some type of emergency or threat.
“A lot of health systems drill when it is convenient, and they try to drill without disrupting their operational flow of the hospital. If you are truly going test your system, it may be uncomfortable, but you have got to test your processes to the point where they start to break,” Lee advises. “Understand where your risk points are, and where you can put processes in place to really make a stronger defense and a more reliable process.”
Such processes are constantly tweaked and improved with the assistance of a reporting system that invites staff to comment on any processes or situations with patients that did not go well or as intended. Staff can input what the experience was and what they believed the problem was. Then, a risk and safety team will review the situation, Lee explains. For example, he notes that if there is an event during which a patient comes into the ED and a staff member finds a knife or a firearm on the patient that was missed at a safety check, that event will be entered into the system. “The team will put a root cause analysis around it, and then put a process in place that will prevent that from ever happening again,” Lee says.
The improvement process is built around what Lee refers to as an ED joint practice model. Under this model, stakeholders meet every month and learn from each other about what is working and what is not. This also is an opportunity to anticipate any ED challenges that may be coming down the road.
“We also have what is called an ED psychiatric operations meeting,” Lee adds. “The ED team, security, and behavioral health meet. We talk about what trends we are seeing in our processes for patients who may be coming to the ED for a mental health crisis or mental health illness.”
In addition, there is a system-wide behavioral health safety committee that focuses on everything from education and processes to even the physical layout of the EDs, with an eye on making sure the health system is using the safest equipment and innovations, Lee shares.
One approach that has helped Mission Health ED staff feel more safe and secure is the distribution of wearable devices that essentially act as personal alarms that staff can use if they feel threatened or need assistance. “Security officers will respond immediately ... and it is connected to the computer system throughout the department so even our leadership team knows if a staff member has hit that button and needs help,” Lee notes.
Staff members throughout the system also have at their disposal the option of calling a Code BERT, which triggers a behavioral emergency response team. “The BERT team is called whenever there is an aggressive or escalating patient. Ideally, it is called well in advance of anything becoming physical,” Whiteside shares. “The team shows up, they implement de-escalation tactics and any other nursing protocols [deemed appropriate] such as medication management ... to try to get a handle on things.”
Whiteside is a big believer in de-escalation techniques, and he has security personnel certified to train hospital staff in multiple de-escalation programs such as Verbal Judo and Surviving Verbal Conflict. “I have permeated our department with that de-escalatory, nonescalatory philosophy and practice, and it has had a visible effect and a trackable effect on how we are able to de-escalate patients,” he reports.
Recently, Whiteside says a person was smoking in the parking lot of a Mission Health hospital, which is a tobacco-free campus. A team leader saw the smoker and another person engaging in a quickly escalating conversation. First, the team leader tried using de-escalation techniques to defuse the situation and convince the man to leave the campus. When this initial effort did not work, the team leader used more advanced de-escalation techniques designed to mitigate the chances that a conflict will become physical. “We successfully got the individual to leave the campus without leading to any hands-on [conflict], without having to call law enforcement, and without the kind of escalation tactics that could easily have turned the issue into something that would either have gotten physical or ended up attracting cell phone or camera usage,” Whiteside relates.
Beyond Mission Health’s strong emphasis on violence prevention, there also are resources available to support the needs of any healthcare worker who has been assaulted or attacked. Through a “care for the caregiver” program, the staff member will receive emotional support and any other type of assistance that might be needed to reduce stress or anxiety, Lee notes.
“We have a strong critical incident stress management [CISM] program within our health system. If a team member or a department were to encounter a disruptive patient, we could call that team, and they would bring in resources that have CISM training to help provide therapy and support for an individual, a few team members, or a whole department,” he explains. “If we have an event where a patient was out of control and hurt someone ... we can put a CISM team around a department and have several debriefings throughout the day to make sure staff [members] get what they need emotionally.”
Whiteside acknowledges the constant challenge to stay ahead of the trends in society that fuel or change the nature of violent events. For instance, he notes the opioid epidemic and increases in gun violence events have affected healthcare. He observes that it is particularly difficult to protect hospitals from active assailants because such attacks tend to be random. “When it comes to prevention and mitigation of an active assailant, that is extremely hard,” he says. “You are really managing the response part.”
Like many hospitals, Mission Health trains staff in the Department of Homeland Security’s “Run, Hide, Fight” active shooter protocol so healthcare workers will know what to do if an assailant enters their facility. (Editor’s Note: Learn more about this program at: .) Whiteside adds that any proper active assailant response plan should address preparation, mitigation, response, and recovery.
While internal preparedness is important, Whiteside emphasizes that it is also vital to engage with community partners. “Our hospital participates in a local threat assessment team that is a multijurisdictional, multidisciplinary committee that includes [representatives from] the local sheriff’s department, police department, leadership from Mission Health, [and] some other professionals from the local community,” he says, noting that social workers and representatives from probation and parole also participate.
The threat assessment teams meet regularly, either in person or virtually, to review any perceived threats in the community and to discuss mitigation tactics. “I can’t emphasize enough how important it is to do everything we can do alongside all of our colleagues right here in the health system, but also all of our non-healthcare colleagues in the community,” Whiteside says. “It makes all the difference because you are able to pull from all the different resources.”
Does such a comprehensive approach to violence make frontline clinicians at Mission Health feel more secure? Data from the National Database of Nursing Quality Indicators (NDNQI) suggest that it does make a difference, Lee says.
“It asks a lot of questions about how staff perceive their environment ... one of the actual questions on the NDNQI survey is do they feel safe,” he explains. “We try to compare ourselves to the magnet hospitals across the United States, which probably consists of the top 10%. We exceed the magnet mean for our staffing satisfaction and [whether] staff members feel safe.” (Editor’s Note: For even more data on the connection between physical and emotional safety at work for nurses and the ability to deliver high-value care, visit: .)
Erik Modrzynski, CHSP, CEDP, is an emergency manager at the Medical University of South Carolina (MUSC), an academic medical center in Charleston. He has worked for 15 years on fire and EMS matters, experience that has influenced his approach to ensuring MUSC staff members are optimally prepared for active assailants through scenario-based training.
The training involves two phases. First, staff members learn the government-recommended “Run, Hide, Fight” technique. Then, participants go through the motions of actually putting these lessons into practice. “We teach them how to barricade themselves, and we teach them how to escape and use other techniques that might help them if there was an active shooter,” Modrzynski explains. “After that, they are able to go through our live, active shooter drills that we go through.”
To make the drills as authentic as possible, Modrzynski uses actors who play various roles, including assailants and police officers. Drills even include firing blank rounds. “We have observers that are there ... taking copious notes,” he says. “The actors who play patients and bystanders — they take notes for us, too, so we can see what is going on.” These observations inform the kind of training that staff will receive going forward. For example, in one of these drills, whenever a staff member goes into a building, he or she needs to know the way out.
“It is important to know your escape routes and where you can hide or barricade yourself, so that got added into the training,” observes Modrzynski, noting that this is particularly important for staff members who tend to float between different buildings on campus.
Local law enforcement gets a good experience out of these live-action drills, too, Modrzynski observes. In August 2018, he says police, fire, and EMS personnel practiced rapid-entry procedures that help remove patients from facilities and away from danger.
In surveys, MUSC staff members have voiced strong support for the active shooter training. For example, following the first such drill a few years ago, most said it was very helpful and that they wanted to do it again, Modrzynski shares.
“I get requests from local law enforcement to do it for us. Even our community partners are [asking] us to do this,” he says. Also, it is clear from these live-action events that even the phase one training makes a difference. “During our second [live-action drill], we had some folks [participate] that didn’t go through the training beforehand ... and you could tell,” Modrzynski recalls. “They didn’t really know what they were doing. People were hiding under desks and doing things that we tell them not to do if they can get out.”
These same individuals completed the phase one training and performed much differently during subsequent live-action drills. “It was completely different for them,” Modrzynski says.
Staging such a drill takes time and effort, Modrzynski acknowledges. Typically, he begins preparations roughly three months prior to the actual drill. Also, he notes it is important to respect the time that will be required for staff to participate.
“For the second active shooter drill, we made a movie for that. It was a longer process, and we actually didn’t have as many people show up,” he explains. “But for the [drill] we just did [in August 2018], we did it in two hours, and 130 people showed up.”
One step that has helped offset the staff time required to participate in the drills is a move by the hospital administration to enable employees to leave work a couple of hours early one day as compensation for the time required to participate in the drills, which take place on Saturday. “Even with that, we have people who come in on their day off just to be part of the training,” Modrzynski adds.
Another sweetener involves providing lunch along with the training.
“Especially coming from the fire service myself, food does a lot,” Modrzynski adds.
However, he notes that perhaps the most powerful incentive is to secure leadership support and participation. “When the COO shows up on his day off or the CEO shows up on his day off to do this training, that speaks volumes,” he says.
What works for one organization is not necessarily going to be a perfect fit for another, particularly given variations in the size and staffing of different healthcare organizations, Modrzynski stresses. Consequently, he encourages colleagues to be creative in using the resources available to customize a training solution that works best.
Modrzynski obtained a proper certification to develop this live-action, scenario-based program through the Alert, Lockdown, Inform, Counter, Evacuate (ALICE) Training Institute. However, he notes there is plenty of good information available online through the Department of Homeland Security and other sources.
“Working with your community partners is huge,” he says. “All the surrounding police departments [here] will come out and do the training for little or no charge at all ... you just have to reach out and ask.”
Financial Disclosure: Physician Editor Robert Bitterman, MD, JD, FACEP, Nurse Planner Nicole Huff, MBA, MSN, RN, CEN, Author Dorothy Brooks, Editor Jonathan Springston, Executive Editor Shelly Morrow Mark, and Editorial Group Manager Terrey L. Hatcher report no consultant, stockholder, speaker’s bureau, research, or other financial relationships with companies having ties to this field of study.