Patient or visitor, mentally disturbed individuals may pose a safety threat

A gunman enters an ED in Alaska: How would your staff respond?

When an intruder with a rifle entered Alaska Regional Hospital in Anchorage on March 10, 2004, the ED staff followed the hospital’s procedures, which confined him to a corridor leading to the ED and kept ED staff and patients from being harmed. The gunman eventually shot himself, became a patient in the ED, and died from his wounds.

"He was mentally unstable, but no one knows why he came to the ED," says Hilliard Pettus, RN, MICN, ED director at Alaska Regional.

While no one but the gunman was harmed, the event emphasized the importance of having adequate procedures to deal with mentally unstable individuals — be they patients or visitors. And it underscores the need to coordinate closely with the hospital security department in such incidences. The number of people with mental illness seeking ED treatment is on the upswing: More than 2 million psychiatric patients were treated in EDs in 2002.

"All our staff have training in dealing with aggressive behavior — noticing behavioral changes, [unusual] body language, knowing when a situation is escalating, and what they need to do at every step," Pettus explains.

Staff also know when to call for security or call the police, he points out. "Most security concerns are dealt with by our own in-house security personnel," Pettus adds. "But our security personnel are not armed, so anything else [beyond minor security issues] would involve the police."

The same staff, of course, must know how to deal with threats from within and without. Some hospitals have the benefit of special mental health units that help the ED deal with mentally ill patients.

"We are fortunate because we have 24-hour-a-day acute psychiatric services [APS]," says Carol Halley, RN, nurse manager of the ED at Hennepin County Medical Center in Minneapolis. "They see all of our mental health patients." Thus, if ED triage staff members come in contact with a person pre-admission who they think has a mental health issue, they take that individual to APS, which is on the same floor, and bypass the ED entirely. "If they medically don’t have to be admitted, they go right to APS," she says.

Even with this option, however, ED patients still can become emotionally upset or violent, Halley notes. Hennepin County has 24-hour security in the ED, with a booth in the triage area, and that person doesn’t leave the booth, she adds.

"They sit right across from our triage desk and waiting area — a visible presence," she says. "So, if something was to happen and the officer needed even more help, he could radio the [three] other security officers from other parts of the hospital."

ED staff members are supposed to make the initial call that they need help, but they must remain the clinical leader of the team, Halley explains. "We don’t want security to decide if a patient is to be restrained; we make that call," she notes. "I think that’s really important, because oftentimes security does not have the information we do." The patient may be chemically altered or have diabetes, for example, Halley says.

Alaska Regional does not have a mental health unit, Pettus points out. "We would medically stabilize them and then try to find a psychiatric facility in the community," he says. "We have one room across from the nurse’s station called the observation room where we try to keep an eye on these patients."

Here again, the ED is in charge of clinical decisions. "If patients present a threat of violence, a code strong’ is called, which requires all male staff to respond to the area designated by the operator," notes James Farrell, director of security at Alaska Regional. All staff members responding to the code follow nursing instructions, he says. "Restraints are used under the supervision of nursing," Farrell explains. "All attempts are made to talk to the patient before physical methods are used."

If a patient becomes extremely violent, staff can call the police, who have a substation across the street and take less than three minutes to arrive at the ED.

Dealing with outside threats

When the gunman entered the Alaska Regional ED in March, Pettus noticed him carrying a rifle and did exactly as he had been trained to do.

"Using our security camera, I noticed him come in, then walk around in distress," he recalls. "I called security, and then I called the police." He also pushed a panic button that brought down a metal door to stop the intruder from getting further into the hospital.

Hennepin has similar procedures. "If someone walks into triage, it is the responsibility of the triage nurse to assess what’s going on and then try to get them to APS," Halley adds. "If they come in with a gun, we have panic buttons, which alert the security officer in the booth."

During one recent night shift, a nurse was relatively certain she had seen a gun on a person who came into triage, Halley says. The nurse called security and, while waiting for security to arrive, started to move everyone away from triage. "Security was able to intervene and successfully de-arm the person," she adds.

Recently, Hennepin began locking down the ED at night. "You have to have card access," Halley explains. "There’s a main entrance that comes right into our triage area, so there’s a double set of doors, and you have to stop at the security booth and explain why you need to get into the ED."

ED managers can learn from violent or potentially violent incidents, regardless of the outcome. For example, Alaska Regional conducted a root-cause analysis after the March incident, as well as a six-hour debriefing with the chaplain, Pettus says. "This was for all employees involved, so they could discuss the emotions they were feeling and work through them," he explains. "Every time you have a traumatic thing like that occur, it’s very important to do a debriefing."

Even though no staff or patient was harmed during the incident, Farrell says several new measures have been instituted since the incident to make the facility even more secure. They include the following:

  • Additional cameras are being installed throughout the hospital.
  • Improved release of the protective steel door by the ED entrance enables staff to simply push a button to activate it, instead of having to hold a button down until the door is fully closed.
  • Bulletproof glass has been installed in the window of the door leading to triage and the double doors that lead into the ED proper.
  • The director of security’s office has been moved to the ED.
  • The Anchorage Police substation has been relocated to the second floor, near the ED.

Staff education is performed on a regular basis at Alaska Regional. "Every year, everybody on the staff takes our course on handling potentially violent individuals, including the security director," Pettus notes. "Every time I take it, I learn something new." He says it’s very important to take the course every year, even if you’ve taken it several times before, because "there are things you forget."

At Hennepin, members of the security department sit on the task force that periodically reviews security procedures. "In addition, if there are specific things we are concerned about, we can call for a special meeting and review them," Halley adds.


For more information on increasing ED security, contact:

  • Carol Halley, RN, ED Nurse Manager, Hennepin County Medical Center, 701 Park Ave., Minneapolis, MN 55415. Phone: (612) 873-6222. E-mail:
  • Hilliard Pettus, RN, MICN, ED Director, Alaska Regional Hospital, 2801 DeBarr Road, Anchorage, AK 99508. Phone: (907) 264-1713. E-mail: