The trusted source for
healthcare information and
ED Accreditation Update
Sentinel Event Alert says access control holds the key to reducing ED violence
Manager must interact with internal and external security personnel
[Editor's note: This is the third in a three-part series on reducing violence in the ED. In the first article, our experts discussed the importance of a "zero tolerance" policy. In last month's article, we outlined key steps recommended by government agencies for reducing violence and discussed the importance of having clear procedures when it comes to dealing with patients and their families. This month we examine the Sentinel Event Alert recently published by The Joint Commission, which discusses why the ED is particularly susceptible to episodes of violence, outlines leading causal factors, and provides additional guidance for violence prevention.]
"Once considered safe havens, health care institutions today are confronting steadily increasing rates of crime, including violent crimes such as assault, rape and homicide," asserts The Joint Commission in Sentinel Event Alert 45, "Preventing violence in the health care setting," issued June 2, 2010.
"As criminal activity spills over from the streets onto the campuses and through the doors, providing for the safety and security of all patients, visitors and staff within the walls of a health care institution, as well as on the grounds, requires increasing vigilant attention and action by safety and security personnel as well as all health care staff and providers."
The ED, says The Joint Commission, "is typically the hardest area to secure." How can that challenge be overcome? "A key to providing protection to patients is controlling access," said Russell L. Colling, MS, CHPA, a health care security consultant based in Salida, CO, and the founding president of the International Association for Healthcare Security and Safety, Glendale Heights, IL, in the Alert.
Detective William M. Rogers, MD, FACEP, pharmaceutical diversion group supervisor/investigator for the Drug Abuse Reduction Task Force (DART) and a practicing ED physician in Cincinnati, OH, says, "Teleologically that stands to reason, in that the ED is the gateway to the hospital. It is typically responsible for a third of the admissions, and you are going to have a mix of families and patients from diverse backgrounds with diverse expectations and all coupled under high stress."
When it comes to improving access control, says Rogers, the first thing that needs to be done is a threat assessment. This assessment involves steps such as a look at the population served and the most prevalent crimes. Rogers same these are some of the questions that must be asked: Do you see a lot of domestic assaults or gang violence? What caliber weapons are used on the street? Is there a history of violence spilling in to the ED? The threat assessment should be conducted by ED managers and security staff, and it requires buy-in from the administration, he says. "If they don't buy into the validity of the assessment, they will not fund what needs to happen," Rogers explains.
Physical control barriers also must be examined, he says. "In addition, you can control access with keypads at the EMS entrance, the walk-in entrance, and from other parts of the hospital, so if someone gets in from another part of the hospital, they still can't get into the ED," Rogers says.
There are also basic skills that can be taught to your staff, he says. "They can be as simple as staff learning how to walk through a doorway, learning angles and geometry so when they walk into a room they can see it, rather than looking down at the chart," he explains. "Some very simple prevention does not cost money, just training time."
Key role for manager
Once a threat assessment is completed, says Rogers, "it falls under the ED manager to be the driving force" behind implementation of the access control strategy, in cooperation with appropriate security personnel.
"You may find out that your hospital security staff is underfunded and understaffed, and may not be able to handle a crisis," he says. "In that case you need to partner early with law enforcement." Rogers adds that "after the assessment, the ED manager needs to be part of the all-hazards response plan."
In concert with security, plans to meet threats should be divided into immediate actions, intermediate (6-18 months) strategic needs, and long- range plans that require capital budgeting and must be brought to administration, he says.
ED managers should be aware of all the resources available in the community, Rogers says. "For example," he says, "law enforcement may be able to direct the officers that patrol the area to not be in uniform." If there is drug activity in the area, for example, Rogers says these officers would be better able to observe activity. If an event occurs, he adds, "you can more readily send someone in for observation."
If for some reason law enforcement does not respond enthusiastically, "you can go to the chief prosecutor's office about strategies," Rogers suggests. "They would be only too happy to be pro-active. They don't want another case file, and it would be a political feather in their cap if they are able to put out a 'stop the violence' program."
The ED manager also should establish relationships with key people in the community, he says. "It's always good to know the key players before something happens," Rogers says.
ED, community group join forces
One example of just such cooperation with the community occurred at Loyola University Medical Center in Maywood, IL, where "street justice" was prevented following a gang-related incident. The ED collaborated with Maywood CeaseFire, a violence-prevention group that uses street-savvy people to mediate disputes and quell conflicts between high-risk youths and their families and friends.
The collaboration between Loyola and CeaseFire began in May 2009. Interventions now begin soon after victims of violence arrive at the hospital for treatment, explained the Loyola system in a news release.1
Victims and their families are screened by Loyola trauma staff, chaplains, and social workers for possible referral to the CeaseFire Hospital Response team, who are specially trained to effectively intervene when emotions are running at their highest. The team is comprised solely of CeaseFire volunteers. Some are chaplains, while others are just concerned members of the community.
Thomas Esposito, MD, chief of the division of trauma, surgical critical care, and burns in the Department of Surgery at Loyola Stritch School of Medicine, says, "The solution to street violence needs to be multi-faceted, multidisciplinary, and community-based."