Safeguard the ED: Act Before Violence Strikes

Metal detectors, security guards are precautions departments are taking in response to an increase in violent incidents

As violence continues to increase in hospitals across the country, the challenge of ensuring a secure ED has become a top priority. After several gang members opened fire in the ED at Los Angeles County-University of Southern California Medical Center in 1993, ED managers nationwide were motivated to increase security.

"After the shooting in Los Angeles, we realized that while we don’t have as many violent patients as many EDs do, something like that could easily happen here," observes Seth Wright, MD, FACEP, associate professor of emergency medicine at Vanderbilt University Medical Center in Nashville, TN, which added metal detectors in response to the incident.

Although the Los Angeles shooting made headlines, attacks on ED staff, patients, and visitors aren’t unusual. A recent study shows that 20% of EDs report at least one threat with a weapon each month, and 46% report the confiscation of a weapon at least once a month.1 A 1991 national survey of ED nurses found that a third had been assaulted at least once during the previous year.

The ED is vulnerable to violence for several reasons. "It’s a very public area [that is] open 24 hours a day, and we’ve got patients, families, police, and ambulance personnel milling around, whereas most of the other areas in the hospital are pretty restricted," says Diane Mangrum, RN, BSN, CEN, interim director of emergency services at Ben Taub Hospital in Houston. "Also, people are in a crisis situation when they come here, not only the patients but the family members as well, and emotions run high."

At Ben Taub, a woman who had just shot her husband came to the waiting room of the ED where he’d been taken, shot and killed the woman he’d been having an affair with, and wounded her sister. Around the same time period, a man came to the hospital and shot his wife.

After those two unrelated shootings, additional security guards were added and metal detectors were installed. "Everyone without a hospital badge now has to go through the metal detector, and we take weapons off people on a routine basis," says Mangrum.

Metal detectors are located at every entrance to the ED except the ambulance entrance. "When a patient is brought in on a stretcher, if we find a weapon when they come in, we call security and they come and take the weapon," Mangrum explains. Psychiatric patients are searched for anything that could be a possible hazard to themselves or others, she says.

Even with the added security, there are still frequent physical assaults at Ben Taub. Twenty-four assaults on ED staff occurred in 1996, with a significant percentage of those due to substance-abusing patients, says Mangrum. "One guy in the holding area picked up a thermometer on a rolling pole, and hit another patient with it. He was too drunk to go to jail—that’s what they told us," she recalls. "As a general rule, they don’t want to sober them up at the jail because it’s too much of a liability for them."

Recently, when a nurse was trying to move a woman who’d overdosed, the patient violently attacked her. "She’s now suffering from post-traumatic stress disorder and can’t go into a room alone with a patient," notes Mangrum.

One problem is that law enforcement officials don’t always stay with the patients they bring to the ED. "If the police bring patients from the jail or in custody, they need to stay with those patients because I don’t have an extra security guard to observe them, but that doesn’t always happen," Mangrum says. "Sometimes they’ll just drive up and drop them outside and tell them to walk into the ER."

Most violent incidents occur during evening hours. "The most dangerous time for the ED is whenever it’s dark, from dusk until about 1 a.m., with a slight increase on weekends, particularly holidays," says Craig Ewing, director for the Southern California operations of Healthcare Security Services, based in Denver.

Prevent violence with training

Since 1995, California law has required ED staff to receive training in dealing with violent individuals. "Everybody who works in the ED needs to know the assault cycle, de-escalation techniques, and how to restrain somebody if it becomes necessary," stresses Ewing. (See chart on page 111.)

The mandatory education in de-escalation techniques has had a major impact on reducing violence, he says. "It’s made a huge difference in how staff members interact with patients," says Ewing. "If you take the extra 10 seconds to explain why a patient is having to wait, you may not tie yourselves up for an hour later on because that patient has gone ballistic."

Patients are already anxious when they walk into the ED, and problems occur when that anxiety is allowed to build, he explains. "Some people act out verbally and others act out physically. If it’s verbal, isolate them so they can vent and get it out of their system," says Ewing. "Have a security officer escort them out of the waiting area, preferably to an "isolation" room with bolted-down furniture and pictures screwed to walls, where patients can get over their anger."

At Ben Taub’s ED, all staff receive nonviolent crisis intervention classes every year. "They are taught verbal techniques to de-escalate violent patients and physical techniques in case they have to restrain somebody," Mangrum says. "You need to continually educate your staff about the potential for violence, so they are trained to look for clues to help anticipate it."

However, verbal techniques often don’t work well on substance-abusing patients. "If a patient is hopped up on PCP or cocaine, they generally won’t be too receptive to verbal techniques," Mangrum notes. "In those situations, our increased security and metal detector have helped us the most."

Here are some tips to make your ED safer:

Keep track of violence. Tracking of the frequency and type of violence seen in the ED helps to determine changing security needs. The ED at Brigham and Women’s Medical Center in Boston has a "trouble log" in which such incidents are recorded. "You need to always be looking for trends. Is the level of violence increasing or remaining the same? Are you seeing more weapons? If so, what type of weapons? Are more staff verbally abused than three or four months ago?" asks H. Range Hutson, MD, clinical research director for the department of emergency medicine at Brigham and Women’s.

Careful documenting of specific incidents can help prevent future violence. When an employee fills out an incident report at Ben Taub, the situation is always evaluated to determine how a similar incident can be prevented, says Mangrum.

Explain why patients may have to wait. "I don’t think people really understand the meaning of triage," Hutson states. "Most people are real uptight about what’s going on with themselves or a family member, and they just see it as, ‘I’ve been waiting a long time, but somehow you go in before me,’" he says. ED staff should be careful to explain that other patients have life-threatening emergencies and need to be seen immediately.

Keep security nearby. Security should be notified as an agitated person is noticed, before violence occurs, says Hutson. "It should never be an in-your-face issue unless it’s a dire necessity, but security should be near to defuse any type of violence that could occur," he recommends.

Don’t be overly afraid. If you work in a high-crime area, don’t let negative feelings about the community’s bad seeds affect your view of the general population. "At L.A. County-USC, we saw 1500 gunshot wounds a year, but you have to be careful not to let that color your perspective of the community you serve," says Hutson. "If you work in South Central L.A., you have to make sure your judgment isn’t being skewed. Remember that the vast majority of people who live in violent areas are good people."

Make sure security reflects your actual needs. "You have to do an honest assessment, without any preconceived notions, based on the crime history in your area," says Rob McFarland, a health care safety and security consultant based in Orange County, CA. One ED in a low-crime neighborhood had imposing steel doors which barred access unless a clerk released them. "I watched it set people off, just because of the nature of physical barriers," recalls Ewing. "The measures there didn’t match the nature of the population they were serving."

California law also requires a security assessment to determine an ED’s individual security needs. "Instead of recommending a $50,000 camera system or lead-lined walls to absorb bullets, we focus on what can we do to improve based on the reality of the finances of the hospital," Ewing explains.

Several security options

Bulletproof glass. Be realistic about the amount of security bulletproof glass affords. "Its function is to increase the comfort level of the receptionists, but it won’t necessarily protect them," says McFarland. "If someone were to shoot at them point-blank, the glass would deflect it, but all they’d have to do is shoot below the glass, since it doesn’t extend to the floor."

Cameras. Having a camera in the ED waiting area with a monitor at the security desk or nursing station is a cost-effective deterrent, says Ewing. "A camera and monitor can be set up for under $500—we’re not talking big bucks here. If you mount the camera in the corner of the room, you’ll have a good range without fancy zoom lenses," he notes.

Call attention to the camera. "Hang a sign underneath the camera that says, ‘Smile,’ Ewing recommends. "That gives double value to the camera by letting everybody know it’s up there. If someone misbehaves, they will assume it will be patched into a monitor."

Avoid putting up "dummy" cameras. "You are telling the staff and patients they have a degree of safety that doesn’t exist," says Ewing. "You’re making a promise that somebody’s watching this that you’re not going through with, which is a potential liability risk."

Metal detectors. The cost of purchasing and setting up a metal detector is approximately $4,500, but hiring someone to staff it for 24 hours a day is a major expense. Still, EDs in high-crime areas are increasingly installing metal detectors. "If you’re an urban, inner city trauma center, you owe it to your staff to have one of these," says Wright. "As a rule, patients and families accept the use of it and don’t feel they are being put into a danger zone."

At Vanderbilt’s ED, a metal detector was installed as a preventative measure. "A lot of people don’t solve this problem until violence has manifested itself," says Wright. "This is more of a prophylactic for us because we felt we should do something before the problem occurs."

Vanderbilt’s survey of ED patients and family members showed that 89% said it made them feel safer, while 12% felt it invaded their privacy.2 Overall, patients seem to appreciate the concern for their safety, Wright says. "Women weren’t happy about having their purses inspected, but most people are pretty used to walking through metal detectors now, since they do it every time they go to the airport or to a rock concert," he notes.

Other EDs with metal detectors have found patients are not so understanding. "It’s not exactly one of those things that increases your customer satisfaction, that’s for sure," says Mangrum. "They think it’s barbaric, but people have to understand it’s for their safety as well—we don’t want visitors and other patients harmed either."

X-ray machines. A more expensive alternative to metal detectors is a radiographic scanner, which omits

As violence continues to increase in hospitals across the country, the challenge of ensuring a secure ED has become a top priority. After several gang members opened fire in the ED at Los Angeles County-University of Southern California Medical Center in 1993, ED managers nationwide were motivated to increase security.

"After the shooting in Los Angeles, we realized that while we don’t have as many violent patients as many EDs do, something like that could easily happen here," observes Seth Wright, MD, FACEP, associate professor of emergency medicine at Vanderbilt University Medical Center in Nashville, TN, which added metal detectors in response to the incident.

Although the Los Angeles shooting made headlines, attacks on ED staff, patients, and visitors aren’t unusual. A recent study shows that 20% of EDs report at least one threat with a weapon each month, and 46% report the confiscation of a weapon at least once a month.1 A 1991 national survey of ED nurses found that a third had been assaulted at least once during the previous year.

The ED is vulnerable to violence for several reasons. "It’s a very public area [that is] open 24 hours a day, and we’ve got patients, families, police, and ambulance personnel milling around, whereas most of the other areas in the hospital are pretty restricted," says Diane Mangrum, RN, BSN, CEN, interim director of emergency services at Ben Taub Hospital in Houston. "Also, people are in a crisis situation when they come here, not only the patients but the family members as well, and emotions run high."

At Ben Taub, a woman who had just shot her husband came to the waiting room of the ED where he’d been taken, shot and killed the woman he’d been having an affair with, and wounded her sister. Around the same time period, a man came to the hospital and shot his wife.

After those two unrelated shootings, additional security guards were added and metal detectors were installed. "Everyone without a hospital badge now has to go through the metal detector, and we take weapons off people on a routine basis," says Mangrum.

Metal detectors are located at every entrance to the ED except the ambulance entrance. "When a patient is brought in on a stretcher, if we find a weapon when they come in, we call security and they come and take the weapon," Mangrum explains. Psychiatric patients are searched for anything that could be a possible hazard to themselves or others, she says.

Even with the added security, there are still frequent physical assaults at Ben Taub. Twenty-four assaults on ED staff occurred in 1996, with a significant percentage of those due to substance-abusing patients, says Mangrum. "One guy in the holding area picked up a thermometer on a rolling pole, and hit another patient with it. He was too drunk to go to jail—that’s what they told us," she recalls. "As a general rule, they don’t want to sober them up at the jail because it’s too much of a liability for them."

Recently, when a nurse was trying to move a woman who’d overdosed, the patient violently attacked her. "She’s now suffering from post-traumatic stress disorder and can’t go into a room alone with a patient," notes Mangrum.

One problem is that law enforcement officials don’t always stay with the patients they bring to the ED. "If the police bring patients from the jail or in custody, they need to stay with those patients because I don’t have an extra security guard to observe them, but that doesn’t always happen," Mangrum says. "Sometimes they’ll just drive up and drop them outside and tell them to walk into the ER."

Most violent incidents occur during evening hours. "The most dangerous time for the ED is whenever it’s dark, from dusk until about 1 a.m., with a slight increase on weekends, particularly holidays," says Craig Ewing, director for the Southern California operations of Healthcare Security Services, based in Denver.

Prevent violence with training

Since 1995, California law has required ED staff to receive training in dealing with violent individuals. "Everybody who works in the ED needs to know the assault cycle, de-escalation techniques, and how to restrain somebody if it becomes necessary," stresses Ewing. (See chart on page 111.)

The mandatory education in de-escalation techniques has had a major impact on reducing violence, he says. "It’s made a huge difference in how staff members interact with patients," says Ewing. "If you take the extra 10 seconds to explain why a patient is having to wait, you may not tie yourselves up for an hour later on because that patient has gone ballistic."

Patients are already anxious when they walk into the ED, and problems occur when that anxiety is allowed to build, he explains. "Some people act out verbally and others act out physically. If it’s verbal, isolate them so they can vent and get it out of their system," says Ewing. "Have a security officer escort them out of the waiting area, preferably to an "isolation" room with bolted-down furniture and pictures screwed to walls, where patients can get over their anger."

At Ben Taub’s ED, all staff receive nonviolent crisis intervention classes every year. "They are taught verbal techniques to de-escalate violent patients and physical techniques in case they have to restrain somebody," Mangrum says. "You need to continually educate your staff about the potential for violence, so they are trained to look for clues to help anticipate it."

However, verbal techniques often don’t work well on substance-abusing patients. "If a patient is hopped up on PCP or cocaine, they generally won’t be too receptive to verbal techniques," Mangrum notes. "In those situations, our increased security and metal detector have helped us the most."

Here are some tips to make your ED safer:

Keep track of violence. Tracking of the frequency and type of violence seen in the ED helps to determine changing security needs. The ED at Brigham and Women’s Medical Center in Boston has a "trouble log" in which such incidents are recorded. "You need to always be looking for trends. Is the level of violence increasing or remaining the same? Are you seeing more weapons? If so, what type of weapons? Are more staff verbally abused than three or four months ago?" asks H. Range Hutson, MD, clinical research director for the department of emergency medicine at Brigham and Women’s.

Careful documenting of specific incidents can help prevent future violence. When an employee fills out an incident report at Ben Taub, the situation is always evaluated to determine how a similar incident can be prevented, says Mangrum.

Explain why patients may have to wait. "I don’t think people really understand the meaning of triage," Hutson states. "Most people are real uptight about what’s going on with themselves or a family member, and they just see it as, ‘I’ve been waiting a long time, but somehow you go in before me,’" he says. ED staff should be careful to explain that other patients have life-threatening emergencies and need to be seen immediately.

Keep security nearby. Security should be notified as an agitated person is noticed, before violence occurs, says Hutson. "It should never be an in-your-face issue unless it’s a dire necessity, but security should be near to defuse any type of violence that could occur," he recommends.

Don’t be overly afraid. If you work in a high-crime area, don’t let negative feelings about the community’s bad seeds affect your view of the general population. "At L.A. County-USC, we saw 1500 gunshot wounds a year, but you have to be careful not to let that color your perspective of the community you serve," says Hutson. "If you work in South Central L.A., you have to make sure your judgment isn’t being skewed. Remember that the vast majority of people who live in violent areas are good people."

Make sure security reflects your actual needs. "You have to do an honest assessment, without any preconceived notions, based on the crime history in your area," says Rob McFarland, a health care safety and security consultant based in Orange County, CA. One ED in a low-crime neighborhood had imposing steel doors which barred access unless a clerk released them. "I watched it set people off, just because of the nature of physical barriers," recalls Ewing. "The measures there didn’t match the nature of the population they were serving."

California law also requires a security assessment to determine an ED’s individual security needs. "Instead of recommending a $50,000 camera system or lead-lined walls to absorb bullets, we focus on what can we do to improve based on the reality of the finances of the hospital," Ewing explains.

Several security options

Bulletproof glass. Be realistic about the amount of security bulletproof glass affords. "Its function is to increase the comfort level of the receptionists, but it won’t necessarily protect them," says McFarland. "If someone were to shoot at them point-blank, the glass would deflect it, but all they’d have to do is shoot below the glass, since it doesn’t extend to the floor."

Cameras. Having a camera in the ED waiting area with a monitor at the security desk or nursing station is a cost-effective deterrent, says Ewing. "A camera and monitor can be set up for under $500—we’re not talking big bucks here. If you mount the camera in the corner of the room, you’ll have a good range without fancy zoom lenses," he notes.

Call attention to the camera. "Hang a sign underneath the camera that says, ‘Smile,’ Ewing recommends. "That gives double value to the camera by letting everybody know it’s up there. If someone misbehaves, they will assume it will be patched into a monitor."

Avoid putting up "dummy" cameras. "You are telling the staff and patients they have a degree of safety that doesn’t exist," says Ewing. "You’re making a promise that somebody’s watching this that you’re not going through with, which is a potential liability risk."

Metal detectors. The cost of purchasing and setting up a metal detector is approximately $4,500, but hiring someone to staff it for 24 hours a day is a major expense. Still, EDs in high-crime areas are increasingly installing metal detectors. "If you’re an urban, inner city trauma center, you owe it to your staff to have one of these," says Wright. "As a rule, patients and families accept the use of it and don’t feel they are being put into a danger zone."

At Vanderbilt’s ED, a metal detector was installed as a preventative measure. "A lot of people don’t solve this problem until violence has manifested itself," says Wright. "This is more of a prophylactic for us because we felt we should do something before the problem occurs."

Vanderbilt’s survey of ED patients and family members showed that 89% said it made them feel safer, while 12% felt it invaded their privacy.2 Overall, patients seem to appreciate the concern for their safety, Wright says. "Women weren’t happy about having their purses inspected, but most people are pretty used to walking through metal detectors now, since they do it every time they go to the airport or to a rock concert," he notes.

Other EDs with metal detectors have found patients are not so understanding. "It’s not exactly one of those things that increases your customer satisfaction, that’s for sure," says Mangrum. "They think it’s barbaric, but people have to understand it’s for their safety as well—we don’t want visitors and other patients harmed either."

X-ray machines. A more expensive alternative to metal detectors is a radiographic scanner, which omits the need to search through patient’s belongings. "There’s also a lower risk for security people of getting stuck with needles if a person is a drug addict," says Wright.

Locked entrances. At Vanderbilt, the ambulance entrance and other entrances to the ED are locked 24 hours a day. A security camera observes all entrances and will allow access to paramedics who don’t know the code. "You cannot get into the ED by any route without going by the metal detector," says Wright.

Security officers. Many large EDs in urban areas have security officers stationed at the ED round the clock. At Ben Taub, security guards are stationed at the ED entrance, in front of the triage desk, and continually patrol the holding areas. "Sometimes they are our own security, and sometimes we use off-duty police officers, but we always have at least three or four around this area," Mangrum reports.

A debate exists about whether security should be armed. "I’m adamantly opposed to a security guard with a gun. A study found that it takes trained officers 37 feet to pull their gun when someone is coming at them with a knife. Bullets are very dangerous, and it’s just as easy to miss as to hit," says McFarland.

Surprisingly, less intimidating, unarmed security guards are often more effective at defusing violence before it occurs, says Ewing. "If violence happens, unless the person is impaired or intoxicated, we did something wrong," he says. "Smaller guards and females would just as soon not get into a physical confrontation. People are more likely to buy into the concept that security is there to help them if they’re not intimidated, so if a person is getting really fidgety, security can offer them a drink of water which can calm them down."

Security dogs. Brigham and Women’s uses K-9 dogs on security vehicles that patrol its hospital grounds. "When you see one of those dogs, if you have crime in mind, it acts as a deterrent," says Hutson.

K-9 dogs can intimidate even hardened criminals, says McFarland. "When several gang members came into the ED, the subject of dogs came up, and they were terrified," he recalls. "One said, ‘Guns are stupid, but dogs are smart. A bullet is probably going to miss you, but if you run around the corner, a dog will come after you and will get you.’"

Dogs can also have a calming influence on a bad situation. "At one ED, a patient was completely out of control until a guard came in with a dog, and said, ‘Guard.’ The dog sat at foot of the bed watching the patient, and the guy didn’t make a move," says McFarland. "If you have to choose between having armed security guards with guns and dogs, I don’t think that’s much of an argument."

Fire doors. In case of fire, the ED’s fire door falls automatically to provide a smoketight way out of the building. That can be used as a security measure in a difficult situation, says McFarland. "Make sure there is a way to bring down that metal door independently so any windows or doors in a corridor can be closed," he suggests. "That way, if somebody is really out of control, you can isolate them in there and call security or 911. That’s a physical barrier that is there in any kind of waiting room area, so take advantage of it."

References:

1. Lavoie FW, Carter GL, Danzl DF, et al. Emergency department violence in U.S. teaching hospitals. Ann Emerg Med 1988;17:1227-1233.

2. Meyer T, Wrenn K, Wright SW, et al. Attitudes toward the use of a metal detectors in an urban emergency department. Ann Emerg Med 1997:29:621-624.

[Editor’s Note: For more information on Healthcare Security Services’ Techniques of Effective Assault Management (TEAM) class, contact Craig Ewing at 7297 Cherokee Circle, Buena Park, CA 90620. Telephone: (714) 521-1197. Fax: (714) 521-9139.]

Who are the problem patients?