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In a shootout in the emergency department (ED) of Ben Taub Hospital in Houston, a security officer and policeman are killed. In the ED of Mission Bay Hospital in San Diego, a man fatally shoots a nurse and a medical technician trainee and wounds a doctor and a patient’s father. A former patient bursts into Los Angeles County University of Southern California Medical Center ED and wounds three doctors with a handgun.
As an ED manager, you can do a lot to prevent such tragedies, urges Tracy G. Sanson, MD, FACEP, assistant medical director for the department of emergency medicine at Brandon (FL) Regional Medical Center. "The way you train staff is critical," she stresses. "With appropriate training, staff know that the administration takes threats seriously."
When police brought an agitated patient to the ED at University of California at Irvine Medical Center in Orange, the man was released from handcuffs after a verbal agreement not to hurt himself or the staff.
"The patient did well for an hour, but then became very anxious," recalls Sherlene Stepp, RN, MICN, clinical nurse supervisor. When he began pacing back and forth, an ED technician called for extra personnel and asked security to stand by. When the patient suddenly became violent, restraints were used immediately. "Because the staff was trained in managing aggressive behavior, a potential assault was prevented," says Stepp. "The technician knew when to call in reinforcements, which is very important for both patient and staff safety."
All ED staff must be aware of potential hazards and how to protect themselves and co-workers, she adds.
Training in assault prevention has been shown to be effective, according to Tom Scaletta, MD, FAAEM, chairman of the department of emergency medicine at West Suburban Hospital Medical Center in Oak Park, IL. "One institution documented a 10-fold reduction in assault in trained vs. untrained groups," he says.1 "We have accepted mandatory annual fire and infectious disease training so employees will prevent and respond to these types of danger," Scaletta notes. "Obviously, the much more frequent occurrence of hospital violence demands a similar effort." (See checklist for what training should include, below.)
|Components of Training in Assault Prevention|
|•||Explanation of the company’s workplace violence policy|
|•||Enforced "no tolerance" policy for workplace violence|
|•||Encouragement to report incidents|
|•||Techniques to prevent or diffuse violent or threatening situations|
|•||Techniques and skills to manage anger and resolve conflicts|
|•||Review of the location and operation of safety devices such as alarm systems and methods to alert the police or security|
|•||Review of personal security measures|
|•||Review of personal information release policy|
|Source: Tracy G. Sanson, MD, FACEP, Assistant Medical Director, Department of Emergency Medicine, Brandon (FL) Regional Medical Center.|
Here are ways to improve staff training in assault prevention:
• Make sure all staff know how to de-escalate situations. Many EDs do not have security assigned to them, notes Diane Presley, RN, MSN, director of nursing for emergency services/critical care at Seton Medical Center in Austin, TX. "In an industry with shrinking resources, we are all having to do more with less," she emphasizes. "So all ED personnel should be trained in how to de-escalate any potentially violent patient."
By actively using de-escalation skills, staff can reduce their risk of violence, says Scaletta. "Assume a patient advocacy role by avoiding disagreements or issuing directives, always showing respect and empathy, and addressing requests or complaints," he advises. When dealing with an angry patient, Scaletta recommends allowing the individual to vent, ignoring personal affronts, setting limits, and using nonthreatening body language.
• Provide training on an annual basis. Annual training should include management of violent behavior, verbal de-escalation, physical restraints, and defensive techniques, advises Presley. "Local police and also psychiatric institutions could provide this training for annual competencies," she suggests. (See resource box for courses to take, ED Management, June 2001, p. 69.)
• Educate staff to use restraints if needed. In many cases, potentially violent patients can be calmed with de-escalation techniques, says Stepp. "However, this is not always successful," she acknowledges. "So you need to be prepared to move to whatever restraint is needed to ensure safety."
Train staff to approach the patient as a team and apply the least restrictive restraint possible, Stepp recommends. The patient must be monitored continuously while in restraints, she adds. "The ultimate goal is to assist the patient in gaining control during their crisis," Stepp explains.
Instruct staff to make a verbal contract with the patient as to when the restraints can be removed, says Stepp. "As soon as possible, the patient should be changed to less restrictive restraints," she notes. "During this time, keep the patient safe while ensuring his or her dignity by providing confidentiality and showing respect." (For more information on restraint standards, see ED Management, August 2000, p. 93, and October 1999, p. 109.)
1. Infantino J, Musingo SY. Assaults and injuries among staff with and without training aggression control techniques. Hosp Community Psychiatry 1985; 36:1,312-1,314.
For more information on training staff in assault prevention, contact:
• Diane Presley, RN, MSN, Emergency Services/Critical Care, Seton Medical Center, 1201 W. 38th St., Austin, TX 78705. Telephone: (512) 324-1031. Fax: (512) 324-1401. E-mail: DPresley@seton.org.
• Tracy G. Sanson, MD, FACEP, Department of Emergency Medicine, Team Health, Brandon Regional Medical Center, 119 Oakfield Drive, Brandon, FL 33511. Telephone: (813) 571-5150. Fax: (813) 948-8477. E-mail: Oaks61596@ aol.com.
• Tom Scaletta, MD, FAAEM, Department of Emergency Medicine, West Suburban Health Care, 3 Erie Court, Oak Park, IL 60302. Telephone: (708) 763-2227. Fax: (708) 383-4422. E-mail: firstname.lastname@example.org.
• Sherlene Stepp, RN, MICN, Emergency Department, University of California at Irvine Medical Center, 101 The City Drive, Route 128, Orange, CA 92868. Telephone: (714) 456-6549. Fax: (714) 456-5390. E-mail: email@example.com.