It was busy, so I approached my next patient with the detachment that often brings: He was in custody and cuffed, had been injured during apprehension, was subdued and cooperative, and needed suturing. But as the two police officers talked about him, the story that emerged shattered my detachment.
My patient was homeless and had been sleeping in a park, intoxicated. He had not asked for anyone’s help, but a good Samaritan had called 911 and the man had been taken to a local ED. He was intoxicated enough not to know where he was going, much less consent. A nurse went to triage him, and when she reached across him he roused and groped her. The nurse was understandably upset, called security, and wanted him charged. Police were called and when the patient woke to find himself in jeopardy with the police without understanding why, he tried to leave, was restrained, and fell and hit his head. The ED staff refused to help him and told the police he was “banned” from their ED. So, the police brought him to my ED.
The police were insightful and empathic. They talked to each other about how the patient had no record and no resources, and he was now more alert and remorseful. On the other hand, they said they understood that ED nurses have a tough job and should not have to tolerate being abused by patients. But another element of the story bothered me: What had been achieved by banning the patient? The other ED was a large urban center, so surely another nurse could have provided the necessary care. If the patient presented an ongoing risk (which he surely didn’t, as he was in cuffs with police at his side), were my staff members more deserving of being placed at risk?
I’ve always been troubled by the practice of banning or evicting patients. I’m all for holding people accountable for their behavior, and bad behavior is common in EDs. However, while some of this behavior is deliberate (such as petty larceny or seeking drugs) and some of it surely under voluntary control (such as competent patients or family acting badly), EDs are also often the scene of odd behaviors driven by intoxication, injury, dementia, or psychosis.
In part one of this blog I will examine the issues we face as we try to make staff feel safe and ensure patients can access the care they need. In part two I will dig deeper into the treatment of marginalized populations in the ED and how, with better awareness, we can prevent escalation, improve care, and even increase staff morale.
Facing violence in the ED
I’m a member of the Canadian Association of Emergency Physicians’ Public Affairs Committee, which advises the association on advocacy related to our discipline. We have a very engaged email list, and a colleague at a large urban center recently posted a query to the group; her ED is experiencing increasing violence and more and more often nurses are asking her to come out to triage to do a quick assessment to permit immediate discharge of a troublesome patient. Her dilemma was that she wants to support her nurse colleagues and help ensure a safe environment, but she feels unable to truly assess competence and state of mind in a rushed waiting room encounter with the nurses expecting a glance and an immediate eviction. The rising frequency in our urban centers of methamphetamine-induced agitation and psychosis was mentioned as an important contributing factor to the problems being faced.
The resulting email conversation was swift and shocking. Many of my colleagues reported similar challenges, including increasing violence overall and methamphetamine problems specifically, inadequate security provisions that often pitted staff against patients and staff against staff (generally nurses versus doctors), and security staff who were inadequate and/or unhelpful (reportedly often escalating situations instead of helping resolve them). All too often these situations resulted in front-line staff seeking solutions that diminished patient access in some way by banning or evicting patients and establishing a zero-tolerance policy for staff abuse.
Our hospitals have a legal and ethical duty to provide staff with a safe workplace. In my ED in Ontario, the hypothetical risk of Ebola a few years ago brought the provincial Ministry of Labour to our hospital to ensure we were protecting staff from the threat, yet many studies have documented the frequency with which ED staff encounter violence and abuse [1,2] without eliciting any response from government authorities. Nurses bear the brunt of the abuse, as their roles bring them into close physical proximity with patients and some people feel less inhibited in acting out against a nurse than against a doctor. We should not tolerate this in any hospital. But to me, zero tolerance implies a reaction to a voluntary decision by the perpetrator—in other words, competence—and the penalty usually includes banishment from the ED. That might be okay for an overbearing relative who is getting in the way or a patient we’ve determined is responsible for their abusive actions. But can we reasonably expect a psychotic patient to understand and follow a poster outlining expected behavior in the ED?
The ED as a sanctuary for care and support
Early in my career an incident at a community ED was widely reported in the media. A young man had sustained multiple injuries in a motor vehicle collision. When the on-call surgeon arrived and was met with a string of profanity from the patient, he became incensed and refused to see him, and he ordered the staff to transfer the patient to an academic center. At the referral center he was found to have a cerebral contusion and was not intoxicated. It also emerged that the patient was an A student and a solid citizen. The media reports and public reaction expressed no sympathy for the surgeon. The public expects the ED to be a safe place for patients in crisis due to illness, injury, intoxication, etc.—a sanctuary for care and support regardless of socio-economic status or age, race, dress, etc. It is that very aspect of the ED that attracts many of us to work there.
So, how can we reconcile our obligations to our staff and to our patients? The answer is to provide a safe ED where all patients can be assessed without endangering staff. Yet the literature on this subject is thin, and community and regulatory standards are inconsistent.
I was an ED chief for 30 years, and my hospital and I took our security obligations seriously. The recent email exchange with my peers showed me my ED is in very good shape relative to others, but I admit many of our strategies were introduced reactively as we experienced incidents that pointed out vulnerabilities.
Important safety considerations
For the purposes of a blog I won’t write a dissertation on ED security (see reference 3 for a useful review), but here are a few major considerations:
- Incorporate security concerns into ED design. Entry should be controlled so there is only one way in for the public past security staff. We use magnetic locks on other doors so authorized staff gain entry using their ID badges. As well, the placement of mental health rooms should make elopement difficult and facilitate security supervision of the area.
- Have security staff present 24/7. In our urban ED we post one officer at the entrance and employ others to do patient watches as needed. We have cameras deployed almost everywhere, and they are monitored remotely for added security. We retain video for a period after the date and have found the videos to be helpful in reviewing a range of care and safety incidents.
- Provide de-escalation training. Security staff should be trained in non-violent de-escalation techniques, as should as many of the other staff as possible. Security staff should consider themselves and be viewed by others as important members of the care team. (Reference 4 describes “Code S,” which is a call for support early in situations of escalating patients, and reference 5 describes helpful de-escalation techniques.)
- Have clear restraint protocols. Staff should have clear protocols for requesting physical restraint and then moving quickly to chemical restraint. Patients should not be left in physical restraints for prolonged periods.
- Establish policies to support safe practices. While the application of physical restraints and the monitoring of patients in restraints are important issues requiring strict policies, there should also be liberal policies allowing staff to request patient watches. Patients on watch should be searched for weapons and sharps, and there should be clear policies on how to react to and manage requests for toilet access, smoking privileges, etc.
- Have codes for violent patients. All staff should know how to call a code and how to react when they hear one.
- Have an approach in place for high-risk repeat visitors other than simply banning them. We use individualized care plans that are readily available to triage staff, and for select patients security is called on their arrival and stays with them until they are assessed. For some frequent visitors we encourage an early assessment by the physician so if the presentation is typical of that patient and they do not require admission they can be discharged quickly. But we never ban patients. (Reference 6 is an old but positive Veterans Affairs study on reducing violence using a similar system of flagging high-risk patients for preventive strategies.)
- Understand the law. Some hospitals and security firms incorrectly believe they cannot prevent a patient from leaving the ED unless or until a physician certifies the patient. However, under common law staff are allowed to request a watch as soon as they become aware that a patient in the ED poses a risk to themselves or others, and this watch can continue until a doctor is available to make a determination.
Other administrative supports that should be in place include: clear lines of accountability for the safety and security of staff and patients; a committee or other mechanism that allows staff to engage with leadership on safety issues; a system for reporting incidents of concern; and a clear procedure for reviewing incidents and acting on them. A forum, such as a liaison committee, for engaging in ongoing conversations with local police and ambulance services is also useful.
Cost is always an issue when implementing policies, providing training, or increasing staff. I don’t know of any published benchmarks for what an ED should spend on security, but in general a survey of peers on current practices is a helpful tool for assessing where your hospital stands and advocating for investments where warranted.
Security’s perspective on zero-tolerance policies in the ED
We are lucky to have a conscientious head of security at my hospital, Mark McCormick, who is committed to staff and public safety. Recently, after a difficult encounter with a patient, one of my doctors complained to me about some of the “undersized” security staff. Mark wisely pointed out that the mere presence of a big, buff guard may provoke some patients to take them on, and in the great majority of cases effective security requires brains and technique, not brawn! Mark graciously agreed to provide his perspective; I thought it was worth including verbatim:
Prior to taking on the mantle of Hospital Security Manager, I started my career staffing and then managing security operations in both retail and corporate environments. In those areas, trespassing, banning, barring and employing a zero-tolerance policy toward workplace violence and its perpetrators is a normal perspective. In health care, however, those individuals we would ban from a mall are the exact people that we, as a society, need to have come to a hospital. They are often the sickest, most volatile, most disadvantaged members of society who need the most help, and we as an industry need to do more to help them. If we ban those patients, they will likely get worse and could harm themselves, a member of the public, maybe even our own loved ones.
I often hear health care workers asking about banning patients and talking about zero-tolerance policies. I take every opportunity to instead advise that we “flag” them as Dr. Ovens described for faster, more precise interventions in future. My team and I use the various measures at our disposal as a means to set parameters for these individuals [and] create and establish limits to which they need to adhere in order to demonstrate their willingness to receive help. These methods also allow us to help protect not just the experienced physician or nurse dealing with them today but also the new resident or student nurse who starts tomorrow and has no prior experience with this person.
Where some will use the term zero-tolerance policy, we should instead be using the term 100 per cent response policy. By law and by ethics we have a duty to respond to, investigate, mitigate and make safe every single event that happens in our facilities.
In our hospital we have upwards of 10,000 people crossing through our doors every single day, and as I teach my staff, those are 10,000 people who need our help and 10,000 opportunities to make someone else’s life a bit better. Be it a kind word, a gentle approach, a thorough investigation or even, when absolutely necessary, a firm and undeniable physical response to stop a threat, the help we provide these folks creates an incalculable ripple effect on their friends and family, our employees and even the city around us.
Mark McCormick, CHPA
Security Manager and Fire Marshal
Mount Sinai Hospital
Reframing the issue of zero-tolerance policies in the ED
When a nurse asks a doctor to help do a superficial assessment on a taxing patient or when an ED bans someone, it’s a sign that the hospital has not done its job in providing a safe workplace and the staff is trying to fill the gap. If our EDs are not safe places for us and for our patients, we have some serious reflection to do.
We can also think about violence in the ED as a public health issue. Often the patients involved are homeless and/or have mental health and addiction issues. We all know this population has a high incidence of traumatic brain injury, childhood trauma, fetal alcohol syndrome, and a host of other conditions that lead to social and behavioral deficits, including anger management issues. Many have experienced stigma and/or trauma as a result of interactions with hospital clinical staff, security, police, and others in authority and may find many ED routines and responses triggering. In her career as a social worker, my daughter works with a marginalized homeless population; in part two of this blog on safety and security in the ED she will share some of her experiences accompanying her clients and advocating for them in a range of urban EDs. I’ll also draw on an impactful study from the 1980s that has been foundational to my attitude toward patients in the ED and remains as relevant today as when it was originally published.
—Dr. Howard Ovens, January 2019
Dr. Ovens has no conflicts of interest to declare.
- Copeland D, Henry M. Workplace Violence and Perceptions of Safety Among Emergency Department Staff Members: Experiences, Expectations, Tolerance, Reporting, and Recommendations. J Trauma Nurs. 2017;24(2):65-77.
- Kowalenko T, Gates D, Gillespie GL, Succop P, Mentzel TK. Prospective study of violence against ED workers. Am J Emerg Med. 2013;31(1):197-205.
- Occupational Safety and Health Administration. Guidelines for Preventing Workplace Violence for Healthcare and Social Service Workers. Washington, DC. Occupational Safety and Health Administration. 2016. Available at https://www.osha.gov/Publications/osha3148.pdf. Accessed 2018 Dec 30.
- Kelley EC. Reducing violence in the emergency department: a rapid response team approach. J Emerg Nurs. 2014;40(1):60-64.
- Richmond JS, Berlin JS, Fishkind AB, Holloman GH, Zeller SL, Wilson MP, et al. Verbal De-escalation of the Agitated Patient: Consensus Statement of the American Association for Emergency Psychiatry Project BETA De-escalation Workgroup. West J Emerg Med. 2012;13(1):17-25.
- Drummond DJ, Sparr LF, Gordon GH. Hospital Violence Reduction among High-Risk Patients. JAMA. 1989;261(17):2531-2534.
- Ontario Hospital Association. Form 1 Assessments Under the Mental Health Act Frequently Asked Questions. Available at https://www.oha.com/Documents/Form%201%20Assessments%20Under%20the%20Mental%20Health%20Act.pdf. Accessed 2018 Dec 30.
Cite this blog as: Ovens, H., McCormick, M. Waiting to Be Seen #17 – Zero-Tolerance Policies in the ED, Part One: The delicate balance of protecting staff while ensuring patient access. Emergency Medicine Cases. https://emergencymedicinecases.com/zero-tolerance-policies-ed/. Published January 15th, 2019. Accessed [date].