This is WTBS 18 Zero-Tolerance Policies in the ED, Part 2: Taking a look in the mirror
In part 1 of this blog I looked at some of the ways we respond to escalating or violent patients in the ED, and I made the case that some of the strategies—those of evicting and banning patients—reflect inadequate hospital management of the issue of staff safety and can compromise our obligations to patients in need. In part 2 I want to challenge readers to have a look in the mirror: Are there things we can do in the ED to reduce the risk of violence? I will focus on some of the high-risk populations that are often involved in situations that escalate and suffer the consequences of ED responses. My hope is for us to move beyond non-violent de-escalation, examine our underlying attitudes, and explore strategies to prevent escalation.
I don’t have any data on this, but it’s my impression that for at least urban and inner-city EDs a large proportion of the patients who come into conflict with staff are from marginalized populations; they are typically homeless or underhoused, often suffer from mental health or addiction issues, and often are heavy users of ambulance and ED services. My introductory anecdote in part 1—a story about providing care for a patient who had been banned at another ED—involved a homeless man who was intoxicated.
How do other health care providers view zero-tolerance policies?
My daughter is a social worker at an inner-city community service agency in Toronto, Ontario, where she works closely with a vulnerable, marginalized population. In her job she often comes into contact with Toronto EDs (there are nine in the central Toronto health region if you include pediatric and mental health specialty EDs). She sends patients to the hospital, sees them in follow-up, and often accompanies them to the ED. I asked her about her impressions of this issue from her experience, and her comments are illuminating:
People who are homeless or who use drugs often have had a lifetime of experiences with institutions, from foster care, residential schools, and child welfare systems to food banks, shelters, courts, and prisons. Whatever else you can say about the institutions, their missions and the staff who work there, a common element is the client’s powerlessness and the need for them to follow a rigid set of often arbitrary rules, with significant consequences if they don’t or can’t follow them. Those experiences with institutions can blur together, and hospitals are no different.
On the streets, in prison, and even in some shelters you have to be on alert all the time and ready to fight or defend yourself. EDs are busy places and they need rules for safety and efficiency, but sometimes it feels to me and to my clients like hospital staff get into power struggles with patients when flexibility could have been possible.
My clients aren’t stupid, but they avoid going to the hospital—at risk to their own health—because they’ve had bad experiences in EDs, including being judged or mistreated because of their substance use, physically restrained, evicted, even banned. Some have been beaten up by hospital security and may be afraid to return. And this isn’t just because they are unable to follow certain hospital rules. They are sensitive and intelligent people who know when they are being spoken to with disrespect or as if they are dumb.
Their lives can be incredibly chaotic and difficult, but because they engage in high-risk behaviors or have trouble complying, staff may believe and speak to them as if they are undeserving of care because they see these patients as being responsible for their own problems. So often a smile, a little flexibility, and a willingness to negotiate and not sweat the small stuff will go a long way. Instead, I’ve frequently witnessed staff clearly baiting patients by being overly rigid, knowing the patient may choose to leave or escalate and be evicted, either way relieving their need to care for them.
One small example I witnessed involved a woman who’d been using intravenous drugs for 30 years, and she needed an IV as part of her care. She apologetically told the first nurse who approached that her veins were bad, but she’d been having luck in one particular spot lately. The nurse ignored her completely, poked her unsuccessfully several times in a different spot, and then called over another nurse to try. She and a third nurse also ignored the patient while unsuccessfully poking her, and clearly displayed their resentment at having to care for this woman and her difficult veins. Finally, a fourth nurse approached with a different demeanor; she apologized for all the poking, thanked the patient for the tip about the good vein, attempted to insert the IV exactly where the patient advised, and was successful on her first try.
I’ve mentioned how hard it is to get some clients to go to the ED and how chaotic their lives are. After a visit people are often discharged with printed instructions regarding follow-up, referrals to specialists, or prescriptions. These papers are typically lost almost immediately. If a community worker is able to accompany the patient, we are always welcomed to the ED and treated as a partner. But if we can’t be there, it’s almost impossible for us to find out any of that follow-up info; if we call the ED or send a note asking for someone to call and tell us the plan, we never hear back. If we call the ED the next day, we encounter the privacy wall. This is frustrating because it means we can’t support people in attending future appointments, getting test results, or getting and taking medication as ordered. A little extra time by hospital staff spent investigating a patient’s community supports and informing those supports of the plan could go a long way toward ensuring people aren’t repeatedly showing up in the ED with the same issues.
Drug withdrawal is another barrier clients encounter in getting the care they sometimes desperately need. Patients in withdrawal can get agitated, impatient, and ill. They may escalate or have to leave the ED to get a fix before they can be seen. I’ve encouraged folks I work with to take a fix with them to the ED so they can tolerate the full stay, but it would help so much if ED staff could adopt their own harm-reduction philosophy with these people. Recognize what might be withdrawal, set a tone for the relationship by asking about substance use in a non-judgmental tone, explain why it is relevant to their care, and even thank a person for their honesty when they disclose. Then skip the lecture and either facilitate a fast visit to get them on their way or offer a dose of something to ameliorate their symptoms. People who are homeless and criminalized live with a huge amount of risk on a daily basis, so it is frustrating and feels out of touch when physicians seem so worried about their own potential professional risk that they’re unable or unwilling to give care or advice that may not be exactly standard, but which fits the needs and abilities of the patient in front of them.
-Sarah Ovens, MSW
The benefits of kindness in managing marginalized populations
It was painful for me to hear some of the above. Whether these events occurred in my ED or another, the people involved are my colleagues and emergency medicine is my discipline—and I’m generally quite proud to be a member of it. Yet clearly stigma exists and is a major issue in caring for a population that in many ways is at the heart of our mission.
While our first priority is responding to acute illness and injury to prevent death and disability where possible, our position in society and our hours, as well as our turn-no-one-away philosophy, make us ideally positioned to be a modern day “sanctuary”—a safe place to turn to for care and comfort when nothing else is available. This concept of the ED as a modern-day sanctuary was the focus of my Professorial Address at the University of Toronto. Sarah’s comments reminded me of my favorite journal article ever, which looked at how kindness affected return visits in the ED—it certainly has the best title!
The study was carried out at an inner-city hospital in Toronto whose ED had the highest volume of homeless patients in the city. The authors were aware that some staff in the ED felt that if they were too nice to these patients, it would encourage them to come back more often. In my experience, this is often expressed as either a rationale for not offering a kindness or as a criticism of a colleague who had done so. The authors decided to test the underlying hypothesis using a brilliant model; patients were randomized to an intervention group that had a trained volunteer approach them with the instructions to be kind and engage in conversation, offer (where possible) food and drink, and see what else the patient needed. The control group was not approached by volunteers. The professional staff were blinded to the study. The number of repeat visits was counted and, counter to the hypothesis, those patients who had volunteers engage with them made fewer repeat visits—one-third fewer in the following month compared with the control group. The authors speculated that patients tended to return until they were satisfied with their care, perhaps until they felt their needs had been met.
That study is more than 20 years old, but I still encounter people who believe we shouldn’t be “too nice”—by which they mean “Be a bit nasty!” or its more recent counterpart: “If we reduce wait times too much the volume of inappropriate visits will rise.” To which I say maybe, but I also note that some folks needing time-sensitive care might be less likely to delay seeking it, too.
Strategies to consider to manage marginalized populations
How can we all learn to provide the “right” level of kindness? A few strategies that have helped in my ED over the years are fairly simple. We keep a supply of clothing for patients in need that started with donated clothes from staff, progressed to clothes we purchased with staff donations, and is now provided through a partnership with a community agency called New Circles. I’ve worked hard in my career to save lives and relieve pain, but the best demonstration of gratitude I can recall from 37 years in emergency practice was by a homeless man who danced a jig when I gave him a sharp-looking raincoat on a cold and rainy night!
It helps to have a decent number of snacks to provide patients 24/7, and having a bit of flexibility in the budget for transit tokens and taxi chits to help people get home or to a shelter safely is to me funds well spent.
In part 1 I mentioned the value of relying on individualized care plans and “patient watches” rather than banning patients. Our care plans are devised mostly in response to staff requests, which generally occur when a patient’s visit frequency and behaviors are challenging. A small group that includes a social worker, emergency physician, nurse, and (when necessary) a liaison psychiatrist create the plans. No one has protected time for this, but we all make time because we feel it’s important. The original project was evaluated after the first two years; as part of that evaluation a comment from one of our nurses stuck with me. She was confronted with one of our most challenging frequent visitors, a man who sometimes took life-threatening overdoses but usually lied about having done so and often refused to cooperate with ED routines, leading to inconsistent decisions from the doctors on duty about whether to restrain and treat or discharge him (with advice to return if he decided he wanted our help). We decided after much review and debate that his care plan should advise staff to forgo restraints and instead politely inform him that he might have taken a dangerous overdose, but we weren’t going to fight with him. He could cooperate or leave and return when he was ready to cooperate (with blood taking, IVs, etc.). In general, the plan worked well; the patient sometimes left on his own and sometimes cooperated, and overall he survived. In our evaluation the nurse commented: “I felt like I was no longer alone in dealing with him.”
A call to action for managing marginalized populations to make our EDs safer and more compassionate
ED work is difficult, and if our staff feel “alone” in dealing with challenging, escalating, or potentially dangerous patients, we’ve neglected our obligations as ED and hospital leaders and let down our staff and patients. Although I started by pointing out the issues within our control as individual providers—our attitudes toward and behaviors with specific patient populations—I am ending with a reminder that as leaders we always have a role to play in creating the conditions in which best care is most likely to take place. This is a call to review our policies and procedures, but we too need to look in the mirror—are we good role models? By our actions in and around the ED as well as our administrative priorities, do we signal our own respect for the marginalized patients we care for and the priority we put on that mission as leaders and as organizations?
We can never eliminate risk totally, but we can make our EDs safer and more compassionate places for patients, and we can improve staff morale at the same time. I hope some of the insights and strategies in these two posts will help your ED better support your staff in these situations.
—Dr. Howard Ovens, January 2019
Dr. Ovens has no conflicts of interest to declare.
- SREMI – The Schwartz/Reisman Emergency Medicine Institute. Dr Howard Ovens Professorial Address. YouTube. 2014 Nov 7. Available from: https://www.youtube.com/watch?v=_iTahFV2nt0. Accessed 2019 Jan 26.
- Redelmeier DA, Molin JP, Tibshirani RJ. A randomized trial of compassionate care for the homeless in an emergency department. Lancet. 1995;345(8958):1131-1134.
Episode 115 – Emergency Management of the Agitated Patient
Episode 51 – Effective Patient Communication: Managing Difficult Patients
Cite this article as: Ovens, H., Ovens, S. Waiting to Be Seen #18 – Zero-Tolerance Policies in the ED, Part Two: Taking a look in the mirror. Emergency Medicine Cases. http://emergencymedicinecases.com/zero-tolerance-policies-in-the-ed-part-2-taking-a-look-in-the-mirror. Published January, 2019. Accessed [date].
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