Violence in the emergency department and how to promote ER safety


by Patricia B. Allen, MBA, RN

What would you differently tomorrow if you had a violent episode in your emergency department today?

Violence in the ED is a growing and alarming phenomenon. A recent survey conducted by the Emergency Nurses Association (ENA) revealed that 25 percent of the RN respondents report experiencing physical violence more than 20 times in the past three years and 20 percent of the respondents revealed encountering verbal abuse more than 200 times in the past three years.

A recently released article by the Journal of Nursing Administration discusses – and supports – the results of the ENA survey. ED Violence is a serious threat that needs immediate attention. ED nurses and physicians are on the front lines of aggression, violence and abuse from patients, families, visitors, gang members.

What puts the ED at such high risk?

The main risk factor that places ED’s at risk is that hospitals do not recognize the threat, reality or prevalence of ED violence. A large number of hospitals and their administrators believe that “violence can’t happen here”. But violence can happen – no matter the size or location of the hospital. Being unprepared and downplaying the risk places hospitals in an extremely vulnerable position.

The ED’s chaotic environment, EMTALA, crowding and boarding, the closure of many inpatient psychiatric hospitals, the lack of primary care physicians and clinics, the growth of gang activity, limited staff de-escalation training and inadequate triage resources/training all impact the ED, imperiling those ED’s and hospitals that are uninformed and unprotected.

The absent dialogue

Hospital administrators and CEOs generally do not seem to regard ED violence as one of their top concerns; herein lies the problem. ED management must do a better job of educating and communicating ED violence and near-miss violent episodes to the CEO and the CEO must in turn, implement, as a start, violence incident reporting mechanisms and empower the ED staff to report violence without fear of reprisal and with a good-faith commitment to rapidly make important and necessary safety and security improvements.

It is crucial that the ED staff feels safe at work. I encourage you to ask your ED staff if they are safe or feel safe at work in the emergency department of your hospital.

A 3-step beginning

1. A risk assessment of the ED will help you evaluate doors and other access points, the presence or absence of duress alarms, an overhead paging code to alert a “red team” for rapid, additional assistance in the ED in the event that a violent episode erupts, plus the identification of other risk factors in your facility. Fix the most egregious problems as your budget permits.

2. Communication. Bump up the communication with the CEO and hospital administrators using statistics from your ED. Communicate with the CEO in language that they understand using numbers and statistics. Communicate the requirement that violent episodes are to be reported and implement a method to do so, guaranteeing that there is no threat or concern for reprisal. Be certain to follow-up with the person reporting the violence.

Consider the adoption of a customer service policy and hospitality strategy. Communicating with patients in the waiting room to inform them of their place in the queue or reasons for delays can reduce the potential for angry outbursts or outright violence. Long waits in the waiting room to see a physician for care is one of the documented reasons for violent patient eruptions.

Revamp your triage area and re-educate the nurses and techs who are assigned to triage. The triage RN is a key staff member in thwarting potential violence. Communicate with the ED staff and devise a violence prevention plan.

3. Does your facility warrant the consideration of metal detectors and around-the clock security? Talk with the local police department to help evaluate the presence of gangs and crime in your hospital’s geographic location. The only failsafe way to eliminate the presence of contraband in the ED is via electronic screening for weapons.

Patricia B. Allen is author of Violence in the Emergency Department: Tools & Strategies to Create a Violence-Free ED.

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