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LISTEN NOW: My iPad Went to Medical School
Mobile devices put information in the palm of your hand. For hospitalists, this presents real opportunities to engage patients, improve care, and streamline hospital workflows. Two hospitalists who were early adopters of mobile tech in their practices, Dr. Henry Feldman of Beth Israel Deaconess and Dr. Richard Pittman of Emory University/Grady share their lessons learned, and their advice for other hospital clinicians and informaticists on using mobile tech in their practices.
Mobile devices put information in the palm of your hand. For hospitalists, this presents real opportunities to engage patients, improve care, and streamline hospital workflows. Two hospitalists who were early adopters of mobile tech in their practices, Dr. Henry Feldman of Beth Israel Deaconess and Dr. Richard Pittman of Emory University/Grady share their lessons learned, and their advice for other hospital clinicians and informaticists on using mobile tech in their practices.
Mobile devices put information in the palm of your hand. For hospitalists, this presents real opportunities to engage patients, improve care, and streamline hospital workflows. Two hospitalists who were early adopters of mobile tech in their practices, Dr. Henry Feldman of Beth Israel Deaconess and Dr. Richard Pittman of Emory University/Grady share their lessons learned, and their advice for other hospital clinicians and informaticists on using mobile tech in their practices.
LISTEN NOW: David Pressel, MD, PHD, FHM, discusses violence in hospitals
DAVID PRESSEL, MD, PHD, FHM, medical director of inpatient services at Nemours Children’s Health System, talks about the nature of violence in hospitals and a training program he has helped put into place at his center.
DAVID PRESSEL, MD, PHD, FHM, medical director of inpatient services at Nemours Children’s Health System, talks about the nature of violence in hospitals and a training program he has helped put into place at his center.
DAVID PRESSEL, MD, PHD, FHM, medical director of inpatient services at Nemours Children’s Health System, talks about the nature of violence in hospitals and a training program he has helped put into place at his center.
Movers and Shakers in Hospital Medicine, March 2015
Sam Bagchi, MD,
George Bailey, MD, has been named 2014 Physician of the Year by the Ob Hospitalist Group (OBHG), based in Mauldin, S.C. Dr. Bailey has been a practicing OB/GYN hospitalist at Yakima Valley Memorial Hospital in Yakima, Wash., since the OB hospitalist program began there in July 2013. Dr. Bailey’s colleagues cite his emphasis on safety, communication, and mentorship as a few of the characteristics that define him as a leader at their hospital.
Martha Buckley, MD, is the new chief quality officer at Fairfield Medical Center in Lancaster, Ohio. Dr. Buckley joined FMC as a hospitalist in 2010 before serving as a part-time chief medical quality officer. FMC is a 222-bed, nonprofit, acute care center serving Athens, Fairfield, Hocking, and Perry counties in central Ohio.
Marina Farah, MD, MHA, has been promoted to vice president of clinical innovation at Sound Physicians, based in Tacoma, Wash. Prior to her new role, Dr. Farah served as senior medical director of performance management at Sound. Dr. Farah has been with Sound since 2002, and, in 2011, she received the Milliman Care Guidelines Richard L. Doyle Award for Innovation and Leadership in Healthcare.
Robert Holloway, MD, SFHM, is the new executive vice president of management services and consulting for Hospitalists Now, Inc., based in Austin, Texas. Dr. Holloway comes to HNI from his role as CEO and chief medical officer for InCompass Health, an Atlanta-based national hospitalist service provider that he founded in 1999. Dr. Holloway will continue his work as a clinical faculty member at Emory University School of Medicine in Atlanta.
Salima Oukachbi, MD, received the Physician Assistant Educator Award from the Canadian Physician Assistant Education Association and the Canadian Association of Physician Assistants in recognition for her performance as an educator of physician assistants in Northwestern Ontario. Dr. Oukachbi is a hospitalist at Thunder Bay Regional Health Sciences Centre in Thunder Bay, Ontario, Canada.
Olevia Pitts, MD, SFHM, has been appointed executive director of IPC Healthcare’s Kansas City Region. Prior to her new role, Dr. Pitts served as regional medical director of IPC’s Kansas City Region. She is also a member of IPC’s Practice Group Leadership Council, where she serves as a mentor for future physician leaders.
Syed A. Raza, MD, is the new chief medical officer at CHI St. Luke’s Health—The Woodlands Hospital in The Woodlands, Texas. Most recently, Dr. Raza worked as associate chief of medicine and chief hospitalist for The Woodlands Hospital’s primary hospitalist group. In 2006, he helped establish the original hospitalist group at CHI St. Luke’s The Woodlands and Memorial Hermann The Woodlands hospitals.
Thomas Whalen, DO, received the Hal Belknap Heart of Gold award from Norman Regional Health System in Norman, Okla., for outstanding service to his community. Dr. Whalen is the hospitalist service medical director at Norman Regional Hospital. Before Norman, he served as an Air Force major and chief of medicine at Tinker Air Force Base in Oklahoma City. Dr. Whalen is also recognized as a respected Angel Flight pilot and frequent blood donor.
Business Moves
Michael O’Neal is a freelance writer in New York City.
Sam Bagchi, MD,
George Bailey, MD, has been named 2014 Physician of the Year by the Ob Hospitalist Group (OBHG), based in Mauldin, S.C. Dr. Bailey has been a practicing OB/GYN hospitalist at Yakima Valley Memorial Hospital in Yakima, Wash., since the OB hospitalist program began there in July 2013. Dr. Bailey’s colleagues cite his emphasis on safety, communication, and mentorship as a few of the characteristics that define him as a leader at their hospital.
Martha Buckley, MD, is the new chief quality officer at Fairfield Medical Center in Lancaster, Ohio. Dr. Buckley joined FMC as a hospitalist in 2010 before serving as a part-time chief medical quality officer. FMC is a 222-bed, nonprofit, acute care center serving Athens, Fairfield, Hocking, and Perry counties in central Ohio.
Marina Farah, MD, MHA, has been promoted to vice president of clinical innovation at Sound Physicians, based in Tacoma, Wash. Prior to her new role, Dr. Farah served as senior medical director of performance management at Sound. Dr. Farah has been with Sound since 2002, and, in 2011, she received the Milliman Care Guidelines Richard L. Doyle Award for Innovation and Leadership in Healthcare.
Robert Holloway, MD, SFHM, is the new executive vice president of management services and consulting for Hospitalists Now, Inc., based in Austin, Texas. Dr. Holloway comes to HNI from his role as CEO and chief medical officer for InCompass Health, an Atlanta-based national hospitalist service provider that he founded in 1999. Dr. Holloway will continue his work as a clinical faculty member at Emory University School of Medicine in Atlanta.
Salima Oukachbi, MD, received the Physician Assistant Educator Award from the Canadian Physician Assistant Education Association and the Canadian Association of Physician Assistants in recognition for her performance as an educator of physician assistants in Northwestern Ontario. Dr. Oukachbi is a hospitalist at Thunder Bay Regional Health Sciences Centre in Thunder Bay, Ontario, Canada.
Olevia Pitts, MD, SFHM, has been appointed executive director of IPC Healthcare’s Kansas City Region. Prior to her new role, Dr. Pitts served as regional medical director of IPC’s Kansas City Region. She is also a member of IPC’s Practice Group Leadership Council, where she serves as a mentor for future physician leaders.
Syed A. Raza, MD, is the new chief medical officer at CHI St. Luke’s Health—The Woodlands Hospital in The Woodlands, Texas. Most recently, Dr. Raza worked as associate chief of medicine and chief hospitalist for The Woodlands Hospital’s primary hospitalist group. In 2006, he helped establish the original hospitalist group at CHI St. Luke’s The Woodlands and Memorial Hermann The Woodlands hospitals.
Thomas Whalen, DO, received the Hal Belknap Heart of Gold award from Norman Regional Health System in Norman, Okla., for outstanding service to his community. Dr. Whalen is the hospitalist service medical director at Norman Regional Hospital. Before Norman, he served as an Air Force major and chief of medicine at Tinker Air Force Base in Oklahoma City. Dr. Whalen is also recognized as a respected Angel Flight pilot and frequent blood donor.
Business Moves
Michael O’Neal is a freelance writer in New York City.
Sam Bagchi, MD,
George Bailey, MD, has been named 2014 Physician of the Year by the Ob Hospitalist Group (OBHG), based in Mauldin, S.C. Dr. Bailey has been a practicing OB/GYN hospitalist at Yakima Valley Memorial Hospital in Yakima, Wash., since the OB hospitalist program began there in July 2013. Dr. Bailey’s colleagues cite his emphasis on safety, communication, and mentorship as a few of the characteristics that define him as a leader at their hospital.
Martha Buckley, MD, is the new chief quality officer at Fairfield Medical Center in Lancaster, Ohio. Dr. Buckley joined FMC as a hospitalist in 2010 before serving as a part-time chief medical quality officer. FMC is a 222-bed, nonprofit, acute care center serving Athens, Fairfield, Hocking, and Perry counties in central Ohio.
Marina Farah, MD, MHA, has been promoted to vice president of clinical innovation at Sound Physicians, based in Tacoma, Wash. Prior to her new role, Dr. Farah served as senior medical director of performance management at Sound. Dr. Farah has been with Sound since 2002, and, in 2011, she received the Milliman Care Guidelines Richard L. Doyle Award for Innovation and Leadership in Healthcare.
Robert Holloway, MD, SFHM, is the new executive vice president of management services and consulting for Hospitalists Now, Inc., based in Austin, Texas. Dr. Holloway comes to HNI from his role as CEO and chief medical officer for InCompass Health, an Atlanta-based national hospitalist service provider that he founded in 1999. Dr. Holloway will continue his work as a clinical faculty member at Emory University School of Medicine in Atlanta.
Salima Oukachbi, MD, received the Physician Assistant Educator Award from the Canadian Physician Assistant Education Association and the Canadian Association of Physician Assistants in recognition for her performance as an educator of physician assistants in Northwestern Ontario. Dr. Oukachbi is a hospitalist at Thunder Bay Regional Health Sciences Centre in Thunder Bay, Ontario, Canada.
Olevia Pitts, MD, SFHM, has been appointed executive director of IPC Healthcare’s Kansas City Region. Prior to her new role, Dr. Pitts served as regional medical director of IPC’s Kansas City Region. She is also a member of IPC’s Practice Group Leadership Council, where she serves as a mentor for future physician leaders.
Syed A. Raza, MD, is the new chief medical officer at CHI St. Luke’s Health—The Woodlands Hospital in The Woodlands, Texas. Most recently, Dr. Raza worked as associate chief of medicine and chief hospitalist for The Woodlands Hospital’s primary hospitalist group. In 2006, he helped establish the original hospitalist group at CHI St. Luke’s The Woodlands and Memorial Hermann The Woodlands hospitals.
Thomas Whalen, DO, received the Hal Belknap Heart of Gold award from Norman Regional Health System in Norman, Okla., for outstanding service to his community. Dr. Whalen is the hospitalist service medical director at Norman Regional Hospital. Before Norman, he served as an Air Force major and chief of medicine at Tinker Air Force Base in Oklahoma City. Dr. Whalen is also recognized as a respected Angel Flight pilot and frequent blood donor.
Business Moves
Michael O’Neal is a freelance writer in New York City.
Ways Hospitalists Can Support Advocacy for Patients, Hospital Medicine
There are so many ways to advocate for your patients, for your profession, for the future of hospital medicine. The easiest way? Getting involved.
We know how important it is to you that your patients receive the best care possible. We know that you do your absolute best as their provider but that sometimes there are hurdles that can hinder your capabilities until some kind of legislative change is enacted. SHM does its best to foresee these obstacles and works rigorously to achieve positive legislative outcomes, but often there are details we cannot fathom without your input and expertise. That’s why we need you, our hospitalist members, to fill in the gaps.
On April 1, the final day of Hospital Medicine 2015, SHM is hosting another “Hospitalists on the Hill” in Washington, D.C. We are so excited to join members on Capitol Hill again. Discussing healthcare issues that impact your patients and the specialty by meeting personally with legislators and their staff is an opportunity to share your experiences as a frontline hospitalist and directly impact key policy issues.
Want to learn more about how you can impact the process prior to heading to the Hill? Unable to attend Hill Day, but still want a better understanding of the legislative process and how SHM gets involved? Come to our “Policy Basics 101” session March 31 at HM15, where you’ll hear from SHM’s Government Relations team and from members of the Public Policy Committee. You will not only learn about the legislative and regulatory processes, but you can also discover where hospitalists can take part and exert influence along the way.
If you find that you’re unable to attend the face-to-face meetings on April 1, or even if you are, make sure that you are a member of SHM’s Grassroots Network. SHM uses this venue to keep you informed of the healthcare policy decisions on the horizon and asks you to take only a few minutes to reach out to your representatives via e-mail to take action on the issues most important to hospital medicine.
The Grassroots Network has grown substantially over the past few years, but we are always looking for more hospitalists to take up the cause. Strength in numbers is the most effective way to tell Congress where change is needed. Sign up directly.
Whether you do it in person on Capitol Hill or through periodic e-mails to legislators, advocating for patients and the specialty of hospital medicine is important work, and we hope you’ll continue to help us in even greater numbers in the future. Hospitalists have a unique voice in the healthcare system—one that needs to be shared and engaged in critical policy discussions. We hope you’ll join us in the movement to advocate for hospitalists, for your patients, and for hospital medicine.
Ellen Boyer is SHM’s government relations project coordinator.
There are so many ways to advocate for your patients, for your profession, for the future of hospital medicine. The easiest way? Getting involved.
We know how important it is to you that your patients receive the best care possible. We know that you do your absolute best as their provider but that sometimes there are hurdles that can hinder your capabilities until some kind of legislative change is enacted. SHM does its best to foresee these obstacles and works rigorously to achieve positive legislative outcomes, but often there are details we cannot fathom without your input and expertise. That’s why we need you, our hospitalist members, to fill in the gaps.
On April 1, the final day of Hospital Medicine 2015, SHM is hosting another “Hospitalists on the Hill” in Washington, D.C. We are so excited to join members on Capitol Hill again. Discussing healthcare issues that impact your patients and the specialty by meeting personally with legislators and their staff is an opportunity to share your experiences as a frontline hospitalist and directly impact key policy issues.
Want to learn more about how you can impact the process prior to heading to the Hill? Unable to attend Hill Day, but still want a better understanding of the legislative process and how SHM gets involved? Come to our “Policy Basics 101” session March 31 at HM15, where you’ll hear from SHM’s Government Relations team and from members of the Public Policy Committee. You will not only learn about the legislative and regulatory processes, but you can also discover where hospitalists can take part and exert influence along the way.
If you find that you’re unable to attend the face-to-face meetings on April 1, or even if you are, make sure that you are a member of SHM’s Grassroots Network. SHM uses this venue to keep you informed of the healthcare policy decisions on the horizon and asks you to take only a few minutes to reach out to your representatives via e-mail to take action on the issues most important to hospital medicine.
The Grassroots Network has grown substantially over the past few years, but we are always looking for more hospitalists to take up the cause. Strength in numbers is the most effective way to tell Congress where change is needed. Sign up directly.
Whether you do it in person on Capitol Hill or through periodic e-mails to legislators, advocating for patients and the specialty of hospital medicine is important work, and we hope you’ll continue to help us in even greater numbers in the future. Hospitalists have a unique voice in the healthcare system—one that needs to be shared and engaged in critical policy discussions. We hope you’ll join us in the movement to advocate for hospitalists, for your patients, and for hospital medicine.
Ellen Boyer is SHM’s government relations project coordinator.
There are so many ways to advocate for your patients, for your profession, for the future of hospital medicine. The easiest way? Getting involved.
We know how important it is to you that your patients receive the best care possible. We know that you do your absolute best as their provider but that sometimes there are hurdles that can hinder your capabilities until some kind of legislative change is enacted. SHM does its best to foresee these obstacles and works rigorously to achieve positive legislative outcomes, but often there are details we cannot fathom without your input and expertise. That’s why we need you, our hospitalist members, to fill in the gaps.
On April 1, the final day of Hospital Medicine 2015, SHM is hosting another “Hospitalists on the Hill” in Washington, D.C. We are so excited to join members on Capitol Hill again. Discussing healthcare issues that impact your patients and the specialty by meeting personally with legislators and their staff is an opportunity to share your experiences as a frontline hospitalist and directly impact key policy issues.
Want to learn more about how you can impact the process prior to heading to the Hill? Unable to attend Hill Day, but still want a better understanding of the legislative process and how SHM gets involved? Come to our “Policy Basics 101” session March 31 at HM15, where you’ll hear from SHM’s Government Relations team and from members of the Public Policy Committee. You will not only learn about the legislative and regulatory processes, but you can also discover where hospitalists can take part and exert influence along the way.
If you find that you’re unable to attend the face-to-face meetings on April 1, or even if you are, make sure that you are a member of SHM’s Grassroots Network. SHM uses this venue to keep you informed of the healthcare policy decisions on the horizon and asks you to take only a few minutes to reach out to your representatives via e-mail to take action on the issues most important to hospital medicine.
The Grassroots Network has grown substantially over the past few years, but we are always looking for more hospitalists to take up the cause. Strength in numbers is the most effective way to tell Congress where change is needed. Sign up directly.
Whether you do it in person on Capitol Hill or through periodic e-mails to legislators, advocating for patients and the specialty of hospital medicine is important work, and we hope you’ll continue to help us in even greater numbers in the future. Hospitalists have a unique voice in the healthcare system—one that needs to be shared and engaged in critical policy discussions. We hope you’ll join us in the movement to advocate for hospitalists, for your patients, and for hospital medicine.
Ellen Boyer is SHM’s government relations project coordinator.
De-Escalation Training Prepares Hospitalists to Calm Agitated Patients
If a patient shows signs of agitation, Aaron Gottesman, MD, SFHM, says the best way to handle it is to stay calm. It may sound simple, but, in the heat of the moment, people tend to become defensive and on guard rather than acting composed and sympathetic. He suggests trying to speak softly and evenly to the patient, make eye contact, keep your arms at your side, and ask opened-ended questions such as, “How can I help you?” in a genuine manner.
Dr. Gottesman, director of hospitalist services at Staten Island (N.Y.) University Hospital (SIUH), learned these strategies in a voluntary one-hour course on de-escalation training. Although he says he feels fortunate that he has never had to deal with a physically volatile patient, he has used the verbal de-escalation training. In some cases, he believes that employing it may have prevented a physically violent situation from occurring.
Specifically, de-escalation training teaches how to respond to individuals who are acting aggressive or agitated in a verbal or physical manner. The techniques focus on how to calm someone down, while also teaching basic self-defense skills.
Various companies offer this type of training; some will train staff onsite.
“It is money well-spent,” says Scott Zeller, MD, chief of psychiatric emergency services at Alameda Health System in Oakland, Calif. “This is truly a situation where an ounce of prevention is worth a pound of cure. It only takes one unfortunate episode to result in a serious injury, where a healthcare professional will have to miss work or go on disability, which results in a far greater cost than that of the training.”
Appropriate Responses
By the nature of their work, hospitalists regularly come into contact with agitated patients. “Knowing how to safely help a patient calm down will result in better outcomes for the patient, the physicians, and everyone nearby,” Dr. Zeller says.
“Hospitalists should focus on what they can control,” says Judith Schubert, president of Crisis Prevention Institute (CPI), a Milwaukee, Wis.-based company that offers de-escalation training in 400 cities annually. This includes physicians’ own behavior/demeanor, responsiveness, environmental factors, communication protocols, and a continuous assessment of risk and an understanding of how to balance duty of care with responsibilities to maintain safety.
Hospitalists should be aware of behaviors that could lead to volatility.
“Challenging or oppositional questions and emotional release or intimidating comments often mark the beginning stages of loss of rationality. These are behaviors that warrant specific, directive intervention aimed at stimulating a rational response and diffusing tension,” Schubert says. “Before it even gets to that point, empathy, demonstrated with the patient and family members, can reduce contagion of emotional displays that are likely rooted in fear and anxiety.”
Agitation usually doesn’t arise out of the blue.
“It is typically seen over a spectrum of behaviors, from merely restless and irritable up to sarcastic and demeaning, pacing, unable to sit still, all the way up to screaming, combative, and violent to persons and property,” Dr. Zeller says. “It is best to intervene in the earlier stages and help a person to calm before a situation gets out of hand.”
Thus, hospitalists should be wary of people who are increasingly hostile and energetic and should seek help or work to de-escalate promptly.
Although you may suspect that patients with mental illnesses are more prone to volatility, Dr. Zeller says that isn’t necessarily the case. The most common psychiatric illnesses that can lead to agitation are schizophrenia and bipolar mania. In addition, being intoxicated—especially with alcohol and stimulants—can predispose someone to agitation. Many other medical conditions can cause someone to become agitated, such as confusion, a postictal state, hypoglycemia, or a head injury.
How Bad Is It?
According to the Emergency Nurses Association’s Institute for Emergency Nursing Research, violence is especially prevalent in the ED; about 11% of ED nurses report being physically assaulted each week. The agency states that the data is most likely grossly underreported, since reporting is voluntary.1
Healthcare workers in psychiatric wards are the most likely to suffer an injury caused by an agitated patient, Dr. Zeller says. Of those, nurses are the ones most commonly affected, followed by physicians.
“But agitation-related assaults and injuries can happen just about anywhere in a hospital,” he adds.
According to a study conducted by the Emergency Nurses Association, pushing/grabbing and yelling/shouting were the most prevalent types of violence. Eighty percent of cases occurred in the patient’s room.2 Dr. Zeller says that the most common injuries are those resulting from being struck, kicked or punched, or knocked down. Injuries include heavy bruising, sprains, and broken bones.
Dr. Zeller says it’s difficult to quantify exactly what types and costs of injuries occur. Injuries related to agitation are known to cause staff to miss work frequently. “That can cost a lot in terms of lost hours and replacement wages, as well as medical care for the injured party,” he says.
The Most Dangerous Circumstances
According to a series of 2012 articles on best practices guidelines for the evaluation and treatment of agitation published in Western Journal of Emergency Medicine, two-thirds of all staff injuries occur during the “takedown,” which is when staff attempt to tackle and restrain an agitated patient.3
“If interactions with a patient could help the person to regain control without needing the takedown or restraints, there would be fewer injuries and better outcomes,” says Dr. Zeller, who co-authored the article. “To help these patients in a collaborative and noncoercive way, and avoid restraints, verbal de-escalation is the necessary approach.”
As part of the study, a team of more than 40 experts nationwide was established to create Project BETA (Best practices in Evaluation and Treatment of Agitation). Participants were divided into five workgroups: triage and medical evaluation, psychiatric evaluation, de-escalation techniques, psychopharmacology of agitation, and use and avoidance of seclusion and restraint.
The guidelines were intended to cover all aspects of working with an agitated individual, with a focus on safety and outcomes, but also had a goal of being as patient-centric, collaborative, and noncoercive as possible.
“Every part of Project BETA revolves around verbal de-escalation, which can be done in a very short amount of time while simultaneously doing an assessment and offering medications,” Dr. Zeller says.
As a result of incorporating the guidelines in Project BETA, the psychiatric emergency room at Alameda Health System—which deals with a highly acute, emergency population of patients with serious mental illnesses—restrains less than 0.5% of patients seen. Dr. Zeller points out that this is much lower than the numbers restrained at other institutions. For instance, an article published in October 2013 reported several studies showing that 8% to 24% of patients in psychiatric EDs were placed into physical restraints or seclusion.4
What’s Required of Hospital Administration?
Under its Environment of Care standards, The Joint Commission requires accredited healthcare facilities to address workplace violence risk. The requirements mandate facilities to maintain a written plan describing how the security of patients, staff, and facility visitors will be ensured, to conduct proactive risk assessments considering the potential for workplace violence, and to determine a means for identifying individuals on their premises and controlling access to and egress from security-sensitive areas.1
The standard states that “staff are trained in the use of nonphysical intervention skills,” says Cynthia Leslie, APRN, BC, MSN, associate director of the Standards Interpretation Group at The Joint Commission, which is based in Oakbrook Terrace, Ill. “These skills may assist the patient in calming down and prevent the use of restraints and/or seclusion.”
In addition, staff must be trained before they participate in a restraint or seclusion episode and must have periodic training thereafter.
Anyone who wants de-escalation training can contact a company like CPI directly or establish in-house training teams (CPI offers an Instructor Certification Program). “This allows a cost-effective way [approximately $10 per person] to cascade training to others within the hospital who are part of care teams,” Schubert says.
In Sum
Providing for the care and welfare of patients while maintaining a safe and secure environment for everyone is a balancing act that requires the involvement of a multidisciplinary hospital team, Schubert says.
“Coordination, communication, and continuity among all members of a hospital team are crucial to minimize conflict, avoid chaos, and reduce risks,” she explains. “By being armed with information and skills, hospitalists are less likely to isolate themselves from other team members or react in a nonproductive way when crisis situations emerge.
“Training will help staff to take steps to ensure that their behavior and attitudes don’t become part of the problem and increase risks for others involved. Care team perceptions of physician involvement in solution-focused interventions are important for hospitalists to fully understand so risks can be avoided.”
Karen Appold is a freelance medical writer in Pennsylvania.
References
- ECRI Institute. Healthcare Risk, Quality, and Safety Guidance. Violence in healthcare facilities. March 1, 2011. Available at: https://www.ecri.org/components/HRC/Pages/SafSec3.aspx?tab=1. Accessed February 11, 2015.
- Emergency Nurses Association. Emergency department violence surveillance study. November 2011. Available at: http://www.ena.org/practice-research/research/Documents/ENAEDVSReportNovember2011.pdf. Accessed February 11, 2015.
- Richmond JS, Berlin JS, Fishkind AB, 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.
- Simpson SA, Joesch JM, West II, Pasic J. Risk for physical restraint or seclusion in the psychiatric emergency service (PES). Gen Hosp Psychiatry. 2014;36(1):113-118.
If a patient shows signs of agitation, Aaron Gottesman, MD, SFHM, says the best way to handle it is to stay calm. It may sound simple, but, in the heat of the moment, people tend to become defensive and on guard rather than acting composed and sympathetic. He suggests trying to speak softly and evenly to the patient, make eye contact, keep your arms at your side, and ask opened-ended questions such as, “How can I help you?” in a genuine manner.
Dr. Gottesman, director of hospitalist services at Staten Island (N.Y.) University Hospital (SIUH), learned these strategies in a voluntary one-hour course on de-escalation training. Although he says he feels fortunate that he has never had to deal with a physically volatile patient, he has used the verbal de-escalation training. In some cases, he believes that employing it may have prevented a physically violent situation from occurring.
Specifically, de-escalation training teaches how to respond to individuals who are acting aggressive or agitated in a verbal or physical manner. The techniques focus on how to calm someone down, while also teaching basic self-defense skills.
Various companies offer this type of training; some will train staff onsite.
“It is money well-spent,” says Scott Zeller, MD, chief of psychiatric emergency services at Alameda Health System in Oakland, Calif. “This is truly a situation where an ounce of prevention is worth a pound of cure. It only takes one unfortunate episode to result in a serious injury, where a healthcare professional will have to miss work or go on disability, which results in a far greater cost than that of the training.”
Appropriate Responses
By the nature of their work, hospitalists regularly come into contact with agitated patients. “Knowing how to safely help a patient calm down will result in better outcomes for the patient, the physicians, and everyone nearby,” Dr. Zeller says.
“Hospitalists should focus on what they can control,” says Judith Schubert, president of Crisis Prevention Institute (CPI), a Milwaukee, Wis.-based company that offers de-escalation training in 400 cities annually. This includes physicians’ own behavior/demeanor, responsiveness, environmental factors, communication protocols, and a continuous assessment of risk and an understanding of how to balance duty of care with responsibilities to maintain safety.
Hospitalists should be aware of behaviors that could lead to volatility.
“Challenging or oppositional questions and emotional release or intimidating comments often mark the beginning stages of loss of rationality. These are behaviors that warrant specific, directive intervention aimed at stimulating a rational response and diffusing tension,” Schubert says. “Before it even gets to that point, empathy, demonstrated with the patient and family members, can reduce contagion of emotional displays that are likely rooted in fear and anxiety.”
Agitation usually doesn’t arise out of the blue.
“It is typically seen over a spectrum of behaviors, from merely restless and irritable up to sarcastic and demeaning, pacing, unable to sit still, all the way up to screaming, combative, and violent to persons and property,” Dr. Zeller says. “It is best to intervene in the earlier stages and help a person to calm before a situation gets out of hand.”
Thus, hospitalists should be wary of people who are increasingly hostile and energetic and should seek help or work to de-escalate promptly.
Although you may suspect that patients with mental illnesses are more prone to volatility, Dr. Zeller says that isn’t necessarily the case. The most common psychiatric illnesses that can lead to agitation are schizophrenia and bipolar mania. In addition, being intoxicated—especially with alcohol and stimulants—can predispose someone to agitation. Many other medical conditions can cause someone to become agitated, such as confusion, a postictal state, hypoglycemia, or a head injury.
How Bad Is It?
According to the Emergency Nurses Association’s Institute for Emergency Nursing Research, violence is especially prevalent in the ED; about 11% of ED nurses report being physically assaulted each week. The agency states that the data is most likely grossly underreported, since reporting is voluntary.1
Healthcare workers in psychiatric wards are the most likely to suffer an injury caused by an agitated patient, Dr. Zeller says. Of those, nurses are the ones most commonly affected, followed by physicians.
“But agitation-related assaults and injuries can happen just about anywhere in a hospital,” he adds.
According to a study conducted by the Emergency Nurses Association, pushing/grabbing and yelling/shouting were the most prevalent types of violence. Eighty percent of cases occurred in the patient’s room.2 Dr. Zeller says that the most common injuries are those resulting from being struck, kicked or punched, or knocked down. Injuries include heavy bruising, sprains, and broken bones.
Dr. Zeller says it’s difficult to quantify exactly what types and costs of injuries occur. Injuries related to agitation are known to cause staff to miss work frequently. “That can cost a lot in terms of lost hours and replacement wages, as well as medical care for the injured party,” he says.
The Most Dangerous Circumstances
According to a series of 2012 articles on best practices guidelines for the evaluation and treatment of agitation published in Western Journal of Emergency Medicine, two-thirds of all staff injuries occur during the “takedown,” which is when staff attempt to tackle and restrain an agitated patient.3
“If interactions with a patient could help the person to regain control without needing the takedown or restraints, there would be fewer injuries and better outcomes,” says Dr. Zeller, who co-authored the article. “To help these patients in a collaborative and noncoercive way, and avoid restraints, verbal de-escalation is the necessary approach.”
As part of the study, a team of more than 40 experts nationwide was established to create Project BETA (Best practices in Evaluation and Treatment of Agitation). Participants were divided into five workgroups: triage and medical evaluation, psychiatric evaluation, de-escalation techniques, psychopharmacology of agitation, and use and avoidance of seclusion and restraint.
The guidelines were intended to cover all aspects of working with an agitated individual, with a focus on safety and outcomes, but also had a goal of being as patient-centric, collaborative, and noncoercive as possible.
“Every part of Project BETA revolves around verbal de-escalation, which can be done in a very short amount of time while simultaneously doing an assessment and offering medications,” Dr. Zeller says.
As a result of incorporating the guidelines in Project BETA, the psychiatric emergency room at Alameda Health System—which deals with a highly acute, emergency population of patients with serious mental illnesses—restrains less than 0.5% of patients seen. Dr. Zeller points out that this is much lower than the numbers restrained at other institutions. For instance, an article published in October 2013 reported several studies showing that 8% to 24% of patients in psychiatric EDs were placed into physical restraints or seclusion.4
What’s Required of Hospital Administration?
Under its Environment of Care standards, The Joint Commission requires accredited healthcare facilities to address workplace violence risk. The requirements mandate facilities to maintain a written plan describing how the security of patients, staff, and facility visitors will be ensured, to conduct proactive risk assessments considering the potential for workplace violence, and to determine a means for identifying individuals on their premises and controlling access to and egress from security-sensitive areas.1
The standard states that “staff are trained in the use of nonphysical intervention skills,” says Cynthia Leslie, APRN, BC, MSN, associate director of the Standards Interpretation Group at The Joint Commission, which is based in Oakbrook Terrace, Ill. “These skills may assist the patient in calming down and prevent the use of restraints and/or seclusion.”
In addition, staff must be trained before they participate in a restraint or seclusion episode and must have periodic training thereafter.
Anyone who wants de-escalation training can contact a company like CPI directly or establish in-house training teams (CPI offers an Instructor Certification Program). “This allows a cost-effective way [approximately $10 per person] to cascade training to others within the hospital who are part of care teams,” Schubert says.
In Sum
Providing for the care and welfare of patients while maintaining a safe and secure environment for everyone is a balancing act that requires the involvement of a multidisciplinary hospital team, Schubert says.
“Coordination, communication, and continuity among all members of a hospital team are crucial to minimize conflict, avoid chaos, and reduce risks,” she explains. “By being armed with information and skills, hospitalists are less likely to isolate themselves from other team members or react in a nonproductive way when crisis situations emerge.
“Training will help staff to take steps to ensure that their behavior and attitudes don’t become part of the problem and increase risks for others involved. Care team perceptions of physician involvement in solution-focused interventions are important for hospitalists to fully understand so risks can be avoided.”
Karen Appold is a freelance medical writer in Pennsylvania.
References
- ECRI Institute. Healthcare Risk, Quality, and Safety Guidance. Violence in healthcare facilities. March 1, 2011. Available at: https://www.ecri.org/components/HRC/Pages/SafSec3.aspx?tab=1. Accessed February 11, 2015.
- Emergency Nurses Association. Emergency department violence surveillance study. November 2011. Available at: http://www.ena.org/practice-research/research/Documents/ENAEDVSReportNovember2011.pdf. Accessed February 11, 2015.
- Richmond JS, Berlin JS, Fishkind AB, 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.
- Simpson SA, Joesch JM, West II, Pasic J. Risk for physical restraint or seclusion in the psychiatric emergency service (PES). Gen Hosp Psychiatry. 2014;36(1):113-118.
If a patient shows signs of agitation, Aaron Gottesman, MD, SFHM, says the best way to handle it is to stay calm. It may sound simple, but, in the heat of the moment, people tend to become defensive and on guard rather than acting composed and sympathetic. He suggests trying to speak softly and evenly to the patient, make eye contact, keep your arms at your side, and ask opened-ended questions such as, “How can I help you?” in a genuine manner.
Dr. Gottesman, director of hospitalist services at Staten Island (N.Y.) University Hospital (SIUH), learned these strategies in a voluntary one-hour course on de-escalation training. Although he says he feels fortunate that he has never had to deal with a physically volatile patient, he has used the verbal de-escalation training. In some cases, he believes that employing it may have prevented a physically violent situation from occurring.
Specifically, de-escalation training teaches how to respond to individuals who are acting aggressive or agitated in a verbal or physical manner. The techniques focus on how to calm someone down, while also teaching basic self-defense skills.
Various companies offer this type of training; some will train staff onsite.
“It is money well-spent,” says Scott Zeller, MD, chief of psychiatric emergency services at Alameda Health System in Oakland, Calif. “This is truly a situation where an ounce of prevention is worth a pound of cure. It only takes one unfortunate episode to result in a serious injury, where a healthcare professional will have to miss work or go on disability, which results in a far greater cost than that of the training.”
Appropriate Responses
By the nature of their work, hospitalists regularly come into contact with agitated patients. “Knowing how to safely help a patient calm down will result in better outcomes for the patient, the physicians, and everyone nearby,” Dr. Zeller says.
“Hospitalists should focus on what they can control,” says Judith Schubert, president of Crisis Prevention Institute (CPI), a Milwaukee, Wis.-based company that offers de-escalation training in 400 cities annually. This includes physicians’ own behavior/demeanor, responsiveness, environmental factors, communication protocols, and a continuous assessment of risk and an understanding of how to balance duty of care with responsibilities to maintain safety.
Hospitalists should be aware of behaviors that could lead to volatility.
“Challenging or oppositional questions and emotional release or intimidating comments often mark the beginning stages of loss of rationality. These are behaviors that warrant specific, directive intervention aimed at stimulating a rational response and diffusing tension,” Schubert says. “Before it even gets to that point, empathy, demonstrated with the patient and family members, can reduce contagion of emotional displays that are likely rooted in fear and anxiety.”
Agitation usually doesn’t arise out of the blue.
“It is typically seen over a spectrum of behaviors, from merely restless and irritable up to sarcastic and demeaning, pacing, unable to sit still, all the way up to screaming, combative, and violent to persons and property,” Dr. Zeller says. “It is best to intervene in the earlier stages and help a person to calm before a situation gets out of hand.”
Thus, hospitalists should be wary of people who are increasingly hostile and energetic and should seek help or work to de-escalate promptly.
Although you may suspect that patients with mental illnesses are more prone to volatility, Dr. Zeller says that isn’t necessarily the case. The most common psychiatric illnesses that can lead to agitation are schizophrenia and bipolar mania. In addition, being intoxicated—especially with alcohol and stimulants—can predispose someone to agitation. Many other medical conditions can cause someone to become agitated, such as confusion, a postictal state, hypoglycemia, or a head injury.
How Bad Is It?
According to the Emergency Nurses Association’s Institute for Emergency Nursing Research, violence is especially prevalent in the ED; about 11% of ED nurses report being physically assaulted each week. The agency states that the data is most likely grossly underreported, since reporting is voluntary.1
Healthcare workers in psychiatric wards are the most likely to suffer an injury caused by an agitated patient, Dr. Zeller says. Of those, nurses are the ones most commonly affected, followed by physicians.
“But agitation-related assaults and injuries can happen just about anywhere in a hospital,” he adds.
According to a study conducted by the Emergency Nurses Association, pushing/grabbing and yelling/shouting were the most prevalent types of violence. Eighty percent of cases occurred in the patient’s room.2 Dr. Zeller says that the most common injuries are those resulting from being struck, kicked or punched, or knocked down. Injuries include heavy bruising, sprains, and broken bones.
Dr. Zeller says it’s difficult to quantify exactly what types and costs of injuries occur. Injuries related to agitation are known to cause staff to miss work frequently. “That can cost a lot in terms of lost hours and replacement wages, as well as medical care for the injured party,” he says.
The Most Dangerous Circumstances
According to a series of 2012 articles on best practices guidelines for the evaluation and treatment of agitation published in Western Journal of Emergency Medicine, two-thirds of all staff injuries occur during the “takedown,” which is when staff attempt to tackle and restrain an agitated patient.3
“If interactions with a patient could help the person to regain control without needing the takedown or restraints, there would be fewer injuries and better outcomes,” says Dr. Zeller, who co-authored the article. “To help these patients in a collaborative and noncoercive way, and avoid restraints, verbal de-escalation is the necessary approach.”
As part of the study, a team of more than 40 experts nationwide was established to create Project BETA (Best practices in Evaluation and Treatment of Agitation). Participants were divided into five workgroups: triage and medical evaluation, psychiatric evaluation, de-escalation techniques, psychopharmacology of agitation, and use and avoidance of seclusion and restraint.
The guidelines were intended to cover all aspects of working with an agitated individual, with a focus on safety and outcomes, but also had a goal of being as patient-centric, collaborative, and noncoercive as possible.
“Every part of Project BETA revolves around verbal de-escalation, which can be done in a very short amount of time while simultaneously doing an assessment and offering medications,” Dr. Zeller says.
As a result of incorporating the guidelines in Project BETA, the psychiatric emergency room at Alameda Health System—which deals with a highly acute, emergency population of patients with serious mental illnesses—restrains less than 0.5% of patients seen. Dr. Zeller points out that this is much lower than the numbers restrained at other institutions. For instance, an article published in October 2013 reported several studies showing that 8% to 24% of patients in psychiatric EDs were placed into physical restraints or seclusion.4
What’s Required of Hospital Administration?
Under its Environment of Care standards, The Joint Commission requires accredited healthcare facilities to address workplace violence risk. The requirements mandate facilities to maintain a written plan describing how the security of patients, staff, and facility visitors will be ensured, to conduct proactive risk assessments considering the potential for workplace violence, and to determine a means for identifying individuals on their premises and controlling access to and egress from security-sensitive areas.1
The standard states that “staff are trained in the use of nonphysical intervention skills,” says Cynthia Leslie, APRN, BC, MSN, associate director of the Standards Interpretation Group at The Joint Commission, which is based in Oakbrook Terrace, Ill. “These skills may assist the patient in calming down and prevent the use of restraints and/or seclusion.”
In addition, staff must be trained before they participate in a restraint or seclusion episode and must have periodic training thereafter.
Anyone who wants de-escalation training can contact a company like CPI directly or establish in-house training teams (CPI offers an Instructor Certification Program). “This allows a cost-effective way [approximately $10 per person] to cascade training to others within the hospital who are part of care teams,” Schubert says.
In Sum
Providing for the care and welfare of patients while maintaining a safe and secure environment for everyone is a balancing act that requires the involvement of a multidisciplinary hospital team, Schubert says.
“Coordination, communication, and continuity among all members of a hospital team are crucial to minimize conflict, avoid chaos, and reduce risks,” she explains. “By being armed with information and skills, hospitalists are less likely to isolate themselves from other team members or react in a nonproductive way when crisis situations emerge.
“Training will help staff to take steps to ensure that their behavior and attitudes don’t become part of the problem and increase risks for others involved. Care team perceptions of physician involvement in solution-focused interventions are important for hospitalists to fully understand so risks can be avoided.”
Karen Appold is a freelance medical writer in Pennsylvania.
References
- ECRI Institute. Healthcare Risk, Quality, and Safety Guidance. Violence in healthcare facilities. March 1, 2011. Available at: https://www.ecri.org/components/HRC/Pages/SafSec3.aspx?tab=1. Accessed February 11, 2015.
- Emergency Nurses Association. Emergency department violence surveillance study. November 2011. Available at: http://www.ena.org/practice-research/research/Documents/ENAEDVSReportNovember2011.pdf. Accessed February 11, 2015.
- Richmond JS, Berlin JS, Fishkind AB, 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.
- Simpson SA, Joesch JM, West II, Pasic J. Risk for physical restraint or seclusion in the psychiatric emergency service (PES). Gen Hosp Psychiatry. 2014;36(1):113-118.
Hospitalists Should Lead Training, Preparedness for Hospital Violence Prevention
On Jan. 20, a 44-year old surgeon was shot and killed in the middle of the day at one of the country’s top hospitals. Michael Davidson, MD, an endovascular surgeon at Brigham and Women’s Hospital in Boston, was in a second-floor hospital clinic when 55-year-old Stephen Pasceri asked for him by name. Dr. Davidson, the division director of endovascular cardiac surgery and assistant professor at Harvard Medical School, had taken care of Pasceri’s mother before her death in November 2014. Witnesses reported that Dr. Davidson came out to talk to Pasceri; during that conversation, Pasceri shot Dr. Davidson twice.
Dr. Davidson was quickly taken to the ED but died 12 hours later.
The shooter died of a self-inflicted gunshot wound to the head.
The motive is not clear, but Pasceri had voiced frustrations with the medical industry during the care of both his father and his mother. In addition, his mother seemed to have suffered some type of complication after a surgery performed by Dr. Davidson. Interviews of Pasceri’s relatives, friends, and neighbors found they were all shocked and dismayed. The shooter was, by all accounts, an upstanding citizen in his work, home, church, and community; he was an accountant with four children, with no past history of criminal or violent activity.1
A Disheartening Trend
Two other fatal events in medical centers occurred within weeks of the Davidson shooting. In December 2014, at Wentworth-Douglass Hospital in Dover, N.H., a man shot and killed his wife before killing himself.
Days later, at a Veterans Hospital clinic in El Paso, Texas, another shooting left both the perpetrator and a psychologist dead.2
In the healthcare setting, providers encounter many types of violence. Nonfatal violence, ranging from physical aggression to various levels of physical harm, has become commonplace. Inciters of such violence tend to be those who “can’t help themselves,” often patients with primary psychiatric illness or those with medically induced mental impairment, such as delirium or withdrawal. For these patients, there is at least some level of compassion and tolerance for their behavior, and because they tend to be relatively predictable, preparedness and mitigation of such acts can give providers some sense of control over the situation.
But the Davidson event represents a type of violence that is frightening, unpredictable, and very difficult to prevent, prepare for, or adequately handle.
Actual shootings on medical campuses are, fortunately, rare. A recent study by the Johns Hopkins Office of Critical Event Preparedness and Response found 154 hospital shootings between 2000 and 2011, resulting in 235 injured or dead victims. The most commonly occurring scenario is that of people acting against family members, with healthcare workers getting caught in the crosshairs. The most common victim is the shooter (45% of the time), and the least common victims are physicians and nurses. Over half (59%) of medical center shootings occur within the hospital; the other 41% occur somewhere else on the hospital grounds.3
So what can hospitalists and hospitals do about the real threat of physical violence and shootings within medical centers? Some have recommended metal detectors as effective barriers for preventing weapons from entering medical centers. The primary problem with this solution is that the majority of medical centers have found this plan impossible to implement, given the number of entrances in typical hospitals; Johns Hopkins for example, has more than 80 entrances. Metal detectors also require security staffing at each entrance 24/7.4
Because of the barriers, metal detectors present an insurmountable financial obstacle for most hospitals. In addition, they present an issue with public perception. Many would argue that hospitals are (and should be) places of healing and sanctuary (e.g. “safe havens”), not places for suspicion and searches. In addition, although there is evidence that the use of metal detectors results in increased confiscation of weapons, there is no evidence that they result in fewer on-site assaults.5 Further complicating matters, almost a quarter of the shootings that occur in EDs result from the perpetrator grabbing a weapon from a security guard.3
Others advocate for stricter gun control laws and enforcement, an argument that has vehement advocates and critics on both sides and is unlikely to be resolved in the near future.
Take Action: Be Prepared
In the meantime, hospitalists are left with preparedness tactics that range from situational awareness to active shooter drills. Both are equally important and should be a part of disaster preparedness at any medical center regardless of size, type, or location. Hospitalists can and should take a lead in such preparedness. Current statistics show that hospitalists are employed in at least 85% of all U.S. hospitals. With such widespread penetration, hospitalists can have a huge impact on the preparedness efforts that can prevent such acts from occurring, as well as on organizational resilience and recovery if such an act does occur.
Such training is more important in healthcare settings than other workplaces, as medical personnel have to be specially trained to resist the temptation to help. For example, active shooter training instructs personnel to run, hide, or fight, none of which come “naturally” to those trained to save and rescue for a living. This training instructs anyone in the “Hot Zone” (where life is in direct danger) to run away from the scene (always preferred if feasible), hide (barricade the door, silence any devices, and stay still), or fight (use anything in sight to fight the shooter, and work as a team if feasible). These responses are the exact opposite of what most trained healthcare personnel are accustomed to doing in cases of emergency.
In Sum
The Michael Davidson story is very sobering by all accounts. Healthcare violence such as this, while rare, is devastating.
Hospitalists should lead the way in training and preparedness for violence prevention and mitigation, including active shooter simulation scenarios. We can all have a huge impact in reducing the risk of casualties should such an unpredictable event occur in our hospital.
References
- Freyer FJ, Kowalczyk L, Murphy SP. Surgeon slain, gunman found dead in day of crisis at Brigham. January 20, 2015. The Boston Globe online. Available at: http://www.bostonglobe.com/metro/2015/01/20/boston-police-investigate-report-shooting-brigham-and-women/Jhig9z8LO8A5PH9Er4vTiP/story.html?rss_id=Top-GNP&utm_source=Managed&utm_campaign=386d2ff709-Quality+%26+Patient+Safety+Update&utm_medium=email&utm_term=0_ebe1fa6178-386d2ff709-319388717. Accessed February 5, 2015.
- Barnet S. Gun violence in hospitals: how much of a threat is it really? January 21, 2015. Becker’s Hospital Review. Available at: http://www.beckershospitalreview.com/healthcare-blog/gun-violence-in-hospitals-how-much-of-a-threat-is-it-really.html. Accessed February 5, 2015.
- Kelen GD, Catlett CL, Kubit JG, Hsieh Y-H. Hospital-based shootings in the United States: 2000 to 2011. Annals of Emergency Medicine online. September 20, 2012. Available at: http://www.annemergmed.com/article/S0196-0644%2812%2901408-4/abstract. Accessed February 5, 2015.
- Calvert S, Scharper J, Roylance F. Experts: no need for metal detectors at Hopkins. September 17, 2010. The Baltimore Sun online. Available at: http://articles.baltimoresun.com/2010-09-17/business/bs-md-hopkins-hospital-security-20100916_1_metal-detectors-healthcare-security-and-safety-hospital-security-experts. Accessed February 5, 2015.
- Rankins RC, Hendey GW. Effect of a security system on violent incidents and hidden weapons in the emergency department. Ann Emerg Med. 1999;33(6):676-679.
On Jan. 20, a 44-year old surgeon was shot and killed in the middle of the day at one of the country’s top hospitals. Michael Davidson, MD, an endovascular surgeon at Brigham and Women’s Hospital in Boston, was in a second-floor hospital clinic when 55-year-old Stephen Pasceri asked for him by name. Dr. Davidson, the division director of endovascular cardiac surgery and assistant professor at Harvard Medical School, had taken care of Pasceri’s mother before her death in November 2014. Witnesses reported that Dr. Davidson came out to talk to Pasceri; during that conversation, Pasceri shot Dr. Davidson twice.
Dr. Davidson was quickly taken to the ED but died 12 hours later.
The shooter died of a self-inflicted gunshot wound to the head.
The motive is not clear, but Pasceri had voiced frustrations with the medical industry during the care of both his father and his mother. In addition, his mother seemed to have suffered some type of complication after a surgery performed by Dr. Davidson. Interviews of Pasceri’s relatives, friends, and neighbors found they were all shocked and dismayed. The shooter was, by all accounts, an upstanding citizen in his work, home, church, and community; he was an accountant with four children, with no past history of criminal or violent activity.1
A Disheartening Trend
Two other fatal events in medical centers occurred within weeks of the Davidson shooting. In December 2014, at Wentworth-Douglass Hospital in Dover, N.H., a man shot and killed his wife before killing himself.
Days later, at a Veterans Hospital clinic in El Paso, Texas, another shooting left both the perpetrator and a psychologist dead.2
In the healthcare setting, providers encounter many types of violence. Nonfatal violence, ranging from physical aggression to various levels of physical harm, has become commonplace. Inciters of such violence tend to be those who “can’t help themselves,” often patients with primary psychiatric illness or those with medically induced mental impairment, such as delirium or withdrawal. For these patients, there is at least some level of compassion and tolerance for their behavior, and because they tend to be relatively predictable, preparedness and mitigation of such acts can give providers some sense of control over the situation.
But the Davidson event represents a type of violence that is frightening, unpredictable, and very difficult to prevent, prepare for, or adequately handle.
Actual shootings on medical campuses are, fortunately, rare. A recent study by the Johns Hopkins Office of Critical Event Preparedness and Response found 154 hospital shootings between 2000 and 2011, resulting in 235 injured or dead victims. The most commonly occurring scenario is that of people acting against family members, with healthcare workers getting caught in the crosshairs. The most common victim is the shooter (45% of the time), and the least common victims are physicians and nurses. Over half (59%) of medical center shootings occur within the hospital; the other 41% occur somewhere else on the hospital grounds.3
So what can hospitalists and hospitals do about the real threat of physical violence and shootings within medical centers? Some have recommended metal detectors as effective barriers for preventing weapons from entering medical centers. The primary problem with this solution is that the majority of medical centers have found this plan impossible to implement, given the number of entrances in typical hospitals; Johns Hopkins for example, has more than 80 entrances. Metal detectors also require security staffing at each entrance 24/7.4
Because of the barriers, metal detectors present an insurmountable financial obstacle for most hospitals. In addition, they present an issue with public perception. Many would argue that hospitals are (and should be) places of healing and sanctuary (e.g. “safe havens”), not places for suspicion and searches. In addition, although there is evidence that the use of metal detectors results in increased confiscation of weapons, there is no evidence that they result in fewer on-site assaults.5 Further complicating matters, almost a quarter of the shootings that occur in EDs result from the perpetrator grabbing a weapon from a security guard.3
Others advocate for stricter gun control laws and enforcement, an argument that has vehement advocates and critics on both sides and is unlikely to be resolved in the near future.
Take Action: Be Prepared
In the meantime, hospitalists are left with preparedness tactics that range from situational awareness to active shooter drills. Both are equally important and should be a part of disaster preparedness at any medical center regardless of size, type, or location. Hospitalists can and should take a lead in such preparedness. Current statistics show that hospitalists are employed in at least 85% of all U.S. hospitals. With such widespread penetration, hospitalists can have a huge impact on the preparedness efforts that can prevent such acts from occurring, as well as on organizational resilience and recovery if such an act does occur.
Such training is more important in healthcare settings than other workplaces, as medical personnel have to be specially trained to resist the temptation to help. For example, active shooter training instructs personnel to run, hide, or fight, none of which come “naturally” to those trained to save and rescue for a living. This training instructs anyone in the “Hot Zone” (where life is in direct danger) to run away from the scene (always preferred if feasible), hide (barricade the door, silence any devices, and stay still), or fight (use anything in sight to fight the shooter, and work as a team if feasible). These responses are the exact opposite of what most trained healthcare personnel are accustomed to doing in cases of emergency.
In Sum
The Michael Davidson story is very sobering by all accounts. Healthcare violence such as this, while rare, is devastating.
Hospitalists should lead the way in training and preparedness for violence prevention and mitigation, including active shooter simulation scenarios. We can all have a huge impact in reducing the risk of casualties should such an unpredictable event occur in our hospital.
References
- Freyer FJ, Kowalczyk L, Murphy SP. Surgeon slain, gunman found dead in day of crisis at Brigham. January 20, 2015. The Boston Globe online. Available at: http://www.bostonglobe.com/metro/2015/01/20/boston-police-investigate-report-shooting-brigham-and-women/Jhig9z8LO8A5PH9Er4vTiP/story.html?rss_id=Top-GNP&utm_source=Managed&utm_campaign=386d2ff709-Quality+%26+Patient+Safety+Update&utm_medium=email&utm_term=0_ebe1fa6178-386d2ff709-319388717. Accessed February 5, 2015.
- Barnet S. Gun violence in hospitals: how much of a threat is it really? January 21, 2015. Becker’s Hospital Review. Available at: http://www.beckershospitalreview.com/healthcare-blog/gun-violence-in-hospitals-how-much-of-a-threat-is-it-really.html. Accessed February 5, 2015.
- Kelen GD, Catlett CL, Kubit JG, Hsieh Y-H. Hospital-based shootings in the United States: 2000 to 2011. Annals of Emergency Medicine online. September 20, 2012. Available at: http://www.annemergmed.com/article/S0196-0644%2812%2901408-4/abstract. Accessed February 5, 2015.
- Calvert S, Scharper J, Roylance F. Experts: no need for metal detectors at Hopkins. September 17, 2010. The Baltimore Sun online. Available at: http://articles.baltimoresun.com/2010-09-17/business/bs-md-hopkins-hospital-security-20100916_1_metal-detectors-healthcare-security-and-safety-hospital-security-experts. Accessed February 5, 2015.
- Rankins RC, Hendey GW. Effect of a security system on violent incidents and hidden weapons in the emergency department. Ann Emerg Med. 1999;33(6):676-679.
On Jan. 20, a 44-year old surgeon was shot and killed in the middle of the day at one of the country’s top hospitals. Michael Davidson, MD, an endovascular surgeon at Brigham and Women’s Hospital in Boston, was in a second-floor hospital clinic when 55-year-old Stephen Pasceri asked for him by name. Dr. Davidson, the division director of endovascular cardiac surgery and assistant professor at Harvard Medical School, had taken care of Pasceri’s mother before her death in November 2014. Witnesses reported that Dr. Davidson came out to talk to Pasceri; during that conversation, Pasceri shot Dr. Davidson twice.
Dr. Davidson was quickly taken to the ED but died 12 hours later.
The shooter died of a self-inflicted gunshot wound to the head.
The motive is not clear, but Pasceri had voiced frustrations with the medical industry during the care of both his father and his mother. In addition, his mother seemed to have suffered some type of complication after a surgery performed by Dr. Davidson. Interviews of Pasceri’s relatives, friends, and neighbors found they were all shocked and dismayed. The shooter was, by all accounts, an upstanding citizen in his work, home, church, and community; he was an accountant with four children, with no past history of criminal or violent activity.1
A Disheartening Trend
Two other fatal events in medical centers occurred within weeks of the Davidson shooting. In December 2014, at Wentworth-Douglass Hospital in Dover, N.H., a man shot and killed his wife before killing himself.
Days later, at a Veterans Hospital clinic in El Paso, Texas, another shooting left both the perpetrator and a psychologist dead.2
In the healthcare setting, providers encounter many types of violence. Nonfatal violence, ranging from physical aggression to various levels of physical harm, has become commonplace. Inciters of such violence tend to be those who “can’t help themselves,” often patients with primary psychiatric illness or those with medically induced mental impairment, such as delirium or withdrawal. For these patients, there is at least some level of compassion and tolerance for their behavior, and because they tend to be relatively predictable, preparedness and mitigation of such acts can give providers some sense of control over the situation.
But the Davidson event represents a type of violence that is frightening, unpredictable, and very difficult to prevent, prepare for, or adequately handle.
Actual shootings on medical campuses are, fortunately, rare. A recent study by the Johns Hopkins Office of Critical Event Preparedness and Response found 154 hospital shootings between 2000 and 2011, resulting in 235 injured or dead victims. The most commonly occurring scenario is that of people acting against family members, with healthcare workers getting caught in the crosshairs. The most common victim is the shooter (45% of the time), and the least common victims are physicians and nurses. Over half (59%) of medical center shootings occur within the hospital; the other 41% occur somewhere else on the hospital grounds.3
So what can hospitalists and hospitals do about the real threat of physical violence and shootings within medical centers? Some have recommended metal detectors as effective barriers for preventing weapons from entering medical centers. The primary problem with this solution is that the majority of medical centers have found this plan impossible to implement, given the number of entrances in typical hospitals; Johns Hopkins for example, has more than 80 entrances. Metal detectors also require security staffing at each entrance 24/7.4
Because of the barriers, metal detectors present an insurmountable financial obstacle for most hospitals. In addition, they present an issue with public perception. Many would argue that hospitals are (and should be) places of healing and sanctuary (e.g. “safe havens”), not places for suspicion and searches. In addition, although there is evidence that the use of metal detectors results in increased confiscation of weapons, there is no evidence that they result in fewer on-site assaults.5 Further complicating matters, almost a quarter of the shootings that occur in EDs result from the perpetrator grabbing a weapon from a security guard.3
Others advocate for stricter gun control laws and enforcement, an argument that has vehement advocates and critics on both sides and is unlikely to be resolved in the near future.
Take Action: Be Prepared
In the meantime, hospitalists are left with preparedness tactics that range from situational awareness to active shooter drills. Both are equally important and should be a part of disaster preparedness at any medical center regardless of size, type, or location. Hospitalists can and should take a lead in such preparedness. Current statistics show that hospitalists are employed in at least 85% of all U.S. hospitals. With such widespread penetration, hospitalists can have a huge impact on the preparedness efforts that can prevent such acts from occurring, as well as on organizational resilience and recovery if such an act does occur.
Such training is more important in healthcare settings than other workplaces, as medical personnel have to be specially trained to resist the temptation to help. For example, active shooter training instructs personnel to run, hide, or fight, none of which come “naturally” to those trained to save and rescue for a living. This training instructs anyone in the “Hot Zone” (where life is in direct danger) to run away from the scene (always preferred if feasible), hide (barricade the door, silence any devices, and stay still), or fight (use anything in sight to fight the shooter, and work as a team if feasible). These responses are the exact opposite of what most trained healthcare personnel are accustomed to doing in cases of emergency.
In Sum
The Michael Davidson story is very sobering by all accounts. Healthcare violence such as this, while rare, is devastating.
Hospitalists should lead the way in training and preparedness for violence prevention and mitigation, including active shooter simulation scenarios. We can all have a huge impact in reducing the risk of casualties should such an unpredictable event occur in our hospital.
References
- Freyer FJ, Kowalczyk L, Murphy SP. Surgeon slain, gunman found dead in day of crisis at Brigham. January 20, 2015. The Boston Globe online. Available at: http://www.bostonglobe.com/metro/2015/01/20/boston-police-investigate-report-shooting-brigham-and-women/Jhig9z8LO8A5PH9Er4vTiP/story.html?rss_id=Top-GNP&utm_source=Managed&utm_campaign=386d2ff709-Quality+%26+Patient+Safety+Update&utm_medium=email&utm_term=0_ebe1fa6178-386d2ff709-319388717. Accessed February 5, 2015.
- Barnet S. Gun violence in hospitals: how much of a threat is it really? January 21, 2015. Becker’s Hospital Review. Available at: http://www.beckershospitalreview.com/healthcare-blog/gun-violence-in-hospitals-how-much-of-a-threat-is-it-really.html. Accessed February 5, 2015.
- Kelen GD, Catlett CL, Kubit JG, Hsieh Y-H. Hospital-based shootings in the United States: 2000 to 2011. Annals of Emergency Medicine online. September 20, 2012. Available at: http://www.annemergmed.com/article/S0196-0644%2812%2901408-4/abstract. Accessed February 5, 2015.
- Calvert S, Scharper J, Roylance F. Experts: no need for metal detectors at Hopkins. September 17, 2010. The Baltimore Sun online. Available at: http://articles.baltimoresun.com/2010-09-17/business/bs-md-hopkins-hospital-security-20100916_1_metal-detectors-healthcare-security-and-safety-hospital-security-experts. Accessed February 5, 2015.
- Rankins RC, Hendey GW. Effect of a security system on violent incidents and hidden weapons in the emergency department. Ann Emerg Med. 1999;33(6):676-679.
Little Progress Made Training Hospitalists to Stem Shortage of Intensivists
What would the status be for a hospitalist who could train for one year to become a critical care intensivist to address the shortage of intensivists? I’m one of the hospitalists who love critical care but cannot do two more years out for critical care training.
—Amadeo Rivera, MD
Has there been any progress in the 2012 SCCM/SHM proposal to train hospitalists as intensivists?
—Stephen M. Pastores, MD, Memorial
Sloan-Kettering Cancer Center, New York, N.Y.
Dr. Hospitalist responds:
As you may recall, SHM and the Society of Critical Care Medicine (SCCM) published a joint position paper in the Journal of Hospital Medicine in June 2012 in which they proposed a one-year critical care fellowship for hospitalists with at least three years of experience.
Since only one year of clinical rotations is required for critical care board eligibility, and there already exists a one-year track for other medical subspecialists (e.g. nephrology, infectious disease), most of us in hospital medicine thought the recommendation would have been much better received. Well, you guessed it. The following month, the leadership of the American College of Chest Physicians and the American Association of Critical-Care Nurses wrote in an editorial that a one-year fellowship was inadequate for hospitalists to gain competence in critical care medicine. Since then, there has not been much progress, at least not publicly, toward a standardized, streamlined, and accredited process for hospitalists to achieve critical care certification in one year.
Nevertheless, employing a standard search engine (Google) and terminology, I was able to locate one U.S.-based training program offering a one-year critical care medicine fellowship program recognized by the Accreditation Council for Graduate Medical Education for candidates with a background in anesthesiology, surgery, or internal medicine.
What would the status be for a hospitalist who could train for one year to become a critical care intensivist to address the shortage of intensivists? I’m one of the hospitalists who love critical care but cannot do two more years out for critical care training.
—Amadeo Rivera, MD
Has there been any progress in the 2012 SCCM/SHM proposal to train hospitalists as intensivists?
—Stephen M. Pastores, MD, Memorial
Sloan-Kettering Cancer Center, New York, N.Y.
Dr. Hospitalist responds:
As you may recall, SHM and the Society of Critical Care Medicine (SCCM) published a joint position paper in the Journal of Hospital Medicine in June 2012 in which they proposed a one-year critical care fellowship for hospitalists with at least three years of experience.
Since only one year of clinical rotations is required for critical care board eligibility, and there already exists a one-year track for other medical subspecialists (e.g. nephrology, infectious disease), most of us in hospital medicine thought the recommendation would have been much better received. Well, you guessed it. The following month, the leadership of the American College of Chest Physicians and the American Association of Critical-Care Nurses wrote in an editorial that a one-year fellowship was inadequate for hospitalists to gain competence in critical care medicine. Since then, there has not been much progress, at least not publicly, toward a standardized, streamlined, and accredited process for hospitalists to achieve critical care certification in one year.
Nevertheless, employing a standard search engine (Google) and terminology, I was able to locate one U.S.-based training program offering a one-year critical care medicine fellowship program recognized by the Accreditation Council for Graduate Medical Education for candidates with a background in anesthesiology, surgery, or internal medicine.
What would the status be for a hospitalist who could train for one year to become a critical care intensivist to address the shortage of intensivists? I’m one of the hospitalists who love critical care but cannot do two more years out for critical care training.
—Amadeo Rivera, MD
Has there been any progress in the 2012 SCCM/SHM proposal to train hospitalists as intensivists?
—Stephen M. Pastores, MD, Memorial
Sloan-Kettering Cancer Center, New York, N.Y.
Dr. Hospitalist responds:
As you may recall, SHM and the Society of Critical Care Medicine (SCCM) published a joint position paper in the Journal of Hospital Medicine in June 2012 in which they proposed a one-year critical care fellowship for hospitalists with at least three years of experience.
Since only one year of clinical rotations is required for critical care board eligibility, and there already exists a one-year track for other medical subspecialists (e.g. nephrology, infectious disease), most of us in hospital medicine thought the recommendation would have been much better received. Well, you guessed it. The following month, the leadership of the American College of Chest Physicians and the American Association of Critical-Care Nurses wrote in an editorial that a one-year fellowship was inadequate for hospitalists to gain competence in critical care medicine. Since then, there has not been much progress, at least not publicly, toward a standardized, streamlined, and accredited process for hospitalists to achieve critical care certification in one year.
Nevertheless, employing a standard search engine (Google) and terminology, I was able to locate one U.S.-based training program offering a one-year critical care medicine fellowship program recognized by the Accreditation Council for Graduate Medical Education for candidates with a background in anesthesiology, surgery, or internal medicine.
Hospital Violence Hits Home
Hospitalists could hardly be faulted for wondering: Am I safe? After all, the inpatient setting can be a tense place, and it’s where hospitalists work day in and day out.
David Pressel, MD, PhD, FHM, a pediatric hospitalist and medical director of inpatient services at Nemours Children’s Health System, which has locations in Delaware, New Jersey, Pennsylvania, and Florida, says it’s no wonder violence can erupt in the hospital setting.
“Violence is an issue in hospitals that is a reflection of our society, unfortunately,” says Dr. Pressel, a member of Team Hospitalist. “And it happens because these are very stressful places where people’s behavior can get outside the norm given the stress of the problems.”
Dr. Pressel, in collaboration with many others, has developed a workplace violence prevention program at Nemours aimed at de-escalating situations to avoid physical violence. The program teaches providers how to respond when something violent does happen. It’s a tiered training regimen that involves more training for those most involved in handling violent situations.
Dr. Pressel is no stranger to violence himself. Although he is a pediatric hospitalist and his patients are younger, some adolescent patients can have the physical presence of adults and pose just as serious a threat. He said that before the training program was put into place about a year ago, an episode of violence every month or two would require a patient to be placed in restraints.
“Staff has been hurt,” he explains. “I’ve been bitten twice by a patient. I have a scar on my arm that will be with me for life from one episode.”
A Slow, Disheartening, Upward Trend
Whether violence in hospitals and medical facilities is really a growing problem—or whether awareness of the issue is simply greater given these recent, high profile incidents—is not entirely known.
But according to the latest figures available from the Bureau of Labor Statistics (BLS), provided by the Occupational Safety and Health Administration (OSHA), violent incidents in hospitals did appear to be on the rise through 2013. The number of hospital assaults rose from 5,030 in 2011 to 5,500 in 2012 to 5,660 in 2013.
The number of assaults rose across all private sector industries over that span, but the percentage of those assaults that occurred in hospitals grew greater during that time—an indication that hospitals might be getting more violent at a faster pace than other workplaces. In 2011, according to BLS data, 21.4% of all assaults in private sector industries occurred in hospitals. That number rose to 21.8% in 2012 and to 22.1% in 2013.
According to the 2014 Healthcare Crime Survey, published by the International Association for Healthcare Security and Safety (IAHSS)—an organization of hospital security officials and administrators—violent crime at U.S. facilities rose from two incidents per 100 beds in 2012 to 2.5 incidents per 100 beds in 2013. That category includes murder, rape, aggravated assault, and robbery.
Assaults rose from 10.7 incidents per 100 beds in 2012 to 11.1 incidents per 100 beds in 2013.
BLS data also show that more injuries in hospitals are due to assaults compared with the private sector overall. In 2011, 2.6% of all private sector injuries were due to assault; in 2012, the number rose to 2.8%; and, in 2013, it was 2.8%. In hospitals in 2011, 8.6% of all injuries resulted from assaults. That percentage rose to 9.5% in 2012 and to 9.8% in 2013.
“BLS data show that nonfatal injuries due to violence are greater in the healthcare/social assistance setting than in other workplaces,” an OSHA spokesperson says. “Assaults represent a serious safety and health hazard within healthcare, and data indicate that hospitals comprise a large percentage of workplace assaults.”
Incident Prevention
Programs aimed at preventing violence can reduce these incidents.
“How well prepared hospital workers are in dealing with violent situations depends on the workplace violence prevention program implemented at a facility,” the OSHA spokesperson says. “Some states have passed legislation that specifically requires workplace violence prevention programs in the healthcare setting.”
These programs should address management commitment and employee participation, worksite analysis, hazard prevention and control, safety and health training, and recordkeeping and program evaluation. These elements should be assessed regularly, with changes made to respond to changing conditions, OSHA says.
A large number of OSHA inspections in the healthcare setting occur because of complaints regarding lack of protections against workplace violence. In 2014, the agency did 35 inspections in response to such complaints; 25 of those were in a healthcare setting, with 12 specifically at hospitals. As a result, five citations were issued, all of which were in healthcare, including two at hospitals.
Last year, Brookdale University Hospital and Medical Center in Brooklyn, N.Y., was fined $78,000 after an OSHA inspection found 40 incidents of workplace violence between Feb. 7 and April 12. They included employees who were threatened or verbally or physically assaulted by patients and visitors or while breaking up fights between patients. In the worst attack, a nurse sustained severe brain injuries.
The bulk of the hospital’s fines came as a result of a willful violation—an intentional or voluntary disregard for laws meant to protect workers against hospital violence.
While data from IAHSS and the BLS show an increase in hospital violence, those national figures aren’t as important as what is happening at your own facility, says David LaRose, MS, CHPA, CPP, the president of IAHSS and director of safety, security, and emergency management at Lakeland Regional Medical Center in Florida.
“You have to do a vulnerability assessment, and you specifically have to look at your demographic,” he says. “You specifically have to look at what is the history and the culture of the facility” to determine a hospital’s specific risk factors.
Although it’s crucial that a hospital track its own statistics on violence, that’s not to say that incidents elsewhere are irrelevant.
“You also want to look at what’s happening in the real world,” he says. “Somebody else’s unfortunate (occurrence) is a learning experience for my system, so we can try to be proactively preventing that.”
Educate, Recognize, React
At Nemours, Dr. Pressel didn’t develop the training in response to a perceived rise in incidents there. It was apparent, he says, that deficiencies in readiness needed to be addressed.
In the Nemours program, every staff member with some level of patient care responsibility gets basic training in aggressive child emergencies: identifying these situations, responding appropriately, and keeping safe. This group includes doctors, nurses, and nurse’s aids. The training involves actually playing out scenarios of violence, with staff members attempting to subdue a would-be attacker.
Depending on the job, each worker receives extra training that is specific to the role he or she would play in handling violent scenarios.
The training is designed to help individuals respond to such situations with “the same alacrity and acuity as they would respond to a Code Blue,” Dr. Pressel says. “Drop what you’re doing and run. These events are dangerous. That’s what they teach people. They’re dangerous and they’re scary and they’re chaotic, just like a Code Blue. That’s how people need to treat it.”
The goal is to de-escalate a situation, verbally or physically, without more aggressive means. But if that doesn’t work, physical restraints, medication, or both are used.
Throughout the medical field, training in this area is scarce, Dr. Pressel says. In nursing school and medical school, “for the most part, it’s zero,” he says.
“If you’re in a psychiatric facility, these events happen,” he adds. “And then you get a lot of enhanced training.” But, he notes, “I had no formal training until I became tasked with dealing with this.”
Since the program was implemented at Nemours, it seems to have worked.
“We have had many of these episodes that have been resolved by verbal de-escalation, as opposed to physical restraints or medication,” he says.
His hospital has also made other changes. The facility used to have multiple entrances and exits that were unsecured, and anybody could walk into any unit “with no challenge whatsoever.” Now, everyone entering has to pass hospital personnel. And, to get into a patient unit, visitors have to check in and be issued a photo ID. Also, in response to an incident in 2013, the hospital now has “constables” who are trained and licensed to carry firearms, Dr. Pressel says.
Above all, he notes, is personal safety. If you yourself are hurt, you won’t be able to help anyone else.
“That’s absolutely the first thing that people hear, the last thing that people hear, and it’s repeated over and over again,” he says.
Both Dr. Pressel and LaRose say that even with the drumbeat of high profile incidents, they haven’t heard from colleagues that health professionals are concerned about people losing interest in entering the field or are feeling burned out because of safety concerns. Being prepared is the key, and the level of preparedness varies by facility, LaRose says. The IAHSS provides security and healthcare safety guidelines at iahss.org.
“We recognize that we are in an occupation that tends to be on the receiving end of more aggression and more violence than the average worker,” LaRose says. “Therefore, how proactively does the organization or the institution take that knowledge and provide the tools and the training to the staff?
“What can we do as a team to increase our sense of security and safety and make this a great place to continue your career?”
Tom Collins is a freelance writer in South Florida.
Hospitalists could hardly be faulted for wondering: Am I safe? After all, the inpatient setting can be a tense place, and it’s where hospitalists work day in and day out.
David Pressel, MD, PhD, FHM, a pediatric hospitalist and medical director of inpatient services at Nemours Children’s Health System, which has locations in Delaware, New Jersey, Pennsylvania, and Florida, says it’s no wonder violence can erupt in the hospital setting.
“Violence is an issue in hospitals that is a reflection of our society, unfortunately,” says Dr. Pressel, a member of Team Hospitalist. “And it happens because these are very stressful places where people’s behavior can get outside the norm given the stress of the problems.”
Dr. Pressel, in collaboration with many others, has developed a workplace violence prevention program at Nemours aimed at de-escalating situations to avoid physical violence. The program teaches providers how to respond when something violent does happen. It’s a tiered training regimen that involves more training for those most involved in handling violent situations.
Dr. Pressel is no stranger to violence himself. Although he is a pediatric hospitalist and his patients are younger, some adolescent patients can have the physical presence of adults and pose just as serious a threat. He said that before the training program was put into place about a year ago, an episode of violence every month or two would require a patient to be placed in restraints.
“Staff has been hurt,” he explains. “I’ve been bitten twice by a patient. I have a scar on my arm that will be with me for life from one episode.”
A Slow, Disheartening, Upward Trend
Whether violence in hospitals and medical facilities is really a growing problem—or whether awareness of the issue is simply greater given these recent, high profile incidents—is not entirely known.
But according to the latest figures available from the Bureau of Labor Statistics (BLS), provided by the Occupational Safety and Health Administration (OSHA), violent incidents in hospitals did appear to be on the rise through 2013. The number of hospital assaults rose from 5,030 in 2011 to 5,500 in 2012 to 5,660 in 2013.
The number of assaults rose across all private sector industries over that span, but the percentage of those assaults that occurred in hospitals grew greater during that time—an indication that hospitals might be getting more violent at a faster pace than other workplaces. In 2011, according to BLS data, 21.4% of all assaults in private sector industries occurred in hospitals. That number rose to 21.8% in 2012 and to 22.1% in 2013.
According to the 2014 Healthcare Crime Survey, published by the International Association for Healthcare Security and Safety (IAHSS)—an organization of hospital security officials and administrators—violent crime at U.S. facilities rose from two incidents per 100 beds in 2012 to 2.5 incidents per 100 beds in 2013. That category includes murder, rape, aggravated assault, and robbery.
Assaults rose from 10.7 incidents per 100 beds in 2012 to 11.1 incidents per 100 beds in 2013.
BLS data also show that more injuries in hospitals are due to assaults compared with the private sector overall. In 2011, 2.6% of all private sector injuries were due to assault; in 2012, the number rose to 2.8%; and, in 2013, it was 2.8%. In hospitals in 2011, 8.6% of all injuries resulted from assaults. That percentage rose to 9.5% in 2012 and to 9.8% in 2013.
“BLS data show that nonfatal injuries due to violence are greater in the healthcare/social assistance setting than in other workplaces,” an OSHA spokesperson says. “Assaults represent a serious safety and health hazard within healthcare, and data indicate that hospitals comprise a large percentage of workplace assaults.”
Incident Prevention
Programs aimed at preventing violence can reduce these incidents.
“How well prepared hospital workers are in dealing with violent situations depends on the workplace violence prevention program implemented at a facility,” the OSHA spokesperson says. “Some states have passed legislation that specifically requires workplace violence prevention programs in the healthcare setting.”
These programs should address management commitment and employee participation, worksite analysis, hazard prevention and control, safety and health training, and recordkeeping and program evaluation. These elements should be assessed regularly, with changes made to respond to changing conditions, OSHA says.
A large number of OSHA inspections in the healthcare setting occur because of complaints regarding lack of protections against workplace violence. In 2014, the agency did 35 inspections in response to such complaints; 25 of those were in a healthcare setting, with 12 specifically at hospitals. As a result, five citations were issued, all of which were in healthcare, including two at hospitals.
Last year, Brookdale University Hospital and Medical Center in Brooklyn, N.Y., was fined $78,000 after an OSHA inspection found 40 incidents of workplace violence between Feb. 7 and April 12. They included employees who were threatened or verbally or physically assaulted by patients and visitors or while breaking up fights between patients. In the worst attack, a nurse sustained severe brain injuries.
The bulk of the hospital’s fines came as a result of a willful violation—an intentional or voluntary disregard for laws meant to protect workers against hospital violence.
While data from IAHSS and the BLS show an increase in hospital violence, those national figures aren’t as important as what is happening at your own facility, says David LaRose, MS, CHPA, CPP, the president of IAHSS and director of safety, security, and emergency management at Lakeland Regional Medical Center in Florida.
“You have to do a vulnerability assessment, and you specifically have to look at your demographic,” he says. “You specifically have to look at what is the history and the culture of the facility” to determine a hospital’s specific risk factors.
Although it’s crucial that a hospital track its own statistics on violence, that’s not to say that incidents elsewhere are irrelevant.
“You also want to look at what’s happening in the real world,” he says. “Somebody else’s unfortunate (occurrence) is a learning experience for my system, so we can try to be proactively preventing that.”
Educate, Recognize, React
At Nemours, Dr. Pressel didn’t develop the training in response to a perceived rise in incidents there. It was apparent, he says, that deficiencies in readiness needed to be addressed.
In the Nemours program, every staff member with some level of patient care responsibility gets basic training in aggressive child emergencies: identifying these situations, responding appropriately, and keeping safe. This group includes doctors, nurses, and nurse’s aids. The training involves actually playing out scenarios of violence, with staff members attempting to subdue a would-be attacker.
Depending on the job, each worker receives extra training that is specific to the role he or she would play in handling violent scenarios.
The training is designed to help individuals respond to such situations with “the same alacrity and acuity as they would respond to a Code Blue,” Dr. Pressel says. “Drop what you’re doing and run. These events are dangerous. That’s what they teach people. They’re dangerous and they’re scary and they’re chaotic, just like a Code Blue. That’s how people need to treat it.”
The goal is to de-escalate a situation, verbally or physically, without more aggressive means. But if that doesn’t work, physical restraints, medication, or both are used.
Throughout the medical field, training in this area is scarce, Dr. Pressel says. In nursing school and medical school, “for the most part, it’s zero,” he says.
“If you’re in a psychiatric facility, these events happen,” he adds. “And then you get a lot of enhanced training.” But, he notes, “I had no formal training until I became tasked with dealing with this.”
Since the program was implemented at Nemours, it seems to have worked.
“We have had many of these episodes that have been resolved by verbal de-escalation, as opposed to physical restraints or medication,” he says.
His hospital has also made other changes. The facility used to have multiple entrances and exits that were unsecured, and anybody could walk into any unit “with no challenge whatsoever.” Now, everyone entering has to pass hospital personnel. And, to get into a patient unit, visitors have to check in and be issued a photo ID. Also, in response to an incident in 2013, the hospital now has “constables” who are trained and licensed to carry firearms, Dr. Pressel says.
Above all, he notes, is personal safety. If you yourself are hurt, you won’t be able to help anyone else.
“That’s absolutely the first thing that people hear, the last thing that people hear, and it’s repeated over and over again,” he says.
Both Dr. Pressel and LaRose say that even with the drumbeat of high profile incidents, they haven’t heard from colleagues that health professionals are concerned about people losing interest in entering the field or are feeling burned out because of safety concerns. Being prepared is the key, and the level of preparedness varies by facility, LaRose says. The IAHSS provides security and healthcare safety guidelines at iahss.org.
“We recognize that we are in an occupation that tends to be on the receiving end of more aggression and more violence than the average worker,” LaRose says. “Therefore, how proactively does the organization or the institution take that knowledge and provide the tools and the training to the staff?
“What can we do as a team to increase our sense of security and safety and make this a great place to continue your career?”
Tom Collins is a freelance writer in South Florida.
Hospitalists could hardly be faulted for wondering: Am I safe? After all, the inpatient setting can be a tense place, and it’s where hospitalists work day in and day out.
David Pressel, MD, PhD, FHM, a pediatric hospitalist and medical director of inpatient services at Nemours Children’s Health System, which has locations in Delaware, New Jersey, Pennsylvania, and Florida, says it’s no wonder violence can erupt in the hospital setting.
“Violence is an issue in hospitals that is a reflection of our society, unfortunately,” says Dr. Pressel, a member of Team Hospitalist. “And it happens because these are very stressful places where people’s behavior can get outside the norm given the stress of the problems.”
Dr. Pressel, in collaboration with many others, has developed a workplace violence prevention program at Nemours aimed at de-escalating situations to avoid physical violence. The program teaches providers how to respond when something violent does happen. It’s a tiered training regimen that involves more training for those most involved in handling violent situations.
Dr. Pressel is no stranger to violence himself. Although he is a pediatric hospitalist and his patients are younger, some adolescent patients can have the physical presence of adults and pose just as serious a threat. He said that before the training program was put into place about a year ago, an episode of violence every month or two would require a patient to be placed in restraints.
“Staff has been hurt,” he explains. “I’ve been bitten twice by a patient. I have a scar on my arm that will be with me for life from one episode.”
A Slow, Disheartening, Upward Trend
Whether violence in hospitals and medical facilities is really a growing problem—or whether awareness of the issue is simply greater given these recent, high profile incidents—is not entirely known.
But according to the latest figures available from the Bureau of Labor Statistics (BLS), provided by the Occupational Safety and Health Administration (OSHA), violent incidents in hospitals did appear to be on the rise through 2013. The number of hospital assaults rose from 5,030 in 2011 to 5,500 in 2012 to 5,660 in 2013.
The number of assaults rose across all private sector industries over that span, but the percentage of those assaults that occurred in hospitals grew greater during that time—an indication that hospitals might be getting more violent at a faster pace than other workplaces. In 2011, according to BLS data, 21.4% of all assaults in private sector industries occurred in hospitals. That number rose to 21.8% in 2012 and to 22.1% in 2013.
According to the 2014 Healthcare Crime Survey, published by the International Association for Healthcare Security and Safety (IAHSS)—an organization of hospital security officials and administrators—violent crime at U.S. facilities rose from two incidents per 100 beds in 2012 to 2.5 incidents per 100 beds in 2013. That category includes murder, rape, aggravated assault, and robbery.
Assaults rose from 10.7 incidents per 100 beds in 2012 to 11.1 incidents per 100 beds in 2013.
BLS data also show that more injuries in hospitals are due to assaults compared with the private sector overall. In 2011, 2.6% of all private sector injuries were due to assault; in 2012, the number rose to 2.8%; and, in 2013, it was 2.8%. In hospitals in 2011, 8.6% of all injuries resulted from assaults. That percentage rose to 9.5% in 2012 and to 9.8% in 2013.
“BLS data show that nonfatal injuries due to violence are greater in the healthcare/social assistance setting than in other workplaces,” an OSHA spokesperson says. “Assaults represent a serious safety and health hazard within healthcare, and data indicate that hospitals comprise a large percentage of workplace assaults.”
Incident Prevention
Programs aimed at preventing violence can reduce these incidents.
“How well prepared hospital workers are in dealing with violent situations depends on the workplace violence prevention program implemented at a facility,” the OSHA spokesperson says. “Some states have passed legislation that specifically requires workplace violence prevention programs in the healthcare setting.”
These programs should address management commitment and employee participation, worksite analysis, hazard prevention and control, safety and health training, and recordkeeping and program evaluation. These elements should be assessed regularly, with changes made to respond to changing conditions, OSHA says.
A large number of OSHA inspections in the healthcare setting occur because of complaints regarding lack of protections against workplace violence. In 2014, the agency did 35 inspections in response to such complaints; 25 of those were in a healthcare setting, with 12 specifically at hospitals. As a result, five citations were issued, all of which were in healthcare, including two at hospitals.
Last year, Brookdale University Hospital and Medical Center in Brooklyn, N.Y., was fined $78,000 after an OSHA inspection found 40 incidents of workplace violence between Feb. 7 and April 12. They included employees who were threatened or verbally or physically assaulted by patients and visitors or while breaking up fights between patients. In the worst attack, a nurse sustained severe brain injuries.
The bulk of the hospital’s fines came as a result of a willful violation—an intentional or voluntary disregard for laws meant to protect workers against hospital violence.
While data from IAHSS and the BLS show an increase in hospital violence, those national figures aren’t as important as what is happening at your own facility, says David LaRose, MS, CHPA, CPP, the president of IAHSS and director of safety, security, and emergency management at Lakeland Regional Medical Center in Florida.
“You have to do a vulnerability assessment, and you specifically have to look at your demographic,” he says. “You specifically have to look at what is the history and the culture of the facility” to determine a hospital’s specific risk factors.
Although it’s crucial that a hospital track its own statistics on violence, that’s not to say that incidents elsewhere are irrelevant.
“You also want to look at what’s happening in the real world,” he says. “Somebody else’s unfortunate (occurrence) is a learning experience for my system, so we can try to be proactively preventing that.”
Educate, Recognize, React
At Nemours, Dr. Pressel didn’t develop the training in response to a perceived rise in incidents there. It was apparent, he says, that deficiencies in readiness needed to be addressed.
In the Nemours program, every staff member with some level of patient care responsibility gets basic training in aggressive child emergencies: identifying these situations, responding appropriately, and keeping safe. This group includes doctors, nurses, and nurse’s aids. The training involves actually playing out scenarios of violence, with staff members attempting to subdue a would-be attacker.
Depending on the job, each worker receives extra training that is specific to the role he or she would play in handling violent scenarios.
The training is designed to help individuals respond to such situations with “the same alacrity and acuity as they would respond to a Code Blue,” Dr. Pressel says. “Drop what you’re doing and run. These events are dangerous. That’s what they teach people. They’re dangerous and they’re scary and they’re chaotic, just like a Code Blue. That’s how people need to treat it.”
The goal is to de-escalate a situation, verbally or physically, without more aggressive means. But if that doesn’t work, physical restraints, medication, or both are used.
Throughout the medical field, training in this area is scarce, Dr. Pressel says. In nursing school and medical school, “for the most part, it’s zero,” he says.
“If you’re in a psychiatric facility, these events happen,” he adds. “And then you get a lot of enhanced training.” But, he notes, “I had no formal training until I became tasked with dealing with this.”
Since the program was implemented at Nemours, it seems to have worked.
“We have had many of these episodes that have been resolved by verbal de-escalation, as opposed to physical restraints or medication,” he says.
His hospital has also made other changes. The facility used to have multiple entrances and exits that were unsecured, and anybody could walk into any unit “with no challenge whatsoever.” Now, everyone entering has to pass hospital personnel. And, to get into a patient unit, visitors have to check in and be issued a photo ID. Also, in response to an incident in 2013, the hospital now has “constables” who are trained and licensed to carry firearms, Dr. Pressel says.
Above all, he notes, is personal safety. If you yourself are hurt, you won’t be able to help anyone else.
“That’s absolutely the first thing that people hear, the last thing that people hear, and it’s repeated over and over again,” he says.
Both Dr. Pressel and LaRose say that even with the drumbeat of high profile incidents, they haven’t heard from colleagues that health professionals are concerned about people losing interest in entering the field or are feeling burned out because of safety concerns. Being prepared is the key, and the level of preparedness varies by facility, LaRose says. The IAHSS provides security and healthcare safety guidelines at iahss.org.
“We recognize that we are in an occupation that tends to be on the receiving end of more aggression and more violence than the average worker,” LaRose says. “Therefore, how proactively does the organization or the institution take that knowledge and provide the tools and the training to the staff?
“What can we do as a team to increase our sense of security and safety and make this a great place to continue your career?”
Tom Collins is a freelance writer in South Florida.
