2. General Consideration about Safety in
Emergency Department
Montinee Sangtian, MD
Emergency Physician
Rajavithi Hospital

3. Common safety and health topics:
Emergency Department (ED) Module
http://www.osha.gov

4. Workplace Violence Facts
 70% of all workplace violence incidents do not get
reported.
 2637 nonfatal assaults on hospital workers (1999)
(8.3 assaults per 10,000 workers)
• Government employees have a higher rate of
violence than private sector employees
• Women are over 8 times more likely to be
victims of Workplace Violence than men
National Institute for Occupational Safety and Health : Violence: Occupational Hazards in Hospitals

5. The highest frequency of violent attacks
emergency department
psychiatric ward
waiting rooms
geriatric units.

6. Violent in ED
 A 1988, 127 U.S. teaching hospitals ( > 40,000 visits/yr)
• 32% reported at least one verbal threat daily
• 18% reported at least one threat with a weapon daily
• 25% reported restraining at least one patient daily
• 7% had experienced a violent death in the ED.
• 80% had a staff member injured by violence.
Lavoie FW, Carter GL, Danzl DF, Berg RL: Emergency department violence in United States teaching hospital.
Ann Emerg Med1988;17:1227

7. ER : Potential Hazard

8. Are your ED at risk?
• emergency department > 50,000 per year
• and an average waiting time>2 hours
• were significantly associated with increased
incidence of violence.

9. Resident Life
 1994 , 461 emergency medicine residents
 62% were concerned about their personal
safety while working in the emergency
department
 50% thought that security measures in their
hospitals were inadequate.
 1999, survey of psychiatry residents
 36% had been physically assaulted in
residency.

11. Well, we work in the high risk area of violent.
How should we prepare for the situation…..???

13. Ummm…………
 However, only 40% of hospitals surveyed
provided formal nursing education on violent.
 The survey found that 24- hour security was in
place at only 23% of emergency departments.

14. Security in Emergency Department

15. PREPARING THE EMERGENCY DEPARTMENT
TO PREVENT VIOLENCE
 Only 21.4% control access to the emergency
department during high-risk hours

16. War or ED ?
 Weapons carriage in ED : 4% to 8%
 5.4 weapons a day using a metal detector.
 26.7% of major trauma patients were armed with
lethal weapons.
Ordog GJ: Weapons carriage among major trauma victims in the emergency department.
Acad Emerg Med1995;2:109

17. Should assume :
all violent patients are armed (until proved)
especially those presenting with major trauma.
Ordog GJ: Weapons carriage among major trauma victims in the emergency department.
Acad Emerg Med1995;2:109

18. What is EP’s role in violent?
Emergency physician should…
 control the patient and the situation
 diagnose and treat reversible causes of violence
 protect the patient and staff from harm
 Scene Safety
 Preservation of Evidence and Documentation
 Reporting
 Duty to warn Third Parties

19. ECombative patients : Organic or Functional ?

20. FIND ME

21. Predictors of Violence Patients
Positive Predictor Not Reliable
 Male  Ethnicity
 Prior history of  Diagnosis
violence.  Age
 Drug or Alcohol abuse  Marital status
 Education

22. PREPARING THE EMERGENCY DEPARTMENT
TO PREVENT VIOLENCE

24. PREPARING THE EMERGENCY DEPARTMENT
TO PREVENT VIOLENCE
 Security Personnel
 Patient Searches (Early recognition)
 Alarm Systems (Direct to local police)
 Limited Access to the Emergency Department
 Controlling flow into the emergency department
 Use of a Designated Room
 Prevention

25. Prevention
• To control the factors in the
Primary environment that encourage the
development of frustration and
Prevention aggression.
Secondary • involves response to pre-violent
agitation and aggression.
Prevention
Tertiary • To limitation of the actual act of
violence itself once it has occurred
Prevention

26. Prevention : Primary prevention
 To control the factors in the environment that
encourage the development of frustration and
aggression.
 Attempts to shorten waiting times .
 Pleasant waiting room environment.
 The presence of surveillance cameras and a visible
security force also act as deterrents (although their
implementation is a form of tertiary prevention).

27. Secondary prevention
 involves response to pre-violent agitation and
aggression.
• Early recognition of high-risk patients
• Managing Aggression
• Communication
• Non-verbal communication
• Defusion strategies
• De-escalation techniques and skills

28. De-escalation Technique
1. Simple Listening
2. Active Listening
3. Acknowledgement
4. Allow Silence
5. Agreeing
6. Apologizing
7. Inviting Criticism
8. Develop a Plan
WHEN NOTHING WORKS : Explain what will happen next if
the angry person does not follow the instruction you offer.

29. • Give clear, brief, assertive instructions
• Explain your purpose or intention
• Negotiate options
• Avoid threats
• Move towards a “safer place” (i.e. avoid being trapped in a
corner)
• Ensure your non-verbal communication is non-threatening
• Allow greater body space than normal
• Appear calm, self controlled, and confident without being
dismissive or over-bearing

30. • De-escalation is a very difficult and humbling skill.
• You cannot be unsure of your own pride or self-esteem.
• You must be able to control your own anger.
• You must be able to see the bigger picture.
• You must be willing to practice what you’ve learned.

31. NEVER THREATEN
unless you are prepared to take the next step !
Once you have made a threat, or given an ultimatum,
you have ceased all Negotiations and put yourself in
a potential win-lose situation.

32. Tertiary prevention
 To limitation of the actual act of violence itself once
it has occurred.
 Physical and chemical restraints are used, and
security and police intervention are often needed.
 Emergency department protocols.
 Security measures.

33. Restrain and Seclusion
The Joint Commission on Accreditation of Health Care Organizations (JCAHO)
1. The implementation of restraint or seclusion is limited to
emergencies where imminent risk of harm exists to
patient or others.
2. Staff is trained and competent to apply restraint safely.
3. Staff is trained to minimize the use of restraint.
4. Patients in restraints are regularly evaluated and
monitored.
5. Orders for restraint use are provided by licensed
practitioners and are time limited.
6. Medical records document that the use of restraint or
seclusion is consistent with organizational policy.

34. American College of Emergency Physicians. Emergency physicians’ patient care
responsibilities outside of the emergency department [policy statement];
Approved September 1999. Ann Emerg Med 2000;35:209

35. The violent patient suffered as well !
 13% of hospitals reporting injuring patients
while restraining them, including one
strangulation death.
 Litigation was pending in 16% of surveyed
emergency departments because of restraint
of patients.

36. Prevention Strategies that Work
• Metal Detectors installed in a Detroit Hospital
prevented the entry of 33 handguns, 1,324 knives,
and 97 macetype sprays in 6 months
• A system of restricting movement of visitors in a
NYC hospital using identification badges and passes
limiting visitors reduced violent crime by
65% in 18 months

37. KEY CONCEPTS
 Emergency department staff should be trained to
recognize the early signs of impending violent behavior
and to implement appropriate de escalating techniques.
 Every emergency department should have a formal plan of
action to deal with violent patients.
 Violent patients should be evaluated for possible medical
and psychiatric conditions
An ounce of prevention is worth a pound of cure.

38. References and Further Reading
• ACEP Policy Statement : 2009 Policy Compendium
• Joint commission on accreditation of healthcare organization
(JCAHO) Standard 2009
• Rosen’s emergency medicine, 6th ed, ch.189
• Emergency Psychiatry: Principles and Practice, By Rachel
Lipson Glick, Jon S Berlin, Avrim Fishkind
• Managing violent and aggression : a manual for nurses and
health care workers, Tom Mason, Mark Chandley
• Security in the Health Care Environment. By David H. Sells,
Jr.; published by Aspen Publishers, Inc.
• Guidelines for Preventing Workplace Violence for Health Care &
Social Service Work : www.ohca.gov
• www.crisisprevention.com

39. Case Studies

54. Deadly shootings at US army base
Major Nidal Malik Hasan,
Psychiatrist
A US Army major has opened fire on fellow soldiers at the Fort Hood
military base in Texas, killing 13 people and injuring 30, officials say.
http://news.bbc.co.uk/2/hi/americas/8345713.stm