(*)Tracy G. Sanson, MD, FACEP
Emergency Department Directors
Academy – Phase II
May 19-23, 2014
Dallas, TX
Breakout Session II:
ED Safety and Security
Hospital and ED safety and security are critical to our
physical and emotional well-being. “The 24-hour
accessibility of the ED, the lack of adequately trained,
armed or visible security guards, and an overall stressful
environment are among the reasons the ED setting is
vulnerable to violence.” A one year survey of emergency
physicians reported verbal threats (75%), physical
assaults (28%). In another study, 82% of emergency
nurses reported being physically assaulted at work in the
preceding year.
Objectives:
 Define the scope of the problem.
 Institute a process to review safety and security
risks.
 Develop reporting methods for all safety and
security breaches.
 List technology and personnel solutions.
 Describe staff training.
5/20/14
3:30 PM - 5:00 PM
Course Number: TU-10
Trinity Ballroom 4-8
(*)Salary: TeamHealth, EmCare
Dr. Sanson is Associate Professor at the University of
South Florida, Education Director for their Emergency
Medicine Residency. She is Director of USF’s
Division of Global Emergency Medical Sciences and
Co-Chief Editor of their Journal of Emergencies,
Trauma and Shock; an on line Emergency Medicine
international journal. A frequent speaker for
Emergency Medicine programs, Dr. Sanson also
serves as a core faculty member for the American
College of Emergency Physicians and received
ACEP’s National Emergency Medicine Faculty
Teaching Award in 2006. Dr. Sanson has consulted
and lectured nationally and internationally on
administrative and management issues, leadership,
professionalism, communication, patient safety, brand
development, personal development, women’s issues
and emergency medical clinical topics for a wide
range of health care organizations.
Dr. Sanson’s experience spans 20 years in Emergency
Medicine Education and ED management and
leadership development. She has held director
positions in the US Air Force, University of South
Florida and TeamHealth for the past 15 + years. Dr.
Sanson trained at the University of Illinois @ Chicago
for medical school and her emergency medicine
residency. She is well versed in leadership, patient
safety and medical management issues serving on
TeamHealth’s Medical Advisory Board, Patient Safety
Office Division Director and faculty in their
Leadership Courses.
Dr. Sanson and her husband fellow EM leader and
educator Dr. Kelly O’Keefe home educate their three
daughters, frequently coordinating their educational
efforts, both nationally and internationally, to travel
and explore as a family.
Emergency Department Security and Safety Tracy G. Sanson, MD, FACEP 1 Emergency Department Security and Safety 
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Tracy G. Sanson, MD, FACEP Define the scope of the problem. Institute a process to review safety and security risks. Develop reporting methods for all safety and security breaches. List technology and personnel solutions. Describe staff training. DETECT, DEFUSE, PROTECT Violence is a public health problem of epidemic proportion. The danger to health care providers in professional settings escalates as violence moves off the streets and into the medical setting. Violence is not an inescapable part of our lives. The reduction of violence in our offices, clinics, and hospitals requires that we make violence personally and culturally intolerable. Optimal patient care is achieved only when patients, visitors, and health‐care workers are protected against violent acts occurring within the health‐care setting. A safe working environment is conducive to improved staff morale, and enhanced productivity. Medical personnel must develop strategies to prevent victimization. Preventive measures include the control of environmental factors that may provoke those with violent tendencies and graded management options including verbal or psychological intervention, show of force, and physical and/or chemical restraints. The key to violence reduction is the early recognition of potential violence by a calm and prepared health care provider. Occupational health and safety laws say employees must be provided with a safe working environment and safe systems of work. “General Duty Clause” of the Occupational Safety and Health Act requires employers to have a workplace that is “free from recognized hazards.” ENA (Emergency Nurses Association) Position Statement states, “Health care organizations have a responsibility to provide a safe and secure environment for their employees and the public. Emergency nurses have the right to take appropriate measures to protect themselves and their patients from injury due to violent individuals.” Employers should prepare a plan to identify, assess, and control potentially threatening or violent situations and incidents at work. The management plan should include procedures to cope with and defuse potentially violent situations, alert co‐workers, call police and provide personal protection, personal alarms, or self‐defense training. JCAHO EC.1.10 Hospitals must manage safety risks; EC 1.20 Hospitals must maintain safe environments Effective January 1, 2009 for all accreditation programs, The Joint Commission has a new Leadership standard (LD.03.01.01) that addresses disruptive and inappropriate behaviors in two of its elements of performance: EP 4: The hospital/organization has a code of conduct that defines acceptable and disruptive and inappropriate behaviors. EP 5: Leaders create and implement a process for managing disruptive and inappropriate behaviors. Emergency Department Security and Safety Tracy G. Sanson, MD, FACEP 2 OSHA Guideline Preventing Workplace Violence in Healthcare and Social Service Settings, General Duty Clause 5A‐1‐ Employers must furnish a place of employment free from recognized hazards Extent of the problem Workplace violence Leading cause of occupational death for women Third leading cause of death for all workers October 2006 survey conducted by Emergency Nurses Association found that 86% of respondents indicated that they were victims of workplace violence in the previous three years. The results of an Emergency Nurses Association survey released in 2009 found that more than 50% of ED nurses had experienced violence by patients on the job and more than 25% had experienced 20 or more violent incidents in the past three years. Research showed long wait times, a shortage of nurses, drug and alcohol use by patients, and treatment of psychiatric patients all contributed to violence in the ED. Per New Jersey press release for Senator Girgenit Bill upgrading penalties for assaulting healthcare workers  According to the U.S. Department of Justice, more than 400,000 nurses and healthcare professionals are victims of violent crimes in the workplace each year.  Twenty‐five percent of nurses list physical assault as their top safety concern on the job, according to the American Nurses Association.  Assaults on nurses are classified as a felony in the New York, and other healthcare workers were added to that existing statute in January.  Similar laws also have been enacted in Alabama, Arizona, Illinois, Nevada and New Mexico. Reprinted with permission from Massachusetts Nurses Association  Workplace violence affects an estimated 1.7 million U.S. employees directly and millions more indirectly each year  Forty‐eight percent of all non‐fatal assaults in the U.S. workplace are committed by health care patients  Nurses and other personal care workers are at the highest risk. Health care workers suffer violent assaults at a rate 4 times higher than other industries; for nurses and other personal care workers, this rate jumps to 12 times higher than other industries.  In a 2004 survey of Massachusetts nurses, 50 percent indicated they had been punched at least once in the last two years; 44% reported frequent threats of abuse (9 or more times in the last two years); and 25‐ 30% were regularly or frequently pinched, scratched, spit on or had their hand or wrist twisted. The majority of acts were inflicted by patients; and furniture, pencils, pens, and medical equipment, and even hypodermic needles were most often used as weapons  Over half of those reporting said they later had difficulty concentrating on their job. Only 40% of the nurses had reported the incidents to management  Physicians are also at risk. In one study of Emergency physicians, 75% said they had been threatened in the last year, 28% had experienced at least one assault, and 18% had obtained a gun to protect themselves. Twelve percent were confronted outside of the Emergency Department Security and Safety Tracy G. Sanson, MD, FACEP 3 emergency room, and 4% had experienced a stalking event. Only 33% had security personnel permanently assigned to the department. From OSHA.Gov “Injury rates also reveal that health care and social service workers are at high risk of violent assault at work. BLS rates measure the number of events per 10,000 full‐time workers—in this case, assaults resulting in injury. In 2000, health service workers overall had an incidence rate of 9.3 for injuries resulting from assaults and violent acts. The rate for social service workers was 15, and for nursing and personal care facility workers, 25. This compares to an overall private sector injury rate of 2.  The average annual rate for non‐fatal violent crime for all occupations is 12.6 per 1,000 workers  The average annual rate for physicians is 16.2  For nurses, 21.9  For mental health professionals, 68.2  For mental health custodial workers, 69 (Note: These data do not compare directly to the BLS figures because DOJ presents violent incidents per 1,000 workers and BLS displays injuries involving days away from work per 10,000 workers. Both sources, however, reveal the same high risk for health care and social service workers.) As significant as these numbers are, the actual number of incidents is probably much higher. Incidents of violence are likely to be underreported, perhaps due in part to the persistent perception within the health care industry that assaults are part of the job. Underreporting may reflect a lack of institutional reporting policies, employee beliefs that reporting will not benefit them or employee fears that employers may deem assaults the result of employee negligence or poor job performance.” Impediments to quantifying the full extent and magnitude of workplace violence It is estimated that less than 25% of ED violence is reported. Lack of a uniform definition of violence or the severity of the incident Aggressive Violent Abusive Dangerous Disruptive Destructive Threatening Rude  We have a high threshold for reporting incident and a reluctance to notify police and file charges Our perceived professional responsibility to the patient overrides our feelings about the abusive incident  Denial: Emergency Department Security and Safety Tracy G. Sanson, MD, FACEP 4 " I try not to dwell on it. It won't happen again." " It really wasn't that bad, I'm OK."  Rationalization: " He was ill/upset/drunk...." Personal safety questions for your employer Is there adequate security coverage? Does the ED treatment area and hospital have secured exterior doors? Are security assessments done to determine risks and vulnerabilities? Are there training opportunities for the staff? Is the staff educated and equipped to deal with violent or disruptive behavior? Does the administration support an aggressive stance against violence? Costs: Police involvement Medical evaluations Physical and psychological therapy Temporary hires Employee assistance programs Loss of security Loss of personnel Loss of productivity Decrease in morale From Emergency Nurses Association What are the specific factors that may promote violence in the emergency department? The emergency department has a number of additional risk factors due to the type of services provide and the overall stressful environment that describes these care settings. Those factors include:  24‐hour accessibility of the emergency department  Lack of adequately trained, armed, or visible security guards  Patient pain and discomfort  Family member stress due to patient’s condition and fear of the unknown  Family member anger related to hospital policies and the health care system in general  Cramped space  Long wait times Definitions: Assaulted nurse: (From Massachusetts Nurses Associations Workplace Violence) One who is reasonably put in fear of being actually or potentially physically harmed while at work from a patient, co‐worker, or visitor. This includes menacing gesture. Battered nurse: One who experiences actual physical contact from another (whether or not a physical injury occurred.) Physical Assaults: Emergency Department Security and Safety Tracy G. Sanson, MD, FACEP 5 Violent acts of unwanted physical contact towards others. This includes slapping, pushing, kicking, punching, biting, scratching, deliberately throwing an object at a staff member, drawing a potential or actual weapon on a nurse. Sexual Assaults: Unwanted sexual acts toward a nurse. This includes unwanted embraces, touching, exposures, or rape. Verbal or non‐verbal Intimidation: Verbal includes conversation, written, email, or voice mail communication that is meant to threaten, slur, harass or frighten. Non‐verbal includes acts meant to frighten or threaten a nurse such as throwing an object at a wall, pounding walls or doors, stalking, tampering with data systems, stealing, etc. Workplace violence falls into four broad categories. TYPE 1: Violent acts by criminals who have no other connection with the workplace, but enter to commit robbery or another crime. ~80 percent of workplace homicides Motive is usually theft In many cases the criminal is carrying a gun or other weapon, increasing the likelihood that the victim will be killed or seriously wounded Preventive strategies include an emphasis on physical security measures, special employer policies, and employee training TYPE 2: Violence directed at employees by customers, clients, patients, students, inmates, or any others for whom an organization provides services Violent acts occur as workers are performing their normal tasks. Highest rate in healthcare occupations Nurses in particular TYPE 3: Violence against coworkers, supervisors, or managers by a present or former employee TYPE 4: Violence committed in the workplace by someone who doesn’t work there, but has a personal relationship with an employee—an abusive spouse or domestic partner When the violence comes from an employee or someone close to an employee Greater chance there was/ were warning sign(s) That knowledge, along with the appropriate prevention programs, may help prevent or lessen violent episodes An article by the American Bar Association Commission on Domestic Violence suggests the following to help monitor employees for signs of Intimate Partner Violence The Following Observable Behavior May Suggest Possible Victimization  Tardiness or unexplained absences Emergency Department Security and Safety 
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Tracy G. Sanson, MD, FACEP 6 Frequent‐and often unplanned‐use of leave time Anxiety Lack of concentration Change in job performance A tendency to remain isolated from coworkers or reluctance to participate in social events Discomfort when communicating with others Disruptive phone calls or e‐mail Sudden or unexplained requests to be moved from public locations in the workplace, such as sales or reception areas  Frequent financial problems indicating lack of access to money  Unexplained bruises or injuries  Noticeable change in use of makeup (to cover up injuries)  Inappropriate clothes (e.g., sunglasses worn inside the building, turtleneck worn in the summer)  Disruptive visits from current or former intimate partner  Sudden changes of address or reluctance to divulge where she is staying  Acting uncharacteristically moody, depressed, or distracted  In the process of ending an intimate relationship; breakup seems to cause the employee undue anxiety  Court appearances  Being the victim of vandalism or threats Intimate partner violence all too often follows the employee into work. Security measures must be taken to protect both the employee and fellow staff members. OSHA.Gov lists the following risk factors for Health care and social service workers for work related assaults. These include:  The prevalence of handguns and other weapons among patients, their families or friends  The increasing use of hospitals by police and the criminal justice system for criminal holds and the care of acutely disturbed, violent individuals  The increasing number of acute and chronic mentally ill patients being released from hospitals without follow‐up care (these patients have the right to refuse medicine and can no longer be hospitalized involuntarily unless they pose an immediate threat to themselves or others)  The availability of drugs or money at hospitals, clinics and pharmacies, making them likely robbery targets  Factors such as the unrestricted movement of the public in clinics and hospitals and long waits in emergency or clinic areas that lead to client frustration over an inability to obtain needed services promptly  The increasing presence of gang members, drug or alcohol abusers, trauma patients or distraught family members  Low staffing levels during times of increased activity such as mealtimes, visiting times and when staff are transporting patients  Isolated work with clients during examinations or treatment  Solo work, often in remote locations with no backup or way to get assistance, such as communication devices or alarm systems (this is particularly true in high‐crime settings);  Lack of staff training in recognizing and managing escalating hostile and assaultive behavior Emergency Department Security and Safety 
Tracy G. Sanson, MD, FACEP 7 Poorly lit parking areas http://www.osha.gov/Publications/OSHA3148/osha3148.html Guidelines for Preventing Workplace Violence for Health Care & Social Service Workers Violence Prevention Programs At a minimum, workplace violence prevention programs should:  Create and disseminate a clear policy of zero tolerance for workplace violence, verbal and nonverbal threats and related actions. Ensure that managers, supervisors, coworkers, clients, patients and visitors know about this policy  Ensure that no employee who reports or experiences workplace violence faces reprisals  Encourage employees to promptly report incidents and suggest ways to reduce or eliminate risks. Require records of incidents to assess risk and measure progress  Outline a comprehensive plan for maintaining security in the workplace. This includes establishing a liaison with law enforcement representatives and others who can help identify ways to prevent and mitigate workplace violence  Assign responsibility and authority for the program to individuals or teams with appropriate training and skills. Ensure that adequate resources are available for this effort and that the team or responsible individuals develop expertise on workplace violence prevention in health care and social services  Affirm management commitment to a worker‐supportive environment that places as much importance on employee safety and health as on serving the patient or client  Set up a company briefing as part of the initial effort to address issues such as preserving safety, supporting affected employees and facilitating recovery OSHA and Massachusetts Nurses Association identifies the following key components of a Workplace Violence Prevention Program: 1) Management commitment and employee involvement 2) Worksite hazard analysis 3) Hazard prevention and control 4) Safety and health training for workers, managers and supervisors including where and how to report injuries 5) Post incident debriefing activities including appropriate evaluation and treatment of all workers affected by an incident of violence 6) Accurate recordkeeping 7) Policies that address harassment and bullying 8) Methods for detection, confiscation and control of firearms and weapons from anyone (other than law enforcement officers) who enter the facility 9) Security guards trained according to national standards The five main components of any effective safety and health program also apply to the prevention of workplace violence: * Management commitment and employee involvement * Worksite analysis * Hazard prevention and control Emergency Department Security and Safety Tracy G. Sanson, MD, FACEP 8 * Safety and health training * Recordkeeping and program evaluation Management Commitment and Employee Involvement Management commitment, including the endorsement and visible involvement of top management, provides the motivation and resources to deal effectively with workplace violence. This commitment should include:  Demonstrating organizational concern for employee emotional and physical safety and health  Exhibiting equal commitment to the safety and health of workers and patients/clients  Assigning responsibility for the various aspects of the workplace violence prevention program to ensure that all managers, supervisors and employees understand their obligations  Allocating appropriate authority and resources to all responsible parties  Maintaining a system of accountability for involved managers, supervisors and employees  Establishing a comprehensive program of medical and psychological counseling and debriefing for employees experiencing or witnessing assaults and other violent incident  Supporting and implementing appropriate recommendations from safety and health committees Employee involvement and feedback enable workers to develop and express their own commitment to safety and health and provide useful information to design, implement and evaluate the program. Employee involvement should include:  Understanding and complying with the workplace violence prevention program and other safety and security measures  Participating in employee complaint or suggestion procedures covering safety and security concerns  Reporting violent incidents promptly and accurately  Participating in safety and health committees or teams that receive reports of violent incidents or security problems, make facility inspections and respond with recommendations for corrective strategies  Taking part in a continuing education program that covers techniques to recognize escalating agitation, assaultive behavior or criminal intent and discusses appropriate responses Worksite Analysis A worksite analysis involves a step‐by‐step, commonsense look at the workplace to find existing or potential hazards for workplace violence. This entails reviewing specific procedures or operations that contribute to hazards and specific areas where hazards may develop. A team evaluates the vulnerability to workplace violence and determines the appropriate preventive actions to be taken. The team or coordinator can review injury and illness records and workers' compensation claims to identify patterns of assaults that could be prevented by workplace adaptation, procedural changes or employee training. As the team or coordinator identifies appropriate controls, they should be instituted. The recommended program for worksite analysis includes, but is not limited to: Emergency Department Security and Safety Tracy G. Sanson, MD, FACEP 9  Analyzing and tracking records  Screening surveys  Analyzing workplace security One important screening tool is an employee questionnaire or survey to get employees' ideas on the potential for violent incidents and to identify or confirm the need for improved security measures. The team or coordinator should periodically inspect the workplace and evaluate employee tasks to identify hazards, conditions, operations and situations that could lead to violence. To find areas requiring further evaluation, the team or coordinator should:  Analyze incidents, including the characteristics of assailants and victims, an account of what happened before and during the incident, and the relevant details of the situation and its outcome. When possible, obtain police reports and recommendations.  Identify jobs or locations with the greatest risk of violence as well as processes and procedures that put employees at risk of assault, including how often and when.  Note high‐risk factors such as types of clients or patients (for example, those with psychiatric conditions or who are disoriented by drugs, alcohol or stress); physical risk factors related to building layout or design; isolated locations and job activities; lighting problems; lack of phones and other communication devices; areas of easy, unsecured access; and areas with previous security problems.  Evaluate the effectiveness of existing security measures, including engineering controls. Determine if risk factors have been reduced or eliminated and take appropriate action. Hazard Prevention and Control After hazards are identified through the systematic worksite analysis, the next step is to design measures through engineering or administrative and work practices to prevent or control these hazards. If violence does occur, post‐incident response can be an important tool in preventing future incidents. Engineering controls and workplace adaptations to minimize risk Engineering controls remove the hazard from the workplace or create a barrier between the worker and the hazard. There are several measures that can effectively prevent or control workplace hazards, such as those described in the following paragraphs. The selection of any measure, of course, should be based on the hazards identified in the workplace security analysis of each facility. Among other options, employers may choose to:  Assess any plans for new construction or physical changes to the facility or workplace to eliminate or reduce security hazards.  Install and regularly maintain alarm systems and other security devices, panic buttons, hand‐held alarms or noise devices, cellular phones and private channel radios where risk is apparent or may be anticipated. Arrange for a reliable response system when an alarm is triggered. Emergency Department Security and Safety 
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Tracy G. Sanson, MD, FACEP 10 Provide metal detectors—installed or hand‐held, where appropriate—to detect guns, knives or other weapons, according to the recommendations of security consultants. Use a closed‐circuit video recording for high‐risk areas on a 24‐hour basis. Public safety is a greater concern than privacy in these situations. Place curved mirrors at hallway intersections or concealed areas. Enclose nurses' stations and install deep service counters or bullet‐resistant, shatter‐proof glass in reception, triage and admitting areas or client service rooms. Provide employee "safe rooms" for use during emergencies. Establish "time‐out" or seclusion areas with high ceilings without grids for patients who "act out" and establish separate rooms for criminal patients. Provide comfortable client or patient waiting rooms designed to minimize stress. Ensure that counseling or patient care rooms have two exits. Lock doors to staff counseling rooms and treatment rooms to limit access. Arrange furniture to prevent entrapment of staff. Use minimal furniture in interview rooms or crisis treatment areas and ensure that it is lightweight, without sharp corners or edges and affixed to the floor, if possible. Limit the number of pictures, vases, ashtrays or other items that can be used as weapons. Provide lockable and secure bathrooms for staff members separate from patient/client and visitor facilities. Lock all unused doors to limit access, in accordance with local fire codes. Install bright, effective lighting, both indoors and outdoors. Replace burned‐out lights and broken windows and locks. Keep automobiles well maintained if they are used in the field. Lock automobiles at all times. Administrative and work practice controls affect the way staff perform jobs or tasks. Changes in work practices and administrative procedures can help prevent violent incidents. Some options for employers are to:  State clearly to patients, clients and employees that violence is not permitted or tolerated.  Establish liaison with local police and state prosecutors. Report all incidents of violence. Give police physical layouts of facilities to expedite investigations.  Require employees to report all assaults or threats to a supervisor or manager (for example, through a confidential interview). Keep log books and reports of such incidents to help determine any necessary actions to prevent recurrences.  Advise employees of company procedures for requesting police assistance or filing charges when assaulted and help them do so, if necessary.  Provide management support during emergencies. Respond promptly to all complaints.  Set up a trained response team to respond to emergencies.  Use properly trained security officers to deal with aggressive behavior. Follow written security procedures.  Ensure that adequate and properly trained staff are available to restrain patients or clients, if necessary.  Provide sensitive and timely information to people waiting in line or in waiting rooms. Adopt measures to decrease waiting time.  Ensure that adequate and qualified staff are available at all times. The times of greatest risk occur during patient transfers, emergency responses, mealtimes and at night. Areas with the greatest risk include admission units and crisis or acute care units. Emergency Department Security and Safety 
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Tracy G. Sanson, MD, FACEP 11 Institute a sign‐in procedure with passes for visitors, especially in a newborn nursery or pediatric department. Enforce visitor hours and procedures. Establish a list of "restricted visitors" for patients with a history of violence or gang activity. Make copies available at security checkpoints, nurses' stations and visitor sign‐in areas. Review and revise visitor check systems, when necessary. Limit information given to outsiders about hospitalized victims of violence. Supervise the movement of psychiatric clients and patients throughout the facility. Control access to facilities other than waiting rooms, particularly drug storage or pharmacy areas. Prohibit employees from working alone in emergency areas or walk‐in clinics, particularly at night or when assistance is unavailable. Do not allow employees to enter seclusion rooms alone. Establish policies and procedures for secured areas and emergency evacuations. Determine the behavioral history of new and transferred patients to learn about any past violent or assaultive behaviors. Establish a system—such as chart tags, log books or verbal census reports—to identify patients and clients with assaultive behavior problems. Keep in mind patient confidentiality and worker safety issues. Update as needed. Treat and interview aggressive or agitated clients in relatively open areas that still maintain privacy and confidentiality (such as rooms with removable partitions). Use case management conferences with coworkers and supervisors to discuss ways to effectively treat potentially violent patients. Prepare contingency plans to treat clients who are "acting out" or making verbal or physical attacks or threats. Consider using certified employee assistance professionals or in‐house social service or occupational health service staff to help diffuse patient or client anger. Transfer assaultive clients to acute care units, criminal units or other more restrictive settings. Ensure that nurses and physicians are not alone when performing intimate physical examinations of patients. Discourage employees from wearing necklaces or chains to help prevent possible strangulation in confrontational situations. Urge community workers to carry only required identification and money. Survey the facility periodically to remove tools or possessions left by visitors or maintenance staff that could be used inappropriately by patients. Provide staff with identification badges, preferably without last names, to readily verify employment. Discourage employees from carrying keys, pens or other items that could be used as weapons. Provide staff members with security escorts to parking areas in evening or late hours. Ensure that parking areas are highly visible, well lit and safely accessible to the building. Use the "buddy system," especially when personal safety may be threatened. Encourage home health care providers, social service workers and others to avoid threatening situations. Advise staff to exercise extra care in elevators, stairwells and unfamiliar residences; leave the premises immediately if there is a hazardous situation; or request police escort if needed. Emergency Department Security and Safety 
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Tracy G. Sanson, MD, FACEP 12 Develop policies and procedures covering home health care providers, such as contracts on how visits will be conducted, the presence of others in the home during the visits and the refusal to provide services in a clearly hazardous situation. Establish a daily work plan for field staff to keep a designated contact person informed about their whereabouts throughout the workday. Have the contact person follow up if an employee does not report in as expected. Employer responses to incidents of violence Post‐incident response and evaluation are essential to an effective violence prevention program. All workplace violence programs should provide comprehensive treatment for employees who are victimized personally or may be traumatized by witnessing a workplace violence incident. Injured staff should receive prompt treatment and psychological evaluation whenever an assault takes place, regardless of its severity. Provide the injured transportation to medical care if it is not available onsite. Victims of workplace violence suffer a variety of consequences in addition to their actual physical injuries. These may include: * Short‐ and long‐term psychological trauma; * Fear of returning to work; * Changes in relationships with coworkers and family; * Feelings of incompetence, guilt, powerlessness; and * Fear of criticism by supervisors or managers. Consequently, a strong follow‐up program for these employees will not only help them to deal with these problems but also help prepare them to confront or prevent future incidents of violence. Safety and Health Training Training and education ensure that all staff are aware of potential security hazards and how to protect themselves and their coworkers through established policies and procedures. Training for all employees Every employee should understand the concept of "universal precautions for violence"— that is, that violence should be expected but can be avoided or mitigated through preparation. Frequent training also can reduce the likelihood of being assaulted. Employees who may face safety and security hazards should receive formal instruction on the specific hazards associated with the unit or job and facility. This includes information on the types of injuries or problems identified in the facility and the methods to control the specific hazards. It also includes instructions to limit physical interventions in workplace altercations whenever possible, unless enough staff or emergency response teams and security personnel are available. In addition, all employees should be trained to behave compassionately toward coworkers when an incident occurs. The training program should involve all employees, including supervisors and managers. Emergency Department Security and Safety Tracy G. Sanson, MD, FACEP 13 New and reassigned employees should receive an initial orientation before being assigned their job duties. Visiting staff, such as physicians, should receive the same training as permanent staff. Qualified trainers should instruct at the comprehension level appropriate for the staff. Effective training programs should involve role playing, simulations and drills. Topics may include management of assaultive behavior, professional assault‐response training, police assault‐avoidance programs or personal safety training such as how to prevent and avoid assaults. A combination of training programs may be used, depending on the severity of the risk. Employees should receive required training annually. In large institutions, refresher programs may be needed more frequently, perhaps monthly or quarterly, to effectively reach and inform all employees. What training should cover The training should cover topics such as:  The workplace violence prevention policy  Risk factors that cause or contribute to assaults  Early recognition of escalating behavior or recognition of warning signs or situations that may lead to assaults  Ways to prevent or diffuse volatile situations or aggressive behavior, manage anger and appropriately use medications as chemical restraints  A standard response action plan for violent situations, including the availability of assistance, response to alarm systems and communication procedures  Ways to deal with hostile people other than patients and clients, such as relatives and visitors  Progressive behavior control methods and safe methods to apply restraints  The location and operation of safety devices such as alarm systems, along with the required maintenance schedules and procedures  Ways to protect oneself and coworkers, including use of the "buddy system"  Policies and procedures for reporting and recordkeeping  Information on multicultural diversity to increase staff sensitivity to racial and ethnic issues and differences  Policies and procedures for obtaining medical care, counseling, workers' compensation or legal assistance after a violent episode or injury Training for supervisors and managers Supervisors and managers need to learn to recognize high‐risk situations, so they can ensure that employees are not placed in assignments that compromise their safety. They also need training to ensure that they encourage employees to report incidents. Supervisors and managers should learn how to reduce security hazards and ensure that employees receive appropriate training. Following training, supervisors and managers should be able to recognize a potentially hazardous situation and to make any necessary changes in the physical Emergency Department Security and Safety Tracy G. Sanson, MD, FACEP 14 plant, patient care treatment program and staffing policy and procedures to reduce or eliminate the hazards. Training for security personnel Security personnel need specific training from the hospital or clinic, including the psychological components of handling aggressive and abusive clients, types of disorders and ways to handle aggression and defuse hostile situations. The training program should also include an evaluation. At least annually, the team or coordinator responsible for the program should review its content, methods and the frequency of training. Program evaluation may involve supervisor and employee interviews, testing and observing and reviewing reports of behavior of individuals in threatening situations. Record keeping and Program Evaluation How employers can determine program effectiveness Recordkeeping and evaluation of the violence prevention program are necessary to determine its overall effectiveness and identify any deficiencies or changes that should be made. Important Records:  OSHA Log of Work‐Related Injury and Illness (OSHA Form 300) Any new work‐related injury that results in: o Death o Days away from work o Days of restriction or job transfer o Medical treatment beyond first aid o Loss of consciousness or a significant injury diagnosed by a licensed health care professional  Medical reports of work injury and supervisors' reports for each recorded assault. These records should describe the type of assault, such as an unprovoked sudden attack or patient‐to patient altercation; who was assaulted; and all other circumstances of the incident. The records should include a description of the environment or location, potential or actual cost, lost work time that resulted and the nature of injuries sustained. These medical records are confidential documents and should be kept in a locked location under the direct responsibility of a health care professional  Records of incidents of abuse, verbal attacks or aggressive behavior that may be threatening, such as pushing or shouting and acts of aggression toward other clients. This may be kept as part of an assaultive incident report. Ensure that the affected department evaluates these records routinely  Information on patients with a history of past violence, drug abuse or criminal activity recorded on the patient's chart. All staff who care for a potentially aggressive, abusive or violent client should be aware of the person's background and history. Log the admission of violent patients to help determine potential risks  Documentation of minutes of safety meetings, records of hazard analyses and corrective actions recommended and taken Emergency Department Security and Safety 
Tracy G. Sanson, MD, FACEP 15 Records of all training programs, attendees and qualifications of trainers Violence Prevention Strategies: Patient interaction Allow a family member to stay with the patient and calm them Limit the visitors (traffic) in the treatment area Screen visitors for trauma patients (avoids the potential for restitution) Institute liaisons between patients and families (improves communication) Interviewing techniques: Honest, straight forward and frank; but not overly friendly Avoid excessive eye contact Avoid entering the patient’s personal space Trust your "gut" feelings; if you feel uncomfortable, reassess the situation Observe the patient for: Tense posture Provocative behavior, staring Angry demeanor or threatening and/or loud speech Tough, intimidating stance Hypervigilance Signs of agitation: Tremors Sweating Pacing Clenching of fists, teeth and hands Pounding walls Throwing furniture Interview setting‐ "Privacy but not isolation" Give yourself unrestricted access to the door and emergency buttons/exits Store or remove supplies/equipment, which could be used as weapons Staff protection Professional training First names only on nametags Increase staff assertiveness and unity Limit access to staff information (phone number, address, schedule) Stop the attitude‐ "it (violence) comes with the territory" Personal measures: Obtain training and education Dress for work: comfortable clothes, low shoes, and safe jewelry Tuck ties in shirt; avoid stethoscopes hanging around your neck Set realistic deadlines for the patient and visitors Don’t divulge personal information Summon security as soon as danger is appreciated Review your institutions policies regarding filing charges against a perpetrator Position yourself carefully Stand about 1.5 meters (4 to 5 feet) in front of the patient but off to the side Do not face him or her directly Emergency Department Security and Safety Tracy G. Sanson, MD, FACEP 16 Close enough to allow you to develop a rapport But far enough away to not threaten personal space and out of reach This is a less provocative and intimidating stance, and Provides a narrower target reducing exposure Don’t turn your back Always approach from the front Learn defusing techniques Maintain personal space Allow some degree of venting Ignore personal affronts Avoid arguing or defending Avoid threatening body language Calmly and firmly set limits Impose your own peace: Tame your emotions by training yourself to stay cool Recognize your own physical cues and remind yourself to stay calm In a situation:  Calmly state, without issuing hostile commands, that violence will not be tolerated  Avoid asking “why” questions: can seem accusatory or challenging  Play the fixer: Ask: “What can I do to help?  “What would make things easier for you?”  Do not ignore threats:  No threat of violence is harmless  Failure to respond may make an angry patient or make him feel that he is not being taken seriously  Set limits  Violent patients may become even more agitated when they sense that others are not in control  Don't look directly into the patient's eyes: this is threatening Focus your eyes on the chin: Perceived as less threatening You can easily see the hands Check your body language Adopt a submissive pose  Arms relaxed and hanging down at the side  Palms open below your waist and facing the person  Shoulders drooping,  Legs relaxed  Remain calm; ensure help is on the way  Back out of the room quickly. Run if you have to!  If there are two of you, run in opposite directions  If necessary lock yourself into a room or run out of the building:  A violent patient is unlikely to hurt other patients; the staff is more at risk Carry a portable phone Emergency Department Security and Safety Tracy G. Sanson, MD, FACEP 17 If attacked:  Maintain your own airway  Tuck your chin: protect your carotids and trachea  Find and use shields  Move quickly  If the situation warrants, use chemical and/or physical restraints  If you have the potential to get hurt, let the patient leave o No Heroics  If the patient has a weapon o Ask the patient to place it on the floor, and then both leave the room o Do not try and retrieve the weapon o Let police disarm patients Most violent and aggressive behavior is criminal in nature Call the police immediately if the patient: * Makes any threats, verbal or physical * Acts destructively (hits the walls, destroys equipment, hits someone) * Is noisy, hyperactive and won't quiet down after one or two requests * Is armed (e.g., gun, knife, broken bottle) Once the situation is under control, differentiate between an organic or functional cause of the violence Departmental policies: Separate patients with minor illnesses from those with major illnesses Institute security, restraints, and strategies‐ before * Injecting Narcan * Attempting any intervention in an escalating patient * Separating a child from an angry, intoxicated, or psychotic parent * Telling an angry psychiatric patient of a hospital transfer  Train staff in the proper use of restraints  Use a minimum of five people to restrain a patient  Undress all psychiatric patients‐ examine clothing and personal items for weapons  Give immediate attention to any agitated patient or visitor  Realize that restraining a patient intent on leaving is not a job for medical staff  Warn all hospital staff, referral physicians, and authorities of a patient’s violence  Notify authorities if a violent patient leaves the hospital  Obtain a psychiatric evaluation on violent patients  Assign the "right" personnel Staff may unknowingly escalate a patient’s agitation Unacceptable: Snappy retorts Intolerance of complaints Ignoring requests for information Failure to recognize physical or verbal signals Overreaction to people or situations Emergency Department Security and Safety Tracy G. Sanson, MD, FACEP 18 Verbal and Physical Interventions: Training programs should stress verbal strategies and non‐abusive physical strategies:  Verbal techniques Show concern and respect Speak in a calm, slow voice empathizing with the patient’s concerns Talking softly is particularly effective when a patient is loud and belligerent Acknowledge their anger and direct it toward an appropriate cause Behave politely, and listen uncritically and actively Remain nonjudgmental Do not attempt to “correct “ the patient’s perception Do not take the person’s anger personally, even when directed at you Tell the patient what you want of him, not what you don’t want Give the patient options (preferably three options), not ultimatums Ex. you may either sit in the chair, lie on the stretcher, or be restrained An offer of food, drink, or medication Reduces the patient's anxiety Demonstrates concern, sharing food is a natural bond between people People aren't as likely to argue if they're eating Avoid hot drinks or potential weapons (eating utensils, plates) Avoid “why” questions They may be perceived as an attack Avoid emotional or judgmental comments Do not make promises you cannot keep  Verbal techniques are rarely effective in an intoxicated, psychotic, delirious or extremely agitated patient  Physical techniques (training in the following) Team restraints Moving, walking and carrying a person Escapes from simple holds: wrist grips, hair pulls, bites. clothes pulls Escapes from life‐threatening attacks: ex. front and back chokes Restraints: Restraints are any physical or pharmacological means used to restrict a patient’s movement, activity or access to their body. Physical Restraints Patients have a right to be free from restraints unless the restraint is necessary to:  Prevent imminent harm to the patient or other persons when other means of control are ineffective or inappropriate  Prevent serious disruption of the medical evaluation and treatment Emergency Department Security and Safety Tracy G. Sanson, MD, FACEP 19  Prevent significant damage to the physical environment  To treat the patient’s medical symptoms The FDA estimates that at least 100 deaths from improper use of restraints may occur annually.  Reports of burns, broken bones, and other injuries related to patient restraints  Many problems with restraint devices are never reported to the FDA Prior to using restraints, consider the following: Risks: Aspiration Skin breakdown or injury Suffocation Rhabdomyolysis Neurovascular compromise and its sequelae  Carefully weigh the benefits against the risks  Consider other alternatives  Use the least restrictive method of restraint  Restraints may never be used for discipline or staff convenience  Obtain a written order which includes: Time limitation Type of restraint Clinical justification of the necessity for restraint Monitoring tool for reassessment, attention to patient needs, neurovascular checks ED personnel may initiate restraints in an emergency situation prior to obtaining the written order, but it must then be obtained within one hour. Effective 2 Aug. 1999: HCFA regulations on patient rights set new guidelines limiting the use and duration for chemical and physical restraints as well as seclusion. Under this regulation, as Federal law, the standards are that the order for restraint or seclusion cannot be written for more than: 4 hours for an adult 2 hours for children ages 9 to 17 1 hour for patients under 9 The original order can be renewed up to a maximum of 24 hours, before requiring that the practitioner see and reevaluate the patient The regulation states that “a restraint can only be used if needed to improve the patient’s well‐
being and less restrictive interventions have been determined to be ineffective” General recommendations:  Find alternatives to using restraints whenever possible.  Use with patient or family consent.  Discontinue use as soon as feasible.  Observe patients in restraints frequently. Emergency Department Security and Safety Tracy G. Sanson, MD, FACEP 20  Remove restraints as often as possible to allow for normal body functioning and daily activities.  Apply and adjust the restraint so that it is comfortable for the patient. Follow the manufacturer's directions to:  Select the type of restraint recommended for the patient's condition  Use the correct size for the patient's weight and height  Note the front and back of the restraint and apply correctly  Tie knots that can be released quickly  Secure bed restraints to the bedsprings or frame, never to the mattress or bed rails.  With an adjustable bed, secure the restraints to the parts of the bed that move with the patient Documentation: Document: assessment, intervention and outcome including:  Patient behaviors requiring the restraints to prevent or manage the behavior  Less restrictive interventions used, which were unsuccessful in re‐establishing patient self‐
control.  Patient cooperation sought in implementing safety interventions.  Specific interventions employed and patient response.  Management of the patient: If verbal interventions have failed move to the next level of intervention  Show of Force 5 people as a minimum One person to control the head and one person for each extremity One person to serve as the leader and four followers Initially gather around the leader with an image of confidence. The leader states, "come calmly or you will go in restraints" The leader states the reason restraints are needed Give the patient a few seconds to back down If the show of force fails then move to  The Take Down At signal of the leader each extremity is controlled and one staff member holds the head. Control is most easily obtained by immobilizing the major joints. The patient is brought to the floor in a backward motion and then rolled over.  Most should be restrained in the supine position  Consider the side position for the elderly or ill to prevent aspiration Restraints are then applied Debrief: Discuss the events with the staff and later the patient to aid in prevention of further incidents. All staff that have direct patient contact must have ongoing education and training in
the proper and safe use of seclusion and restraint application and techniques
http://www.hcfa.gov/quality/4b2.htm
Emergency Department Security and Safety Tracy G. Sanson, MD, FACEP 21 Chemical Restraints Agitated patients are a danger to themselves and others. The immediate goal of treatment of the acutely agitated individual is to reduce the agitation, irritability, and/or hostility to a level where the patient is not a physical danger to himself or others and to a level where they can be medically managed. This may involve the use of antipsychotics and benzodiazepines either alone or in combination. The rationale behind the combination approach is to take advantage of the anxiolytic/sedative effects of the benzodiazepine and allow for a lower dose of the antipsychotic. OSHA’s on‐line Hospital e‐tool on Workplace Violence ‐ www.osha.gov/SLTC/etools/hospital/hazards/workplaceviolence/viol.html This e‐tool is a comprehensive approach to violence prevention for hospitals and health care employers Public Employees Federation on‐line Resource List for Workplace Violence. www.pef.org/healthandsafety/resource_list_workplace_violence_prevention.htm Guidelines for Preventing Workplace Violence for Health Care and Social Service Workers, Appendix A: Workplace Violence Program Check lists www.osha.gov/SLTC/workplaceviolence www.nursingworld.org/MainMenuCategories/OccupationalandEnvironmental/occupationalheal
th/workplaceviolence/ANAResources/PreventingWorkplaceViolence.aspx Bureau of Labor Statistics, U.S. Department of Labor, Career Guide to Industries, 2006‐ 07 Edition, Health Care, on the Internet at www.bls.gov/oco/cg/cgs035.htm Guidelines for Preventing Workplace Violence for Health Care & Social Service Workers”; U.S. Department of Labor Occupational Safety and Health Administration;OSHA 3148‐ 01R 2004, www.osha.gov/Publications/osha3148.pdf “2004 Survey on Workplace Violence”. Massachusetts Nurse’s Association, Congress on Health and Safety and Workplace Violence and Abuse Prevention Task Force. www.massnurses.org/health/docs/Research04 Kowalenko T, Walters B, Khare R, Compton S. Workplace Violence: A Survey of Emergency Physicians in the State of Michigan, Ann Emerg Med 2005; 45(3). Massachusetts Nurses Association slogan: In Healthcare or Anywhere: Violence is NOT part of the job. Workplace violence is the leading cause of occupational death for women
and third leading cause of death for all workers.
Death is a high price to pay to practice one’s profession.
Emergency Department Security and Safety Tracy G. Sanson, MD, FACEP 22 Workplace Violence Checklist*
The following items serve merely as an example of what might be used or modified by employers to help
identify potential workplace violence problems.
This checklist helps identify present or potential workplace violence problems. Employers also may be aware
of other serious hazards not listed here.
Designated competent and responsible observers can readily make periodic inspections to identify and evaluate
workplace security hazards and threats of workplace violence. These inspections should be scheduled on a
regular basis; when new, previously unidentified security hazards are recognized; when occupational deaths,
injuries, or threats of injury occur; when a safety, health and security program is established; and whenever
workplace security conditions warrant an inspection.
Periodic inspections for security hazards include identifying and evaluating potential workplace security
hazards and changes in employee work practices, which may lead to compromising security. Please use the
following checklist to identify and evaluate workplace security hazards. TRUE notations indicate a potential
risk for serious security hazards:
__T__F This industry frequently confronts violent behavior and assaults of staff.
__T__F Violence has occurred on the premises or in conducting business.
__T__F Customers, clients, or coworkers assault, threaten, yell, push, or verbally abuse employees or use
racial or sexual remarks.
__T__F Employees are NOT required to report incidents or threats of violence, regardless of injury or
severity, to employer.
__T__F Employees have NOT been trained by the employer to recognize and handle threatening, aggressive,
or violent behavior.
__T__F Violence is accepted as "part of the job" by some managers, supervisors, and/or employees.
__T__F Access and freedom of movement within the workplace are NOT restricted to those persons who have
a legitimate reason for being there.
__T__F The workplace security system is inadequate-i.e., door locks malfunction, windows are not secure,
and there are no physical barriers or containment systems.
__T__F Employees or staff members have been assaulted, threatened, or verbally abused by clients and
patients.
__T__F Medical and counseling services have NOT been offered to employees who have been assaulted.
__T__F Alarm systems such as panic alarm buttons, silent alarms, or personal electronic alarm systems are
NOT being used for prompt security assistance.
__T__F There is no regular training provided on correct response to alarm sounding.
__T__F Alarm systems are NOT tested on a monthly basis to assure correct function.
__T__F Security guards are NOT employed at the workplace.
__T__F Closed circuit cameras and mirrors are NOT used to monitor dangerous areas.
__T__F Metal detectors are NOT available or NOT used in the facility.
__T__F Employees have NOT been trained to recognize and control hostile and escalating aggressive
behaviors, and to manage assaultive behavior.
__T__F Employees CANNOT adjust work schedules to use the "Buddy system" for visits to clients in areas
where they feel threatened.
__T__F Cellular phones or other communication devices are NOT made available to field staff to enable them
to request aid.
__T__F Vehicles are NOT maintained on a regular basis to ensure reliability and safety.
__T__F Employees work where assistance is NOT quickly available.
*This form was taken from: Guideline for Preventing Workplace Violence for Health Care and Social Service
Workers. OSHA 3148 1996.
State
Classification
Covered Personnel
Covered Situations
Crime Classification
Alabama
Felony
All Medical Treatments
Assault
Alaska
Felony or Misdemeanor
All Health Care Workers including
EM personnel
Medical Professional
EMS Personnel
Performance of Official Duties
Assault/Harassment
Arizona
Felony
Health care practitioners
Performance of Official Duties
Assault
Arkansas
Felony
All Health Care Workers
Battery
California
Felony or Misdemeanor (based on
prison terms)
Assault/Battery
Colorado
Misdemeanor
EMT
Mobile intensive care paramedic
Physician or nurse engaged in
rendering emergency medical care
outside a hospital, clinic, or other
health care facility
EMTs
Medical treatment
Emergency Medical Services
Performance of Official Duties
Performance of Official Duties
Assault
Connecticut
Felony
Employee of an emergency medical
service organization
Emergency room physician or nurse
Performance of Official Duties
Assault
Delaware
Felony
Florida
Felony or Misdemeanor
Georgia
Felony or Misdemeanor
Hawaii
Felony
Idaho
Felony
Illinois
Felony and Misdemeanor
Indiana
Felony
Rescue squad member, LPN, RN,
Rendering emergency care
paramedic, licensed medical doctor
Ambulance driver, EM technician
Rendering emergency care
paramedic, RN, physician medical
director
EM technician
Providing emergency care
Any EM professional
Mobile intensive care technician
Performance of Official Duties
EMT
EMT
Performance of Official Duties
EM technician-ambulance
Advanced EM technician
EMT-paramedic
EMT ambulance
Assault while engaged in the
EMT
execution of any of his official duties,
Paramedic
prevented from engaging in
Ambulance driver
performing duties or retaliated for
Other Medical assistance or first aid
performing duties
personnel
Health care provider
Performance of Official Duties
Iowa
Felony or Misdemeanor
Health care provider
Must be identifiable as health care
provider
Notes
Has law for serious physical injury or
death of EMT, paramedic,
ambulance attendant, or other
emergency responder
Assault
Assault/Battery
Obstruction of lawful discharge of the official duties
Assault
Battery
Assault
Battery
Assault
Violence - Assault by State
1 OF 4
State
Classification
Covered Personnel
Covered Situations
Crime Classification
Kansas
Kentucky
No laws dealing with health care and
assault
Felony
Certified or licensed EM personnel
Performance of Official Duties
Assault
Louisiana
Felony
Performance of Official Duties
Obstructing - ranges from manslaughter to simple assault
Maine
Can't find
Certified first responders
EMTs
EM care provider including hospital
personnel assisting in an emergency
Providing emergency care
Assault
EM technician
Ambulance operator
Ambulance attendant
Does not specify occupation "person who the individual knows or
has reason to know is performing his
or her duties"
Member of EM services personnel
unit
Physician, nurse, or other person
providing health care services in ED
Treating or transporting
Assault/Battery
Performing duties
Assault/Battery
Performance of Official Duties
Assault
Performance of Official Duties
Assault
Does not specify
Assault
Performance of Official Duties
(Not sure if limited to just emergency
services)
Assault with bodily fluid
Performance of Official Duties
Assault
No laws dealing with health care and
assault
Massachusetts
Can't find but probably both
Notes
Maryland
Michigan
Felony
Minnesota
Felony
Mississippi
Felony (based on prison term)
Missouri
Felony or Misdemeanor
Montana
Misdemeanor (based on prison term)
Nebraska
Nevada
No laws dealing with health care and
assault
Felony or Misdemeanor
New Hampshire
Felony or Misdemeanor
EM personnel
Public health personnel
Emergency room or trauma center
personnel
EM medical technician
Health care provider
Emergency responder
All Health Care Workers
Licensed EM care provider (Person
Health services to individuals
having responsibility for the delivery
experiencing illness or injury at a
of health services to individuals
location other than a hospital or other
experiencing illness or injury at a
medical facility.
location other than a hospital or other
medical facility.)
Assault
Violence - Assault by State
2 OF 4
State
Classification
Covered Personnel
Covered Situations
Crime Classification
New Jersey
Felony?
Person engaged in emergency firstaid or medical services
Assault
New Mexico
Felony or Misdemeanor
New York
Felony
North Carolina
Felony or Misdemeanor
Health care worker" means an
employee of a health facility or a
licensed emergency medical
technician
Paramedic or EM medical technician
administering first aid in the course of
performance of duty
Medical or related personnel in a
hospital ED
EM technician
Medical responder
ED nurse
ED physician
Performance of his duties while in
uniform or otherwise clearly
identifiable as being engaged in
emergency first-aid or medical
services
Performance of the duties of a health
care worker
North Dakota
Ohio
No laws dealing with health care and
assault (Laws not searchable)
Felony
Oklahoma
Notes
Assault/Battery
Performance of Official Duties
Assault
Performance of Official Duties
Assault or affray
First responders
EM medical technicians
Paramedics
Performance of Official Duties
Assault
Felony
Doctors, residents, interns, nurses,
nurses’ aides, ambulance attendants
and operators, paramedics, EM and
hospital security force
Medical care duties
Assault and battery
Oregon
Felony
Performance of Official Duties
Assault
Pennsylvania
Felony
EMT
Paramedic
Doctors, residents, interns,
registered nurses, licensed practical
nurses, nurse aides, ambulance
attendants and operators,
paramedics, emergency technicians
and hospital security force
Scope of their employment
Assault
Rhode Island
Felony
Health care provider and/or EM
services personnel
Engaged in providing health care
services
Assault
Emergency medical services performed before or during any
transport of a patient, including
transports between hospitals and
transports to and from helicopters.
Violence - Assault by State
3 OF 4
State
Classification
South Carolina
Felony or Misdemeanor
South Dakota
Tennessee
Misdemeanor
Felony or Misdemeanor
Texas
Felony
Utah
Misdemeanor
Vermont
Virginia
Felony or Misdemeanor (based on
prison terms)
Felony
Washington
Felony
West Virginia
Felony or Misdemeanor
Wisconsin
Felony
Wyoming
No laws dealing with health care
workers and assault
Covered Personnel
Covered Situations
Emergency physicians, nurses,
Course of his employment or training
EMTs, paramedics, members of
rescue squads, and anyone directed
by these individuals
EMT
Performance of Official Duties
Emergency medical worker
Performance of Official Duties
EMT or paramedic,
Emergency care attendant
Providing emergency services
EMTs
Paramedic
Health care provider and/or EM
Performing emergency or life saving
services personnel
duties
Emergency room personnel
Performing a lawful duty
Member of emergency services
Emergency medical services
Performance of his public duties
personnel" means persons
responsible for the direct provision of
emergency medical services in a
given medical emergency including
all persons who could be described
as attendants, attendants-in-charge,
or operators.
Nurse, physician, or health care
Performing health care duties
provider
Nurse, nurse practitioner, physician,
Performance of Official Duties
physician assistant or technician
Health care provider working in ED
EMT
First responder
Ambulance driver
Performance of Official Duties
Crime Classification
Notes
Assault/Battery
Obstructing
Assault
May enhance regular sentence
Assault
Assault
Assault
Assault/Battery
Assault
Assault/Battery
Battery
Violence - Assault by State
4 OF 4
ACTIVE SHOOTER LITERATURE REVIEW: Focus on Hospital-Based Incidents
Armstrong JH, Frykberg ER. Lessons from the response to the Virginia Tech shootings.
Disaster Medicine & Public Health Preparedness. 2007, September; 1(1 Suppl): S7-8.
Arterburn T. What hospital security should be doing now to better prepare for future terrorist
activity. Journal of Healthcare Protection and Management. 2002; 18(1): 6-14.
Hospital security plays a critical role. Recommendations from terrorist experts and
healthcare can assist in meeting these responsibilities.
Ashkenazi I, Kessel B, Khashan T, Haspel J, Oren M, Olsha O, Alfici R. Precision of inhospital triage in mass-casualty incidents after terror attacks. Prehospital Disaster Medicine.
2006; 21(1): 20-23.
The precision of 2 experienced triage officers was examined in 2 large MCI’s and compared
to actual injury severity (including ISS).Primary triage, even when carried out by
experienced trauma physicians, can be unreliable in an MCI (of 15 severely injured victims,
only 7 were identified).
Branas CC, Culhane D, Richmond T, Wiebe D. Novel linkage of individual and geographic
data to study firearm violence. Homicide Studies. 2008; 12(3): 298-320.
Population-based case control study of firearm violence in Philadelphia. Explores
geographic risk factors of the environment and individuals who engage in risky behaviors or
are simply in a risk area. Philadelphia’s demographics are similar to other big cities.
Hospitals are required by law to report cases of firearm violence. The vast majority of
people who survive firearm violence seek medical treatment, even criminals. Police
departments are a good source of data, and this is typically in electronic format. ATF has
data on firearms themselves purchased in an area. Also look at geographic data on alcohol
and drug use, fast food and groceries, crime and public safety data, land use data (renters,
vacant units, housing code violations) and demographics for an area. Total of 3,485
shootings (92% were assaults) for a 2 year data collection period.
Claasen C, Kashner TM, Kashner TK, Xuan L, Larkin GL. Psychiatric emergency “surge
capacity” following acts of terrorism and mass violence with high media impact: what is
required? General Hospital Psychiatry. 2011; 33(3): 287-293.
Treatment-seeking for anxiety-related issues show an increase following disasters with
major media coverage.
Florida Department of Health. Mass Casualty Incidents. 2012. Available at:
http://www.doh.state.fl.us/demo/bpr/hospprepared.html Accessed: January 24, 2013.
Guidance provides planning recommendations for Mass Casualty Incidents (MCI) as related to hospital and health care facility emergency preparedness planning. It is for public and private health personnel who are involved in emergency management, disaster preparedness, planning, response, mitigation, protection, and/or recovery. 
Hospital Medical Surge Planning for Mass Casualty Incidents 1 



Hospital Mass Casualty Incident Planning Checklist Hospital Mass Casualty Incident Planning Resources MCI Acuity Level Calculator MCI Staffing Information Fact Sheet Friedman E. Johns Hopkins Hospital gunman shoots doctor then kills self and mother. ABC
News (Internet). September 16, 2010. Available at http://abcnews.go.com/US/shootinginside-baltimores-johns-hopkins-hospital/story?id=11654462. Accessed January 22, 2013.
Male had just gotten bad news about his mother. Shot MD (survived), then mother (dead)
and then himself (dead).
Gacki-Smith J, Juarez AM, Boyett L, Homeyer C, Robinson L, MacLean SL. Violence
against nurses working in US emergency departments. Journal of Nursing Administration.
2009; 39(7-8): 340-349.
Physical violence and verbal abuse is prevalent in ED’s. RN’s reported fear of retaliation
and lack of support from hospital administration and ED management as barriers to
reporting workplace violence. Commitment from hospital administrators, ED managers and
hospital security is necessary to facilitate improvement and ensure a safer workplace for ED
nurses.
Gardner C, Jorgensen J, Kolstadbraaten KM et al. The twin terrorist attacks in Norway on
July 22, 2011: the trauma center response. Journal of Trauma & Acute Care Surgery. 2012;
73 (1): 269-275.
A bomb explosion (98 casualties; 8 dead on scene) was followed by a mass shooting 61
injured; 68 deaths on scene). The trauma center used a dual command approach between
ED triage and Trauma surgical team (retriage).Trauma center received a total of 8 patients
from the explosion (first arrival within 18 minutes) and 21 patients from the shooting. Surge
capacity in the ED, OR or ICU’s was never exceeded, despite high ISS scores of the
injured. A trauma center can handle many patients with severe injury, with low critical
mortality, when protected from a large number of less wounded persons.
Gomez D, Haas B, Ahmed N, Tien H, Nathens A. Disaster preparedness of Canadian
trauma centres: the perspective of medical directors of trauma. Canadian Medical
Association. 2011; 54(1): 9-16.
Recommendations for improvement included standardization of MCI planning and response
at a regional level and the implementation of strategies such as stockpiling of resources and
novel communication strategies to avoid functional collapse during an MCI.
Graham CJ, Shirm S. Security in pediatric emergency departments. Pediatric Emergency
Care. 1995; 11(4):220-222.
Most ED’s are not using all measures recommended by the American College of
Emergency Physicians. 35% of surveyed pediatric ED’s reported having a firearm related
incident within the past year.
Graham J, Shirm S, Liggin R, Aitken ME, Dick R. Mass-casualty events at schools: a
national preparedness survey. Pediatrics. 2006; 117 (1): e8-15.
2 There remain deficiencies in school emergency/disaster planning. Rural school districts are
less well prepared than urban districts. 86% of respondents had a response plan, but only
57% had a plan for prevention. 22% had no disaster plan provisions for children with special
health care needs; 25% had no plans for post-disaster counseling. Recommended
improved coordination of school officials and local medical and emergency response
agencies.
Heins M, Kahn R, Bjornal. Gunshot wounds in children. American Journal of Public Health.
1974; 64(4): 326-330.
A study of penetrating trauma in a Detroit pediatric ED (131 GSW cases); majority involved
males. An increase in the number of GSW’s appeared to be related to an increase in the
number of guns in the area.
Kansagra SM, Rao SR, Sullivan AF, Gordon JA, Magid DJ, Kaushal R, Camargo CA Jr.,
Blumenthal D. A survey of workplace violence across 65 U.S. emergency departments.
Academic Emergency Medicine. 2008; 15(12): 1268-1274.
20% of ED’s reported that guns or knives were brought to the ED on a daily or weekly basis.
ED nurses reported that they were less likely to feel safe “most of the time” or “always”
when compared to other staff.
Kaplowitz L, Reece M, Hershey JH, Gilbert CM. Regional health system response to the
Virginia Tech mass casualty incident. Disaster Medicine & Public Health preparedness,
2007; (1 Suppl): S9-13.
Direct transport of 26 victims from the 2007 VA Tech mass shooting to a trauma center was
not possible due to both distance and weather. Care was provided at 3 non-trauma center
hospitals instead. A successful response with a low regional health system mortality rate
occurred even though 38% (10/26 patients) required urgent intervention and surgery within
the first 24 hours. This was felt to be due to collaborative planning, training, exercising,
improved communications, but also in essential relationships and trust among all of the
responders.
Kelen G, Catlett C, Kubit J, Hsieh Y. Hospital-based shootings in the United States: 20002011. Annals of Emergency Medicine. 2012. Available at:
http://dx.doi.org/10.1016/j.annemergmed.2012.08.012. Accessed January 22, 2013.
154 hospital-based shootings in 40 states (3% of U.S. hospitals) identified: 91 (59%) within
the hospital, 63 (41%) on hospital grounds. Total of 235 injured or dead victims.
Perpetrators are largely men (91%), but can represent all age groups. Sites for shootings
included: ED (34%), patient rooms (32%), parking lot (23%. Events were precipitated by a
grudge (27%), suicide (21%), “euthanizing” an ill relative (14%) and prisoner escape (11%).
Most common victims were the perpetrators (45%), hospital employees (20%), nurses (5%)
and MD’s (3%). Most perps had a personal association with the victims: personal or intimate
relations (32%), current/former pts (25%), current or former employees (5%). ED shootings
tend to have younger perpetrators, those in custody(11%) and grudge against hospital staff
person. 50% of ED shootings involved security personnel firearms (23% taken from an
officer. 5 states accounted for more than 1/3rd of the events: FL, CA, Tx, OH & NC. Larger
hospitals (൒ 400 beds) had the highest incidence for shootings.61% of shootings involved 1
3 victim; 10% had 3 or more victims. Case fatality rate for “innocent” victims was 55%; among
perpetrators 85%. 30-60% of events could have been prevented with a metal detector. Less
than 2% of workplace shootings occur within the healthcare sector. Unlike educational
targets, 75% of hospital shootings tend to have a specific target.1/5th of all victims were
hospital employees.
Kosashbilli Y, Aharonson-Daniel L, Peleg K, Horoqitz A, Laor D, Blumenfeld A. Israeli
hospital preparedness for terrorism-related multiple casualty incidents: can the surge
capacity and injury severity distribution be better predicted? Injury. 2009; 40(7): 727-731.
Hospital preparedness can be better defined by a fixed number of casualties rather than a
percentile of its bed capacity. Only 20% of the arriving casualties will require immediate
medical treatment. This concept may improve the use of emergency resources both in the
preparation phase and real time.
Linkous D, Ferren-Carter K. Responding to the shootings at Virginia Tech: planning and
preparedness. Journal of Emergency Nursing. 2009; 35(4): 321-325.
McAlister VC. Drills and exercises: the way to disaster preparedness. Canadian Journal of
Surgery. 2011; 54(1):7-8.
Includes a review of disaster preparedness at Canadian trauma centers. Less than half said
that they were ready. Many still relied on communication plans that only included landlines
or cell phones. No hospital had a call-back system for off-duty staff or had a plan in place
for blast injured victims who were all deaf. The survey focused on trauma centers, however
community hospitals are just as likely to receive patients and have fewer resources in place.
Tools to assess preparedness and response should be incorporated into accreditation
programs. Surgeons are typically not included in exercises, yet need to have leadership
roles. None of the hospitals that coped with well known events such as Hurricane Katrina or
the Madrid bombing had actually experienced or prepared for such occurrences. During
catastrophic events, demand outstrips resources. If hospitals are not prepared, treatment of
some patients is delayed while the hospital continues to function or hospital-wide systems
can collapse.
Merz K. The Columbine High School tragedy: one emergency department’s experience.
Journal of Emergency Nursing. 1999;25(6):526-528.
Mims K. In tending to shooting victims, nurses don’t forget each other. ENA Connection.
2012, December 18; 8-9.
Hospital call centers need surge support. Difficult to follow family-centered care practices,
even for children.
Motzer EJ. Safety tips & guidelines regarding potential “active shooter”incidents occurring
on healthcare organization campuses. 2007. Source?
4 part document: Pre-incident prevention and preparation; Management during an incident;
post-event management and safety; safety tips for personnel.

Pre-incident strategic planning includes for pre-employment screening, ongoing staff
evaluations, community relationships, security management plan, improving
4 


internal/external communications, establishing ground rules for behavior, employee
and manager training, reporting procedures, preparing a threat management plan,
using all available resources;
Management during an incident includes in a department or office, in hallways or
corridors, in large room or auditoriums, trapped with the shooter, open spaces, if you
are a victim;
Post-event management: trauma plan, support prosecution of offenders, evaluate
security after a threat;
Tips for employees: make your workplace secure, safety in transit, parking lot sense,
office security, general awareness, indicators of violent situations.
No author listed. Virginia Tech disaster response shows value of regular drills and planning.
ED Manager. 2007; 19(6):61-63.
Well designed and regularly practiced disaster plan drills can help staff quickly mobilize into
action. Accurate and uninterrupted communications are critical. Using a color-coded triage
process in the field can help avoid bottlenecks in the ED. Placing a triage nurse at the ED
entrance supports appropriate care. A well-defined telephone tree in place will ensure
adequate staff. Make sure planning accounts for the loss of traditional sources of
communications, such as cell phones.
No author listed. Mass shooting in Colorado: practice drills, disaster preparations key to
successful emergency response. ED Manager. 2012, October; (10): 109-112.
23 critically ill/injured patients from the Aurora, CO shooting arrived to two hospitals within a
30 minute time period. All not DOA (1) survived. The emotional impact was difficult for staff.
Resources were made available from spiritual support, grief counselors to psychiatric help.
Peleg K, Rozenfeld M, Doley E. Children and terror casualties receive preference in ICU
admissions. Disaster Medicine and Public Health Preparedness. 2012; 6(1): 14-19.
Retrospective study of 121,609 trauma patients from the Israel Trauma Registry over a 5
year period. Both terror-related casualties and children had a higher probability of being
admitted to the ICU compared to MVC’s or other trauma mechanisms (adjusted for injury
severity).
Phelps S, Russell R, Doering G. Model “code silver” internal lockdown policy in response to
active shooters. American Journal of Disaster Medicine.2007; 2(3): 143-150.
Even hospitals that had experienced shootings did not institute basic security measures
such as metal detectors and identification checks. This article presents a model “code
silver” policy that hospitals can adopt to mitigate some of the risk. Key concepts of the
policy include training hospital staff to “shelter in place” during a violent event, marking
locked doors, and having hospital security respond in an appropriate manner.
Ray MM. The dark side of the job: violence in the emergency department. Journal of
Emergency Nursing. 2007; 33(3): 257-261.
Report of the Review Panel. Mass Shootings at Virginia Tech Presented to Governor Kaine.
August 2007. March 6, 2008. Available at:
http://www.governor.virginia.gov/TempContent/techPanelReport-docs/FullReport.pdf and
5 http://www.emsworld.com/article/10321548/virginia-tech-mass-shooting-reviewpanel-report
32 students and faculty were killed and 17 others injured in two related incidents comprising the
worst school shooting in American history at Virginia Tech in 2007. 3 days later, Virginia
Governor Timothy M. Kaine commissioned a panel of experts to investigate the tragedy and
recommend improvements to Virginia laws, policies, procedures, systems and institutions to help
prevent similar incidents in the future. The panel was officially established through executive
order. The panel was directed to review the response of the agencies involved in the event,
including the emergency medical response. Panelists were to recommend measures to improve the
pertinent agencies, systems, laws, policies and procedures based on their findings.
EMS Response; Discusses prehospital treatment, transport and the hospital care of the wounded
patients, as well as transport of the deceased. In addition, the panel was tasked with evaluating the
on-scene EMS response, implementation of mass-casualty and ICS plans (including NIMS
compliance and patient stabilization) both in the field and at the hospital, the types of
communications systems used and coordination of resources. Twenty minutes after arrival on
scene, VTPD announced that the shooter was down and that EMS crews could enter the building.
The EMS Command assigned a Triage Officer, and triage of patients continued both inside and
outside Norris Hall. Critical patients were transported to local hospitals via ambulance, and
noncritical patients were moved to a secondary triage area. Providers confirmed 31 people were
dead, and the decision was made not to attempt resuscitation. No one appeared to have been
mistriaged. Additionally, there were no reported injuries of any law enforcement or EMS
personnel. Interviews of prehospital and hospital personnel indicated that triage tags were used on
some patients, but not all. Not using the tags may have led to some confusion regarding patient
identification and classification upon arrival at the hospital. Just over an hour after the initial
dispatch, all patients from Norris Hall were transported to hospitals or moved to secondary
treatment units. In addition to VTRS, 14 agencies from the area responded to Virginia Tech that
morning to transport patients, and additional agencies provided interfacility transportation of
critical victims. Twenty-seven ambulances and more than 120 EMS personnel were utilized, and
assisted with coverage through established mutual aid agreements.
Lessons Learned, Good and Bad
The report contains over 70 key findings. The chapter addressing the EMS response contains 21,
both positive lessons and areas for improvement. Among these are:

Positive Lessons
EMS responses to both scenes occurred in a timely manner.

Patients were correctly triaged and transported to appropriate facilities.
6 
The incident was managed in a safe manner, with no reported injuries among responders.

Local hospitals were prepared for patient surges and managed those patients well.

All patients who were alive after the Norris Hall incident survived through hospital discharge.

EMS agencies demonstrated an exceptional working relationship, which was likely an outcome of
training and drills among the agencies.

The overall EMS response was excellent, and the lives of many were saved that day.

Areas for Improvement
There was a delay between VTRS's monitoring of the incident and its actual dispatch to Norris
Hall.

Radio traffic occurred on multiple frequencies, leading to issues regarding vehicle staging and
clearance into Norris Hall.

Triage tags were used on some, but not all patients.

Police ordered transport of deceased patients under emergency conditions.

The lack of a unified command post.

Communication issues and barriers led to frustration during the incident.
Additional Items
Later that afternoon, the medical examiner authorized the removal of the deceased from Norris
Hall to the medical examiner's office in Roanoke. Several options were considered, including the
use of refrigerated trucks, funeral coaches or EMS units. It was decided that, though not generally
used for transports of the deceased, EMS units would be acceptable, being that 9-1-1 response to the
area would not be compromised, and that refrigerated trucks and funeral vehicles on campus may
be undesirable. Critical incident stress management activities such as defusings and debriefings
were made available to all responders immediately post-incident.
Hospital Response
Twenty-seven patients were treated at area hospitals. The report says it's unknown if
individuals involved in the shootings may have been treated at other hospitals, clinics or doctors'
offices. Most of the hospitals involved initiated internal ICS and mobilized internal resources in
anticipation of potential patient surges. Patient injuries ranged from gunshot wounds to asthma
attacks, fractures and even burns. The report notes that a lack of communication between the
scene and area hospitals presented a challenge, as hospitals didn't know how many patients they'd
be receiving. Of the patients transported via EMS, only the two initial victims from West Ambler
Johnston died in or prior to arrival at the hospital.
Emergency Management: the relationships among the state, regional and local authorities
involved in the incident at Virginia Tech were reviewed, including agencies created to facilitate
7 coordinated emergency response in both the hospital and prehospital settings. The report notes
that the regional MCI plan was used correctly, but that the use of multiple radio frequencies, a lack
of unified command, and communication with the hospital by many different sources, instead of
through the ICS, created some confusion during the course of the incident. The panel made 10
recommendations based on its findings. Most focus on improving the coordination of resources
during MCI responses, holding disaster drills on a routine basis, and continuing to make CISM
available to providers as needed.
Richter PV. Hospital disaster preparedness: meeting a requirement or preparing for the
worst? Healthcare Facility Management Services. 1997, August; 1-11.
Recommend that hospitals learn from those impacted by disasters to improve their
preparedness with in-depth planning and exercising beyond personal recall and mass
casualty response. Documents are drafted to meet TJC requirements but are not tested.
Roman LM. Aftermath of a shooting: Tightened security in our ED. RN. 2007: 70(12):38-42.
Shepherd J, Gerdes C, Nipper M, Naul LG. Are you ready? Lessons learned from the Fort
Hood shooting in Texas. Emergency Radiology. 2011; 18 (2): 109-117.
Guidelines formulated for a general radiology surge model for mass casualty events.
Sollid SJ, Rimstad R, Rehn M, Nakstad AR, Tomlinson AE, Strand T, Heimdal SJ, Nilsen
JE, Sandberg M. Oslo government district bombing and Utoya island shooting July 22,
2011: the immediate prehospital emergency medical response. Scandinavian Journal of
Trauma, Resuscitation and Emergency Medicine. 2012; 20(1): 3.
Important lessons were learned in triage and evacuation, patient flow and communication,
the use and need for emergency equipment, and the coordination of helicopter EMS.
Taubman J. ED nurses caring for victims from Columbine High School appreciate
support of colleagues. Journal of Emergency Nursing. 1999; 25(4): 261.
Thompson T, Lyle K, Mullins SH, Dick R, Graham J. A State survey of emergency
department preparedness for the care of children in a mass casualty event. American
Journal of Disaster Medicine. 2009; 4(4):227-232.
Children are involved in most MCI’s, however there are deficiencies in the day-to-day and
disaster emergency care of children. Hospitals are relatively well prepared for adults in
disaster situations.
U.S. Department of Labor Occupational Health and Safety Administration. Guidelines for
preventing workplace violence for health care and social service workers. Available at:
http://www.osha.gov/Publications/OSHA3148/osha3148.html. Accessed: January 22, 2013.
Includes statistics, risk factors, guidelines including violence prevention programs,
management commitment, employee involvement, recommendations for workplace
analysis, records analysis and tracking, screening surveys, hazard prevention and controls,
8 administrative and work practice controls, employer responses to incidents of violence,
safety and health training & program evaluation.
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