Portal de Periódicos da CAPES

Patient Safety Versus Workplace Safety

2011; Elsevier BV; Volume: 57; Issue: 4 Linguagem: Inglês

10.1016/j.annemergmed.2011.02.009

1097-6760

Jan Greene,

Workplace Violence and Bullying

One emergency department (ED) gets cited by a federal agency for using stun guns to subdue violent patients. Another is fined for failing to provide a safe workplace. It is a federal catch-22, leaving ED administrators caught between seemingly contradictory mandates from federal bureaucratic silos.“You have 2 federal agencies in contradiction to each other,” says Joe Bellino, former president of the International Association for Healthcare Security and Safety.There's a regulatory disconnection between the federal agencies whose rules bump into one another on this issue, argues Belino. He'd like to see officials of Centers for Medicare & Medicaid Services (CMS), tasked with patient safety, and Occupational Safety and Health Administration (OSHA), concerned with workplace safety, sit down with hospital security representatives and come up with some workable solutions, given the increase in violence in EDs.At one of the hospitals where her medical group practices, Lehigh Valley Hospital in Allentown, PA, the security force is regularly called in to help when the medical staff runs out of tools to defuse a tense situation. Until recently, security personnel carried stun guns as backup, just in case a person became so violent that there was no other option. But in December 2010, the hospital leadership took the stun guns away from security after being cited by the Pennsylvania Department of Health, which said federal rules prohibit using any type of weapon against patients. Citing rules from the CMS, the health department found that in 4 cases Lehigh Valley's use of stun guns on patients was inappropriate.The move worries Dr. Kane, who works at Lehigh Valley and 4 other hospitals in the area, which she says all have the same problem with violent patients. With certain cases in mind, she said, “I think the training and techniques are helpful, but I definitely think that no amount of talking down is going to help.”She says encounters with violent patients are common. “I personally deal with difficult patients every week,” she says. “If I'm seeing my share of it, then among the 60 or so physicians there are many incidents of violence.” At one hospital where she works, Dr. Kane says, a patient pulled a gun on a nurse. In another incident, a man entered the ED restroom and shot himself.Dr. Kane has the sense that violence in hospitals is getting worse. Statistics back up her perception. ED visits resulting in violence increased from 16,277 to 21,406 between 2005 and 2008, nearly a one-third increase, according to the federal Substance Abuse and Mental Health Services Administration. Visits to the ED for drug- and alcohol-related incidents increased during that time from 1.6 million to 2 million.The mayhem is having an influence on hospital staff. More than half of ED nurses are victims of physical or verbal abuse at work in a given week, according to a survey by the Emergency Nurses Association released in September 2010.CMS's actions in Pennsylvania raise a question: Should all hospitals that must comply with CMS regulations stop using stun guns? According to a survey in Campus Safety Magazine, 26% of hospital security officers carry “less-lethal” weapons such as neuromuscular incapacitating devices (stun guns made by Taser International), 7% carry handguns, and 13% carry both.Not a National Mandate?CMS spokeswoman Ellen Griffiths was careful not to extend the Lehigh Valley case into a national mandate for all hospitals. CMS, and any state agencies that act on CMS's behalf, usually respond to complaints rather than actively inspecting hospitals for compliance with rules. But she did observe, as did a Pennsylvania Health Department spokeswoman, that the CMS rules strongly discourage use of weapons with patients. The rules state: “CMS does not consider the use of weapons in the application of restraint or seclusion as a safe, appropriate health care intervention. For the purposes of this regulation, the term “weapon” includes, but is not limited to, pepper spray, mace, nightsticks, tazers, cattle prods, stun guns, and pistols. Security staff may carry weapons as allowed by hospital policy, and State and Federal law. However, the use of weapons by security staff is considered a law enforcement action, not a health care intervention. CMS does not support the use of weapons by any hospital staff as a means of subduing a patient in order to place that patient in restraint or seclusion. If a weapon is used by security or law enforcement personnel on a person in a hospital (patient, staff, or visitor) to protect people or hospital property from harm, we would expect the situation to be handled as a criminal activity and the perpetrator be placed in the custody of local law enforcement.”1Centers for Medicare & Medicaid Services. CMS state operations manual, appendix A. Regulations and interpretive guidelines for hospitals. Section 482.13(e).Google ScholarGriffiths said CMS would not discuss whether hospital security should carry stun guns or other weapons because that is a “law enforcement” issue that falls outside CMS jurisdiction.No RestraintLehigh Valley's actions ran afoul of patient protection rules meant to limit the ways patients can be restrained, said Holli Senior, deputy press secretary for the Pennsylvania Health Department. Weapons should not be used in the context of restraining a patient. If a physical confrontation goes beyond the point at which usual restraints are in order, then local police should be called, Senior said.The health department, which has “deemed status” in Pennsylvania to carry out CMS rules for hospitals governed by Medicare rules, responded to a complaint about a specific incident in which a Lehigh Valley security officer used a stun gun on a patient. The resulting inspection led to a review of patient records, which showed 3 other incidents with stun guns during the previous few years. Lehigh Valley started using stun guns in 2007.The regulators found fault with Lehigh Valley, according to an October 2010 inspection report, because the stun guns were used without a preceding attempting to restrain or seclude the patients. The incidents involved the following: •An agitated patient in the ED received multiple doses of Ativan, Haldol, and valium during about 2 hours and was still agitated. Security staff was called and the patient “came at” security, at which point the patient was stunned.•A patient was asked to sign a transfusion consent and refused, becoming agitated, and began yelling at staff. The patient was using an intravenous pole as a weapon and barricaded himself in the restroom. Security talked to the patient, but he became more agitated and ultimately a stun gun was used. Police were called and took a report.•An ED patient ran out of an examination room, slamming the door, hitting the wall, and yelling. Medical staff tried to calm the person, and eventually security was called. The patient attempted to punch a security officer, “who intercepted the patient's punches and took the patient to the ground.” The patient began fighting with both officers, and one used a stun gun to subdue him.•An upset patient left the ED, and security staff pursued the person for fear he would harm himself or others and called police. The patient pushed a security officer, striking the officer with his fist and grabbing for the officer's belt containing pepper spray and a stun gun. Another officer warned the patient 3 times and then discharged a stun gun. In each instance, the health department said, security staff should have followed policy and restrained or secluded the patient or waited for police to arrive.Lehigh Valley officials resolved the health department complaint with a plan of correction that involved taking stun guns from security personnel, reviewing policies on responses to behavioral control problems, and carrying out targeted training with staff.Beyond that, hospital officials have been reticent to discuss the issue publicly. But hospital chief operating officer Terry Capuano agreed to explain how Lehigh Valley came to use stun guns in the first place. Capuano said the idea was first brought up by the hospital security department and considered carefully by the administration and board of directors before going forward. “What led to our decision to use Tasers was the sheer intention to protect patients, staff, and visitors. It is truly that simple.” Once the idea was proposed by security, she said, “We had to really think it through. It's not something we took lightly or that came to a committee one time.”Hospital leaders were shown a box of weapons that the security department had taken from patients as they were admitted to the hospital. “It included weapons I have never seen in my entire life, brass knuckles, a throwing star,” Capuano said. “It was scary and it felt like we really put those inside the organization at risk by not being able to defend them.”The chief operating officer said she hopes to maintain good relations with regulatory agencies such as CMS and the health department by continuing to have a dialogue about security measures, including the future availability of stun guns on the rare occasions when they are needed.Protecting Patients Versus Protecting StaffHospital officials struggle with balancing the need to protect patient rights and the responsibility to maintain a safe workplace. Danbury Hospital in Connecticut was fined by OSHA for failing to provide employees with adequate safeguards against workplace violence. Although the situation did not involve stun guns, it resulted from complaints about how violent incidents were handled.Asked whether OSHA would weigh in on the question of hospital security protecting the workplace with stun guns, an agency spokesman said he did not believe OSHA would get involved in that question but referred questions to the written OSHA “Guidelines for Preventing Workplace Violence for Health Care & Social Service Workers.”2Occupational Safety and Health AdministrationGuidelines for preventing workplace violence for health care & social service workers.http://www.osha.gov/Publications/OSHA3148/osha3148.htmlGoogle Scholar The article does not address what types of weapons should be used to enforce a safe workplace, instead offering advice largely focused on preventing violent incidents with patients.ED as “Dumping Ground”Bellino, the former president of the International Association for Healthcare Security and Safety, believes part of the problem is that increasingly, the ED is being used inappropriately as a “dumping ground” for drunk patients the police have no other place to take and psychiatric patients for whom community resources have disappeared. The poor economy also has an effect, Dr. Kane says; she observed an increase in angry patients and families as the recession wore on.Dr. Kane believes many of the people who come to the ED are not seeking services that would typically define them as patients. “They're not always there looking for help or medical care,” she says. “Many are brought in against their will. There might be drug and alcohol issues, mental health issues.”CMS regulations have separate standards for handling “patients” and people who are posing a law enforcement problem. For Bellino, the line is clear: when a patient assaults someone, he has broken the law. “You can use state statutes as a guideline for assault, and that's universal,” he says. “Simple assault is slapping, hitting, biting. Aggravated assault involves serious bodily injury. The Lehigh Valley cases sounded pretty bad. If somebody's swinging an IV pole, that's a bad situation.”It's easy to establish that strong measures might be appropriate once an assault has taken place. But what if hospital staff feel threatened by someone's anger and want to protect themselves before an injury takes place? That's more of a gray zone.For security measures to be effective, hospital staff members need to be willing to report assaults. In many places, that runs counter to a traditional culture of accepting a certain level of physical resistance from patients, or a sense that they shouldn't publicize problems within the hospital, says Anthony Phipps, a spokesman for the Emergency Nurses Association (ENA).The nursing group advocates for a “zero tolerance” policy on workplace violence against hospital staff. When a policy of full reporting is in place, the ENA says, violent acts are cut in half. “Hospitals that have policies in place to respond to violence and to prevent it are safer for the health care professionals that work in them and the patients who seek treatment in them,” ENA President Diane Gurney, RN, said in a statement.The issue isn't just one for the security department. Bellino recommends a comprehensive planning and training effort akin to those hospitals undertake for other topics that affect multiple departments. “Workplace violence is everybody's responsibility. It's got to be a team effort. You need to teach people to see the signs (of an escalating situation) and prevent it from happening.” One emergency department (ED) gets cited by a federal agency for using stun guns to subdue violent patients. Another is fined for failing to provide a safe workplace. It is a federal catch-22, leaving ED administrators caught between seemingly contradictory mandates from federal bureaucratic silos. “You have 2 federal agencies in contradiction to each other,” says Joe Bellino, former president of the International Association for Healthcare Security and Safety. There's a regulatory disconnection between the federal agencies whose rules bump into one another on this issue, argues Belino. He'd like to see officials of Centers for Medicare & Medicaid Services (CMS), tasked with patient safety, and Occupational Safety and Health Administration (OSHA), concerned with workplace safety, sit down with hospital security representatives and come up with some workable solutions, given the increase in violence in EDs. At one of the hospitals where her medical group practices, Lehigh Valley Hospital in Allentown, PA, the security force is regularly called in to help when the medical staff runs out of tools to defuse a tense situation. Until recently, security personnel carried stun guns as backup, just in case a person became so violent that there was no other option. But in December 2010, the hospital leadership took the stun guns away from security after being cited by the Pennsylvania Department of Health, which said federal rules prohibit using any type of weapon against patients. Citing rules from the CMS, the health department found that in 4 cases Lehigh Valley's use of stun guns on patients was inappropriate. The move worries Dr. Kane, who works at Lehigh Valley and 4 other hospitals in the area, which she says all have the same problem with violent patients. With certain cases in mind, she said, “I think the training and techniques are helpful, but I definitely think that no amount of talking down is going to help.” She says encounters with violent patients are common. “I personally deal with difficult patients every week,” she says. “If I'm seeing my share of it, then among the 60 or so physicians there are many incidents of violence.” At one hospital where she works, Dr. Kane says, a patient pulled a gun on a nurse. In another incident, a man entered the ED restroom and shot himself. Dr. Kane has the sense that violence in hospitals is getting worse. Statistics back up her perception. ED visits resulting in violence increased from 16,277 to 21,406 between 2005 and 2008, nearly a one-third increase, according to the federal Substance Abuse and Mental Health Services Administration. Visits to the ED for drug- and alcohol-related incidents increased during that time from 1.6 million to 2 million. The mayhem is having an influence on hospital staff. More than half of ED nurses are victims of physical or verbal abuse at work in a given week, according to a survey by the Emergency Nurses Association released in September 2010. CMS's actions in Pennsylvania raise a question: Should all hospitals that must comply with CMS regulations stop using stun guns? According to a survey in Campus Safety Magazine, 26% of hospital security officers carry “less-lethal” weapons such as neuromuscular incapacitating devices (stun guns made by Taser International), 7% carry handguns, and 13% carry both. Not a National Mandate?CMS spokeswoman Ellen Griffiths was careful not to extend the Lehigh Valley case into a national mandate for all hospitals. CMS, and any state agencies that act on CMS's behalf, usually respond to complaints rather than actively inspecting hospitals for compliance with rules. But she did observe, as did a Pennsylvania Health Department spokeswoman, that the CMS rules strongly discourage use of weapons with patients. The rules state: “CMS does not consider the use of weapons in the application of restraint or seclusion as a safe, appropriate health care intervention. For the purposes of this regulation, the term “weapon” includes, but is not limited to, pepper spray, mace, nightsticks, tazers, cattle prods, stun guns, and pistols. Security staff may carry weapons as allowed by hospital policy, and State and Federal law. However, the use of weapons by security staff is considered a law enforcement action, not a health care intervention. CMS does not support the use of weapons by any hospital staff as a means of subduing a patient in order to place that patient in restraint or seclusion. If a weapon is used by security or law enforcement personnel on a person in a hospital (patient, staff, or visitor) to protect people or hospital property from harm, we would expect the situation to be handled as a criminal activity and the perpetrator be placed in the custody of local law enforcement.”1Centers for Medicare & Medicaid Services. CMS state operations manual, appendix A. Regulations and interpretive guidelines for hospitals. Section 482.13(e).Google ScholarGriffiths said CMS would not discuss whether hospital security should carry stun guns or other weapons because that is a “law enforcement” issue that falls outside CMS jurisdiction. CMS spokeswoman Ellen Griffiths was careful not to extend the Lehigh Valley case into a national mandate for all hospitals. CMS, and any state agencies that act on CMS's behalf, usually respond to complaints rather than actively inspecting hospitals for compliance with rules. But she did observe, as did a Pennsylvania Health Department spokeswoman, that the CMS rules strongly discourage use of weapons with patients. The rules state: “CMS does not consider the use of weapons in the application of restraint or seclusion as a safe, appropriate health care intervention. For the purposes of this regulation, the term “weapon” includes, but is not limited to, pepper spray, mace, nightsticks, tazers, cattle prods, stun guns, and pistols. Security staff may carry weapons as allowed by hospital policy, and State and Federal law. However, the use of weapons by security staff is considered a law enforcement action, not a health care intervention. CMS does not support the use of weapons by any hospital staff as a means of subduing a patient in order to place that patient in restraint or seclusion. If a weapon is used by security or law enforcement personnel on a person in a hospital (patient, staff, or visitor) to protect people or hospital property from harm, we would expect the situation to be handled as a criminal activity and the perpetrator be placed in the custody of local law enforcement.”1Centers for Medicare & Medicaid Services. CMS state operations manual, appendix A. Regulations and interpretive guidelines for hospitals. Section 482.13(e).Google Scholar Griffiths said CMS would not discuss whether hospital security should carry stun guns or other weapons because that is a “law enforcement” issue that falls outside CMS jurisdiction. No RestraintLehigh Valley's actions ran afoul of patient protection rules meant to limit the ways patients can be restrained, said Holli Senior, deputy press secretary for the Pennsylvania Health Department. Weapons should not be used in the context of restraining a patient. If a physical confrontation goes beyond the point at which usual restraints are in order, then local police should be called, Senior said.The health department, which has “deemed status” in Pennsylvania to carry out CMS rules for hospitals governed by Medicare rules, responded to a complaint about a specific incident in which a Lehigh Valley security officer used a stun gun on a patient. The resulting inspection led to a review of patient records, which showed 3 other incidents with stun guns during the previous few years. Lehigh Valley started using stun guns in 2007.The regulators found fault with Lehigh Valley, according to an October 2010 inspection report, because the stun guns were used without a preceding attempting to restrain or seclude the patients. The incidents involved the following: •An agitated patient in the ED received multiple doses of Ativan, Haldol, and valium during about 2 hours and was still agitated. Security staff was called and the patient “came at” security, at which point the patient was stunned.•A patient was asked to sign a transfusion consent and refused, becoming agitated, and began yelling at staff. The patient was using an intravenous pole as a weapon and barricaded himself in the restroom. Security talked to the patient, but he became more agitated and ultimately a stun gun was used. Police were called and took a report.•An ED patient ran out of an examination room, slamming the door, hitting the wall, and yelling. Medical staff tried to calm the person, and eventually security was called. The patient attempted to punch a security officer, “who intercepted the patient's punches and took the patient to the ground.” The patient began fighting with both officers, and one used a stun gun to subdue him.•An upset patient left the ED, and security staff pursued the person for fear he would harm himself or others and called police. The patient pushed a security officer, striking the officer with his fist and grabbing for the officer's belt containing pepper spray and a stun gun. Another officer warned the patient 3 times and then discharged a stun gun. In each instance, the health department said, security staff should have followed policy and restrained or secluded the patient or waited for police to arrive.Lehigh Valley officials resolved the health department complaint with a plan of correction that involved taking stun guns from security personnel, reviewing policies on responses to behavioral control problems, and carrying out targeted training with staff.Beyond that, hospital officials have been reticent to discuss the issue publicly. But hospital chief operating officer Terry Capuano agreed to explain how Lehigh Valley came to use stun guns in the first place. Capuano said the idea was first brought up by the hospital security department and considered carefully by the administration and board of directors before going forward. “What led to our decision to use Tasers was the sheer intention to protect patients, staff, and visitors. It is truly that simple.” Once the idea was proposed by security, she said, “We had to really think it through. It's not something we took lightly or that came to a committee one time.”Hospital leaders were shown a box of weapons that the security department had taken from patients as they were admitted to the hospital. “It included weapons I have never seen in my entire life, brass knuckles, a throwing star,” Capuano said. “It was scary and it felt like we really put those inside the organization at risk by not being able to defend them.”The chief operating officer said she hopes to maintain good relations with regulatory agencies such as CMS and the health department by continuing to have a dialogue about security measures, including the future availability of stun guns on the rare occasions when they are needed. Lehigh Valley's actions ran afoul of patient protection rules meant to limit the ways patients can be restrained, said Holli Senior, deputy press secretary for the Pennsylvania Health Department. Weapons should not be used in the context of restraining a patient. If a physical confrontation goes beyond the point at which usual restraints are in order, then local police should be called, Senior said. The health department, which has “deemed status” in Pennsylvania to carry out CMS rules for hospitals governed by Medicare rules, responded to a complaint about a specific incident in which a Lehigh Valley security officer used a stun gun on a patient. The resulting inspection led to a review of patient records, which showed 3 other incidents with stun guns during the previous few years. Lehigh Valley started using stun guns in 2007. The regulators found fault with Lehigh Valley, according to an October 2010 inspection report, because the stun guns were used without a preceding attempting to restrain or seclude the patients. The incidents involved the following: •An agitated patient in the ED received multiple doses of Ativan, Haldol, and valium during about 2 hours and was still agitated. Security staff was called and the patient “came at” security, at which point the patient was stunned.•A patient was asked to sign a transfusion consent and refused, becoming agitated, and began yelling at staff. The patient was using an intravenous pole as a weapon and barricaded himself in the restroom. Security talked to the patient, but he became more agitated and ultimately a stun gun was used. Police were called and took a report.•An ED patient ran out of an examination room, slamming the door, hitting the wall, and yelling. Medical staff tried to calm the person, and eventually security was called. The patient attempted to punch a security officer, “who intercepted the patient's punches and took the patient to the ground.” The patient began fighting with both officers, and one used a stun gun to subdue him.•An upset patient left the ED, and security staff pursued the person for fear he would harm himself or others and called police. The patient pushed a security officer, striking the officer with his fist and grabbing for the officer's belt containing pepper spray and a stun gun. Another officer warned the patient 3 times and then discharged a stun gun. In each instance, the health department said, security staff should have followed policy and restrained or secluded the patient or waited for police to arrive. Lehigh Valley officials resolved the health department complaint with a plan of correction that involved taking stun guns from security personnel, reviewing policies on responses to behavioral control problems, and carrying out targeted training with staff. Beyond that, hospital officials have been reticent to discuss the issue publicly. But hospital chief operating officer Terry Capuano agreed to explain how Lehigh Valley came to use stun guns in the first place. Capuano said the idea was first brought up by the hospital security department and considered carefully by the administration and board of directors before going forward. “What led to our decision to use Tasers was the sheer intention to protect patients, staff, and visitors. It is truly that simple.” Once the idea was proposed by security, she said, “We had to really think it through. It's not something we took lightly or that came to a committee one time.” Hospital leaders were shown a box of weapons that the security department had taken from patients as they were admitted to the hospital. “It included weapons I have never seen in my entire life, brass knuckles, a throwing star,” Capuano said. “It was scary and it felt like we really put those inside the organization at risk by not being able to defend them.” The chief operating officer said she hopes to maintain good relations with regulatory agencies such as CMS and the health department by continuing to have a dialogue about security measures, including the future availability of stun guns on the rare occasions when they are needed. Protecting Patients Versus Protecting StaffHospital officials struggle with balancing the need to protect patient rights and the responsibility to maintain a safe workplace. Danbury Hospital in Connecticut was fined by OSHA for failing to provide employees with adequate safeguards against workplace violence. Although the situation did not involve stun guns, it resulted from complaints about how violent incidents were handled.Asked whether OSHA would weigh in on the question of hospital security protecting the workplace with stun guns, an agency spokesman said he did not believe OSHA would get involved in that question but referred questions to the written OSHA “Guidelines for Preventing Workplace Violence for Health Care & Social Service Workers.”2Occupational Safety and Health AdministrationGuidelines for preventing workplace violence for health care & social service workers.http://www.osha.gov/Publications/OSHA3148/osha3148.htmlGoogle Scholar The article does not address what types of weapons should be used to enforce a safe workplace, instead offering advice largely focused on preventing violent incidents with patients. Hospital officials struggle with balancing the need to protect patient rights and the responsibility to maintain a safe workplace. Danbury Hospital in Connecticut was fined by OSHA for failing to provide employees with adequate safeguards against workplace violence. Although the situation did not involve stun guns, it resulted from complaints about how violent incidents were handled. Asked whether OSHA would weigh in on the question of hospital security protecting the workplace with stun guns, an agency spokesman said he did not believe OSHA would get involved in that question but referred questions to the written OSHA “Guidelines for Preventing Workplace Violence for Health Care & Social Service Workers.”2Occupational Safety and Health AdministrationGuidelines for preventing workplace violence for health care & social service workers.http://www.osha.gov/Publications/OSHA3148/osha3148.htmlGoogle Scholar The article does not address what types of weapons should be used to enforce a safe workplace, instead offering advice largely focused on preventing violent incidents with patients. ED as “Dumping Ground”Bellino, the former president of the International Association for Healthcare Security and Safety, believes part of the problem is that increasingly, the ED is being used inappropriately as a “dumping ground” for drunk patients the police have no other place to take and psychiatric patients for whom community resources have disappeared. The poor economy also has an effect, Dr. Kane says; she observed an increase in angry patients and families as the recession wore on.Dr. Kane believes many of the people who come to the ED are not seeking services that would typically define them as patients. “They're not always there looking for help or medical care,” she says. “Many are brought in against their will. There might be drug and alcohol issues, mental health issues.”CMS regulations have separate standards for handling “patients” and people who are posing a law enforcement problem. For Bellino, the line is clear: when a patient assaults someone, he has broken the law. “You can use state statutes as a guideline for assault, and that's universal,” he says. “Simple assault is slapping, hitting, biting. Aggravated assault involves serious bodily injury. The Lehigh Valley cases sounded pretty bad. If somebody's swinging an IV pole, that's a bad situation.”It's easy to establish that strong measures might be appropriate once an assault has taken place. But what if hospital staff feel threatened by someone's anger and want to protect themselves before an injury takes place? That's more of a gray zone.For security measures to be effective, hospital staff members need to be willing to report assaults. In many places, that runs counter to a traditional culture of accepting a certain level of physical resistance from patients, or a sense that they shouldn't publicize problems within the hospital, says Anthony Phipps, a spokesman for the Emergency Nurses Association (ENA).The nursing group advocates for a “zero tolerance” policy on workplace violence against hospital staff. When a policy of full reporting is in place, the ENA says, violent acts are cut in half. “Hospitals that have policies in place to respond to violence and to prevent it are safer for the health care professionals that work in them and the patients who seek treatment in them,” ENA President Diane Gurney, RN, said in a statement.The issue isn't just one for the security department. Bellino recommends a comprehensive planning and training effort akin to those hospitals undertake for other topics that affect multiple departments. “Workplace violence is everybody's responsibility. It's got to be a team effort. You need to teach people to see the signs (of an escalating situation) and prevent it from happening.” Bellino, the former president of the International Association for Healthcare Security and Safety, believes part of the problem is that increasingly, the ED is being used inappropriately as a “dumping ground” for drunk patients the police have no other place to take and psychiatric patients for whom community resources have disappeared. The poor economy also has an effect, Dr. Kane says; she observed an increase in angry patients and families as the recession wore on. Dr. Kane believes many of the people who come to the ED are not seeking services that would typically define them as patients. “They're not always there looking for help or medical care,” she says. “Many are brought in against their will. There might be drug and alcohol issues, mental health issues.” CMS regulations have separate standards for handling “patients” and people who are posing a law enforcement problem. For Bellino, the line is clear: when a patient assaults someone, he has broken the law. “You can use state statutes as a guideline for assault, and that's universal,” he says. “Simple assault is slapping, hitting, biting. Aggravated assault involves serious bodily injury. The Lehigh Valley cases sounded pretty bad. If somebody's swinging an IV pole, that's a bad situation.” It's easy to establish that strong measures might be appropriate once an assault has taken place. But what if hospital staff feel threatened by someone's anger and want to protect themselves before an injury takes place? That's more of a gray zone. For security measures to be effective, hospital staff members need to be willing to report assaults. In many places, that runs counter to a traditional culture of accepting a certain level of physical resistance from patients, or a sense that they shouldn't publicize problems within the hospital, says Anthony Phipps, a spokesman for the Emergency Nurses Association (ENA). The nursing group advocates for a “zero tolerance” policy on workplace violence against hospital staff. When a policy of full reporting is in place, the ENA says, violent acts are cut in half. “Hospitals that have policies in place to respond to violence and to prevent it are safer for the health care professionals that work in them and the patients who seek treatment in them,” ENA President Diane Gurney, RN, said in a statement. The issue isn't just one for the security department. Bellino recommends a comprehensive planning and training effort akin to those hospitals undertake for other topics that affect multiple departments. “Workplace violence is everybody's responsibility. It's got to be a team effort. You need to teach people to see the signs (of an escalating situation) and prevent it from happening.”