Management of Violence in the Emergency Department

1. Management of Violence in the Emergency Department by Dr Sharon Fish

2. Overview Violence in the Emergency Department Gangs Recognition of gangs & potential for violence Causes of violence & the emergency room Violence Management Physical methods Protocols & Procedures Case Studies Focus Groups Sport / Crowd violence Local effects Discussion

3. Prevalence � Emergency Department ED often first point of entry Intoxication, concealed weapons and stress potentially all present at the same time Research suggests that staff in the Emergency Department receive the most amount of verbal and physical abuse out of any other department. Nature of the work implies exposure to violence, so methods of violence management are vital

4. Gangs Socio-economic unbalance unequal distribution of wealth societal exclusion poor education Means of expressing an identity outside of the status quo Crime - easiest access to rewards and goals drugs as the economy. May include entire families, yet can lead to unfair stereo-types of communities or racial groups.

5. Western Cape Gangs Street gangs the Americans the Hard Livings the Sexy Boys the School Boys the Junky Funky Kids (JFK) Young Dixie Boys (YDB) Prison Gangs 26�s, 27�s, 28�s Tatoo�s indicating rank

6. Recognition of Violence Aggression towards an individual toward creating fear Stress behaviours in individuals include use of profanity and verbal outbursts pacing or frequent alteration of body position or posture indicate increasing agitation

7. Recognition of Gangs Awareness of the local gang culture Access this information from local law enforcement Distinctive markings & behaviours Observe when gang members are present in hospital Security must be aware of an injured gang member arriving Types of injuries should be noted. Rivals may visit the hospital to finish their job Volatile in group or if rival gang members are present

8. Causes of Violence Not always gang related; and not all gang members are violent in certain situations (i.e. child birth) Understand root of behaviour psychiatric drug induced (either intoxication or withdrawal) child, elder or spousal abuse frustration due to long waits, unrealistic expectation

9. Causes of Violence Overcrowding Creates volatile situations Increased wait times Neglect of patients who require urgent attention Proximity of rival groups gangs intoxicated driver in close proximity to victims

10. Management throughPhysical Methods Access control Minimised unguarded entrances; lock extraneous entrances / exits at night Secure sensitive areas with access control Hand-held metal detectors used by security Enforce visible identification of all staff Plexiglass between waiting room & ED dept Block unauthorised vehicle access to the emergency department Visible security inside & outside

11. Management throughPhysical Methods Rankins and Hendey suggest that removing weapons did not decrease number of assaults Training of ED staff to handle violent situations remains crucial

12. Management throughProtocol & Procedure Develop a safety plan with hospital security Rehearse response mechanisms Code word called out when violence erupts Close contact with law enforcement during high-volume or disaster management scenarios Debrief after major incidents to refine procedures Access patient history either by records, friends or family to gain proper perspective on a patient Undress patients to reveal concealed weapons and disarm if necessary

13. Management throughProtocol & Procedure Security should recognise an escalating situation Either between parties or individual misconduct Separate rival gang members or victim-perpetrator groups Do not show condescension towards gang members. Cultural differences and language barriers may already cause tension Immediately use chemical and/or physical restraints with sufficient personnel

14. Case Study � Leven et al. Insights of nurses about assault in hospital-based emergency departments on subjective factors to reduce risk of assault Personal attitude & body language determine respect given by patients Workplace security must be trained to recognise and defuse violent situations authoritatively uniformed security who perform proactive, visible patrols perceived as more effective than more casually dressed security that respond reactively Geographic location Determines the type of incidents that occur Perception that police default to bringing intoxicated individuals to the emergency department as a holding area until they sober up

15. Case Study � Soccer Violence Winterbottom describes soccer players who arrive at casualty in a group Patients with minor injuries become belligerent because they must wait their turn, but at the same time want to get back to the remainder of the match In conjunction, patients escorted by their healthy friends cause disruption, worsened if supporters of the opposing team are present Describes violence and aggression as being rooted in frustration, fear and anger

16. Closer to Home � Security Upgrade at Livingston Hospital Gun wielding gangs attacked patients, security staff & rival gang members patient shot dead during surgery September 2007 - Nurses robbed at gun point at Dora Nginza Hospital, Tower Psychiatric Hospital in Beaufort West. Stated Solutions CCTV cameras Swipe card system for maternity wards & ICU

17. Discussion Personal Perspectives / Experience Long term effects of violence experienced on staff morale and performance Continuous process of managing violent behaviour and associated reactions Which security strategy carries most weight: physical or procedure-based security measures?

18. Questions

19. References Irvin Kinnes, The Future, Gangs and Society. Monograph No 48, From urban street gangs to criminal empires: The changing face of gangs in the Western Cape, June 2000. Irvin Kinnes, Gang culture in South Africa and its Impact, Institute of Criminology, University of Cape Town. McAcams, Russell, Walukewcz, Gangstas � not in my hospital!, Nursing 2004, Volume 34, Number 9, September 2004. Robert W. Derlet, John R. Richards , Overcrowding in the Nation's Emergency Departments: Complex Causes and Distrurbing Effects, Annals of Emergency Medicine, Volume 35, Number 1, January 2000. Ordog et al, Violence and General Security in the Emergency Department, Academic Emergency Medicine, February 1995, Volume 2, Number 2. Beth R. Keely, Recognition and Prevention of Hospital Violence, Dimensions of Critical Care Nursing, Volume 21, Number 6, 2002. Robert C. Rankins, Gregory W Hendey, Effects of a Security System on Violent Incidents and Hidden Weapons in the Emergency Department, Annals of Emergency Medicine, Volume 33, Number 6, June 1999. Pamela F. Levin, Jeanne Beauchamp Hewitt, Susan Terry Misner, Insights of nurses about assault in hospital-based emergency departments, Journal of Nursing Scholarship, 1998. Department of Health, Easter Cape Provincial Government, http://www.ecdoh.gov.za (2008) Sylvia Winterbottom; Coping with the violent patient in accident and emergency. Journal of medical ethics, 1979, 5, 124-127.