Behavioral Health Patient Boarding in the ED

Laws Related to ED Violence

Occupational health and safety laws assert the importance of safe working environment for the employees. According to the “General Duty Clause 5A-1” of the Occupational Safety and Health Act (OSHA), employers are required to have a workplace that is “free from recognized hazards.”¹⁵ ENA (Emergency Nurses Association) reinforces the same by stating that, “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.”¹⁵

According to the Criminal Code of Canada, every individual have the right to “use much force as it is reasonably necessary to prevent an assault from occurring, or to defend himself or anyone under his protection as long as he uses no more force than is reasonably necessary to prevent the assault or the repetition of it”.¹⁷

The Occupational Health and Safety (OHS) regulation under section 4.28 calls for a risk assessment of the work place to ensure that the workplace is in compliance with OHS regulation. Under section 4.29 the employer is mandated to establish policies and procedures are in place to address worker’s needs.¹⁷ Training and education forms an important component of the confronting workplace violence. Criminal Code of Canada, the Workers Compensation Act and OHS regulation 4.30 advocates the workers right of refusing unsafe work and full disclosure from the employer about the exposure for the risk of violence.¹⁷

Workplace violence is the third highest cause for all occupation related death in the U.S. and the top most reason of occupational death for females. According to the American Nurse’s Association 25 percent of nurses’ list physical assault as the prime safety concern on job.^3,15  Therefore, arises the need for stringent laws.

Strategies to Reduce Violence in the ED

A safe working environment is the key for improved staff morale and greater productivity. Therefore, preventive strategies to reduce victimization of medical personnel in ED assumes immense importance.¹⁵

1. Early recognition of potential violence prepares health care providers and can result in a reduction in violence related incidences

2. Control of environmental factors provoking violent tendencies by –
   • Verbal or psychological intervention approach
   • Early recognition of potential violence by a calm and prepared health provider
   • Physical and/or chemical restraints based upon regulatory and legal guidelines.

3. Management plans to identify and control potential violent situations at the ED. The plan should include procedures to:
   • Confront and cope with violent situations
   • Procedures and methods to alert co-workers and call security and/or law enforcement
   • Self-defense training and conflict resolution education for the staff members
   • Procedures to cope with and diffuse potentially violent situations, call security and / or police and provide personal protection while awaiting assistance.

Mitigation Strategies for Violence in the ED²⁹

Innumerable causes and challenges are associated with violence against caregivers in EDs and hospital administrators have the sole accountability for taking measures to curb the likelihood of violence and provide better management readiness and strategies to minimize the harmful effects. A multifaceted approach crafted to provide customized solutions according to the results of a hospital risk and trend analysis.

The Haddon’s Matrix can be used to identify the factors that contribute to workplace violence and corresponding mitigation strategies that can be implemented before, during and after the event that may influence the outcomes³⁰.  Haddon’s matrix is the most commonly used paradigm in the injury prevention field. It was developed by William Haddon in 1970. It is a table showing the host, agent and environmental factors responsible for an incident set against the time sequence³⁰.  The cells of the matrix illustrate the range of risk or protective factors involved.³⁰ By utilizing this framework, one can evaluate the relative importance of different factors and design interventions.

Following strategy framework aids in assessing the workplace vulnerability for violent incidents and actions needed to prevent them.

1. Identifying the facility violence risk profile. Accomplished by reviewing the findings of²⁹
   • “Most recent Joint Commission hazard vulnerability analysis (2015 standard: EM.01.01.01) and incident reports,
   • Occupational Safety and Health Administration (OSHA) logs and security reports.
   • The local crime statistics”

2. Utilizing trained health workers for reviewing equipment and technology-based security measures. Forming a team at the facility involving staff, security personnel, and local law enforcement to enhance the facility capability for dealing with a violent incident.

3. Improving case management for patients to reduce psychiatric emergencies.
   • Expand the outpatient care³⁷
   • Better management of existing capacity. For example: Use of computerized bed management system – “bed Czars”³⁶

4. Deployment of the crisis clinic staffed with a social worker and nurse. They will act as an additional resource during the maximum psychiatric ED occupancy.³⁶

5. Telehealth services provide a good option for ED without psychiatrists and, during weekend and nights.^32,36

6. A standalone ED completely dedicated to psychiatric patients providing patient evaluation, intensive treatment and observation”. The goal of these services is to provide care for the acute symptoms and reduce hospitalization rates.^34,36

7. Following OSHA’s comprehensive list of fundamental guidelines for accessing and updating workplace violence prevention program. OSHA identifies five key elements for an effective program²⁹
   • “management commitment and employee involvement; worksite analysis;
   • hazard prevention and control;
   • safety and health training;
   • Record keeping and program evaluation.”

Taking appropriate actions on the findings of the above assessment will make the facility safer and makes the staff feel more secure.

8. Screening tools can be used for assessing psychiatric hospitalization for suicidal patients. Examples of validates screening tools are “Emergency Medicine Network’s ED-SAFE Patient Safety Screenerand the Columbia Suicide Severity Rating Scale (C-SSRS)”^35,38

9. Ensure the effectiveness of the training program by involving all the staff members from physician to volunteers and recreating potential events according to the risk profile of the facility. Actual situations can be imitated by role play to teach defensive maneuvers and restrain techniques. Staff training and awareness are critical components for ensuring workplace safety.

10. Hospital administrators should regularly conduct workshops as a source of open ended communication between the staff demonstrating their stand against any kind of violence and encouraging them for reporting every instance of violence. 

11. Crisis debriefing after a violent event to review and process the event is an effective tool for providing emotional support to the staff and helps reduce time to get back to work. Post crisis management expert can also be used depending on the severity of the incident.