Violence In Hospitals

With complete credit to author Whitney L.J. Howell
This article first appeared in the January 2011 issue of H&HN magazine.

Security issues

Violence in Hospitals

By Whitney L.J. Howell
With attacks against staff and patients on the rise, administrators rethink security policies

Shortly after 12:30 a.m. on Sept. 3, Darrell Garner walked into Baton Rouge (La.) General Medical Center with a gun. He entered the room where his teenage stepson was a patient and argued with his estranged wife, allegedly shooting her in the arm and shooting her boyfriend in the arm and head. Local police responded quickly, but Garner apparently left while doctors and nurses treated the victims. (Ten days later, the suspect turned himself in to local police where he remains in custody.) Authorities put the facility on lockdown, and for hours, most employees got either erroneous information or none at all.

"At that time, we had no way to alert people to what had really occurred," says Edgardo Tenreiro, Baton Rouge General's executive vice president and chief operating officer. "We also hadn't yet thought about having a command center outside the hospital, so when I arrived at 1 a.m., I spent valuable time driving around our campus, trying to find the center location."

After a three-hour sweep of the facility, the SWAT team gave the all-clear and the medical center returned to normal operations.

Hospital administrators recognized that their security policies needed an upgrade. For one thing, Code White—the emergency code Baton Rouge General uses to announce violent patients—was not only inaccurate, but in this case, with a gunman involved, it also could have put at risk employees who responded to assist colleagues. The following Monday, leaders instituted Code Silver to alert staff to the presence of an active shooter.

"With the Code Silver, we're able to tell everyone to get out of harm's way—close patient doors, close doors to the unit, and barricade themselves behind desks," Tenreiro says. "In these situations, we don't want any hospital employee trying to control the individual, and we want to keep others from walking into affected areas."

Traditionally, the public perceives hospitals as places of healing—environments that are antithetical to violence. But recent data reveal a different reality. Shootings at Baton Rouge General, Danbury (Conn.) Hospital, and Johns Hopkins Hospital in Baltimore this year have prompted the health care community to re-examine security policies and procedures.

According to the Joint Commission Sentinel Event Database, 256 assaults, homicides and rapes have occurred in hospitals since 1995. The June Sentinel Event Alert showed a marked spike in activity in the last three years—since 2007, 110 violent incidents have occurred. Joint Commission officials, however, believe hospital violence is significantly underreported.

"Hospital administration makes the decision whether to report incidents, and people don't like to report violence more than they have to," says Russell Colling, a health care security consultant who serves as an adviser to the Sentinel Event Alert. "Many incidents go unreported because they don't fall into the hospital's definition of 'violence,' but others are omitted because officials don't want them to reflect negatively on the hospital's image."

The 2010 International Association for Healthcare Security and Safety crime and safety survey of 212 hospitals found that hospital crime of all kinds is rising. There were 660 aggravated assaults and 2,720 simple assaults in 2009.

Changes in the ways patients and police use hospitals place the facilities at greater risk for violent activity. A 2004 Occupational Safety & Health Administration report for health care providers on preventing workplace violence identified three substantial risks to patient and employee safety: an increased number of mental health patients using hospitals for follow-up care because so many psychiatric facilities have closed or lost beds; a rise in police use of hospitals to hold aggressive and intoxicated individuals; and 24-hour public access to hospitals.

However, neither The Joint Commission nor the OSHA guidelines include a mandate to enact any changes in security.

Not all hospital units or employees are at equal risk, however. Heavy traffic, high stress levels and the types of cases that come in make emergency departments most susceptible to violence. Intensive care units are also vulnerable, Colling says, because of elevated stress levels among patients and their loved ones.

Nurses Bear Brunt

Overall, nurses are the most frequent targets of violence because they have the most direct patient contact. A 2009 study from The Journal of Nursing Administration found that in the past three years, 50 percent of ED nurses experienced some type of physical violence, from shoving, hitting, kicking to being spit upon, and 70 percent experienced verbal abuse. In addition to patient volume and stress levels, the study points to long wait times, a lack of privacy, and anger from patients and family members as contributing factors.

Nurses are not automatically inclined to report abuse, says Diane Gurney, R.N., president of the Emergency Nurses Association. "As nurses, we feel a responsibility to assist patients who need our help, and being involved in these violent incidents has generally been accepted as part of the job," Gurney says. "But this part of the health care and nursing culture must change."

The first step to reduce hospital violence is conducting a risk assessment, says Donna Gates, a nursing professor at the University of Cincinnati. Gates works with the federal government to identify strategies for reducing the number of violent acts in health care environments. As part of an assessment, The Joint Commission recommends hospitals review crime rate records and statistics for the area around the facility and survey employees about their perceptions of risk. All disciplines must be included to identify all areas that need more security.

"Nurses and doctors tell us they want to know what to do when, they want to know what the specific guidelines are, and they want to know when to call security," Gates says. "We have to use their input to move toward a culture of safety."

This type of plan is important because it gathers top-down support throughout the hospital, says Joe Bellino, IAHSS president. By bringing together security personnel, chief nursing officers, ED managers, chief operating officers and local police, hospitals can draft and implement zero-tolerance policies that encourage all staff to report actual and perceived threats.

Data from the Emergency Nurses Association shows that hospitals with zero-tolerance policies are 50 percent less likely than hospitals without one to experience a violent incident.

Hospitals can train their employees based on the results of the risk assessment, Bellino says. Depending on the facility's experience with violent events, employees may require extensive training or they may simply need a refresher course on recognizing initial violent signs or on physical techniques to restrain patients safely. Bellino also suggests allocating funds to have an ED nurse or security officer trained to be a certified safety instructor. He or she then can customize the security information for a specific hospital.

Training employees to de-escalate a potentially violent situation is a hospital's first line of defense, Colling says. Active listening and giving patients and their visitors space can help hospitals sidestep many problems. He suggests all staff uniformly enforce such policies as the number of visitors allowed per patient at any given time to avoid prompting anger or frustration. Hospitals also should reduce the number of access points through which the public can enter.

From Police to Panic Buttons

Bellino says local law enforcement agencies should be involved in planning. "I recommend that all hospitals sit down with their local police to discuss protocols and determine the processes to respond to violence in the hospital, as well as what works best for all involved," he says. "It's optimal to invite law enforcement to the training opportunities for your employees so they know how you respond to these situations, and they learn the layout of your facility."

Sandra Schneider, M.D., president of the American College of Emergency Physicians, says doctors and nurses should become comfortable with requesting a security presence with threatening patients before violence occurs. "It's proactive, if you have a violent patient, to arrive with security and to have the officer with you the entire time," says Schneider. "But make sure the officer knows where his or her resources are and that he or she is adequately trained to quickly subdue a dangerous person."

Hospitals also can use discreet tactics to identify volatile patients and alert staff to take precautions, she says, such as color-coding charts or supplying potentially violent patients with different colored socks. ACEP supports installing panic buttons in case of emergencies.

Technology is an effective tool to prevent violence or counteract an event should it occur. Jane Lipscomb, R.N., a professor at the University of Maryland School of Nursing and an expert in workplace violence prevention, says an architect with safety experience can analyze which hospital units need additional security. The IAHSS also recommended closed-circuit television monitoring of high-risk units, metal detectors at ED entrances and electronic access controls.

The OSHA guidelines endorsed giving staff who work with volatile patients hand-held alarms that can be activated in an emergency and installing shatterproof glass in reception, triage and admitting areas.

The confusion associated with having an active shooter on hospital grounds taught Baton Rouge General two valuable lessons, COO Tenreiro says. Hospitals should establish the location for a command center outside the hospital and ensure all personnel involved in managing a crisis know the location. In addition, hospital officials need a listing of all pertinent land line and cell phone numbers, and the command center should offer Internet access to allow administrators to use such social media sites as Facebook and Twitter to communicate messages to staff inside the facility.

"Most importantly, in a situation like ours where we had an armed person in the building, you must accept that you aren't in control. The cops take over immediately," Tenreiro says. "We served as support resources only."

After a patient shot a nurse at Danbury Hospital, now Western Connecticut Healthcare, in March, OSHA cited the hospital for violence-prevention deficiencies. The hospital has implemented new strategies to better protect staff and patients, says John Lucas, director of security, including a policy posted on the hospital's Intranet home page that outlines responsibilities for the CEO on down. The hospital hired six additional security officers, bringing the total to 34, and placed some of them in the ED that serves both medical and psychiatric patients. Visitors must register at the information desk when entering the hospital and must wear visitor passes.

If a patient begins to exhibit unruly behavior, providers at the bedside may request a security consultation to determine whether the patient poses a threat. If officers identify danger, a patient will undergo a safety assessment—a detailed search of personal effects for any weapons or dangerous items. For patient behavior beyond what hospital security can control, the ED attending physician can request a call to the police by asking for a consultation with "Dr. Blueman."

"In the three months after we implemented the new safety protocols, we've seen a 75 percent drop in reported incidents," Lucas says. "Nine out of 10 conflicts are resolved at the bedside through discussion."

Whitney L.J. Howell is a freelance writer in Durham, N.C.

Facts About Violence

A nationwide survey of emergency nurses between May 2009 and February 2010 found that in hospitals:

97.1% of physical violence was perpetrated by patients and their relatives.
80.6% of physical violence occurred in patients' rooms; 23.2% in corridors, hallways, stairs and elevators; and 14.7% at nurses' stations.
38.2% of physical violence against emergency nurses occurred while they were triaging patients, 33.8% while restraining or subduing patients, and 30.9% while they were performing invasive procedures.
15% of male nurses reported having been victims of physical violence compared with 10.3% of female nurses.
13.4% of violent acts occurred in large urban areas compared with 8.3% in rural areas.
Source: The Emergency Nurses Association's Emergency Department Violence Surveillance Study, 2010

This article first appeared in the January 2011 issue of H&HN magazine.

U. of Illinois at Springfield Offers New ‘Massive Open Online Course’

U. of Illinois at Springfield Offers New ‘Massive Open Online Course’
June 21, 2011, 6:52 pm from: CHRONICLE OF HIGHER EDUCATION

By Marc Parry
What happens when you invite the whole world to join an online class?

As The Chronicle reported last year, a growing number of educators are giving that idea a try by offering free “massive open online courses,” or MOOC’s, to anyone who wants to learn. Today, that experimental idea gained some more traction in mainstream higher education. The University of Illinois at Springfield announced a new not-for-credit MOOC devoted to examining the state of online education and where e-learning is heading. Nearly 500 people from two dozen countries have registered so far, with 1,000 expected to sign up by the time the course begins next Monday.

These courses are part of a small but expanding push toward “open teaching.” Universities such as the Massachusetts Institute of Technology have offered free educational materials online for years, but the new breed of open teachers—at the University of Florida, Brigham Young University, and the University of Regina, among other places—is now giving away the learning experience, too.

The idea for the Springfield course grew out of a presentation called “The Open Future of Higher Education” delivered at a conference this spring by Ray Schroeder, director of Springfield’s Center for Online Learning, Research, and Service.

“The discussions there led me to more deeply consider the path of online learning in this era of a ‘higher education bubble,’” Mr. Schroeder said, referring to PayPal co-founder Peter Thiel’s recent claim that college is comparable to previously overvalued markets in technology and housing. Another influence was the concept of an “Open Educational Resources University,” which, as Mr. Schroeder explains it, involves students learning from freely available materials and then seeking certification of their knowledge from traditional universities.

“I found that many others also were taking stock and questioning where we are headed,” Mr. Schroeder added.

Various online-learning leaders are participating in Mr. Schroeder’s course, which runs through August 19. Not enough MOOC for you? Stay tuned. Starting in September, another group will organize what the MOOC pioneer George Siemens calls the “Mother of all MOOCs.”

In a blog post Monday, Mr. Siemens welcomed the growing interest from traditional universities. And he countered the more skeptical take offered by another open-education leader, David Wiley, who wrote recently that “MOOCs and their like are not the answer to higher-education’s problems.”

“I don’t think I’m overstating it when I say that we are at a similar point to open online learning that we experienced with the growth of the LMS (learning-management system) in the late 90s,” Mr. Siemens wrote. “While some have argued that MOOCs are limited in their appeal—mainly for professional development and highly prepared individuals—I believe MOOCs will continue to be easier to develop and deliver as the growing number of institutions develop pedagogies … and new technologies to run the events.”

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Disaster Warnings

HHS releases toolkit of public health emergency text messages

The Department of Health and Human Services yesterday released a toolkit of prepared cell phone text messages that state and local emergency managers can distribute through their emergency notification systems in a disaster. Many communities have text alert systems for emergency notification. The toolkit currently features text messages relevant to hurricanes, floods and earthquakes, which emergency responders can use as is or tailor based on specific local needs. The messages complement public service announcements for radio and television available through the Centers for Disease Control and Prevention. State and local agencies register to use the toolkit by providing contact information to HHS, so they can receive alerts and updates as the content expands to include health tips for additional types of disasters. Agencies can register by e-mailing publichealthemergency@hhs.gov. Community residents should contact their local emergency management agency to learn whether text message alerts are available in their community and to register if available.

"THE POST-AMERICAN WORLD" by Fareed Zakaria NEW BOOK ANNOUNCEMENT

The Post-American World

Fareed Zakaria (Author)



The New York Times bestseller, revised and expanded with a new afterword: the essential update of Fareed Zakaria's international bestseller about America and its shifting position in world affairs.

Fareed Zakaria's international bestseller The Post-American World pointed to the "rise of the rest"-the growth of countries like China, India, Brazil, and others-as the great story of our time, the story that will undoubtedly shape the future of global power. Since its publication, the trends he identified have proceeded faster than anyone could have anticipated. The 2008 financial crisis turned the world upside down, stalling the United States and other advanced economies. Meanwhile emerging markets have surged ahead, coupling their economic growth with pride, nationalism, and a determination to shape their own future.

In this new edition, Zakaria makes sense of this rapidly changing landscape. With his customary lucidity, insight, and imagination, he draws on lessons from the two great power shifts of the past 500 years-the rise of the Western world and the rise of the United States-to tell us what we can expect from the third shift, the "rise of the rest." The great challenge for Britain was economic decline. The challenge for America now is political decline, for as others have grown in importance, the central role of the United States, especially in the ascendant emerging markets, has already begun to shrink. As Zakaria eloquently argues, Washington needs to begin a serious transformation of its global strategy, moving from its traditional role of dominating hegemon to that of a more pragmatic, honest broker. It must seek to share power, create coalitions, build legitimacy, and define the global agenda-all formidable tasks.

None of this will be easy for the greatest power the world has ever known-the only power that for so long has really mattered. America stands at a crossroads: In a new global era where the United States no longer dominates the worldwide economy, orchestrates geopolitics, or overwhelms cultures, can the nation continue to thrive?
Book Details

Norton Books
* Hardcover
* May 2011
* ISBN 978-0-393-08180-0
* 6.5 × 9.6 in / 336 pages
*
* Territory Rights: Worldwide including Canada, but excluding the British Commonwealth.

Endorsements & Reviews

“Starred Review. Zakaria updates his best-selling earlier vision of world economics and politics, which foresaw the decline of American dominance but reassured us that with that decline came the rise of the rest of the world.” — Booklist

“This is a relentlessly intelligent book that eschews simple-minded projections from crisis to collapse.” — Joseph Joffe, The New York Times Book Review

“Zakaria . . . may have more intellectual range and insights than any other public thinker in the West.” — Boston Sunday Globe

“A provocative and often shrewd take that opens a big picture window on the closing of the first American century and the advent of a new world.” — Michiko Kakutani, The New York Times

“Fareed Zakaria is one of the most thoughtful foreign policy analysts of our day and his new book . . . is a must read for anyone interested in globalization—or the Presidential election.” — Bruce Nussbaum, BusinessWeek

“A far-reaching analysis.” — Slate

“Compelling.” — Thomas Friedman, author of The World is Flat

Multicultural Differences in Healthcare Delivery ... A Quality Issue!

Several of my doctoral students have indicated an interest in focusing research on multicultural differences in health care delivery. I would like to bring to their attention the following article with complete credit to authors; H. Awo Osei=Anto and Cynthia Hedges Greising. The article appeared in the online H&HN magazine, May 2011. hhnonline@healthforum.com
R. E. Hoye



Quality

Using Patient Data to Provide Equitable Care

By H. Awo Osei-Anto and Cynthia Hedges Greising

Most hospitals and health care systems collect patient race, ethnicity and primary language data, but using the data to provide equitable patient-centered care is a challenge for many. Providing equitable care—one of the six Institute of Medicine's Six Aims—is a priority as racial and socioeconomic inequity persists in health care. Leading hospitals are moving beyond data collection to analyzing and using the data to develop targeted interventions for improving care for underserved populations.

According to the 2010 National Healthcare Disparities Report released by the Agency for Healthcare Research and Quality, racial and ethnic minorities continue to receive a lower quality of care, as measured by performance on core quality measures. The 2009 NHDR notes three major implementation strategies to accelerate reduction of health care disparities:

Train health care personnel to deliver culturally and linguistically competent care for diverse populations
Raise awareness of disparities using research and data
Form partnerships to identify and test solutions
Heywood Hospital, a 134-bed, nonprofit facility in Gardner, Mass., is one example of a hospital that has focused on training staff to deliver culturally and linguistically competent care, using data to raise awareness of diversity and potential disparities in care, and using a multidisciplinary team to lead improvement.

Though its geographic area seems to lack diversity, Heywood actively collects and uses racial, ethnic, linquistic and religious data and preferences of its patients. This process has revealed pockets of socioeconomic and minority groups who can benefit from specialized services. In 1999, the hospital established a multicultural task force with representation from executive management, information services, telecommunications, nutrition, plumbing services, mental health, social work and food service. Before 1999, Heywood only provided interpreter services for American Sign Language. In 2002, the hospital developed a program that offers video relay for deaf and hard-of-hearing populations, a phone interpreter and in-house interpretation.

Providing multicultural services has had a tremendous impact, including increasing the number of minority patients and attracting diverse staff and volunteers. Before establishing its in-house interpreter program, Heywood had 56 hospital encounters with deaf or hard-of-hearing patients. Last year, the hospital serviced 1,422 encounters with patients having limited English proficiency, including deaf and hard-of-hearing patients. Once Heywood started providing Spanish interpretation, it received more demand for the service. The hospital now provides interpreter services for Vietnamese, the third most frequently used language by its patients.

Heywood mandates cultural competency training for new hires, and trains staff annually on cultural competency issues. April is diversity month at Heywood, and the hospital educates staff on specific topics impacting various patient populations. The local community respects the hospital and looks to Heywood as a resource for cultural competency issues.

Challenges and opportunities remain at Heywood, including the need for more resources to fund equity efforts and to train staff to provide optimal customer service to all patients. Moving to the next step after identifying trends in patient race, ethnicity and primary language data will involve translating materials into patients' preferred languages, providing specific services for patients, and going out into the community to connect with community leaders and provide education.

For other case studies about hospitals working to provide equitable, patient-centered care, visit the Hospitals in Pursuit of Excellence website at www.hpoe.org and download the report Improving Health Equity Through Data Collection AND Use: A Guide for Hospital Leaders.

H. Awo Osei-Anto is a researcher and Cynthia Hedges Greising is a communications specialist, both at the Health Research & Educational Trust. Visit Hospitals in Pursuit of Excellence at www.hpoe.org to explore these and other topics.

This article first appeared in the May 2011 issue of H&HN magazine.