by Neel B. Shah, MD, FACP, FACMG, SFHM
Assistant Professor of Medicine, Mayo Clinic

Perhaps the most troubling aspect of current events in our country is the increase in mass violence. And unfortunately, the health care environment is not immune to societal trends.

In fact, despite frontline health care workers dedicating themselves to healing all with no consideration for factors such as creed, ethnicity, nationality, political affiliation, sexual orientation or social standing, the Occupational Safety and Health Administration has found that we suffer from an ‘overall higher rate of workplace violence than all other workers’. Then you should factor in that workplace violence is underreported in all sectors, but in health care we further minimize patient accountability by conflating our responsibility to patient wellbeing with concern that patients might suffer consequences, legal or otherwise, should staff file a factual report.

One of the first necessary steps in coming to grips with any quality and safety opportunity is developing and collecting accurate metrics. However, a reporting culture does not emerge overnight in an organization. To help foster one, you need to co-opt leaders to the view that protecting the staff who treat the patients is beneficent to the patients as well.

Aggressive patients jeopardize their own care if nurses are too afraid to work with them, or if physicians simply decide to “fire” them and pass them on to someone else. This philosophy counteracts the moral distress that might arise from filing reports on those for whom we are supposed to be caring. In an industry with countless metrics, it is inevitable that they sometimes overlap, and even contradict, one another. The philosophy of protecting staff, in order to improve patient care can also redress any staff perception that management is torn between a need to prioritize patient satisfaction scores over staff safety.

One point is clear, health care-associated violence is widespread and intersects multiple professions and specialty boundaries. Therefore, in our ever more complex health care systems, we need to develop coordinated solutions to protect our staff. And it won’t be one size fits all. An autistic adolescent whose caregivers bring him to the ED in a behavioral crisis has very different needs from one in a clinic who gets agitated in unfamiliar situations but is currently doing well and only there for a checkup.

First, the entire health care team has to operate on the same page. That includes nurses and physicians, but also social workers, security personnel and administrators. Recognizing patients with complex behavioral needs can help focus attention. Clear, structured handoffs for violent patients, as well as door and EMR alerts facilitate communication among staff. Safety plans can be developed that also incorporate patient input, empowering them with a stake in their care plan. De-escalation and violence simulation training leads to both improvements in staff safety, as well as to their perception of safety, and can be directed to areas with the greatest need.

Technology has always had a major role in advancing the quality of our care, but the availability of cameras in every pocket has not yet made it to every hospital room or clinic. Medication storage units often allow overrides for staff to access various drugs based on verbal orders, without the usual pharmacy checks. Ensuring drugs for violent agitation can be given rapidly in this way can help staff deal with the methamphetamine epidemic they face every day.

The design of our facilities provides another area of great opportunity. We ask staff to place mandatory holds on patients, implying that they should place themselves between the patient and the exit to prevent subsequent elopement. Surely the option of a locked area for those patients who staff anticipate might be willing to harm someone in the attempt would improve the morale of frontline workers, along with their willingness to do their best for all patients. When we look at securing our campuses, which can sprawl across numerous buildings, with access points for ambulances, outpatients, staff, and deliveries, we need to make sure that we can restrict access to specified doors and, ideally, identify visitors before they reach a patient area.

Closer examination of violent events can determine that they are not as random as they initially appear. Leadership needs to be involved in analyzing the contributing factors, and show the staff how they intend to prevent the next incident. There are also other regulatory issues for which we are already scrutinized , such as restraint and seclusion use, where the justification for regulatory oversight is readily appreciated. Nevertheless, to be 100% compliant requires joined-up efforts to manage both the practice and documentation (which can be more problematic in the EMR era).

An array of tools to address all the multiple facets are available and can prove very successful in reducing staff injuries, lost work days, attrition and security calls. But it can also improve the mainline metrics of ED throughout and hospital length of stay, and staff perception of safety. And health care workers who feel protected are those who will go the last mile for their patients.

About the author. Dr. Neel Shah is a consultant hospitalist at Mayo Clinic in Rochester, Minn. He is interested in hospital safety and was involved in the conceptualization and implementation of the Complex Intervention Unit (CIU), and now serves as medical director of the CIU and the Behavior Emergency Response Team. Mayo has developed a comprehensive violent patient program that continues to incorporate more specialties, as well as the outpatient practice. Dr. Shah leads the Mayo Clinic Workplace Violence Prevention & Mitigation Committee, and his team has also developed a Healthcare Violence Prediction Tool.

Dr. Shah studied medicine at the University of Edinburgh and completed his internship at the Manchester Royal Infirmary in the United Kingdom, before an internal medicine residency at the University of Illinois at Chicago and a fellowship in medical genetics at Mayo Clinic Rochester. He is currently studying for his master’s degree in health professions education at Johns Hopkins University.

Published: May 23, 2019