Best Practices: Frequent violence in the ED doesn't have to be part of the job

Violent patients were inflicting a growing number of injuries on nurses and doctors at Valley Hospital in Ridgewood, N.J., so hospital officials decided to act.

Last year, they adopted a three-pronged strategy to protect nurses, doctors and other hospital staffers. The hospital stepped up training, created a special de-escalation unit with teams on call 24/7 and purchased mobile alert tags that staff could secure to their badges or lanyards and discreetly notify the unit in situations of duress.

“This was a holistic approach to workplace injuries,” said Daniel Coss, director of security and public safety at Valley Hospital. These protective measures focused on the emergency department, where staff are especially prone to injuries.

More than three-quarters of emergency physicians experience at least one violent incident at work annually, according to the American College of Emergency Physicians.

A survey conducted by the Emergency Nurses Association in 2009 found that a quarter of emergency nurses had experienced physical violence more than 20 times in the past three years.

Education and training are vital in preventing and dealing with these incidents.

“You can recognize signs of incipient violence and mitigate it,” said Lisa Wolf, director of the Institute for Emergency Nursing Research at the Emergency Nurses Association, who was not involved in Valley Hospital's efforts. “Awareness training is a great idea,” she said, because violence in healthcare settings is common, yet all too often is regarded as merely part of the job rather than a problem to be addressed.

The de-escalation unit, dubbed Code Atlas, consists of 90 specially trained staff. At least four people are always on duty, ready to be dispatched to any location where a patient is being disruptive. The number of respondents varies from as few as three to as many as 12.

Nurses, physicians, patient-care technicians and registrars were also given the option of receiving a wearable alert tag.

When a staffer presses the button on a tag, it transmits a silent alert to security and the charge nurse, so that security or Code Atlas can move in, said Rebecca Young, an emergency department supervisor at Valley Health System. Security can also trace the staffer if he or she moves.

Of about 270 emergency department staffers, about 170 opted in. “Some felt that they could take care of themselves,” Young said. Others disliked the idea of being tracked.

Part of the beauty of the system was that it did not alert the patient and potentially exacerbate the situation. If a nurse fiddles with her lanyard in order to press the panic button on the mobile tag, “no one knows,” Coss said.

Wolf said a personal alert badge system has potential, especially because it makes the wearer traceable. But she raised concerns that the lag between the alert and the arrival of help could be too long.

In 2012, Valley Hospital saw 22 workplace injuries hospitalwide. The number rose to 45 the next year and then 55 the year after that. In 2015, when efforts to protect nurses and doctors kicked in, the number dropped to 26. So far this year, Valley Hospital has seen 27 incidents.

Nurses also felt safer. Asked whether they felt safe at work in a September 2015 survey, before the hospital launched emergency preparedness measures, about half said they did. That proportion rose to about 90% in June 2016.

The benefits of defusing potentially violent episodes go beyond preventing injuries. “The quicker that we can negate a threat and we can get rid of a situation, the quicker we're able to move on to the next patient,” Young said.

Violence can also drive nurses to consider quitting the profession. “To have conditions such that nurses are leaving both emergency departments and emergency nursing altogether means that patient care is going to suffer,” Wolf said, “because experience is going to walk out the door.”