Practice Economics

Hospital Violence Hits Home


Hospitalists could hardly be faulted for wondering: Am I safe? After all, the inpatient setting can be a tense place, and it’s where hospitalists work day in and day out.

David Pressel, MD, PhD, FHM, a pediatric hospitalist and medical director of inpatient services at Nemours Children’s Health System, which has locations in Delaware, New Jersey, Pennsylvania, and Florida, says it’s no wonder violence can erupt in the hospital setting.

“Violence is an issue in hospitals that is a reflection of our society, unfortunately,” says Dr. Pressel, a member of Team Hospitalist. “And it happens because these are very stressful places where people’s behavior can get outside the norm given the stress of the problems.”

Dr. Pressel, in collaboration with many others, has developed a workplace violence prevention program at Nemours aimed at de-escalating situations to avoid physical violence. The program teaches providers how to respond when something violent does happen. It’s a tiered training regimen that involves more training for those most involved in handling violent situations.

Dr. Pressel is no stranger to violence himself. Although he is a pediatric hospitalist and his patients are younger, some adolescent patients can have the physical presence of adults and pose just as serious a threat. He said that before the training program was put into place about a year ago, an episode of violence every month or two would require a patient to be placed in restraints.

“Staff has been hurt,” he explains. “I’ve been bitten twice by a patient. I have a scar on my arm that will be with me for life from one episode.”

A Slow, Disheartening, Upward Trend

Whether violence in hospitals and medical facilities is really a growing problem—or whether awareness of the issue is simply greater given these recent, high profile incidents—is not entirely known.

But according to the latest figures available from the Bureau of Labor Statistics (BLS), provided by the Occupational Safety and Health Administration (OSHA), violent incidents in hospitals did appear to be on the rise through 2013. The number of hospital assaults rose from 5,030 in 2011 to 5,500 in 2012 to 5,660 in 2013.

The number of assaults rose across all private sector industries over that span, but the percentage of those assaults that occurred in hospitals grew greater during that time—an indication that hospitals might be getting more violent at a faster pace than other workplaces. In 2011, according to BLS data, 21.4% of all assaults in private sector industries occurred in hospitals. That number rose to 21.8% in 2012 and to 22.1% in 2013.

According to the 2014 Healthcare Crime Survey, published by the International Association for Healthcare Security and Safety (IAHSS)—an organization of hospital security officials and administrators—violent crime at U.S. facilities rose from two incidents per 100 beds in 2012 to 2.5 incidents per 100 beds in 2013. That category includes murder, rape, aggravated assault, and robbery.

Assaults rose from 10.7 incidents per 100 beds in 2012 to 11.1 incidents per 100 beds in 2013.

BLS data also show that more injuries in hospitals are due to assaults compared with the private sector overall. In 2011, 2.6% of all private sector injuries were due to assault; in 2012, the number rose to 2.8%; and, in 2013, it was 2.8%. In hospitals in 2011, 8.6% of all injuries resulted from assaults. That percentage rose to 9.5% in 2012 and to 9.8% in 2013.

“BLS data show that nonfatal injuries due to violence are greater in the healthcare/social assistance setting than in other workplaces,” an OSHA spokesperson says. “Assaults represent a serious safety and health hazard within healthcare, and data indicate that hospitals comprise a large percentage of workplace assaults.”

Incident Prevention

Programs aimed at preventing violence can reduce these incidents.

“How well prepared hospital workers are in dealing with violent situations depends on the workplace violence prevention program implemented at a facility,” the OSHA spokesperson says. “Some states have passed legislation that specifically requires workplace violence prevention programs in the healthcare setting.”

These programs should address management commitment and employee participation, worksite analysis, hazard prevention and control, safety and health training, and recordkeeping and program evaluation. These elements should be assessed regularly, with changes made to respond to changing conditions, OSHA says.

A large number of OSHA inspections in the healthcare setting occur because of complaints regarding lack of protections against workplace violence. In 2014, the agency did 35 inspections in response to such complaints; 25 of those were in a healthcare setting, with 12 specifically at hospitals. As a result, five citations were issued, all of which were in healthcare, including two at hospitals.

Last year, Brookdale University Hospital and Medical Center in Brooklyn, N.Y., was fined $78,000 after an OSHA inspection found 40 incidents of workplace violence between Feb. 7 and April 12. They included employees who were threatened or verbally or physically assaulted by patients and visitors or while breaking up fights between patients. In the worst attack, a nurse sustained severe brain injuries.

The bulk of the hospital’s fines came as a result of a willful violation—an intentional or voluntary disregard for laws meant to protect workers against hospital violence.

You have to do a vulnerability assessment, and you specifically have to look at your demographic. You specifically have to look at what is the history and the culture of the facility [to determine a hospital’s specific risk factors]. —David LaRose, president, IAHSS, director of safety, security, and emergency management, Lakeland Regional Medical Center, Florida.

While data from IAHSS and the BLS show an increase in hospital violence, those national figures aren’t as important as what is happening at your own facility, says David LaRose, MS, CHPA, CPP, the president of IAHSS and director of safety, security, and emergency management at Lakeland Regional Medical Center in Florida.

“You have to do a vulnerability assessment, and you specifically have to look at your demographic,” he says. “You specifically have to look at what is the history and the culture of the facility” to determine a hospital’s specific risk factors.

Although it’s crucial that a hospital track its own statistics on violence, that’s not to say that incidents elsewhere are irrelevant.

“You also want to look at what’s happening in the real world,” he says. “Somebody else’s unfortunate (occurrence) is a learning experience for my system, so we can try to be proactively preventing that.”

Educate, Recognize, React

At Nemours, Dr. Pressel didn’t develop the training in response to a perceived rise in incidents there. It was apparent, he says, that deficiencies in readiness needed to be addressed.

In the Nemours program, every staff member with some level of patient care responsibility gets basic training in aggressive child emergencies: identifying these situations, responding appropriately, and keeping safe. This group includes doctors, nurses, and nurse’s aids. The training involves actually playing out scenarios of violence, with staff members attempting to subdue a would-be attacker.

Depending on the job, each worker receives extra training that is specific to the role he or she would play in handling violent scenarios.

The training is designed to help individuals respond to such situations with “the same alacrity and acuity as they would respond to a Code Blue,” Dr. Pressel says. “Drop what you’re doing and run. These events are dangerous. That’s what they teach people. They’re dangerous and they’re scary and they’re chaotic, just like a Code Blue. That’s how people need to treat it.”

The goal is to de-escalate a situation, verbally or physically, without more aggressive means. But if that doesn’t work, physical restraints, medication, or both are used.

Throughout the medical field, training in this area is scarce, Dr. Pressel says. In nursing school and medical school, “for the most part, it’s zero,” he says.

“If you’re in a psychiatric facility, these events happen,” he adds. “And then you get a lot of enhanced training.” But, he notes, “I had no formal training until I became tasked with dealing with this.”

Since the program was implemented at Nemours, it seems to have worked.

“We have had many of these episodes that have been resolved by verbal de-escalation, as opposed to physical restraints or medication,” he says.

His hospital has also made other changes. The facility used to have multiple entrances and exits that were unsecured, and anybody could walk into any unit “with no challenge whatsoever.” Now, everyone entering has to pass hospital personnel. And, to get into a patient unit, visitors have to check in and be issued a photo ID. Also, in response to an incident in 2013, the hospital now has “constables” who are trained and licensed to carry firearms, Dr. Pressel says.

Above all, he notes, is personal safety. If you yourself are hurt, you won’t be able to help anyone else.

“That’s absolutely the first thing that people hear, the last thing that people hear, and it’s repeated over and over again,” he says.

Both Dr. Pressel and LaRose say that even with the drumbeat of high profile incidents, they haven’t heard from colleagues that health professionals are concerned about people losing interest in entering the field or are feeling burned out because of safety concerns. Being prepared is the key, and the level of preparedness varies by facility, LaRose says. The IAHSS provides security and healthcare safety guidelines at

“We recognize that we are in an occupation that tends to be on the receiving end of more aggression and more violence than the average worker,” LaRose says. “Therefore, how proactively does the organization or the institution take that knowledge and provide the tools and the training to the staff?

“What can we do as a team to increase our sense of security and safety and make this a great place to continue your career?”

Tom Collins is a freelance writer in South Florida.

The stories send chills through the healthcare world:

  • A patient at Mercy-Fitzgerald Hospital outside Philadelphia shoots and kills a caseworker and injures a psychiatrist; the gunman is shot when the psychiatrist returns fire.
  • A patient at St. John’s Hospital in St. Paul, Minn., grabs an IV pole and rampages through a unit beating nurses with the pole, leaving one with a collapsed lung and another with a broken wrist.
  • In January, a man asks to see a cardiologist at Brigham and Women’s Hospital in Boston, then shoots and kills the cardiologist when he enters the exam room.

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