Emergency Room Violence

There is no doubt that we live in a violent society. Violence in our streets, in our schools and in
our homes is a national emergency and a national shame. Violence in our emergency
departments is becoming increasingly common and lethal. Emergency physicians and nurses are
alarmed and incidences of serious harm or death receive widespread media coverage. ED
personnel are demanding more and more security measures to protect themselves and their
patients. Some staff members are taking safety measures into their own hands and some even
carry weapons with them to work.
Main Points

• Until recently, hospital emergency departments were an oasis in the midst of increasing
violence in society. But violence no longer stops at the doors of an emergency
department; it erupts in the waiting rooms and patient treatment areas.
• Hospital administrations often have been reluctant to address security and safety issues in
the emergency department. Few official data are kept on the number of verbal and
physical threats to health care workers and other employees, so administrators may be
reluctant to commit resources to an ill-defined problem.
• The marked increase in the number of sexual assaults, other assaults (some with resultant
deaths), thefts, and robberies have caused many hospitals to rethink their position on
providing a safe workplace for their employees and safe environments for patients
seeking care.
• In 1995, the greatest number of physical assaults (384) and the second largest number of
homicides (8) occurring in hospitals occurred in emergency departments.

Reasons why there is an increase of emergency room violence

• Overall increase in violence in society (the murder rate has doubled in the last 20 years).
• Increased presence of gangs, particularly in urban, inner-city settings.
• Prolonged waits for patients seeking medical care, sometimes compounded by unpleasant
waiting room environments.
• Increased prevalence of drug and alcohol use in society.
• Increased numbers of private citizens arming themselves due to perceived increases in
violence in their neighborhoods.
• Use of emergency department for "medical clearance" of drug- and alcohol-related
arrests.
• Unavailability of acute psychiatric treatment outside of emergency departments, so the
emergency department provides "psychiatric clearance."
• Distrust of physicians, nurses, and paramedics since they may represent "the
establishment" to some population segments.
Common types of violence in E.R.

According the U.S. Department of Labor, 26 physicians, 18 registered nurses, 27 pharmacists, 17

nurses' aides, and 18 other health care workers were killed on the job between 1980 and 1990.
According to the International Association for Healthcare Security and Safety, 221 hospitals in
America and Canada reported 42 homicides, 1,463 physical assaults, 67 sexual assaults, 165
robberies, and 47 armed robberies in 1995. The greatest number of physical assaults (384) and
the second largest number of homicides (8) occurred in emergency departments.

The following tips to anticipate and manage the incidence of emergency department
violence are:

Emergency departments should develop a plan for managing potentially violent situations. This
plan should include who responds, each person's responsibility (including the team leader), and
the steps that should be taken to respond. Each hospital and emergency department must base its
response to violence on physical location, type of patient population, and history of prior violent
incidents. Some measures that can be taken are:

Train Personnel

• Increase training of doctors, nurses, and security personnel on de-escalation techniques

and "take down" techniques, recognition of potentially violent patients early, and getting
help before an incident occurs.

Secure Environments

• Use 24-hour presence of trained security officers and closed circuit television cameras
with 24-hour trained observers (especially useful in low-traffic areas).
• Place "panic buttons" unobtrusively in several locations of an emergency department.
• Use direct phone lines to security in the hospital or local police departments.
• Control access and egress between the emergency department and other areas of the
hospital.
• Use coded badges for patients and visitors.
• Install physical barriers or bullet proof glass at hospital emergency department entrances.
• Have police dogs available.
• Have stun guns available.

Clues to potential violence

• Behavioral clues
o Posture: tense, clenched
o Speech: loud, threatening, insistent
o Motor: restless, pacing, easily started
• Historical and epidemiologic clues
o History of violence (especially if frequent, serious or unprovoked)
o Threats or plans of violence
 o Symbolic acts of violence
o Young and male
o Social class (lower socioeconomic, urban)
o History of abuse as a child
o Poor job or school record, authority problems
• Kind of Diagnosis. Certain diagnoses are associated with violent behavior:
o Substance abuse: either acute intoxication or withdrawal
o Acute psychoses (especially acute mania or acute schizophrenia)
o Acute organic brain syndrome
o Personality disorders
o Partial complex seizures, temporal lobe epilepsy
• Time of Day. Incidents are more likely to occur on a night shift. 31.8 percent of violent
incidents occurred between 11 p.m. and 7 a.m. while only 13.3 percent of the patient
volume was seen during these hours.
 University of San Carlos
College of Nursing
Cebu City

EMERGENCY ROOM VIOLENCE

Submitted by:

Glyde D. Tugot

BSN 4D

Submitted to:

Christopher J. Taboada, D.M.D., R.N.