Emergency departments and high-risk units

Every unit in a hospital has some risk of violence, but two kinds of unit carry far more than the rest: emergency departments and inpatient mental health units. Northbridge's emergency department sees about 38,000 visits a year through its 26 stretchers, and its 16-bed mental health unit admits people in acute crisis, some of them against their will. Together, these two units account for almost half of the hospital's reported violence. This lesson looks at why they are high risk and at the controls, many of them described earlier in the course, that are combined there most intensively.

Why emergency departments are high risk

Almost everything that raises the risk of violence comes together in an emergency department:

• People in crisis: pain, fear, injury, intoxication, withdrawal, psychosis, suicidal thoughts and grief, often at night.
• Long waits: crowding and waits of many hours, often with little information, in uncomfortable rooms.
• Little information: staff often know nothing about a patient's history when they arrive, so flags and risk scores are not yet available.
• Open access: the department is open to anyone, at all hours, often with family and friends who are frightened or angry.
• Patients held against their will: people brought by police or held for mental health assessment, who may not want to be there.
• Busy, rushed staff: frequent interruptions and little time to notice early warning signs.

Joanne's review of the past year's reports from the emergency department shows how incidents cluster by time of day. Her script groups them into four-hour blocks and marks the busiest.

from collections import Counter

hours = [23, 1, 2, 0, 22, 14, 3, 1, 23, 21, 2, 0, 19, 1, 22, 4, 23, 16, 2, 0,
         1, 20, 23, 2, 11, 0, 22, 3, 1, 23]
blocks = Counter(h // 4 for h in hours)
for b in range(6):
    n = blocks.get(b, 0)
    label = f"{b * 4:02d}:00-{b * 4 + 3:02d}:59"
    print(label, "#" * n, n, " <- busiest" if n == max(blocks.values()) else "")

00:00-03:59 ############### 15  <- busiest
04:00-07:59 # 1 
08:00-11:59 # 1 
12:00-15:59 # 1 
16:00-19:59 ## 2 
20:00-23:59 ########## 10

Most incidents happened between 2000 and 0400, when the waiting room is full of people who have been there for hours, alcohol-related visits peak, and staffing is lowest. That pattern drove most of the changes below.

Controls in the emergency department

Northbridge redesigned its emergency department's approach over two years, using the hierarchy of controls:

• Reducing triggers at the source: a rapid assessment area so that patients are seen by a clinician sooner; regular rounding in the waiting room by a nurse who updates people on waits and checks for deterioration; a screen showing approximate wait times; water, blankets and phone chargers; and a quiet area for people who are distressed.
• Engineering controls: a security post at the entrance; metal detectors at the public entrance at night; badge-controlled doors between the waiting room and the treatment area; a triage desk with a glass screen and a panic button; two secure rooms for patients in mental health crisis, designed without fixtures that could be used as weapons or ligature points, with outward-opening doors and windows; and a staff retreat room with a lockable door.
• Administrative controls: a flag lookup at triage, so that a returning patient's flag appears the moment they are registered; a risk screen at triage for every patient; a rule that any patient scoring high or flagged is seen by the charge nurse and security is told; two staff for care of patients scoring very high; security officers who join huddles and know the patients; and a visitor policy limiting the number of people with each patient at night.
• Training: all emergency staff, including physicians, registration clerks and housekeeping, complete de-escalation and team response training, with mock codes four times a year.

After the changes, physical assaults reported in the emergency department fell by about a third over the following year, even though reports of threats rose as staff became more willing to report them. The staff survey showed that staff felt safer, especially at night.

Weapons screening

Screening for weapons at the emergency department entrance is now common in larger hospitals and is spreading to smaller ones. It finds and removes knives and other weapons that would otherwise be carried into the department, and staff report feeling safer. It also has costs: staff and equipment, delays at the entrance, and the risk that it makes the hospital feel like a prison or that some groups are searched more than others. Northbridge decided, with the JHSC and community advisers, to screen at the public entrance from 2000 to 0600, when most incidents happen, and to apply it to everyone entering, including staff without a badge, with clear signs, respectful procedures, a locker system for items that are not allowed in, and regular review of who is being stopped.

Patients in mental health crisis

Many people come to the emergency department in a mental health crisis, some voluntarily and some brought by police or ambulance. In Ontario, the Mental Health Act allows police to take a person to hospital for assessment in certain circumstances, and allows a physician to detain a person for up to 72 hours for psychiatric assessment on a Form 1. The person may be frightened, angry or psychotic, and may have been restrained during transport. Waiting for hours in a busy hallway makes things worse.

Northbridge's approach treats these patients as patients first: a secure room rather than a hallway stretcher; early assessment by the mental health team, including a crisis nurse in the emergency department from noon to midnight; offering food, water, a phone call and an explanation of what is happening; offering medication voluntarily when it is indicated; and keeping security nearby but not standing in the doorway. Police officers who bring a patient stay until a safe handover has been agreed, using a shared protocol designed to shorten their wait.

Intoxication and withdrawal

Alcohol and drugs are involved in a large share of emergency department violence. Intoxicated patients may be disinhibited, impulsive and hard to reason with, and some drugs, such as stimulants, can cause severe agitation and paranoia. Withdrawal from alcohol, a few hours to a few days after the last drink, causes tremor, anxiety, hallucinations and, in its severe form, delirium, and it is a common cause of violence on medical units like 4 West as well as in the emergency department.

The safest approach is clinical as much as behavioural: screening every patient for alcohol and drug use, assessing withdrawal with a standard scale and treating it early according to protocol, giving intoxicated patients a quiet place to settle with regular checks, and watching for medical problems such as head injury or low blood sugar that can look like intoxication. Staff do not argue with a very intoxicated person or try to reason them into compliance; they keep the environment calm, offer simple choices, and wait, with help nearby.

Staffing and the night shift

Many of the controls above depend on having enough people. A nurse who is caring for too many patients cannot round in the waiting room, sit with a frightened patient or notice early warning signs, and a unit with no spare staff cannot send a second person into a flagged patient's room. Northbridge's emergency department added a second charge nurse from 1900 to 0300 and moved one security officer from the main entrance to the emergency entrance overnight. Its staffing request process lets staff ask for extra help when the department is full of high-risk patients and records the answer.

Inpatient mental health units

On the inpatient mental health unit, violence is most likely in the first days after admission, during involuntary admission, when patients are told they cannot leave or have privileges limited, and at times of low structure such as evenings and weekends. Many patients on the unit have themselves experienced violence and trauma, and the unit's approach is built around that fact:

• Trauma-informed care: staff assume that patients may have a history of trauma and avoid practices that repeat it, such as unexplained restraint, being touched without warning, or loss of control over basic decisions.
• Therapeutic engagement: staff spend time with patients doing ordinary things, talking, playing cards, walking, rather than watching them from the station. Patients who know staff and trust them are less likely to be violent, and staff notice changes sooner.
• The Safewards model: a set of ten simple interventions developed in England and used in many Canadian and American units, such as agreeing mutual expectations with patients, calm-down methods, positive words at handover, reassurance after incidents on the unit, and talking down. Units using it have reduced conflict and the use of restraint.
• Restraint and seclusion reduction: a deliberate program, led by senior staff, to use them only as a last resort, to review every use, and to learn from each.
• Staffing and skill mix: enough experienced staff on every shift, and extra staff during known high-risk periods such as evenings.
• A structured day: activities, groups and routines that reduce boredom and uncertainty.

Other high-risk areas

The same principles apply in other places where violence is common. Units caring for patients with delirium, such as 4 West, use delirium screening, early treatment, family presence and consistent caregivers. Birch and the other dementia home areas use the approaches in Lesson 4. Intensive care units, where patients waking from sedation may be confused and pull at tubes, use regular delirium assessment and gentle reorientation. Registration desks, cashiers and the outpatient pharmacy use glass screens, panic buttons and clear sight lines. Each unit's assessment, as Lesson 3 described, picks the controls that fit its patients and its work.