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Design Guidelines for High-Risk Patients in Hospitals


April 1, 2016

Protecting your hospital from high-risk patients

Editor's note: This Q&A was taken from the January 2016 HCPro webcast, "Patients With High-Risk Behaviors: Keeping Your Facility and Workers Safe" with hospital security expert Jeff Puttkammer, M.Ed., vice president of healthcare security for HSS, Inc., Denver. To listen to the full program on demand, check out the HCPro Marketplace at http://hcmarketplace.com/patients-with-high-risk-behaviors.


Q: How big of a problem is patient violence from high-risk patients?


Jeff Puttkammer: The unfortunate reality in this day and age is that hospitals and healthcare staff in particular are not in a neutral free zone. Hospitals are not immune to violence and because of that fact alone, the challenges to healthcare staff are unique and there are many. And they are challenges most other industries don't typically face. There's some very unique challenges or cultural challenges to healthcare employees that amplify a number of these challenges. For example, 'Do no harm' is just one example of an industry statement which can lead to confusion when it comes to providing patient care and also concerning staff safety or personal safety. And we've seen more than enough incidents where staff consider violence to be just part of the job. Where staff view the injuries sustained to them or even to their coworkers as unavoidable and they simply write it off due to the patient's medical or mental condition. The one unfortunate disconnect with this is that healthcare professionals are not typically trained to think in terms of their own personal safety and at the same time, focusing on providing patient care.

And so as an industry the trend is to think of healthcare providers as do no harm and prevention and nurses and doctors or caregivers and that they're the good guys. And that's the truth. And the good news is we are the good guys but as a whole, it's tough to appreciate the deeper understanding of the risks that are associated with managing high-risk patients and being able to avoid and manage aggressive and sometimes violent confrontational behavior.

And so as violence in healthcare continues to be on the rise across the country and in fact, globally, you know, we've had a number of opportunities to meet with healthcare leaders from a number of countries?Canada, Asia, Europe?and they all face similar challenges. This is not unique to the U.S. But the unfortunate truth is you don't have to look very hard to find a news story highlighting the issues of violence in healthcare. The good news though is that because of these news stories, a lot of organizations are paying more attention, and many organizations are starting to address these issues.


Q: What are the effects of aggression in healthcare on care providers?


JP: While we often focus on the aggressive act itself, we do sometimes lose sight of the impact that violence has in the workplace in terms of disruption to productivity and to employee morale. And the scars of aggression from just constant daily verbal attacks are no less real than they are from a physical attack. Certainly hospitals can and most of them do measure the financial impact from workplace violence; however, there are some less obvious negative outcomes which are also associated with workplace violence and may not be as easily measured.

What we're talking about here are things like the impact on relationships, both inside of work and outside of work, with your spouse, with your children, other relatives, impaired concentration of staff members on the job, and all of these things can lead to reduced focus on patient care. And of course, we see the measurable increases in absenteeism and turnover. In fact, one organization we work with, they're able to directly attribute nurse turnover; 25% of their nurses leave and they indicate such that they leave the organization because they don't feel safe working in the environment, which is a huge issue for this particular organization.


Q: What types of events and factors tend to put staff and facilities at risk?


JP: For the most part, emergency departments weren't originally designed to treat or house behavioral health patients, and that seems to be one of the bigger issues we're dealing with when it comes to high-risk or at-risk patients. These EDs weren't designed to house these patients for any length of time, and equally disturbing is the fact that many ER staff aren't trained to provide long-term care for behavioral health patients. What we're seeing across the country is a general trend where behavioral health patients are staying longer in the emergency department, and spaces, of course, aren't designed to house behavioral health patients for any length of time. This tends to present a unique problem for us and what we end up seeing in the current state is a combination of unsafe workplace practices, an unsafe workplace that relates to environmental design, and then that tends to lead to reactive tactics by staff who maybe lack the proper training or the appropriate training, and it goes back to the confidence question as well. Staff just don't have confidence in their own ability to manage. So they resort back to something, a technique perhaps that is ineffective in the emergency department environment when dealing with an at-risk or high-risk patient. The role conflict problem stems from really the internalization of patient care provider and personal safety specialist. So it's a combination of these four or five things that really bring us to our current state and provide a unique challenge for both staff and for our facilities.


Q: Do you think healthcare organizations need to invest in more training resources for their staff?


JP: I think we can all agree that organizations who invest in their people, that the data tends to show that those organizations are more profitable, have higher productivity measures, have higher employee and customer engagement and customer service measures. One of the biggest risks that we see when it comes to managing high-risk patients is organizations that don't invest enough resources, whether it's time or money or equipment into training their staff. They simply don't provide their staff with the skills and the tools they need to successfully manage their unique patient population, those at-risk or high-risk patients. I'm guessing almost every healthcare organization trains their staff to respond to fire alarms and in healthcare, this is something we've trained for years and years and years but for an event that more than likely will not occur. But the data suggests more than half of our hospital staff have been or will become victims of violence, whether it's verbal or physical, in the next week. And so without adequate training, generally staff are generally less confident in their own ability to keep themselves safe which then, of course, can lead to staff injuries and patient injuries and again, ultimately turnover and then potential litigation as well.


Q: Do you have any suggestions for preventing security problems with high-risk patients through facility design improvements?


JP: We often start with the concept known as Crime Prevention Through Environmental Design or (CPTED) when we talk about strategies to manage at-risk or high-risk patients. CPTED is really nothing more than using the environment to your advantage and is comprised of three elements: surveillance, access, and territoriality. Surveillance is really nothing more than just the placement of physical fixtures which maximize visibility and really what we're looking for is a clear line of sight. The concept of access control is simply managing who should be in and who should be out. It's nothing more than taking steps to clearly differentiate between public space, semi-public space, private specific, patient care areas, etc. And we do this through combinations of environmental controls and design, architecture, etc.

Territoriality means the ownership of the space. An owned space generally creates a sense of safety and it also is an environment where strangers and those that might be prone to violent outbursts stand out more easily and they're more easily identified. That could be through the use of gowning a patient, for example, or of course, through the use of signs and even hospital ID badges on staff.

It could be a nurse in a uniform. It could be a security officer in a uniform or some other hospital employee in a uniform, but it presents the sense of territoriality that this space is safe for visitors, patients, and staff. And then you see the application of technology with these monitors. So when visitors or patients walk into the emergency department here, they recognize right away that security is a concern; staff safety is a concern and the organization has taken steps to ensure that.

Equally important of course, though, is we've got to have staff members communicating with the patients because communication is a huge benefit, a really effective technique to help reduce the risk and manage high-risk patients and their escalating behavior.

When we start talking about environmental controls, what we're talking about here are the way patients, visitors, and even staff members to some degree flow through the environment. We've got access control doors, badge readers, and appropriate lighting, having the appropriate signage to direct visitors and patients, where to go, you know, where is Room 6 and not having a visitor wander the halls aimlessly, especially if they might be deemed not so much a high-risk patient but perhaps an at-risk individual. Security presence also starts with staff confidence. That ties back to staff training.


Q: Is there a trend for using escalated use of force or defensive equipment such as Tasers and hand guns to help combat violence in healthcare?


JP: I wouldn't classify what we're seeing in terms of an increase in the use of Tasers in healthcare settings as a trend just yet. What I would say is we're seeing as more of a trend is more and more organizations, hospital administrators, and risk managers wanting to learn more about the Taser device in particular, as well as other use of force options that they might have available to them to help combat the problem of violence in healthcare. And so the use of a Taser device is more often used by security staff or law enforcement, not necessarily by medical staff. But we are seeing an increase in administrators who are looking for answers to their problems, and Tasers certainly present a tool that many are considering.


Q: I've heard a lot about metal detectors in healthcare and that sort of thing. So we're wondering, how common is metal screening in healthcare, and is it limited to just the emergency department or have you seen it in other areas of the hospital?


JP: That's a very fair question and I think the answer is it depends on a number of factors. It depends on where you are in the country. It depends on the trauma designation of the hospital. And it depends on the geographical location within inter-city hospital or rural hospital, etc. And so I guess that's the easy answer. Where we see it most often are in high crime areas?Level I trauma centers are fairly typical and large facilities that can staff it because the other consideration, I'll share with the audience for those considering metal detection, is there's a general rule is you would not want to put a metal detection piece of equipment in your ED, for example, and not have it staffed or manned by anybody. And so there are considerations from a cost perspective, from a staffing perspective, but again, I guess my answer is similar to the previous answer; it does depend on where you are in the country, but we do see more and more administrators seeking information about the pros and cons of using metal detection.


Q: It is important to note that only staff in certain areas such as the ED and behavioral health are required to take special training in our facility. Of those staff, 75% to 100% are compliant and in most cases, the rest of the staff do not have such training. There is a lot of hospital staff that don't have the right kind of training that they need to deal with patient violence. Maybe you could talk a little bit about that.

JP: Sure. I think it's a very astute observation and a very fair comment. Emergency departments, intensive care units, and other high-risk areas tend to devote more resources to training their staff to manage aggressive and combative patients in behavior and that's also the challenge and the opportunity for organizations. I'll give you an example. In an emergency department, it's not uncommon to have the ER nurses go through some type of violence training program. What's less common though is to have the physicians go through that same program as well as have food services and environmental services or housekeeping go through that training program. And so what we often see, as you can imagine, a food service employee walks into a high-risk patient care room with no training whatsoever. The same thing is true with a number of our physicians who typically don't go through the same level of training as perhaps nurses do. So I think that's a very fair observation.


Q: What visible indicators have you seen used to help care providers and others identify high-risk patients?


JP:There's so many shared best practices out there. Let me start by saying identifying high-risk patients and then communicating that information to staff is part of the administrative controls and the work practices that we would advocate that help staff do their jobs more safely and ultimately focus on patient care. And so we've seen a lot of various types of indicators staff may use to help identify high-risk patients, and then just as importantly, the communication and sharing of information amongst their team and their staff. And so I do think it's important though to note that not all indicators need to be exclusively visual. Depending on the circumstance, there might be an audible indicator as well. And so, for example, for those hospitals that use a code announcement such as a "code green response," it's often used as an audible indicator that's used to communicate an awareness level to responding staff. So that's an audible type of indicator.

Visual indicators are more common admittedly and we've seen a lot of common methods for identifying and communicating high-risk patients and the nature of the high-risk patient. I think I mentioned the colored gown earlier. That's one technique that a lot of hospitals use to help communicate to staff members. Of course, the gown is attached to or associated with a unique policy or procedure related to the management of high-risk patients and their unique care plan. Other examples may include staff notes made in the patient record. Typically, that's an electronic type record where maybe the patient's record is flagged. This is important obviously for shift change or a change in staff member or a change in nurse. Having that information fairly readily at the disposal of the staff member can certainly help staff members in identifying those high-risk or at-risk patients.

And then maybe some of the less obvious ones. We've seen facilities, they actually make a magnet, a colored magnet and they may place the magnet on the edge of the door frame leading into the patient's room. Staff are visually alerted to the fact that, okay, this is a high-risk patient. And then that would trigger the response from the staff member then, before they walk into the patient room not knowing what that issue might be, they might go look at the patient chart or talk to another staff member to see what the exact issue might be.

Design Guidelines for High-Risk Patients in Hospitals

Security in the Emergency Care Setting


Healthcare Facilities (HCFs) that provide emergency care have special security needs and should have a security plan specific for that department.


a.The plan should be based on identified risks for the emergency department including volume, types of patients treated and incident activity, and community demographics.

b.The security administrator should be involved in the planning and building phases of emergency department construction and renovation as a resource relative to security design issues.

The emergency department waiting area should be separated from the emergency department treatment area and be self contained to include independent access to restrooms, telephones, and vending machines.

Access controls should be in place to control and limit access of emergency department visitors into the Emergency Department (ED) treatment area and into the main hospital.

A room or area within the emergency department, separate from other patients, should be available for the treatment of behavioral/mental health or other high-risk patients. Consideration for this room should include visibility by staff and the removal or securing of items that could be used by the patient to injure themselves or others (written in accordance with IAHSS Guideline 09.06 Behavioral/Mental Health General).

The ambulance entrance should be separate from the walk-in entrance and waiting room.

c.Security staff provides support services in the care and control of the ED. These services are to be provided at the request and under the direction and supervision of clinical staff unless circumstances require immediate action to prevent injury or destruction of property (written in accordance with IAHSS Guideline 02.04 ? Security Role in Patient Management).

d.Security equipment and systems to protect staff and patients should be in place. These may include electronic access control, video surveillance, and duress alarms. The emergency department should be capable of being rapidly locked down in event of an emergency. Drills should be conducted to exercise the lockdown process.

e.Physical measures and/or procedures should be in place to deter the elopement or removal of patients at risk of harming themselves, others, or of being harmed.

f.Emergency department staff (including security) should receive ongoing training in workplace violence, and aggressive/violent patient management to recognize, avoid, defuse, and respond to potentially violent situations.

g.Periodic meetings, at a minimum annually, with multidisciplinary staff, should be conducted to review security protocols and resolve security issues within the emergency care setting.

h.Policies, procedures, and training programs should be established for security's role in managing high-risk patients including patient watches, holds, searches, and application of patient restraints.


Patient Elopement


Healthcare Facilities (HCFs) providing inpatient services will develop a multidisciplinary procedure for preventing and responding to patient elopements. The procedure should distinguish between elopements; wandering; and leaving "against medical advice" (AMA).



Elopement (referred to in some locations as absconding) is generally defined as a patient incapable of adequately protecting him- or herself, and who departs the HCF without the knowledge and agreement of the clinical staff.

Wandering refers to a patient who 'strays' beyond the view or control of clinical staff, causing concern, but without the intent of leaving.

Leaving against medical advice (AMA) is determined by the patient's decision to leave the facility after being informed of and understanding the risks of leaving without completing treatment.

b.Elopement Prevention procedures are generally a clinical responsibility, and should include:

Assessing each patient's elopement risk during the admission process and reassessing such risk, as indicated, during the patient's stay.

For patients at a high risk of elopement, steps should be taken to minimize the likelihood of a successful elopement such as:

Assigning such patients to rooms nearer and more visible to clinical staff.

Requiring such patients to wear a patient gown that may be of a distinct type or color.

Additional measures may include assignment of a sitter or use of Radio Frequency Identification (RFID) to track patient location.

A means of identifying patients who are authorized to leave the unit.

c.Elopement Response Plans should address the following:

Clinical staff on duty at the time of a wandering or elopement event will conduct a search of the floor and adjacent areas as indicated and notify security if the patient is not found.

Search of the facility's buildings and grounds. Consideration should be given to assignment of staff working near facility exits. Some HCFs enlist help via an overhead page using a unique code?combined with an email or other mass notification alert.

If the patient is located on the grounds, security should notify clinical staff, and attempt to return the patient to their unit.

If the patient is not located within a reasonable time, law enforcement should be notified to obtain assistance in initiating a wider search.

An HCF employee should be identified to coordinate information sharing and other follow-up with law enforcement.

An HCF employee should be identified to coordinate notification of and coordination with the patient's family.

If the patient returns to the HCF, security should meet with clinical staff to evaluate the status of the patient, and possibly develop a plan to prevent the patient from engaging in another elopement.

In the event of a reported patient wandering or elopement, an Incident Report should be completed (written in accordance with IAHSS Guidelines 05.01-Security Incident Reporting).


Behavioral Mental Health


Behavioral/Mental Health (BMH) patients can pose many challenges and risks to HCFs providing care. These risks can be magnified for patients with medical conditions requiring care in settings not primarily constructed for BMH care. These patients can pose risks relating to self-harm and violence toward others and consume considerable security resources. Legal action, regulatory review, and loss of public confidence in HCFs can result from behavioral mental health incidents.


a.HCFs should implement protective measures that minimize the risks and vulnerabilities posed by this patient population.

b.Design of BMH facilities is an important factor in minimizing risks and vulnerabilities. Recommendations include:

Implementing access control devices and procedures for entering and exiting the facility to help reduce the potential for patient elopement and other safety concerns.

Deploying video surveillance systems to support patient observation and care plan.

Integrating security equipment (e.g., motion sensors, door contacts, duress alarms, cameras, RFID) that notifies staff of potential security vulnerabilities and incidents that may require further visual assessment or follow-up.

Involving security leadership involvement in safety planning for the area including security design and policy and procedure development.

c.Periodic assessments should be conducted of internal and external vulnerabilities. Assessments should include risk to patient harm and possible aids to patient harm; e.g., door handles, shower rods, sprinkler heads, phone cords.

d.Establish procedures that address response to patient elopement, patient restraint, response to combative behavior, seclusion room management, and other security risk situations. These procedures should be incorporated into the training program and reviewed during periodic assessments.

e.Training of clinical and support staff (including security officers) should be conducted jointly. Training reports, drills and exercises, and after action assessments and debriefings of actual incidents should document the results and identify areas for improvement.

f.Establish processes for intake of patients to include assessing patient history to determine previous dangerous behavior, security of patient belongings, patient searches, patient identification, and visitors.

g.Some BMH patient populations require added precautions and visitor control. Visitors to these patients may require additional screening.

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