Staff and Patient Safety

Educational Objectives

The goal of this program is to improve patient and staff safety in the ED. After hearing and assimilating this program, the clinicians will be better able to:

1. Identify factors contributing to increased overcrowding and violence in the ED.
2. Develop standardized strategies and protocols to manage behavioral escalations in the ED.

Summary

Overcrowding: pre-pandemic data (2017-2019) from Massachusetts General Hospital (MGH) showed a median of 10 to 20 boarded patients waiting ≥2 hr for an inpatient bed; in 2023, this median has increased to ≈50 patients, with peaks reaching 70 to 100 patients; this overcrowding has led to extended patient stays of 20 to 22 hr (or longer) before an inpatient bed becomes available; this leads to the necessity of providing care to new patients in spaces not generally used for patient care; extended boarding times are not limited to patients with medical issues and include patients with behavioral, substance use disorder, and psychiatric issues; patients with these issues are often less medically acute and therefore more likely to be boarded in hallways and other chaotic environments for extended periods

Alarm fatigue: in the MGH emergency department (ED), alarms are almost constant, with only ≈1.4 alarm-free hr in a 24-hr period; despite adjustments to alarm settings, improvements have been minimal; this continuous noise creates a highly stressful environment, particularly for patients with decompensated behavioral health issues; the relentless alarming and chaotic surroundings worsen their experience, increasing the likelihood of behavioral escalation and violence; additionally, these patients often wait for multiple days in the ED for an inpatient psychiatric bed

Increasing violence in the ED: at MGH, >50% of ED physicians and >70% of nurses have been physically assaulted; violence in the ED has increased by ≈67% over the 10 yr preceding the pandemic, and this has become considerably worse in recent years; incidents are likely underreported because staff may view such violence as “part of the job”; nurses, patient care associates (PCAs), security personnel, and other patients and visitors are frequently affected; many incidents occur in the main ED; biases, particularly against young Black men, lead to a higher likelihood of restraint use; differing perspectives among care team members on handling aggressive patients create inconsistencies in care and response

Plan to address behavioral escalations in ED: the 2-part plan used by MGH to manage behavioral escalation and violence in the ED starts with identifying at-risk patients and follows up with a standardized response; a standardized validated tool (eg, Aggressive Behavior Risk Assessment Tool [ABRAT], Brøset Violence Checklist) is used to assess risk based on behaviors (eg, shouting and agitation); this assessment is conducted by the nurse and documented in the electronic health record; screening is performed for every patient; despite initial concerns about workload, the process is now efficient; patients are reassessed at the change of each 12-hr shift or if behavioral changes occur; language used at handoffs has become standardized; for low-risk patients (score 0), no immediate action is needed; for moderate-risk patients (score 2-4), the care team should communicate openly, monitor the situation, and consider proactive interventions (eg, anxiolytics); high-risk patients (score ≥5) trigger an escalation alert

Escalation alert at MGH: the alert activates a response team, which includes the attending physician, primary nurse, resident or advanced practitioner, security officer, and charge nurse; the response team is expected to respond to the overhead alert ≤3 min (these alerts are considered as urgent as any other emergency); a coordinator records the meeting for later review, and the nurse documents the proceedings; this process is intended to prevent escalation to a violent incident and is not used for patients who are already violent; in cases of active aggression, restraining the patient and administering intramuscular (IM) medications are necessary; this approach complements, but does not replace, using panic buttons, calling the police, or involving security in immediately dangerous situations; during huddles, a laminated sheet is brought by the nurse to the huddle; initially performed at the bedside, huddles are now conducted discreetly in the care area to avoid escalating the situation; participants typically include the physician, nurse, charge nurse, and security or police officers; the nurse activates the huddle, initiates the overhead page, and gathers the team; the huddle reviews the patient’s score, behaviors of concern, and past events, including previous shift summaries and interventions; the physician or attending gathers input from all team members, ensuring everyone, including newer staff and security officers, feels comfortable sharing concerns; explicitly asking for each team member’s input helps overcome communication barriers related to power dynamics and staff turnover; to address bias, the team uses a substitution test, considering how the situation may be perceived if the patient were from a different demographic, eg, an older woman from an upper class neighborhood

Approach to intervention planning: the team now uses clear, time-bound interventions instead of vague plans; this structured approach enhances care efficiency and provides the team with a clear plan and timeline for reassessment; for patients with an ABRAT score of 0, the team offers basic comforts, eg, nicotine replacement, water, blanket; for scores in the middle range, structured de-escalation techniques are used; a score >5 triggers an escalation alert, often requiring medication and potentially temporary restraints; this clear approach ensures all team members are aware of and confident in the next steps; emergency psychiatrists are available but not required for every escalation alert; their early involvement is helpful when their expertise is needed; even if not on-site, off-site crisis teams should be engaged early because their involvement is beneficial

Special populations and visitors: patients with delirium, dementia, or substance use disorders often have underlying physical issues affecting their behavior (eg, pain, withdrawal symptoms); acute psychiatric conditions should be addressed based on the specific diagnosis, considering treatment beyond sedation; high-risk groups, including those with autism spectrum disorder or intellectual disabilities, benefit from early engagement with family or specialists to develop effective, individualized care plans; while the department is not legally responsible for visitors, controlling their behavior is sometimes needed for a safe environment; visitors have worsened a patient’s condition, highlighting the need to address visitor behavior alongside patient care; a code of conduct, introduced a few years ago at MGH, has proven effective; it reassures nonphysician staff about their safety and sets clear standards for visitor behavior; visitors who do not comply should be removed to maintain safety and order

Readings

Currier GW, Brown GK, Brenner LA, et al. Rationale and study protocol for a two-part intervention: Safety planning and structured follow-up among veterans at risk for suicide and discharged from the emergency department. Contemp Clin Trial. 2015; 43:179-184; Jämsä JO, Uutela KH, Tapper AM, et al. Clinical alarms and alarm fatigue in a University Hospital Emergency Department — A retrospective data analysis. Acta Anaesthesiologica Scandinavica. 2021; 65:979-985; Kim SC, Kaiser J, Hosford T et al. A workplace violence prevention program targeting high-risk patients in emergency departments. J Am Coll Emerg Physic Open. 2024;5(4):e13206; Tadros A, Kiefer C. Violence in the emergency department: A global problem. Psych Clin. 2017; 40:575-584.

Disclosures

For this program, members of the faculty and planning committee reported nothing relevant to disclose.

Acknowledgements

Dr. Sonis was recorded at 48th Annual Current Concepts in Emergency Care, held December 3-8, 2023, in Maui, Hawaii, and presented by Emergencies in Medicine. For more information about upcoming CME activities from this presenter, please visit https://emergenciesInMedicine.com. Audio Digest thanks the speakers and presenters for their cooperation in the production of this program.

CME/CE INFO

Accreditation:

The Audio- Digest Foundation is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

The Audio- Digest Foundation designates this enduring material for a maximum of 0.75 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Audio Digest Foundation is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's (ANCC's) Commission on Accreditation. Audio Digest Foundation designates this activity for 0.75 CE contact hours.

Lecture ID:

EM412102

Expiration:

This CME course qualifies for AMA PRA Category 1 Credits™ for 3 years from the date of publication.

Instructions:

To earn CME/CE credit for this course, you must complete all the following components in the order recommended: (1) Review introductory course content, including Educational Objectives and Faculty/Planner Disclosures; (2) Listen to the audio program and review accompanying learning materials; (3) Complete posttest (only after completing Step 2) and earn a passing score of at least 80%. Taking the course Pretest and completing the Evaluation Survey are strongly recommended (but not mandatory) components of completing this CME/CE course.

Estimated time to complete this CME/CE course:

Approximately 2x the length of the recorded lecture to account for time spent studying accompanying learning materials and completing tests.