Hospital Violence: Proactive Steps to Plan and Prevent

Physician leadership is crucial to keeping employees and patients safe. Security experts stress that preparation is key.

It was such a commonplace event that the young hospital security officer simply accepted it as an occupational hazard. He’d been summoned to a room to help restrain a violent patient, and as they struggled she managed to stab him in the arm.

When calm had been restored, he stopped by the emergency room to get the wound cleaned and bandaged. It didn’t occur to him that the assault was a crime. He didn’t bother to file a report.

That was pretty much the way things went down at hospitals in the early 1970s.

“It was cultural,” said Larry Green, director of safety at All Children’s Hospital Johns Hopkins Medicine in St. Petersburg, Florida. “We were never told not to report. But to be quite honest, our culture kind of discouraged it.”

You might think of a children’s hospital as a relatively peaceful place, a sanctuary for wan poster kids and fretful parents. But that isn’t the whole picture. All Children’s — since 2011 a member of the Johns Hopkins Health System, headquartered in Baltimore, Maryland — is the only facility of its kind on Florida’s West Coast. It serves a population of about 3 million in the Tampa Bay area, and as a regional referral center treats children with complex conditions from throughout the world.

Its emergency room receives walk-ins 24/7. It also is required under the state’s mental health law to hold, for up to 72 hours, juveniles voluntarily or involuntarily brought in for evaluation because they’re seen as posing a danger to themselves or others.

"We get a lot of repeat patients,” Green said. “So we know their history. In the 14 to 17 age group, there are those who’ll take a swing at staff. We’ve had three physical batteries in the last year. We had one patient who’d just turned 18, 6 feet tall, 240 pounds, incredibly strong and with a poor support system."

That youth’s admissions invariably triggered a Code Gray — a call over the hospital public address system for an emergency management response. “We fought with him every time he was here,” Green recalled.

“Nurses,” he continued, “seem to feel it’s part of their job to accept verbal abuse. They think they’re supposed to sit there and smile and try to apologize.”

But at All Children’s, as at many U.S. hospitals, that culture of passivity and reactivity (as opposed to proactivity) is undergoing a swift change.

Larry Green

“By being more transparent, by setting boundaries earlier, we’re getting better outcomes,” Green said. “We’re more effective dealing with things out front rather than waiting for them to explode.”

Every member of the hospital’s security and emergency department staff, for example, and all charge nurses and supervisors must now attend an eight-hour course on situational awareness and nonviolent crisis intervention.

"It starts by identifying signs and behaviors, like clenched fists or rapid speech” which signal a potential violent eruption, he said. “The more we tolerate inappropriate behavior, the worse it becomes. We try to nip it in the bud.”

If the de-escalation tactics they’ve been taught don’t work, however, “the last component of the course,” he said, “is a hands-on self-defense-type module.”

Every morning at 9, year-round personnel representing All Children’s 25 departments take part in a “safety call” with hospital security. They go over the day’s census, staffing levels, problematic patient or parental personalities, procedures scheduled, equipment issues, actual or potential disruptions due to construction or power outages or infrastructure repairs.

All floors can be locked down, with only pre-approved access and a screener at the entrances. There are “a large number of cameras,” Green said. Security officers, once stationed out of sight, now stand on a podium in the center of the ER. “They’re as conspicuous as possible, and they round as often as possible,” he said. The cafeteria, open until midnight, offers an employee discount to any police officer who drops by on a break.

“We encourage a police presence as much as possible,” he said.

For all that, he acknowledged, the number of Code Grays actually has increased since the new policies were adopted. But, he insisted, “That’s only because we’ve gotten better at reporting them. We’ve chosen to make information [about violent incidents] widely available.

FROM OUR CEO: Violence, Safety and Physician Leadership

“Before,” he said, “we’d just deal with a situation and then move on. But we found that was a big employee dissatisfier. The people involved [or who’d witnessed a troubling disturbance] were never invited to critique the incident. Now we do what’s called a ‘hot wash.’ We’re using email to allow people to express their thoughts immediately after a particular incident.”

Dangerous Places

Everybody knows hospitals are dangerous places: focal points for viral and bacterial infections, stockpiled with toxic substances, filled with sharp instruments and menacing machines. They’re also congregating points for desperate, scared, angry, pain-addled, disoriented and often distraught patients and family members.

It’s not altogether surprising that the doctors, nurses and support personnel who staff health care facilities are far more likely to be killed or injured by people who go berserk than are employees in the private sector overall.

According to the Bureau of Labor Statistics, between 2011 and 2013 — the latest data available — almost three quarters of all jobsite assaults nationwide occurred in health care/social service settings. That’s an average of more than 18,000 victims a year. Health care personnel were at least three times as likely to lose days off work while recovering from injuries from workplace violence as those in the private sector in general.

Among the lessons learned after a fatal shooting at Boston’s Brigham & Women’s Hospital: Training can make a difference and save lives. “Security is everybody’s responsibility, and it’s critical that all health care workers become familiar with organizational policies,” says medical director of emergency preparedness Eric Goralnick, MD. | Brigham Health

The U.S. Occupational Safety and Health Administration recorded 100 work-related fatalities in health care and social service settings in 2013; 27 caused by violent acts. Medical occupations alone accounted for 10 percent of all violent on-the-job incidents in the United States between 1993 and 2009. (And, it should be stressed, research has found that underreporting persists; the rates are almost certainly higher.)

The International Healthcare Security and Safety Foundation’s 2014 Crime Survey was based on “usable” responses from 242 of 386 U.S. and Canadian hospitals.

Comparisons between 2012 and 2013 data indicate that the violent crime rate — defined as murder, rape, robbery and aggravated assault combined — was up 25 percent, at 2.5 per 100 beds. Assaults of all kinds were up only 4 percent, at 11.1 per 100 beds, but the disorderly conduct rate soared by 40 percent, to 39.2 per 100 beds. (Burglaries, thefts and vandalism held roughly steady.)

“Violence directed at employees by customers, clients, patients, students, inmates or any others for whom an organization provides services” accounted for 93 percent of all assaults and 75 percent of all aggravated assaults in 2013, the survey found.

“Violence against co-workers, supervisors or managers by a present or former employee” accounted for a mere 2 percent of assaults but 15 percent of aggravated assaults. (Aggravated assault usually involves the use of a weapon or serious injury.)

Shootings at Hospitals

The most frightening and potentially catastrophic outbursts of violence — shootings in U.S. hospitals —proliferated in recent years. There were at least 154 in 40 states between 2000 and 2011, according to a study published in the Annals of Emergency Medicine in December 2012. Some 235 victims were wounded or killed.

Many of those gunfire bursts rang out at the hospital itself — 45 in the emergency department (where more than 80 percent of victims survived), 65 in a patient room or on hospital grounds (where almost three-quarters died).

“Most events involved a determined shooter with a strong motive as defined by grudge (27 percent), suicide (21 percent), ‘euthanizing’ an ill relative (14 percent) [or] prisoner escape (11 percent),” the authors wrote. “The most common victim was the perpetrator (45 percent).”

One in five of those who were shot, however, was a hospital employee. Almost a quarter of those shootings involved a gun snatched from a security officer. Recent experience would tend to corroborate those findings. Consider this two-year table of events:

Wauwatosa, Wisconsin, Nov. 14, 2013 — Police learn a man wanted for a minor offense is visiting a child in the neonatal intensive care unit of Children’s Hospital of Wisconsin. When they attempt to take him into custody the man draws a gun and flees. He is shot and wounded by the arresting officers as he runs down a hospital corridor.

Reno, Nevada, Dec. 17, 2013 — A 51-year-old man claiming injury from a botched surgery bursts into a urology practice at Renown Regional Medical Center and produces a sawed-off shotgun. He shoots one physician, fires at a second doctor but hits a patient bystander, seriously wounds the second physician with another fusillade and returns to kill the first. He then commits suicide. A police dispatcher counsels the clinic manager while she hides in place under her office desk. Police first responders save the lives of the two gravely wounded victims.

Woodbury, New Jersey, March 20, 2014 — A 26-yearold man puts a gun to his head and kills himself in the lobby of Inspira Medical Center.

Darby, Pennsylvania, July 24, 2014 — A disgruntled former patient shoots and kills a psychiatric caseworker at Mercy Fitzgerald Hospital’s affiliated wellness center and is in turn felled by the psychiatrist on duty, who pulls his own handgun and exchanges fire.

Camden, New Jersey, Aug. 18, 2014 — A 71-year-old man commits suicide with a pistol in an emergency department restroom at Lourdes Medical Center.

Stratford, Pennsylvania, Aug. 27, 2014 — A 63-yearold man shoots and kills his chronically ailing 62-yearold wife in her hospital bed at Kennedy University Hospital, then fatally shoots himself. His 35-year-old son is later found shot to death at the family home.

Chicago, Illinois, Nov. 3, 2014 — Police accompany a man and his daughter to Highland Park Hospital after a traffic accident. The man balks when instructed to don a gown. He pulls a pistol and is killed by nine shots in rapid succession from the officers present.

El Paso, Texas, Jan. 6, 2015 — A former Fort Bliss Veterans Affairs Health Care System clerk enters a crowded mental health clinic there with a .38-caliber handgun. He shoots and kills a psychologist before turning the gun on himself.

Boston, Massachusetts, Jan. 20, 2015 — Blaming a highly regarded cardiovascular surgeon at Brigham & Women’s Hospital for his mother’s death, an angry man guns the physician down in a second-floor foyer, then shoots himself. The 44-year-old doctor, married to a physician who is pregnant with their fourth child, succumbs.

Falls Church, Virginia, March 31, 2015 — Under custody at Inova Fairfax Hospital after a suicide attempt, a man overpowers a security guard, wrests her pistol from her and shoots his way past another security officer. He is recaptured within hours.

St. Cloud, Minnesota, Oct. 18, 2015 — A domestic violence suspect under guard at St. Cloud Hospital after a suicide attempt grabs a deputy’s service weapon and fatally wounds him. Hospital security officers subdue the shooter with Tasers. The man subsequently dies of apparent cardiac arrest. (St. Cloud officials reported 149 violent incidents at the hospital in 2011, during which 21 guns and more than 3,300 knives were confiscated. Metal detectors have been installed in the ER.)

Time Is Your Friend

If there is any solace to be wrung from that litany of terror and carnage, it’s that to date “technically” none of the hospital gunmen (men account for more than 90 percent of hospital shootings) fits the Department of Homeland Security’s formal definition of an “active shooter.”

“What every physician leader needs to know,” said Leonard Marcus, co-director of the National Preparedness Leadership Institute jointly sponsored by Harvard’s schools of public health and government in Cambridge, Massachusetts, “is that if a crisis happens on their watch, it’s going to be a seminal event in their career. It will be a career- and institution-defining moment.”

With that in mind, he emphasizes, “The time to prepare is not after a crisis has begun, but before. Before, time is your friend. After, time’s your enemy.”

Marcus counsels leaders to “preprogram” themselves to react to emergencies through a “’trigger script’ like the reset button on a computer.” After the initial flood of adrenaline and what he calls the natural “rabbit response”— freeze? fight? flee? — the trigger script prompts, “I can do this.” And then, “We can do this!

Chris Van Gorder

No one agrees more heartily than Chris Van Gorder, president and CEO of Scripps Health, a multi-hospital integrated health care system headquartered in San Diego, California. Van Gorder’s unusual career trajectory has been defined by crisis and violence. As a student moonlighting as a hospital security guard in 1973, it was he who stoically brushed off that patient-inflicted stab wound. He knows from personal experience the perils his frontline staff confronts.

His goal then was to become a police officer — a goal he achieved and then was seriously injured responding to a domestic disturbance when his patrol car was rammed at high speed. After a long period of pain, despair and rehabilitation at Orthopedic Hospital in Los Angeles, he applied for the position of director of safety at that institution and was hired.

Having subsequently equipped himself with a master’s degree in hospital services administration from the University of Southern California, Van Gorder took on wider challenges.

In 2000, newly promoted to head Scripps — then hemorrhaging $15 million annually — he engineered a remarkable organizational turnaround.

For all that, he has continued to train as a reserve assistant sheriff in San Diego County, where he directs volunteer search-and-rescue operations and maintains his license as an EMT. Nevertheless, he makes clear, “If we have a shooter, I’m not going to be rushing in playing policeman.”

Rather, as a leader, he will have assured that the responders who plunge through the doors — and the Scripps staff they encounter — know what to expect of one another and themselves, and how to interact. (As Marcus puts it, “You can’t exchange business cards in the middle of an emergency.”)

Each time a new facility is about to be brought online at Scripps, Van Gorder stages a preliminary active shooter drill with staff members to familiarize them — especially police, firefighters and medics — with the building layout and standard operating procedures before patients occupy the premises. (Among the sobering lessons for staff are that the first cops to arrive are on a mission to neutralize the shooter. They will not stop to tend to the wounded; everyone in sight is initially assumed to be armed and dangerous. Meanwhile, the first duty of a caregiver is to survive to tend patients another day, which may make ducking out on a patient to hide smarter than heroically fighting — although that is a viable last resort.)

“I don’t think it’s appropriate to do a drill in a hospital where there are patients,” Van Gorder explained. “It’s too frightening for them. But the opening of a new building is a great opportunity, and actually it may be more important for law enforcement to drill in a hospital than it is for the employees.”

Postmortem

At Children’s Hospital of Wisconsin, where live gunfire echoed in November 2013, the opening of a new tower at a sister institution, Froedtert Hospital (they’re part of a consortium of six health care institutions that make up the Milwaukee Regional Medical Center) will likewise be prefaced by a full-scale active shooter exercise, according to director of security Mike Thiel. But this one will be accompanied by sheltering-in-place rehearsals for staff throughout the campus, where two active-shooter drills have already been conducted.

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“We go to all the patient rooms and put stickers on the windows explaining that this is just an exercise,” Thiel notes. “We warn that they will see police officers, lights and sirens, but that they are much safer inside this hospital than they are at church, or in a restaurant, or at a movie theater or in a shopping mall or on the street.”

When bullets flew for real at Wisconsin Children’s two years ago, he said — the result of an ill-advised attempt by police to stage an arrest inside the NICU — “we had people fainting, thinking they were having heart attacks. … We had four code responses in two hours.” What’s more, he recalled, police kept the hospital, a Level 1 pediatric trauma center serving the entire southeastern portion of the state, locked down for that two-hour post-shooting period even though one of the officers was present at the incident and “within three minutes we already knew the scene was safe.”

In the aftermath, Children’s Hospital of Wisconsin has undertaken more than 80 procedural changes, Thiel said. Among them was to win an agreement from local law enforcement agencies that their officers will always check in with hospital security first to discuss whether an arrest can more appropriately be made offsite; unified command will be established more quickly so the hospital can return to normal operations; and the old, often confusingly cryptic color-code system will be scrapped in favor of plain-language PA announcements like “medical emergency” or “active shooter.”

That last change was on the radar at Brigham & Women’s too, according to medical director of emergency preparedness Eric Goralnick, MD.

“The first lesson we learned [after the hospital invasion and slaying of Dr. Michael Davidson in January 2015] was that our plain language wasn’t plain enough,” Goralnick explained. Brigham & Women’s had already dropped the term “Code Silver” for such emergencies, he notes, but even phrases like “shelter in place” or “life threatening event” may leave the listener perplexed as to what to do.

Ideally, Goralnick said, hospitals nationwide will come to agreement on a set of clear PA instructions — so, for example, a health care worker who shuttles among facilities doesn’t have to remember that in Florida it may be “Code Gray,” in Texas “Code White” and in Massachusetts “Code Silver” that signals a shooter is afoot in the building.

“Standardization and minimal variations are really helpful,” Goralnick said.

The second lesson Brigham & Women’s leaders derived from the traumatic incident, he said, is that “however many times you think you need to debrief staff, do it three times more.”

Brigham & Women’s relies heavily on the “hot wash” mechanism to allow individuals and teams to vent, grieve and critique what went well and what didn’t. An active-shooter instructional video for staff had been filmed just a few months earlier in the same facility where Davidson was killed, and “from the hot washes we found that training is critical and makes a difference,” Goralnick said.

“That was the third lesson. People said training did make a difference. It saved lives. Security is everybody’s responsibility, and it’s critical that all health care workers become familiar with organizational policies.”

New Social Contract

Dramatic, alarming and headline-grabbing as they may be, hospital shootings remain a minor problem compared to the almost daily assaults suffered by frontline workers in emergency rooms, mental health clinics and similar high-stress health care settings.

Leaders like Van Gorder wrestle to “identify what level of protection we should have” balanced against clinician/patient/ family access needs and the potentially adverse side effects of additional weaponry.

“Hospitals are dangerous places for weapons,” says Chris Van Gorder, president and CEO of Scripps Health. “Even using pepper spray in an ICU might kill people.”

“Hospitals are dangerous places for weapons,” he said. “I worry about the risks to patients. I have security [personnel] that have canines, but they don’t carry arms. Even using pepper spray in an ICU might kill people. If you use a Taser outside a hospital the risk is low, but if you use it on a heart patient it can be fatal. Install metal detectors? There are 58 entrances and exits at one Scripps hospital. We’d have to funnel everyone through just two or three entrances and that would be [unworkable]. Our society wouldn’t tolerate it.”

In 2013, Indiana became the 29th state to allow hospitals to form their own police departments. Several, including Fort Wayne’s Parkview, South Bend’s Memorial and at least four Indiana University Health campuses, have quickly done so. However, given the psychological testing and constant training an in-house police force requires and the liabilities it creates for the organization many observers doubt their viability.

Van Gorder is among them. “Every hospital has to do its own assessment,” he said — and in fact the issue is moot in California, where the law prohibits hospital police forces — “but,” he added, “we don’t believe that at this point the threat level justifies the need for deadly force.”

Thiel, of Children’s Hospital of Wisconsin, agreed. “I have 5,500 employees in 99 different environments I’m responsible for,” he said. “Our officers are armed only with batons, which are generally considered a defensive weapon. Should we arm ourselves with, say, pepper spray? Unless we’re willing to train all our employees to use it, it won’t be effective. And we as an organization are not going to sponsor a police department.

“No,” he said, “what we really need [to combat violence in hospitals] is to develop a different kind of social contract than exists today. Think about the library. Everybody knows how to behave in a library — and it’s not because there are armed librarians walking around. And it’s not as if homeless people, pedophiles, people from all classes of society don’t frequent libraries. They do.

“Banks, churches,” he said, “Everybody knows how to behave in those places. But to a certain extent we tolerate or expect different behavior in hospitals. Oh, we rationalize that people who come in are under stress. Or they’re reacting to the drugs we administer. But really, we shouldn’t expect violence to occur in a hospital any more than we do in a library.”

David Ollier Weber is an award-winning freelance health care writer based in California.