By Julie Liedman
Health-care facilities and the people who work in them face an epidemic of violent crime.
In perhaps the latest outbreak, two people died in an apparent murder-suicide shooting on Sept. 5 at Kindred Hospital, a long-term-care facility in Sycamore, Ill., where one of the victims was a patient.
Meanwhile, an inspection of a Maine psychiatric hospital by the Occupational Safety & Health Administration found more than 90 instances in which workers were assaulted on the job by patients from 2008 through 2010. The hospital was cited for not providing its workers with adequate safeguards against workplace violence and OSHA proposed a fine of more than $6,000. Health-care facilities in New York and Massachusetts, where employees have been killed as a result of assaults, were also cited by OSHA.
The Sycamore incident and the latest federal government data underscore how vulnerable health-care institutions and the workers inside them are to violence.
"[Health-care facilities] were once seen as a sanctuary against violence, but no more," said Diane Doherty, vice president of ACE Medical Risk, in New York The risk is significant."
The numbers tell a painful story.
In a report on workplace violence, OSHA found that "injury and illness statistics have shown that health-care workers are among those most susceptible to workplace violence."
The agency recently issued its first directive citing patient-to-staff violence as the most common type of violence occurring in health-care institutions. It also established uniform procedures for its field workers to respond to incidents and complaints of workplace violence, and to conduct inspections in industries, the health-care industry included, considered vulnerable to violence.
Doherty said health-care facilities need to establish a "zero tolerance" approach to violence. Only a comprehensive violence prevention program will ensure that hospital staffs know what to do before and after an incident occurs. "There's no universal solution to avoid risks," she said. "It varies from unit to unit, hospital to hospital."
On average, the health-care sector is prone to higher frequencies of violence than other sectors, according to the American Nurses Association, with 45 percent of nonfatal assaults against health-care workers resulting in lost workdays in the United States.
The Joint Commission on Accreditation of Healthcare Organizations has reported an increase in reports of assault, rape and homicide in health-care facilities. The statistics vary according to the agencies reporting them.
One agency reported that the number of assaults on health-care employees increased 13 percent between 2009 and 2011, the latest available statistics. And even that number may be too low because of "significant under-reporting of violent crimes in health-care institutions," according to the Commission.
The result of the violence is that every year, insurance companies pay out millions of dollars in property damage to health-care institutions, and millions more in physical and psychological injury claims.
Registered Nurse and attorney Gregg Timmons, manager for global loss prevention in the Healthcare Division of Lexington Insurance Company in Boston, said violence infiltrates health-care institutions in several ways.
Risk factors, Timmons said, include increasing numbers of psychiatric patients seeking care, hospital staffs working late in high-crime and isolated areas, and the economic difficulties that have added stress to an already tense situation, for the patient and visitors.
A VULNERABLE COMMUNITY
Violence in health care occurs in urban and suburban areas alike. The most severe problems occur in community health clinics, drug treatment clinics, long-term-care facilities and hospital emergency departments, Timmons said.
"We're seeing an influx in emergency departments of aggressive behavior by drug-crazed patients with psychiatric problems," he said. "This is a new issue for a lot of emergency departments that previously had resources to deal with these patients."
Several years ago, there was a move to deinstitutionalize psychiatric hospitals on the assumption there would be a social service net for psychiatric patients.
"That's not true anymore," Timmons said. "A lot of social-service agencies are not being funded."
With more psychiatric patients and fewer beds for them -- because patients have to be kept longer -- it takes days instead of hours to place patients in more suitable facilities and that raises tensions in health-care facilities, he said.
But psychiatric patients represent just one risk in health-care facilities.
Hospital staff, patients and visitors can be perpetrators or victims of violence. People who enter to steal drugs or protest medical practices, for instance, are threats. Abortion clinics are sometimes targeted by vandals, and doctors who perform abortions have paid with their lives at the hands of anti-abortion fanatics.
Property damage can occur "if special-interest groups come in or park outside and bomb the facility because it's doing abortions or research on animals," said Pamela Kirks, senior vice president of Wells Fargo Insurance Services in Raleigh, N.C. "So hospitals buy property insurance -- and you can get an endorsement that will include damage to property as a result of terrorism, which has to be certified by the [federal] government."
If the damage is the result of the actions of special-interest groups or individuals, "there's coverage for that, too, and it doesn't have to be certified by the government."
Hospitals are responsible for providing safe and secure environments for their staff, but Kirks said, perpetrators of violence can sue for false arrest. "If a rowdy visitor is detained by security, for instance, he can sue," she said. "Or he can claim excessive force if a staff member injures him while trying to de-escalate a violent situation."
Moreover, physical violence is not the only type of violence facing health-care workers. Many facilities and most health-care workers consider psychological violence to be just as hurtful as physical violence.
"The problem, early on, was within the staff, mostly in the doctor-to-nurse relationship," said Kirks, a registered nurse. "It usually involved bullying and harassment and, unfortunately, was mostly considered to be just part of the job."
Kirks said studies by professional organizations consistently report that nursing is one of the most unhappy jobs in America, with almost all nurses reporting they have been victims of violence, either physical or psychological. Many nurses report being exposed daily to humiliation by doctors, patients and/or visitors, and view their workplace as a hostile environment.
Health-care facilities have typically reacted, taking action or creating procedures only after an incident occurred. But that is changing. "They need to be pro-active and they are, more and more," Kirks said.
Health-care managers need to teach staff what to do when a violent incident occurs, she said. Who do they call? How do they decide whether or not to press charges? Also, they need to recognize when violence is about to escalate, and when to step in and prevent it. Learning how to diffuse violence is a priority for management.
"One of the first steps in trying to mitigate the risks of violence is admitting you have a problem," said Suzanne Holbach, a registered nurse and vice president of the Global Clinical Consulting Practice at Marsh in Atlanta. "It's like a 12-step program."
Health-care institutions need to "take their own temperatures to assess the risk," she said. "I have been to facilities where staff tell me sometimes they don't feel safe, and my response is: 'What have you done, how have you relayed that information?' "
Often, the staff is so busy and overworked putting out fires that they simply forget to report an incident, which is never entered into the record.
Health-care facilities should have an incident reporting system in place, she also said. "You always need to document. It takes time, but it could divert disaster in the future. It helps the administration understand if there is a problem, and what it is."
Once information is gathered, it needs to be analyzed "to try to recognize a trend," she said.Is the institution dealing with a parking lot safety issue? Or is the hospital crammed with bullying doctors on the make? Or does the drug rehabilitation center not do a good enough job of securing supplies and equipment?
In one case, a radiology technician was stealing narcotics from different hospitals over a period of 10 years, Kirks said. Every time a hospital became aware of the theft, the technician was fired. "It turned out he had been replacing syringes with dirty syringes and had infected a number of patients with Hepatitis C," she said.
Eventually, one of the hospitals was sued for negligent hiring and supervision, with plaintiffs alleging that the hospital should have known about the technician's past record. Hospitals often find themselves caught between a rock and a hard place.
Hospitals that issue bad references can be sued for defamation, as employees may think they're being called unemployable.
"Hospitals are loath to give bad references," Kirks said. "Or if a facility suspects an employee has a tendency to commit violence and hires a detective to check him out, he can sue for invasion of privacy."
Not surprisingly, ERs typically pose the highest risk for health-care institutions. "Emergency rooms are at a very high risk," she said. "They have 24/7 accessibility and it's a stressful place with patients in pain and families in crisis."
Raw emotion spills out onto the ER floor and needs an outlet -- often the nearest health-care worker.
The Emergency Nurses Association has developed a toolkit to help administrators assess health-care facilities, including such issues as how to determine where and what the risks are, and how to respond to violent incidents.
"Then they can either build a program based on their findings, or reassess and modify their existing program," Holbach said.
Most claims filed in connection with violence in health-care institutions fall under workers' comp, general liability or professional liability. Employees injured on duty are eligible to file workers' comp claims. "If it's someone other than an employee, it's a liability claim," Kirks said.
Will Eustace, senior vice president, National Casualty Practice at Marsh in New York, has a 360-degree perspective of the insurance implications of violence in health-care facilities. His job focuses on coverage wording, complex claims and "getting our clients paid," he said.
"When I focus on cases or talk about studies on health-care violence, [I find that] most risk factors are in psychiatric wards, waiting rooms, geriatric units and, especially, emergency rooms," he said.
"A significant proportion of injuries are caused by volatile people who may be under the influence of alcohol and drugs or who didn't take their meds when they should have plus all the other factors in a waiting room -- long waits, overcrowding, understaffing, especially on weekends," said Eustace.
Unlike a corporate campus with guards and security cameras, people of all stripes have relatively easy access to hospitals at all hours of the day or night. "So, in assessing risk, we always look at the access the public has and what security measures are in place -- whether there's enough security on the campus, whether employees are escorted to their cars at night, whether there is an emergency signaling system, silent alarms, cameras, well-lit halls, even deep counters at nurses' stations to prevent people from coming over," he said.
"We also always want to know if the staff is trained, how much the employer knows about [new hires], and whether information about patients who are known to have potential violent behavior has been communicated" to everyone who might have contact with them throughout the facility. That's where electronic records can be very helpful.
"We're looking for a zero tolerance policy, he said. "We don't want to insure a burning barn."
JULIE LIEDMAN is a freelance writer and editor. She can be reached at firstname.lastname@example.org.
October 1, 2012
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