Help When It's Needed

Jun 1, 2007 12:00 PM


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Among the areas of highest risk for violence in hospitals are mental health units, emergency departments, waiting areas and geriatric units, according to the National Institute for Occupational Safety and Health (NIOSH). In these areas, violent or aggressive patient behavior can be a daily occurrence.

It is a problem facing Mercy Medical Center in Roseburg, Ore., which is typical of hospitals meeting the challenge of adequate staff security. Although it is located in a town of just more than 20,000 in the largely rural and bucolic Umpqua Valley — with its wineries, covered bridges, and spectacular scenery — the hospital is one of two facilities in Oregon that handle adolescents with mental health problems.

According to Cindi Stephanos, nurse manager of the Behavioral Health Unit at Mercy Medical Center, the hospital cares for patients with the most critical needs, drawn from a wide region. “They're at their worst in their illness, and it's our role to stabilize them so they can return to the community or maybe their local health care provider,” Stephanos notes. These are patients who are a danger to themselves or to others. Severe depression, schizophrenia, bipolar disorder, manic behavior and suicidal tendencies are all common and very frequently acute. Most importantly for security and the prevention of assault, the behavior of these patients is highly unpredictable.

Providing adequate security for medical personnel is a concern for all health care institutions. Hospitals experience levels of workplace violence that are well above the average for all industries. A 1999 study by the Bureau of Labor Statistics of hospital workers estimated that 2,637 non-fatal assaults took place that year, in a workforce of just more than five million people. This corresponds to a rate of 8.3 assaults per 10,000 workers, more than four times the average for all private-sector industries of two assaults per 10,000 workers.

This kind of violence is especially difficult to guard against because it can be intrinsic to providing medical care to patients. It cannot be prevented by standard access control measures, since the perpetrators are exactly where they are supposed to be: getting needed treatment. Passive systems such as closed-circuit television (CCTV) are not ideal either, being better suited to documenting an event than preventing it in the first place. And few hospitals have the resources to provide security guards in all high risk locations.

At Mercy Medical Center, the Behavioral Health Unit is not especially large — it encompasses 29 beds: 11 for adolescents and 18 for adults, including geriatric patients — but it nonetheless experiences aggressive patient behavior on a daily basis. In many cases, such incidents can be handled by de-escalation techniques — essentially talking the patient out of his or her aggressive mood. But there are always times when the patient turns violent.

Mercy Medical Center uses a wireless emergency response system to enable staff to call for help in such a circumstance. Each staff member wears a small tag that incorporates a “panic button.” When the staff member pushes the button, the tag sends a signal to a network of receivers installed throughout the Behavioral Health Unit. The message is then relayed to a personal computer at the main nurse station. The computer is continually staffed by the unit secretary or another staff member, who then directs staff to respond. Although the system, the MyCall product manufactured by Xmark Corp., Ottawa, Ont., is capable of various automated responses to a panic alarm, such as sending page messages or activating an overheard alarm, it is important to have a person actually monitoring the display. This is because the system continues to update the location of the individual even after they have pressed the panic button.

On a typical day, four or five registered nurses carry the panic tags, along with three or four mental health assistants and a handful of other staff members. The system is used regularly; Stephanos estimates that, on average, there is a call for help twice a week. Tags are signed out at the beginning of each shift, and are identified in the system by the type of employee; for example, “RN Adolescent” indicates a registered nurse working in the adolescent area. The facility is small enough that this provides responders with all the information they need, although the system is able to identify each staff member individually, including a photo if desired.

From Stephanos' perspective, the great advantage to the current system is its portability. As a 15-year veteran of the Behavioral Health Unit who has herself spent a lot of time working directly with patients, she has had ample opportunity to evaluate other approaches. The previous emergency response system consisted of fixed panic stations installed at two locations in the unit. Although the system activated when the panic button was pressed, the problem was that, frequently, it was impossible to get to one of the stations. “We'd be stuck holding a patient, and couldn't get to the station. Even if there were two of us, it would be, ‘OK, which one of us is going to let go to go press the button?’”

The importance of a dedicated emergency response system has also been underlined during those brief periods it has been down for essential maintenance. During these times, the Behavioral Health Unit has had to rely on a voice communication system, part of campus-wide system installed at Mercy Medical Center a few years ago. The system is “trained” to recognize each user's voice, and then connects them to the desired party. The problem, as Stephanos points out, is that people's voices change when they are under stress or in a panic — conditions to be expected when one is being attacked — and the system has trouble recognizing them.

Stephanos stresses that successful implementation and use of an emergency response system requires a core team well-versed in the system, and able to provide training and direction to other staff members, as well as vigilance in ensuring that the computer display is monitored at all times. Overall, the staff of the Behavioral Health Unit is extremely pleased with the system. “They wouldn't want to be without it,” she says.

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