Violence in the ED: Planning and Designing for Safety


Reprinted with permission from Minnesota Physician:

Workplace Violence (WPV) is a growing problem in healthcare: “underreported, ubiquitous, and persistent,” according to the New England Journal of Medicine.  A 2014 survey by the Journal of Emergency Nursing found that 76 percent of nurses experienced verbal or physical abuse from patients or visitors in the last year. And a 2015 study by the International Association for Healthcare Security and Safety Foundation discovered a 4-percent rise in hospital assaults in the previous year.

WPV is especially common in the Emergency Department (ED). While nurses are the primary target, physicians are not immune. Approximately one quarter of emergency medicine physicians report being targets of physical assault in the previous year. 

In Minnesota, the problem came to public attention in dramatic fashion in 2014, when an elderly patient at St. John’s Hospital in Maplewood was caught on security cameras rampaging through the hospital and attacking nurses with a metal rod. This event prompted the passage of Minnesota Statute 114.566 Violence Against Health Care Workers, which requires hospitals to design and implement preparedness and incident-response plans for violence that occurs on their premises, and review them annually.

While creating incident-response plans is important, more can be done to prevent incidents in the first place. By understanding the risk factors of WPV, assessing your current vulnerabilities, and taking steps to design physical spaces and hospital policies that respond proactively to those risks, EDs can become safer places to work.

The following article will shed light on the warning signs of WPV, offer an overview of risk-assessment tools available, and give physicians insight into design strategies that should be considered to improve staff safety in the ED.

Warning signs

The Minnesota Department of Labor and Industry is a good local resource for information about the causes of WPV, and tips for complying with Minnesota Statutes 144.566. Using the Department’s free consultation service, MNOSHA Workplace Safety Consultation, employers can also learn about workplace hazards via on-site workplace-violence consultations.

In a video message to trustees of the Minnesota Hospital Association, MNOSHA’s Vikki Sanders stresses that WPV can happen anywhere. It’s not confined to urban locations, but happens thousands of times a day across the nation in every type of healthcare setting. Although your response will depend on your specific threats, all healthcare environments should be considered targets.

Sanders also disputes the myth that WPV events are unpredictable and therefore can’t be prevented. On the contrary, in at least 85 percent of WPV incidents, there are clear warning signs.  These include

  1. Long wait times and delays
  2. Volatile or aggressive people impacted by stress or substance and alcohol abuse
  3. Families and visitors impact
  4. Unrestricted 24-hour service and unrestricted movement of the public
  5. Overcrowded, uncomfortable waiting areas
  6. Effects of Negative progression sequencing
  7. Poorly lit corridors, rooms, or parking lots
  8. Lack of staff training and lack of policies for preventing/ managing WPV risk situations
  9. Inadequate security
  10. Working when understaffed.

If any of these factors are present or common in your ED, it is worth considering policy and/or design changes to address them.

Three steps to a safer ED 

Preparing for the threat of WPV consists of three general steps: 1) assess your risk, 2) adjust your policies, and 3) design against threats.

  • Assess your risk

Resources abound from NIOSH, the Joint Commission, OSHA, AHA and ASHRM to assist healthcare organizations in understanding their risk areas and implementing preventative measures. 

The American Society for Healthcare Risk Management’s Healthcare Facility Workplace Violence Risk Assessment Tool is one of the best, most succinct tools available. It offers a number of checklists, covering both proactive prevention and reactive response to WPV generating from patients, visitors, staff, and even physician actions.

The ASIS International Workplace Violence Prevention and Intervention Standard is longer and more comprehensive. 

No matter what tool you choose, it may be helpful to enlist an expert consultant to help.

  • Address policy concerns

With risks assessed, a hospital-wide response to WPV must include a wide range of representatives, including nurses, physicians, security experts, local law enforcement, top-level administrators, facilities managers, and design professionals.

In addition to policies and procedures for preventing and responding to WPV incidents, steps must be taken to create training and maintenance policies, as well as reporting and record-keeping mechanisms. According to a 2014 article in the Joint Commission’s EC News, many healthcare workers accept violence as part of their jobs, and “when something happens, they take care of it – but they don’t mention it to anyone.” Reporting is a key component in growing a robust, continually improving response to WPV.

Collaboration with law enforcement is equally critical. The Minnesota Department of Health recommends scheduling routine operational meetings between law enforcement and healthcare teams. They offer a “collaboration road map” tool with evidence-based recommendations and standards for how healthcare should interact with law enforcement

  • Design against threats

OSHA’s comprehensive approach to any workplace hazard focuses on “engineering away the harm.” That means embracing design solutions that either remove a hazard from the workplace, or create a barrier between the worker and the hazard.

In architecture and interior design, these goals can be achieved through a variety of means, from using design elements that provide a peaceful, calm environment, to more structural changes such as improving lines of sight within and between hospital areas.

Hot spots

While each ED is different, there are generally five areas that can be thought of as a “hot spots” where design decisions can help engineer away the harm.

  • Parking

Emergency departments should have separate parking outside a walk-in entrance. All parking and ambulance entrances should be well lit, easy to exit, and have security surveillance. As the emergency department often becomes the hospital’s default entrance after hours and on weekends, additional security support should manage these areas at the ED portal. Entrances should be positioned at an angle from driveways to prevent intentional or accidental ramming or vehicular intrusion.

  • Entry Zone/Waiting

Public and private spaces in the ED waiting area should be clearly delineated. Designers should pay special attention to sight lines and visual access to the entrance from registration, triage and security. Duress alarms and lock-down activation buttons should be placed at strategic locations such as central workstations. Seating areas should be arranged to allow free movement of people in the case of an evacuation, and to avoid potential entrapment or blocked egress.

To mitigate and reduce the stress induced by long wait times, lighting and color schemes that are welcoming and have a calming effect should be used.  Designers should maximize access to natural daylight, while taking precautions to avoid public scrutiny of the waiting area. Respite areas, TVs, Children's play areas, calming lighting, comfortable furniture and finishes that provide a feeling of welcome and security should be incorporated.

  • Triage

One major source of stress for patients is known as "negative progression", which occurs when a patient is sent back to the lobby after registration and triage, only to wait a second time. This can lead to a feeling of discrimination or neglect, adding to an already tense situation. This can be avoided by designing waiting areas post-triage with distinct areas for fast-track, high- and low-acuity. These second-stage waiting areas, designed as alcoves, avoid the need for patients to return to a previous location.

  • Care Zones

Isolation of staff within the care delivery space should be avoided as this leaves them vulnerable. Staff areas should enable visibility within and between zones. Likewise, patient rooms should never be cut off from the nurse station's line of sight. Floor plans that isolate nurses in decentralized work stations should be reconsidered.

  • Behavioral Health/ Observation Rooms

Specialized rooms for behavioral-health patients should be located away from other treatment spaces so as not to disturb other patients in the area, but also placed to remain visible to a central work station.  Impact-resistant laminate, locked cabinetry, locked rolldown wall, tamper-proof hardware, anti-ligature devices and an observation window are some of the items to consider in these spaces. 

If you do one thing

According to OSHA, the single most important design element in reducing WPV is offering a system for communicating in an emergency. Physicians and nurses in danger need a way to signal for help, and the people receiving the signal should know how to respond. A variety of alarm systems exist, whether silent or audible, stationary or mobile. Their design and use should be well coordinated with the architecture, operational policies, and training schedule.

Some design solutions to WPV require an overhaul of the existing ED, but most don’t. An experienced architect can help determine which interventions are the most cost-effective for your situation, and should be consulted as part of any WPV prevention and response plan.

Elizabeth Schulze, AIA, LEED AP BD+C, leads the healthcare design practice of LEO A DALY in Minneapolis. She is an architect registered in Minnesota and South Dakota, and received her Bachelors and Masters Degree from the University of Minnesota. Schulze is passionate about using architecture to improve population and community health, and is an expert in sustainable building design and construction.