Tuesday, August 7, 2012

Sharing More from Dr. Anderson...

An oil lamp, the symbol of nursing in many cou...
An oil lamp, the symbol of nursing in many countries (Photo credit: Wikipedia)
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Wishing and Hoping...

By far the best summary of violence against ED nurses was published in the Journal of Nursing Administration July/August 2009 by Jessica Gacki-Smith MPH, et. al. Their documentation of the scope of the problem, their identification of the causes, their identification of the barriers to change, and their documentation cannot be faulted, in my opinion. I would like to quote from their conclusions,

“Most important, federal and state laws to protect ED nurses from violence are needed to address this issue. Whereas some states have made assault of a nurse a felony, other states do not have such stringent laws in place to adequately protect nurses. Unfortunately, legislation such as this is often passed only after a tragic incident against a nurse takes place. To make this a legislative priority, leaders of nursing organizations need to use their government affairs departments to heighten legislator’s awareness. Without legislative action at the state and federal level and innovative strategies at the hospital and department level, there can be no realistic hope of significantly decreasing ED violence.”


As helpful as this summary position is, it lacks an action plan. Without an action plan, nothing happens. It’s second flaw is it fails to set priorities. We are not going to solve all the issues of ED violence with a list of everything that needs to be done by somebody else. Unfortunately, almost nothing has changed since the publication of this landmark study in 2009. Healthcare violence is at an all-time high. Let me ask you a simple question. Would you rather have strict laws punishing someone who assaulted you, or would you rather not be assaulted in the first place? Prevention is more important than punishment. That is why you should concentrate on armed guards, metal detectors, and bullet proof glass first.

I believe that it is time to make decisions and stop expecting a state by state solution. This is incredibly time-consuming and requires a patron saint in Congress from most states. Changes usually do not come about that way in medicine in this country. There are so many agencies in our government that could have taken a leadership role with this violence problem, but they failed to do so because we, the healthcare workers, would not agree on an action plan. It doesn’t help that all of these agencies are filled with people who represent the groups that the agency is supposed to be regulating.

To solve a problem somebody or some group must take ownership of it. They must make it their priority and single-mindedly push for its implementation. Let me give you one example. Emergency nursing organizations and emergency physician organizations have been sitting on the fence over the issue of armed guards, bullet-proof glass, and metal detectors for a decade. Every position paper calls for an evaluation or consideration of these basic steps at preventing violence. I have already covered in a previous post the irrationality of saying that anyone or any group of people can predict where the next disaster will occur, or where a mentally ill person with lots of bullets will want to share his pain. In short, all hospitals, big and small, need the same protection for their staff.

Doesn’t it make sense, after an entire decade of evaluation by Homeland Security, that we accept the reality that physical barriers, metal detectors, and armed guards are remarkably efficient at preventing violence and loss of life? If these measures are good enough for every airport in the country and every government building, shouldn’t they be proficient in hospitals? We need these measures to prepare for those unpredictable disasters, when the lights go out, more people carry guns, and local anarchy breaks out.

The argument that having an armed guard somehow causes violence has been thoroughly discredited by a decade of safe air travel in America. The concept of controlling bad behavior by showing strength has been verified years ago. Hospitals, of course, do not want to pay for such alterations or three shifts of certified, uniformed armed guards. They don’t want employees to sue patients. They don’t want to be sued themselves by patients. They want to pretend that the waiting room and treatment area are safe places when statistics say just the opposite. Their position is entirely motivated by their view of the financial implications of installing these security features, not by concern for employee safety.

Physicians have fears that their contract with a hospital will be in jeopardy if they support something that will cost their hospital millions. They are concerned that having stretcher patients checked with a wand and having everyone who enters the waiting room pass through a metal detector will slow down patient flow. I would say that the national average waiting time of several hours leaves plenty of time for patients to be screened.

The nurses want protection but they will not endorse the only tools we have that have proven effectiveness for the job.

Is there anyone out there who doubts that JCAHO and CMS could have forced these changes if the nursing organizations and physician organizations had demanded them? Medicare is the major facilitator of patient-safety improvement in hospitals. Because hospitals must be accredited by JCAHO and undergo regulatory review by the CMS to participate in Medicare, and because Medicare accounts for at least 40 per cent of hospitals’ total revenues, hospitals must meet JCAHO’s requirements.

Part of JCAHO’s mission statement says “To transform healthcare into a high reliability industry by developing highly effective, durable solutions to health care’s most critical safety and quality problems in collaboration with health care organizations by disseminating the solutions widely and by facilitating their adoption. “Facilitating” means they fine a hospital for not conforming to their regulations.

CMS pays the bills. Because it pays the bills it can enforce just about any change that it wants onto every hospital in the country. Have you forgotten DRGs? Years ago Medicare began adopting regulations that reduced the payments to hospitals under certain conditions. Perhaps you recall the program to reduce certain hospital infections and medical errors which began in 2007. My point is two fold. First, hospitals should bear the financial cost of making their workplace safe. OSHA says that they are responsible for the safety of their employees. They have failed miserably at this because no one has given them an offer they could not refuse.

Second, CMS and JCAHO already have in their mission statements the authority to make new regulations that affect safety. It is the job of doctor and nursing organizations to be specific about what we want, and have the data to back up why they must have it. We have the data to back up our need in this case, but we have not taken a stand for specific action. First we need a list of those things that we believe are minimum requirements for a secure working area. Then we must sell this list to JCAHO and CMS. They must refine our work and produce their own list in the form of new regulations. Hospitals could be given a period of time to present their plans to meet the new regulations and a period of time to make the changes. If these changes do not occur, CMS can withhold payments to any non-compliant hospital.

Are you waiting for your hospital to spend big money out of the goodness of their hearts to protect you, the employee? Without question, hospital resistance to change has been the major factor in our arrival at the point where our workplace is the most dangerous in America. We, those who work in the pit, need the leverage that only these two agencies can apply.

Boarding admitted patients in the ED has been a constant thorn in the ED for decades. Hospitals save money by dumping the management of admitted complex ICU and floor patients onto an already overburdened ED nurse. This causes delays in the treatment of new ED patients, often resulting in confrontations and violence. The ENA has got to say “No more” loudly. All it takes is one JCAHO or CMS regulation making boarding patients illegal and punishable by fines and there would be a huge decompression in EDs. We can’t be all things to all people all the time.

At the present time, hospital marketers seem to look for ways to make the ED more difficult to work in. Without a thought about the potential violent consequences of relatives and friends wandering in and out of the treatment area without armed guards or metal detectors, hospitals are forcing more lenient visitation practices on overstressed EDs. Do any of these marketers realize that this policy needlessly exposes people to the largest collection of the most deadly and resistant organisms in the community? Do they know that most people who are murdered are killed by someone they know? Hospitals are not going to stop doing these things until someone with the muscle to back it up forces a visitation policy that recognizes both infectious disease risks and violence risks. We now have boyfriends insisting on sitting in on their girlfriend’s pelvic exam. This prevents the doctor from asking about abuse. Medical directors have less and less to say about how their ED is run. The marketers have taken over. They do not have a clue regarding the implications of the policies they are shoveling.

In previous posts I have plainly outlined how EMTALA, diplomatically immune alcoholics, and the loss of funding for addiction, homeless, and psychiatric programs continue to concentrate potentially violent patients in the ED. Boarding patients is no longer defensible. It is not safe for the patient, whose ED nurse does not have time to complete all of the admission orders and do her primary job at the same time. JCAHO and CMS should have ended this practice a long time ago, but they won’t as long as emergency nurses are not willing to stand up for what is best for the patient. Hospitals want to continue doing this, and they will fight it tooth and nail. For them, it is a financial decision. Emergency nurses should seek what is best for the admitted patient and new arrivals. If you insist, CMS and JCAHO have the authority to promulgate and implement regulations against boarding. They can force your hospital to support your case for assault by a patient. They can change the attitude of hospitals toward safety for their employees.

If there was a way to insure a safe workplace for nurses without armed guards, metal detectors, and bullet-proof glass I would certainly endorse it. But there is no such thing. I wish that people didn’t try to steal babies from the nursery. I wish that half of all the patients in the ED after midnight were not intoxicated. But wishing and hoping are not going to produce any results with violence toward healthcare workers. The old days of allowing visitors nearly unlimited access to patient areas are over. We must accept the reality of violence lurking everywhere and stop wishing that things were like they were thirty years ago. Nothing is going to change unless nursing leaders get together with CMS and JCAHO and have a list of specific things that they endorse in hand.

Do not expect that every member of your delegation will like the final list. But once the list is produced, those who cannot support it should resign from the delegation. You will not convince an agency to act by bringing a bunch of bickering people to the table. While I think that physician input would be an important part of redesigning patient flow with physical changes in every department, I would not count on physician organizations in general to be your ally with regard to JCAHO and CMS. They just have too many incestuous relationships with hospitals and hospital corporations. The physician organizations have had decades to stand up for you, and they have failed to take any effective leadership role.

I believe that we must act before your situation gets worse. I have no dog in this fight. I’m retired. I can’t be fired. I owe nothing to any organization. I don’t want money. I want to see emergency nurses and all healthcare workers receive the kind of protection they deserve. They stood by me through thick and thin for 38 years. I’ve got a lot of flaws, but one of them is not lack of gratitude.

Charles C. Anderson M.D. FACP, FACEP





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