Special Circumstances

Assault
Unfortunately, physical assault may occur despite appropriate precautions and interventions. If
assaulted, immediately summon help, preferably by use of a panic button. Maintain a sidewards
posture, keeping the arms ready for self-protection. If faced with a punch or a kick,
deflect with an arm or a leg.52 If choking is attempted, tuck the chin in to protect the airway and
carotids. If bitten, do not pull away but rather push toward the mouth and hold the patient’s nose
shut. This will cause them to open their mouth to breathe. If threatened with a weapon, try to
appear calm and comply with demands. Adopt a non-threatening posture and avoid sudden
movements. Do not attempt to grab the weapon. If a weapon is put down, do not reach for
it but rather attempt to verbally resolve the crisis while awaiting security.
Hostage Situations
Avoid argument, despair, or whining, but do attempt to establish a human connection with the
hostage taker. A hostage taker will rarely murder a hostage if a relationship has been
established.Do not bargain or make promises, and do not lie, as the consequences could be
disastrous. Instead, reassure the hostage taker that someone authorized to hear his complaints or
demands should arrive promptly. Legal authorities can be called upon to provide a professional
hostage negotiator if one is needed.
After A Violent Event
After a violent event, when the perpetrator has been restrained, administer to the victim, and
record the entire affair in the incident log. Document whether a weapon was involved, the extent
of injuries, and adequacy of security response. Encourage the Emergency Department staff to be
obsessive in maintaining this incident log, which should document all threats,
Definition: A violent patient is a patient who has intentionally
used physical force against another person or oneself.
1.Identify violent patient
2.Initiate safety precautions for patient, ED staff, visitors, and
other patients
• Notify hospital security—coordinate with local
law enforcement
• Implement security plan
• Weapons confiscation per security
3.Initiate patient confidentiality measures
• No patient identifiers
• Limit release of information
• Private examination room
• Restriction of visitors
4.Evaluate, stabilize, and treat medical conditions
5.Evaluate psychosocial status
6.Provide resources for medical follow-up
7.Refer to appropriate mental health, community, and
social agencies
8.Document:
• History
• Physical examination
• Treatment
• Notification of security and legal authorities
• Indications for restraint if used
• Collection of evidentiary material
• Referrals
• Disposition and follow-up

The Management Of Extreme Violence.

Definition: A condition of extreme violence is present when a patient, visitor, or other
individual threatens the life or safety of another patient, visitor, or person by physical
force or the use of a weapon.
1.Identify the risk factors for extreme violence
2.Initiate safety precautions for patient, ED staff, and visitors
3.Notify hospital security (describe procedure, such as panic
button location, etc.) and coordinate with local law
enforcement and hospital administration
4.Implement security plan
5.Implement hostage plan as appropriate
6.Defuse situation as much as possible
• Verbal techniques
• Physical restraint
• Chemical restraint
7.Evacuate (identify indications, plan, and implementation
of plan)
8.Isolate affected area from other hospital activities
9.Provide medical treatment for injured patients, visitors,
and staff
10. Provide crisis intervention for affected staff
• Immediate critical incident debriefing
• Resources for counseling and follow-up
11. Designate hospital representative for family contacts and
media liaison
12. Investigate violent incident

Outside the Emergency Department

1.After dark, have only one patrolled entrance to the hospital,
but multiple exits.
2.Install metal detectors.
3.Provide ED staff with a security access system (e.g.,
keypad entry).
4.Install protective Plexiglas and/or metal bars between ED
staff and public areas.
5.Lock perimeter doors.
6.Post armed security guards inside and outside the ED.
7.Have multiple methods of summoning police.
8.Let the police disarm any patient brandishing weapons
outside the ED.
9.Actively patrol all parking areas.
10. Provide training to all staff in the above measures.
Inside the ED
1.Give immediate attention to patients who appear agitated.
2.Undress all patients being evaluated in the ED, thus
removing weapons.
3.Limit and search visitors who enter treatment area.
4.Have a seclusion room equipped with panic button for patient interview.
5.Use chemical and/or physical restraints for a combative patient.
6.Ensure all ED personnel wear current photo identification.
7.Immediately report any suspicious individuals to security.
8.Develop a prehospital protocol for management of the violent patient.
9.Fully document all major incidents of violence and review regularly.

Table 9. Sample Physical And Electronic Search Policy.

The following patients will be physically and electronically searched by Security. The
primary care nurse must notify Security as soon as possible when a patient meets
search criteria. Patient’s possessions that are present in an examining room must also
be searched and then removed from the room (e.g., medications, pocketbooks,
backpacks, clothing bags).
1.All patients who will be transported to Mental Health.
2.All patients in the emergency department who are placed in restraints.
3.Patients who present to the emergency department complaining of suicidal, homicidal,
or paranoid thoughts.
4.Patients who are hallucinating.
5.All patients who have taken a drug overdose.
6.Patients who are significantly intoxicated.
7.All patients who are placed in locked seclusion.
8.Patients or visitors who physically threaten or assault
staff members.
9.Any patient whom the attending physician suspects of
being armed or dangerous.
10. Any patient transported from the scene of a shooting
or stabbing.
Security
Security is a key issue in maintaining preparedness for violence. A well-trained and responsive
hospital security force should be available to all hospitals. While no hospital is immune to the
specter of violence, urban hospitals in violent areas may require special measures.