Violence in ED

A dramatic increase in patients with mental health problems or drug and alcohol dependence is putting EDs under unprecedented stress, and violence is increasing as a result.

A lot can happen on a Saturday night at the local Emergency Department. A man may arrive, agitated, and threaten a triage nurse with a long-bladed knife; a disturbed middle-aged woman may rip the NUM’s skirt and kick her in the throat; a police officer may have a face-off in a triage cubicle with a man wielding an axe; or a group of steroid-charged men may use their already-injured friend as a battering ram to skip the emergency queue and charge into the triage area.

Or maybe the most traumatic incident will be a mother’s tears of relief as her daughter’s first asthma attack is brought under control. This is more likely, but anything is possible … all of the incidents mentioned above have happened, too.

The Garling Report states that the number of people using the public health system has surged since 2006. A dramatic increase in elderly patients, as well as adolescents – many of whom present with mental health problems or drug and alcohol dependence – is putting EDs under unprecedented stress, and violence is increasing as a result.

In Australia, only security guards are more exposed to workplace violence than emergency nurses.

NSWNA General Secretary Brett Holmes says the Garling Report highlights that we must react to the increasing demands on the health system with new and improved policies to protect the safety of nurses.

Tony Lochead, NUM of the ED at Tweed Hospital, Tweed Heads, is one of many ED nurses worried about increasing violence at work. He formally requested an OHS review of his unit following several serious incidents there.

At the heart of Tony’s concerns is the question of how best to deal with the large number of mentally ill patients presenting at the ED, and how to train ED nurses to deal with potentially violent situations when they arise.

‘It’s important that every person presenting under a presumption of mental illness is assessed for underlying or co-existing physical conditions. We need to acknowledge that the ED has been mandated in NSW at least as the best place for this to occur, but we need adequate provision of physical resources, the availability 24 hours per day of specialist nursing and medical staff and processes for ED skill development,’ said Tony.

‘The absence of these factors at Tweed Hospital has led to ED nurses having had a “gutful”. There is a definite sense of  “abandonment”, with unskilled, unsupported ED nurses being left to do all the high-end mental health work for ever-extending lengths of time and for ever-increasing numbers of patients.’

Emergency Departments in many of the state’s older hospitals are ill-equipped to cater for the specific needs of the mentally ill. Loud noises, bright lights and long waiting times can all cause or aggravate psychoses.

‘Everything in the waiting room can be a trigger for psychotic episodes and aggression,’ said Barbara Daly, NUM of the ED at Prince of Wales Hospital.

‘People try to stay calm but, environmentally, the odds are against them. Even the general public can be abusive, throwing their weight around, demanding their rights and intentionally intimidating our female nurses,’ said Barbara.

Rachel Meek is the acting NUM of the ED at Calvery Mater Hospital, Newcastle.  She believes that ED nurses should receive the same violence management and minimisation training as mental health nurses, and this is a position the NSWNA supports.

Evidence suggests that basic one-day violence management training for nurses can reduce the incidence of aggression in EDs by as much as 50%. The NSWNA recommends that five-day courses on duress response and de-escalation methods should be compulsory for all ED nurses, and OHS expert Trish Butrej says that drug and alcohol and mental health units need to coordinate more with EDs.

Tony Lochead reports that improvements have occurred at Tweed Hospital ED since an OHS report was conducted by the NSWNA. ‘The improvements include appointment of a permanent person to the CNC position, plans progressed for the creation of architecturally-designed “secure rooms”, the rollout of four-day training to all staff, and improvements in the number of duress pagers with further duress system changes in progress. We are still a long way from being in a position we accept as our minimum standard, and even further away from having the first rural PECC Unit, but with the continued assistance and support of the NSWNA – especially from OHS Officer Trish Butrej – I am confident we will get there.’

Zero tolerance for violent abuse

Shortly before midnight on Saturday, 8 December 2007, a young man was brought to Bankstown Hospital by three of his steroid-charged friends. Frustrated by the long queue, the three men used their friend as a battering ram to charge into the Emergency Department’s triage area.

‘The crazed men demolished half the waiting room, wrecked all the computers in the clerks’ quarters, and terrorised the patients, visitors and staff,’ said Clive Avery, an RN who was on triage duty that night.

‘It was scary for all involved, and it made us think a lot about our safety. The ED has been made a lot more secure since then,’ said Clive.

A study in NSW, which included 650 ED nurses, found that all of the nurses surveyed had experienced violence in the workplace. Alarmingly, evidence suggests that only 30% of incidents are reported. With the help of the NSWNA, Clive and his colleagues had the four men charged.

‘It is important to have a zero-tolerance policy towards violence,’ said Clive.

PECCs, Two Years On

In October 2006, The Lamp reported that the opening of four Psychiatric Emergency Care Centres (PECCs) signalled the transformation of mental health nursing in Sydney hospitals.

PECCs are designed to minimise the time mentally ill patients have to wait for an acute mental health bed, and to decrease the risk of violence towards ED nurses. Their success has led to PECCs being opened in five other metropolitan hospitals, and there are plans to establish more in regional hospitals.

Tony Lochead, NUM of the ED at The Tweed Hospital, would like to have a PECC attached to his department.

‘We need to implement measures to ensure that mentally ill patients receive the same level of skill, privacy and compassion as our other patient groups – be those in the resus room or paediatric bays. Provision of an area with at least three room levels to manage this group and highly-skilled mental health staff are required to improve care. After all, we do not try and resuscitate a neonate with only a wards-person in the primary care room, ’ said Tony.

However, Barbara Daly, NUM of the ED at Prince of Wales Hospital, is disappointed with the lack of communication and co-operation with the PECC there.

‘The access to the PECC at Prince of Wales is skeletal. It only accepts patients who aren’t under the influence of alcohol or drugs, and who aren’t scheduled, but that describes most of the mentally-ill patients presenting in the ED, so we still have to deal with them,’ said Barbara.

PECCS have a policy against admitting patients under the influence of alcohol or drugs because their toxicology must be assessed and stabilised before their psychological state can be established. However, many ED nurses say this policy needs to be more flexible.

‘If a patient is homicidal or suicidal, their psychological condition must take precedence over their toxicology,’ said Rachel Meed, NUM of the ED at Calvery Mater Hospital, Newcastle.