Combating Patient-Generated Violence with Safe Hospital Design

For those not as familiar with the phenomena of violence in healthcare, the bottom line is that aggressive and disruptive behavior continues to be on the rise across every facet of healthcare in the U.S., from hospitals large and small to residential long-term care facilities, to stand-alone ambulatory surgery centers and orthopedic care sites, to home health and hospice. The issue of patient-generated violence extends beyond the U.S. to our friends north of the border in Canada, and healthcare delivery systems across Europe, Australia and Asia – all are facing similar challenges with how to combat the growing and concerning issue. The reality of our current world is that hospital staff (nurses and doctors in particular) are victims of violence every day!  The sad truth is that on any given day, many staff members in healthcare are assaulted by a patient or visitor.

This escalating violent behavior is found among patients in the emergency department, ICU, as well as on general medical-surgical floors. This is not just an issue found only with behavioral health patients or instigated by gang members or meth addicts. It is commonplace to hear of disruptive patient behavior from those young and old alike, stemming from all walks of life. No healthcare facility is immune. No community, large or small, is unaffected. 

Why violence is happening reflects our community, with increased alcohol and substance abuse (read: opioid crisis), and a staggering reduction in psychiatric treatment facilities over the last 25 years.  Have you noticed billboards in your community advertising the average ED wait time at your local hospital?  The American Hospital Association recently reported nearly half of all U.S. hospital-associated medical care is delivered by emergency departments – prolonging wait times and serving to raise the already high temperature of emotions and growing frustration when seeking emergency care.  Add in the societal fatigue associated with COVID-19 and the new screening protocols and visitor restrictions introduced since our fight with the pandemic have only served to turn the temperature of emotions up even higher.

The emotional toll is having an impact on the industry – so many physicians and nurses have experienced or witnessed violent acts, including biting, scratching, spitting, kicking, and punching.  Nearly 50% of emergency physicians say they have been assaulted. In a 2018 American College of Emergency Physicians (ACEP) / Emergency Nurses Association (ENA) survey of its members, 70% of emergency nurses report being hit or kicked on the job. There are countless accounts of patients throwing objects, including chairs. Others have yanked out IV’s and threatened to fling blood at providers. There are so many other instances of verbal and emotional abuse. This must be balanced with the increased regulatory pressure to reduce or eliminate the use of chemicals or force to manage such behavior. Arguments can be made for use of force (restraints) or chemical restraints, but the fact remains, that the use of force often places greater risks to patients, care providers and security staff alike. 

A former CEO of a large hospital shared services organization was fond of saying ‘form follows finance’; the estimated impact of proactive and reactive violence response efforts is estimated to cost U.S. hospitals and health systems approximately $2.7B annually. And when you add in the impact of turnover due to those leaving the industry because they do not feel safe or have been injured on the job, the budgetary impact is believed to be significantly higher. 

How Can Hospitals Be Protected?

All of this has generated concern for hospital administrators, care providers and healthcare security practitioners alike. However, budgets to make major changes or add large volumes of security officers or other security risk mitigations are diminishing. So, how can healthcare be better protected?

One important answer is to incorporate the principles of safe design features into the healthcare environment.  In June 2020, the International Association for Healthcare Security and Safety (IAHSS) published the 3^rd edition of “Security Design Guidelines for Healthcare Facilities”. This edition was developed using the expertise of a multidisciplinary team with experience in various aspects of planning and design, Crime Prevention Through Environmental Design (CPTED), compliance, and development of healthcare facility security and emergency management programs.   

The new edition places considerable attention on its updated guidance to help combat violence in healthcare (harm-to-staff and harm-to-self) using the built environment.  Specific emphasis was placed on the design of high-risk patient/observation rooms that may be used for disruptive or aggressive patients, those at risk for elopement, and forensic (prisoner) patient treatment. Specific guidance was created in the new edition for locked emergency psychiatric section of the Emergency Department (also referred to as Crisis Intake Center).

Additionally, new guidance was developed for emerging areas within the healthcare environment including Stand-Alone Emergency Departments and Behavioral Health patient care settings as well as Urgent Care and Ambulatory Surgical Care facilities. A new chapter was created for Residential Long-Term Care facilities that address securing the various settings that may be used in providing residential care.

The Security Design Guidelines for Healthcare Facilities (SDGHF) are intended to assist security practitioners, design professionals, building owner representatives, and planning leaders in making informed decisions related to the application of proven and effective security principles into each new construction and renovation project.

Build Security Into the Initial Design

Starting with the security vulnerability assessment led by a qualified healthcare security professional, a healthcare project’s security risks are best addressed upfront and early on during design. This simple step has been proven to help healthcare organizations cost-effectively address the safety and security of new or renovated space. Many industry insiders believe this important step will help lower operational protection costs by up to 30%.

Beyond significantly lowering operational costs for security, the payback of designing security features into a new healthcare facility or renovated space early can also be felt in the substantial improvement in patient and staff safety as well as overall satisfaction with the healthcare organization. This is achieved by managing both the real and perceived security concerns. Think about it, if patients, visitors, and staff feel safe walking from the external grounds and parking areas, or even nearby transit facilities, their confidence in the organization is bolstered. They are more able to focus on their reason, their need, for coming to the healthcare facility.

The idea of integrating security into design planning can be easy to overlook with the thinking that video surveillance and access control can be added after the design is complete. However, the security design guidance provided goes well beyond just camera and card reader placement; it includes defining zones of protection, addressing horizontal and vertical circulation routes, as well as the control and restriction of access that address the physical separations provided between general public areas, waiting areas, and restricted-access areas. These security considerations should be made prior to major decisions in the design being established. 

Special considerations are given to controlling access and implementing other safeguards that protect staff, especially when treating patients whose clinical needs require specialized security or who may pose a security threat.  Examples include establishing clear site lines – making sure there are a few blind spots as possible while establishing clear views of patient care rooms (read: no hidden corners in a room where a patient or family can hide from view).  Designing interview bereavement, and treatment rooms to reduce the potential for staff being trapped by the patient or visitors during highly emotional or escalating situations.  Emphasis is placed on departments and rooms serving patients of high-risk to include embedding ligature- and tamper-resistant safeguards to minimize the concern for suicide safety – a current hot topic with hospital accrediting agency The Joint Commission. Several are specific to a behavioral health unit but are also important considerations in the emergency department, intensive care units and medical-surgical units where a patient with an elevated risk for suicide or violence may be placed. 

Additionally, important guidance is provided for patient care areas specifically, to include the safe and smart design of nurses’ stations, triage, and other public-facing workstations as well as waiting rooms serving the organization and care needs of higher security risk patients.  The reception or unit clerk desk is a great example, there should be a clear distinction from the waiting area and protected with a design that prevents unwanted access and is of sufficient height, strength, and depth to make it difficult for someone to jump over the desk or assault an employee.

Some aspects of the design considerations are commonsensical but are often not considered until after the design has been finalized. An example is the placement of the security office and head-in systems for related security equipment and technology. The positioning of the office can be of significant deterrent value, setting the tone for how important safety and security is to the organization. The ability to greet patients can be a very effective psychological deterrent and effectively serve to prevent aggressive behavior from occurring.  Other matters include the consideration for metal screening – especially space for queuing, equipment, searches, and storage of prohibited/confiscated items. This includes consideration for a different pathway out of the public area so that patients and visitors do not have to pass back through the detection and search area when they leave.

Addressing IAHSS Principles

A principle embedded in the IAHSS guidance document is to prevent security flaws from being designed into a project.  Ideally, to minimize expensive change orders and undesirable retrofitting. Retrofitted security features are almost always more obvious and less effective than security features designed in at the early stages. There are some instances when it is nearly impossible to alter a design after-the-fact due to conflicts with local building and life safety codes or cost-prohibitive retrofitting expenses.  Not to mention, add-on security features often take away from the desired look and feel of the new project.  The worst-case scenario occurs when appropriate security features are "value-engineered" or left out entirely, and an adverse security event happens.  When this occurs, security features are added back at a much greater expense and usually less aesthetically pleasing, than if incorporated into the original design.

By addressing potential security vulnerabilities and risks upfront in the planning and design phases, organizations can have a significant impact on the safety of staff, patients, and visitors alike as well as better protect the assets of their new capital investment.  A tenant of the Guidelines is to proactively consider security design principles and mitigation in lieu of being forced to react to security and violence concerns and unwanted liability after the fact. It will save the organization the complication, expense, and resource drain that all add up when security thinking comes after the basic planning designs are in place. 

IAHSS Security Design Guidelines for Healthcare Facilities, 3^rd Edition, can be acquired at  www.iahss.org/designguidelines

Tony W. York, CHPA, CPP, is a founding member and contributing author of the Security Design Guidelines for Healthcare Facilities Task Force. He is a long-term member and former Chair of IAHSS Council on Guidelines and a Past President of IAHSS.  He is co-author of Hospital & Healthcare Security and Executive Vice President for the Paladin Security Group, Ltd that includes PalAmerican Security, Paladin Technologies, and Paladin Risk Solutions. He holds a B.S. degree in Criminal Justice from Appalachian State University, an M.S. in Loss Prevention and Safety from Eastern Kentucky University, and an Executive MBA from the University of Denver.