By Elizabeth Simpson
The Virginian-Pilot © April 13, 2012
For medical tech Charles Hartelius, an emergency room incident ended in a broken nose and ankle, a couple of surgeries, and questions about whether he'll ever walk normally again.
For Joan Mahon, a weekend shift as a psychiatric nurse left teeth marks on her arm and the loss of her job.
And for Terry Wallace, putting a monitor on a patient's chest left her with a court case and a surgery eight months later to repair damage to her nose.
Hospitals are thought of as safe havens, but what happens when patients turn on the people who are trying to help them?
It's a phenomenon common enough that health care workers are conducting surveys, gathering data and taking action. Across the country, they're lobbying for more safety training, off-duty police officers on security staff, and laws increasing the penalty against those who assault health workers.
Last year, Virginia passed a law requiring anyone who assaults an emergency health care provider to spend at least two days in jail. Half the states in the country have passed similar measures, most with even stronger penalties, such as making the offense a felony.
But the increase in punishments also comes with concerns: Should people who are sick, and possibly lashing out because of a medical or mental disorder, be held criminally responsible?
"Arresting a person is not treatment - it is traumatizing to the individual," said Carolyn Wood, a member of the Virginia Beach chapter of the National Alliance on Mental Illness, in an email response. The group wonders whether the law could unfairly target mental health patients.
Health care personnel, though, particularly those who work in emergency rooms, say the more common scenario involves people who are intoxicated or those addicted to prescription drugs who become angry when their medical condition doesn't warrant a prescription refill.
According to the most recent numbers from the Bureau of Labor Statistics, health care and social assistance workers experienced an assault and violent acts rate of 9.7 per 10,000 full-time workers in 2010, compared with an overall rate in private industry of 2.7.
The Occupational Safety and Health Administration says such assaults are probably under-reported, "perhaps due in part to the persistent perception within the health care industry that assaults are part of the job."
"A lot of times the magistrates don't want to prosecute," said Cathy Fox, a nurse for 26 years and currently with the emergency room at Sentara Leigh Hospital. "A lot of cases would get thrown out."
Concerned about reports of violence, and lacking good data, the Emergency Nurses Association began surveying nurses in May 2009.
The most recent survey, involving 7,000 ER nurses in 2010, found that 13 percent experienced physical violence in the seven days prior to the survey. In about half the cases of physical violence, no action was taken against the perpetrator, and in 72 percent of cases, the nurses received no response from the hospital about the assault.
Sixty-five percent of those physically assaulted did not file a formal report.
Factors that put health workers at increased risk:
- 24-hour access makes hospitals a likely landing place for aggressive and intoxicated people;
- The decline in the number of psychiatric beds in Virginia, both private and public, has left hospitals, especially emergency rooms, treating more psychiatric patients;
- Emergency rooms across the country have reported increased volume during the economic downturn, which means emotions run high with longer waits.
Terry Wallace, an emergency room nurse for more than two decades, had already "triaged" a patient who had come into the emergency room at Sentara Leigh in August because of a seizure. Lab work indicated his heart needed to be monitored.
A medical tech had hooked him up to an IV, and Wallace explained she was attaching an electrode patch to his chest. She didn't see his right fist coming. She clutched her face at the blinding pain and staggered backward.
He had struck her between the eyes. Blood poured out of her nose. A medical tech pulled the patient back down on the stretcher, and Wallace was taken for treatment. She missed a week of work, had to go to court as a witness in the malicious wounding charge, and has another surgery - in which her nose has to be rebroken and reset - planned for Monday. The man was arrested and is scheduled for trial in May.
Wallace knows her workplace is at higher risk than other places in the hospital for assaults, but still, she was surprised by the mix of anger and betrayal she felt.
"What's the emotion when someone strikes you in the face?" she asked. "It's demoralizing. There are always people who are not pleased. Emotions are high, stress is high. But why do we have to pay the price?"
A split second also changed life for Charles Hartelius, 55, a medical tech who works in the emergency department at Sentara Virginia Beach General Hospital. He had been assigned to sit with a man who was depressed and suicidal in August 2009.
The patient wanted to go outside and have a cigarette, but because the medical campus is smoke-free, Hartelius said he couldn't. Hartelius was able to keep him in an exam room, but then the man took the IV pole off his stretcher and tried to break the window.
Hartelius went in to remove the IV pole from the room. A rescue worker walking past saw the commotion and came in to help. The patient, feeling threatened, head-butted Hartelius in the nose, then fell into Hartelius when the rescue worker tried to hold him back. Hartelius heard his ankle snap and noted its unusual angle.
"Right away, I thought, 'This is not good.' "
He had surgery that day and spent several days in the hospital. He was out of work for 10 weeks. In June 2010, he had another surgery. He can still feel the bones in his ankle shift when he goes up and down stairs, and he's unable to spend a lot of time on his feet. He's had to switch to desk work rather than medical tech duties.
The man who head-butted him was charged with assault and battery, and he received a suspended 10-day sentence and $100 fine.
"I spent more than that on gas money to physical therapy," Hartelius said.
One of the reasons the emergency nurses began conducting surveys on the issue is that so many incidents were arising, according to Gail Lenehan, president of the Emergency Nurses Association. But no one could definitively answer the question of whether it was getting worse.
"The magnitude was so obvious we felt we needed to document it," she said.
She said more than half the reported assaults involved people who were intoxicated, 47 percent were under the influence of drugs, and 45 percent involved psychiatric patients.
Along with the new laws that call for tougher mandatory sentencing, hospitals are taking more safety measures on their own, in part due to a 2011 directive issued by OSHA for violence-prevention measures.
The Virginia law pertains only to health care personnel in emergency departments, but other states have broader laws that cover the whole hospital and deal with aspects besides jail time. Connecticut, for instance, recently passed a law requiring hospitals to have violence prevention training. In California, nurse-to-patient ratios mandated by state legislatures are credited with helping reduce violence, particularly in psychiatric settings, which are high-risk.
It was a psychiatric unit shift that changed the course of Joan Mahon's nursing career. A nurse for three decades, the 57-year-old Chesapeake woman has worked as a psych nurse in hospitals and at the Hampton Roads Regional Jail in Portsmouth and currently does substitute school nursing in Chesapeake. In April 2010, she was working on the psych unit at Sentara Norfolk General Hospital and went into a room to give a medication to a patient, who had the covers over her head. Mahon told her it was time for her pill and gave it to her in a medicine cup. The patient threw it back at her.
Mahon left the room, and as she was walking down the hallway, the patient ran up to her and sank her teeth into Mahon's arm. Another employee pulled the patient off Mahon, who ended up in the emergency room for treatment. A nurse supervisor told her it wasn't necessary to file a police report, but "I wanted it to be documented," Mahon said, and so she did.
The next day was Easter Sunday, and she went to work. The patient was on the same unit but assigned to another nurse. Mahon checked the electronic record of the patient who had attacked her and found out she had attacked a resident the previous Tuesday and had been court-ordered to take medications on Wednesday.
Three days later, the day of the attack, the patient had not had any medications.
Mahon questions why the hospital did not inform her of the attack earlier in the week and work harder to make sure the patient had taken her court-ordered medications.
"They knew on Tuesday when she knocked the doctor down she wasn't right. She should have had one-on-one care. I wouldn't have approached her by myself if I had known she'd been violent during the week."
Because Mahon had looked at the patient's electronic record on a day when she was not treating her, she was terminated for violating the Health Insurance Portability and Accountability Act, which protects privacy of patients.
She also was reported to the Virginia Board of Nursing. After an investigation, the board decided not to take any disciplinary action, according to a letter sent by the board to Mahon. The letter said the case was being closed as "undetermined" but that the board did have concerns about her accessing the records.
Sentara Healthcare spokesman Dale Gauding said he could not discuss Mahon's specific case because personnel issues are confidential, but that employees who view electronic medical records of patients who are not assigned to them are subject to disciplinary action up to and including termination.
Mahon tried to get Sentara to change her termination to a resignation, based on the board's finding and because she felt the hospital had not adequately informed her of the patient's previous assault. But no change was made.
"I was left to my own devices on how to deal with it," she said. "No one debriefed me; no one counseled me."
Lenehan said the association is working with hospitals and nurses to better educate employees about de-escalating violent situations, make sure proper staffing exists, and inform staff of the situations they are walking into - for instance, by having police officers give them a report on patients brought to emergency rooms.
Locally, hospitals are taking safety measures. Chesapeake Regional Medical Center hired a national consultant to review security about two years ago. Personnel have anti-violence training, security staff in the emergency room, a response team in place when violence erupts, cameras and monitors, and phones in the parking lots.
At Sentara hospitals, some emergency rooms employ off-duty police or sheriff's deputies to provide extra security, and staff also receives crisis prevention training.
Wood, from the National Alliance on Mental Illness, said it's important for staff to distinguish between people who have a mental illness and those with substance abuse addictions, as the latter are more likely to lash out.
She said cuts to Medicaid and Medicare reimbursement rates also have affected staffing in some situations, leaving too few people handling sensitive situations.
The Office of the Inspector General also has tracked a statewide problem of people in mental crisis emergencies not finding adequate inpatient care. The problem, worse in Hampton Roads and Southwest Virginia than other parts in the state, results in people being left too long in emergency rooms. That can add risk to an already high-stress arena.
But Fox, the Sentara Leigh nurse, said the bigger problem has been those who are intoxicated or addicted to drugs, and a line needs to be drawn by health care providers:
"There are people who think we deserve it because we're not making them better," Fox said. "Nothing will happen until we say, 'Enough.' "
Source : hamptonroads.com/