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November 14, 2013
N.H. hospital combats ER violence, long waits
The Keene Sentinel
KEENE, N.H. — Emergency workers deal with life-or-death situations every day, but more are also contending with being attacked in the emergency room.
Hospital officials at Cheshire Medical Center/Dartmouth-Hitchcock Keene say workers are increasingly being verbally and physically abused by patients and their family members.
“That has definitely increased over the past two years,” said Amy W. Matthews, director of emergency services at the Keene hospital.
The problem has also increased statewide. Governor Maggie Hassan recently called for a review into the state’s mental health system after two staff assaults at Manchester’s Elliot Hospital.
To help address the problem of long waits for mental-health patients, the Keene hospital plans to update the emergency room’s layout to provide more private rooms and basic amenities for those waiting to be transferred to New Hampshire Hospital in Concord. Hospital officials said the emergency care staff is also learning new protocol to deal with aggressive patients or family members.
Over the past two years, attacks on medical workers have spiked. Incidences often consist of verbal abuse, but there have also been physical attacks.
A high-profile case occurred in March of this year, when an agitated man from Northfield, Vt., grabbed an emergency room nurse by her face and hair and threw her to the floor at the Keene hospital.
Other cases in the state include an emergency department nurse having her thumb bent fully back by a suicidal patient in 2012, and a nurse being choked to the point of unconsciousness by a patient hallucinating on drugs in 2008. Attacks have originated from intoxicated and mentally ill patients, and the consequences for emergency room staff are dire.
Statistics show an increase in attacks
National numbers reflect the severity of emergency room violence. According to the Bureau of Labor Statistics, 14 health care workers were killed on the job in 2010, and the National Institute for Safety and Health listed health care workers as more likely to be attacked than prison guards or police officers.
A 2009 survey in the Journal of Nursing Administration found that out of 1,000 emergency nurses, 86 percent had experienced workplace violence in the previous three years, and 20 percent reported they experienced violence frequently. The Emergency Nurses Association in New Hampshire pushed legislation raising the jail sentence for those who assault health care workers, but the N. H. House killed the bill in 2012.
Matthews said common problems contributing to violence included stress of patients and family members, patients abusing drugs and alcohol and increasingly long stays for psychiatric patients in the emergency room.
“People are stressed, they’re worried, the economy is not doing well; they have a lot of frustration,” said Matthews.
“There are changes in society where people had abilities to control their actions,” she added. “People seem to have lost that.”
Matthews noted patient aggression often starts as verbal abuse, something she said emergency care staff had previously accepted as part of a high-stress job.
“There was a period of time where staff accepted abuse to a certain level, certainly verbal abuse,” said Paul A. Pezone, Sr., Cheshire Medical’s vice president for Clinical and Support Services. “We’ve since worked with staff to say that’s not acceptable. We set boundaries.”
According to Matthews, boundaries might be as simple as telling a patient or family member that they are frightening the staff.
“It always has to be in a respectful manner,” she added, saying staff is not allowed to yell at their patients, even if they feel threatened. “What they (the patients) often need is to be heard.”
Mental-health issues contribute
Cheshire and other hospitals across the state have seen a dramatic increase in the amount of time mental health patients stay in the emergency room.
“I think the mental system is overworked,” said Dr. Harneet Sethi, medical director of Cheshire’s emergency department. “Just look at the time it takes to get to New Hampshire Hospital.”
A 2013 study by the Foundation for Healthy Communities found one in three New Hampshire patients seeking mental health treatment waited an average of 2.5 days in a hospital’s emergency room for a bed in the state hospital, which is the main facility for inpatient psychiatric services in the state.
Cheshire officials say sometimes the wait can be much longer, up to 11 days in the emergency room. These long stays are a growing problem for hospitals across the state, and can make the already stressful environment worse for staff and short-term patients.
“People in crisis are being brought by police, family, EMS,” said Matthews. “If they are at a point of crisis where they require (admittance), that’s where we hit a bottleneck, and they are in the emergency department for days. It’s incredibly frustrating for patients and families to feel like they’re in limbo.
“It’s not the expectation of anyone that you’ll be in the ER for days,” Pezone added. “There’s a feeling of powerlessness on behalf of the staff. We’re actively trying to give the best care we can, it just is in a place where we were never supposed to give that kind of care.”
Pezone and Matthews said this feeling is multiplied when the emergency department is overflowing with patients, both psychiatric as well as those with physical injuries.
“We can be too full, but we can’t turn anybody away,” said Pezone.
According to Sethi, long waits for mental health patients can create a “disproportionate effect … on the general running.”
To combat this problem, Cheshire officials plan to reorganize the layout of their emergency room, adding more private patient rooms and basic amenities for mental health patients.
“They need to have their basic needs met,” said Matthews. “They need for us to provide for their daily functions.”
“We’re working towards a combo of public and private rooms,” she added. “Specifically for our psychiatric patients, we’re looking to increase capacity in rooms that are safe.”
“The emergency department is a difficult environment,” said Matthews, stating that the high-stress environment makes it tough for patients and families to cope with difficult situations. “You’re building this environment where the stress is high and the ability to cope is low.”
Dartmouth-Hitchcock Medical Center in Lebanon is also updating part of its emergency department to meet the needs of psychiatric patients. Clarence R. Adams, the director of external relations for Dartmouth-Hitchcock, said the hospital is in the process of renovating two rooms to use as private patient rooms.
Hospital administrators are supporting staff in other ways. Cheshire is the first hospital in the state to provide staff with personal infrared transmitters, clip-on devices staff can use to alert security if they are being attacked. The number of emergency department security staff has also been increased.
A lot of Cheshire’s response to the growing problems of long waits and hospital attacks is self-directed, but these issues are all too familiar in many other hospitals across the state.
“It’s just a reality,” said Sethi. “There’s not funding there for the safety net that’s required.”
Matthews said the hospital had met with officials from New Hampshire’s Department of Health and Human Services to discuss the issue.
“There are some very core questions that we have not been able to answer,” she said. “The focus is on state hospital beds; the focus needs to be on community research.”
“If we can rebuild those supports, we avoid the crisis,” she added. “My hope is that the state looks at the whole picture.”
Dr. Robert J. MacLeod, CEO of New Hampshire Hospital, agreed that the state’s mental health system needed more support for community hospitals. MacLeod said his organization was meeting regularly with community hospitals in an effort to move patients to New Hampshire Hospital as efficiently as possible.
Another designated receiving facility for psychiatric patients recently opened at Franklin Regional Hospital, and MacLeod said New Hampshire Hospital plans to add 10 beds in 2014. However, he noted the difficulty of the current situation for community hospitals across the state.
“Community hospital psychiatric beds have dwindled,” said MacLeod, who commended the current practices of Cheshire Medical Center. “I agree with Cheshire Medical Center focusing on the community piece.”
He said there needs to be more of a focus on expanding community psychiatric services across the state.
MacLeod noted that New Hampshire Hospital is also struggling with fewer beds for psychiatric patients and said his staff has also faced problems with assault.
“This violence pervades all of the hospitals,” he said. “The system wasn’t designed for people to sit in emergency rooms for days.”
“We really need to look at this issue as a systemic one,” he added. “I know that hospitals are trying to do the best they can.”
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