ERs turn more violent as government help shrinks for volatile mentally ill, addicted patients

Nurses fear even more ER assaults as programs cut

COLUMBUS, Ohio — Emergency room nurse Erin Riley suffered bruises, scratches and a chipped tooth last year from trying to pull the clamped jaws of a psychotic patient off the hand of a doctor at a suburban Cleveland hospital.

A second assault just months later was even more upsetting: She had just finished cutting the shirt off a drunken patient and was helping him into his hospital gown when he groped her.

“The patients always come first — and I don’t think anybody has a question about that — but I don’t think it has to be an either-or situation,” said Riley, a registered nurse for five years.

Violence against nurses and other medical professionals appears to be increasing around the country as the number of drug addicts, alcoholics and psychiatric patients showing up at emergency rooms climbs.

Nurses have responded, in part, by seeking tougher criminal penalties for assaults against health care workers.

“It’s come to the point where nurses are saying, ‘Enough is enough. The slapping, screaming and groping are not part of the job,’” said Joseph Bellino, president of the International Association for Healthcare Security and Safety, which represents professionals who manage security at hospitals.

Visits to ERs for drug- and alcohol-related incidents climbed from about 1.6 million in 2005 to nearly 2 million in 2008, according to the federal Substance Abuse and Mental Health Services Administration. From 2006 to 2008, the number of those visits resulting in violence jumped from 16,277 to 21,406, the agency said.

Nurses and experts in mental health and addiction say the problem has only been getting worse since then because of the downturn in the economy, as cash-strapped states close state hospitals, cut mental health jobs, eliminate addiction programs and curtail other services.

After her second attack in a year, Riley began pushing her hospital to put uniformed police on duty.

The American College of Emergency Physicians has recommended other safety measures, including 24-hour security guards, coded ID badges, bulletproof glass and “panic buttons” for medical staff to push. Detroit’s Henry Ford Hospital is among hospitals that have had success with metal detectors, confiscating 33 handguns, 1,324 knives, and 97 Mace sprays in the first six months of the program.

But there are practical and philosophical obstacles to locking down an ER. Bellino and others say safety begins with training health care workers to recognize signs of impending violence and defuse volatile situations with their tone of voice, their body language, even the time-outs parents use with children.

He said nurses, doctors, administrators and security guards should have a plan for working together when violence erupts. “In my opinion, every place we’ve put teamwork in, we’ve been able to de-escalate the violence and keep the staff safer,” he said.

Also, he and others said it is important to combat the notion among police, prosecutors, courts — and, at times, nurses themselves, who are often reluctant to press charges — that violence is just part of the job.

“There’s a real acceptance of violence. We’re still dealing with that really intensely,” said Donna Graves, a University of Cincinnati professor who is helping the federal government study solutions.

Robert Glover, executive director of the National Association of State Mental Health Program Directors, said economic hard times are the worst time for cuts to mental health programs because anxieties about job loss and lack of insurance increase drug and alcohol use and family fights.

“Most of them, if it’s a crisis, will end up in emergency rooms,” he said.

Vermont nurse David DeRosia, who has been attacked at work, said patients want McDonald’s-like fast service even when they visit busy emergency rooms. When they don’t get it, some lash out.

“They want to be able to pop in and get what they need immediately, when the emergency department has to see the sickest patients first,” he said. “There are many people who have unrealistic expectations they can get whatever they want immediately, and it isn’t a reality.”

What has heightened fears among nurses and other health professionals is that attacks have become more violent, Graves said. “What’s bringing attention to it now is the type of violence: the increase in guns, in weapons coming in, in drugs, the many psychiatric patients, the alcohol, the people with dementia,” she said.

Twenty-six states apply tougher penalties for assaults against on-the-job health care workers. A renewed push to stiffen punishment began the Emergency Nurses Association reported last year that more than half of 3,465 emergency nurses who participated in an anonymous, online survey had been assaulted at work.

“It came as news to me that they are one of the most assaulted professions out there,” said state Rep. Denise Driehaus, who is pushing tougher nurse-assault penalties in Ohio.

Yet bills making an assault on a nurse a felony instead of a misdemeanor failed in North Carolina and Vermont during sessions that just ended, and Virginia shunted its proposal to a state crime commission.

Rita Anderson, a former emergency nurse who pioneered efforts in New York in 1996 to make it a felony to assault a nurse, said resistance is often strong — among both nurses and law enforcement officials.

In 1999, after her jaw was dislocated by a 250-pound teenager, Anderson pursued charges under the state law she had worked hard to pass. She said police were surprised a nurse would press charges against a patient, and prosecutors were skeptical of the case.

“It doesn’t matter if you’re drunk or you’re on drugs or you’re in pain,” she said. “That doesn’t give you the right to hit another person.”

Seattle ER nurse Jeaux Rinehart had learned to get outside fast to avoid kicks, spit, scratches and punches on the job at Virginia Mason Hospital. Then one day in 2007 Rinehart didn’t move quickly enough and a junkie who had entered the ER in search of a fix smashed him in the face with a billy club. Bones broken, Rinehart sucked meals from a straw for weeks.

“A thing like that sticks in your mind to the point where it’s always there, it’s always present,” Rinehart said. “I’m on heightened alert a hundred percent of the time.”

Rinehart was attacked again in July. An intoxicated patient punched and spit on him, then threatened to come back with a gun and kill him. He is pursuing felony charges.

Online:

Emergency Nurses Association: www.ena.org