- Email: [email protected]
Bridging the Gap: Interagency Task Force
CLINICAL
BRIDGING
THE
GAP: INTERAGENCY TASK FORCE
Author: Cheryl A. Kowal, BS, RN, Warwick, RI
Admission of in-custody patients into an overtaxed emergency department is often frustrating for both law enforcement and ED staff. To facilitate collaboration between law enforcement and ED staff, it would be advantageous to initiate a professional interagency task force. To justify the need for such a task force, a random survey of hospital and law enforcement personnel was
undertaken. Result of this survey revealed major misconceptions by both sides concerning the other's role. One common area of overwhelming agreement between the agencies was the need for such a task force. The data suggest the urgent need for mutually agreed upon policies and procedures for in-custody patients for both agencies to provide a safe environment for all involved.
he citizens of any community rely on a variety of local government and private services; two of the most important are local law enforcement (LE) and the community hospital. They both are trusted and respected servants of the community that address entirely different public needs; however, at times, their spheres of interest overlap. The mission of LE is to protect and serve. The mission of our local community hospital is to provide compassionate, quality health care as part of an integrated delivery system serving community needs. The goals of these 2 agencies intersect when local law enforcement is required to utilize the hospital emergency department for medical treatment of persons in police custody. This interaction primarily poses safety issues for ED staff, LE officers, and most importantly, other ED patients. The recent death of a Providence Rhode Island police officer killed in the police station, in what is perceived as a secure environment for handling in-custody individuals, brings to the forefront the potential for violence. 1 This event could have just as easily taken place in a crowded, overtaxed emergency department with the possibility of far more dire consequences involving an extremely vulnerable population. Therefore it is obvious that there is a need for a collaborative effort between local LE and hospital personnel to minimize risk to all involved. This end may be achieved by establishing a process to improve admission and
treatment of individuals in police custody in a more organized and professional manner. The challenge is that 2 groups of professionals are looking at the same problem through different, highly polarized lenses, which leads to misconceptions and misunderstandings with regard to the role of the other agency in the process. Although safety is the primary consideration, many other factors must be brought into account. These factors include manpower demands from both hospital and LE perspectives, financial implications for both agencies, and the effect on the community left unprotected when resources are allocated away from normal patrol areas. LE's obligation is stated under the eighth and fourteenth amendments of the U.S. constitution. They require LE to provide medical attention to in-custody prisoners when claim of injury or sickness of such parties is known or suspected. 2 In addition, they are called upon to transport individuals in mental health, alcohol, or substance abuse crisis to the emergency department. This may occur even when those individuals may not be technically under arrest or in custody. This situation often leads to misconceptions that the police are just “dumping” patients on an already overtaxed emergency department. The misconceptions and misunderstandings that are part of this relationship can detract from the concept of an effective cooperative effort. Better communication and understanding of each other's roles would improve relations between LE and caregivers. To achieve this goal, it would be beneficial to establish a purposeful dialogue between LE and the hospital. The proposed improvement to the system would be the establishment of an LE–emergency department task force. This task force would address the problems in the current system and work to develop procedures and policies to address these issues. The theoretic basis for this idea is that effective cooperation between these professionals will provide efficient health care with minimum risk to
T
Cheryl A. Kowal is retired Post Anesthesia Care Nurse, Warwick, RI. For correspondence, write: Cheryl A. Kowal, 455 Toll Gate Rd, Warwick, RI 0288; E-mail: [email protected]. J Emerg Nurs 2013;39:e19-e23. Available online 26 December 2006. 0099-1767/$36.00 Copyright © 2013 Published by Elsevier Inc. on behalf of Emergency Nurses Association. http://dx.doi.org/10.1016/j.jen.2006.10.010
March 2013
VOLUME 39 • ISSUE 2
WWW.JENONLINE.ORG
e19
CLINICAL/Kowal
all involved. It is important to clarify the perceptions of the current process from both sides of the spectrum. This was achieved by conducting a random survey of LE and hospital staff (HS) to establish the current status of cooperation and misconceptions. Methods
A sample questionnaire was created that incorporated demographic information and 10 questions relating to the current processing of in-custody individuals brought to the local hospital emergency department. These questions were derived from personal conversations with both ED staff and LE personnel. The demographic questions focused on 4 areas, including (1) age, (2) sex, (3) occupation, and (4) years of experience in one's current job. The questions themselves were grouped into 2 main categories. The initial 7 questions dealt with opinions regarding the appropriate management of patients brought to the emergency department in the custody of local LE agencies. The final 3 questions dealt with the idea of establishing a task force composed of LE and ED representatives. There also was a space for additional comments to be added by the respondents, particularly in response to “no” answers. A letter attached to each questionnaire explained the purpose and scope of the survey. The survey was a random voluntary sampling of the respondents' views on the questions previously outlined. A total of 120 questionnaires were distributed equally among the 3 local LE departments servicing the area and ED staff. Approval for conducting the survey was obtained from senior LE officers in each department and the nurse manager of the emergency department. The questionnaires were collected after a week and compiled for evaluation and statistical analysis of demographic information. The demographics were subjected to descriptive statistical evaluation by Microsoft Excel to derive mean, range, and standard deviation. The questions were evaluated for percentages of positive (Yes) responses. For purposes of compilation, unspecified or sometimes responses were classified as a negative response. Results
Table 1 provides information on the demographics of the respondents. A total of 81 questionnaires were returned out of 120 distributed for an overall response rate of 67.5%. The response rate for LE and HS were similar, with 67.7 % (61/90) responding from LE and 66.7% (20/30) from HS. The age of respondents had a mean (SD) of 36.7 (9.8) years. When separated into job categories, the mean age of the HS
e20
JOURNAL OF EMERGENCY NURSING
TABLE 1
Demographic information Law Hospital enforcement (n = 20) (n = 61)
Age (y) 34.7 (6.9) Experience (y) 9.8 (7.3)
All respondents (n = 81)
43.4 (13.9) 36.7 (9.8) 17.3 (11.8) 11.7 (9.2)
was significantly higher than those of LE. The mean age (SD) of HS was 43.4 (13.9) as opposed to 34.7 (6.9) for LE. The mean (SD) experience in current position was also significantly higher in HS, 17.3 (11.9) as opposed to 9.8 (7.2) for LE (Table 1). Table 2 provides information specific to each of the 7 questions requiring a “Yes” or “No” response. Respondents from both disciplines had similar responses to 3 of the questions. In question No. 5, dealing with the presence of hospital security, and in question No. 7, concerning appropriate restraints, there was a significant positive response. In question No. 8, which was of utmost importance to making the vision for the facility a reality, there was an overwhelming positive response (88.9%) to the need for a interprofessional task force (Table 2). There were major disagreements between the disciplines with regard to prior notification (question No. 1), where LE felt notification was sufficient (70.5%), as opposed to HS (50%). In question No. 2, dealing with a designated area, HS believed it was appropriate (70%), as opposed to LE (47.5%). Question No. 3 dealt with a cooperative effort to expedite in-custody patients. HS (70%) believed it was cooperative, contrary to the perception of LE (45.9%). Finally, in question No. 7, which dealt with the feelings of rapport between LE and the hospital staff, the HS believed that the relationship was good (75%), whereas LE disagreed (45.9%). Questions 8-10 dealt with the idea of establishing a task force composed of LE and ED representatives, the goal of which would be to foster mutual cooperation and understanding. Question No. 9, “Who do you feel should be represented on such a committee?” dealt with respondents' perceptions of participants necessary for an effective task force to deal with the issues discussed. There was major agreement among all respondents that the task force should include ED nurse and physician representation as well as a representative of LE from each local community. The general consensus from the LE respondents was that those representatives should include line officers who have direct experience with the emergency department. To a
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Kowal/CLINICAL
TABLE 2
Percentages of positive responses to survey questions Question
No. 1. Is prior notification of the pending arrival of in-custody patients timely and appropriate? No. 2. Is the designated area for treatment of in-custody patients appropriate at this time? No. 3. Is the admission process a cooperative effort designed to expedite the handling of in-custody patients? No. 5. Is hospital security notified and present upon admission of in-custody patients? No. 6. Do you believe that appropriate restraints are used in all areas involved in the care of in-custody patients? No. 7. Do you feel that there is a good rapport between local law enforcement and ED staff? No. 8. Do you feel that the establishment of such a task force would be beneficial?
lesser degree, administration from both the hospital and LE were suggested. In question No. 10, respondents were asked, “How often should such a committee meet?” The majority (56.8%) believed that quarterly meetings were needed. Many believed that monthly meetings were necessary (24.9%), whereas 18% of respondents suggested alternative schedules. One respondent suggested an initial meeting to discuss the problems, a follow-up meeting in 1 month to propose solutions, then a 6-month period to evaluate the impact of the solutions. Question No. 4, “Based on the assumption that timely and efficient handling and discharge of in-custody patients will minimize risk to ED staff as well as other patients, what do you feel is the greatest barrier to expediting this process?” was designed to elicit personal perceptions of the current process. The responses given varied from thoughtful to extremely critical and antagonistic to the other agency involved. However, there was a basic underlying tone to each group's responses. In general, ED staff believed that patient load as well the disruptive nature of the patients that the police brought in were the biggest obstacles. They also cited ancillary departments such as laboratory and radiology as being major contributors to delays. They made particular mention of alcohol intoxication and substance abuse patients as the major disruptive influences. Many persons believed that the police were “dumping” these patients on them and that the emergency department was becoming a “detox” center. The tone extracted from LE responses was
March 2013
VOLUME 39 • ISSUE 2
Hospital (n = 20) (%)
Law enforcement (n = 61) (%)
All respondents (n = 81) (%)
10 (50)
43 (70.5)
53 (65.4)
14 (70)
29 (47.5)
43 (53.1)
14 (70)
28 (45.9)
42 (51.9)
17 (85)
52 (85.3)
69 (85.2)
16 (80)
46 (75.4)
62 (76.5)
15 (75)
28 (45.9)
43 (53.1)
17 (85)
55 (90.2)
72 (88.9)
that the whole process took too much time and these patients were not expedited. Many respondents cited the fact that they are required to wait in areas with other patients before being seen. Their concern is the exposure of these sometimes agitated and disruptive patients to the general public. They also believe that the ED staff strongly resents their presence and tends to ignore their needs. One respondent referred to the fact that they were treated as “second-class citizens” by the ED staff. They note that there is a definite communication gap regarding where each side is coming from. One respondent stated that “The in-custody patients know the system and purposely delay the process, preferring to spend the night in a nice warm hospital bed as opposed to a cell.” Discussion
The results of this survey tend to suggest a general lack of understanding and appreciation among LE and HS for the other's role. There is an undertone of resentment and at times animosity by each group directed at the other. It is important that steps be taken to initiate a cooperative dialogue between these institutions to promote better communication between all involved. The fact that both groups overwhelmingly agreed that a task force is needed attests to this idea. The goals of this task force would include (1) establishing policies and procedures for both LE and the
WWW.JENONLINE.ORG
e21
CLINICAL/Kowal
hospital concerning in-custody patients, (2) establishing a line of communication and education for future problems, (3) planning and implementation of commonly agreed upon changes to the system, and (4) providing a forum for further study and refinement of processes. The most important goal will be to establish effective policies and procedures for the handling of in-custody patients. Many LE agencies nationwide have laid out specific protocols for handling sick and injured prisoners. The Chandler Police Department in Arizona has one such policy, which specifies action of police depending on the type of injury and provides for arrest response dependent upon pre-existing medical conditions such as intoxication or diabetes. 3 There must be multi-agency guidelines designed to provide protocols for both agencies. One such guideline exists in a memorandum of understanding between police and health care agencies in New South Wales, Australia. They have incorporated multi-agency brief risk assessment guidelines for handling prisoners based on factors agreed upon by both agencies. 4 The role of hospital security should also be examined. The current policy of many hospitals is that the prisoner is the sole responsibility of the local law enforcement.
Implications for Emergency Nurses
The emergency department typically is the focal point for the interaction between the associated hospitals and the LE agencies servicing the area. It is by nature the most vulnerable in respect to the potential for violence and disruption by incustody patients. When one factors in the tendency of the emergency department for overcrowding, confusion, and staffing shortages, it is apparent that compromises to public and ED staff security and safety may arise. To minimize these safety issues, it is important to ensure maximum cooperation between ED staff and LE. This may best be accomplished by opening a forum and mechanism for dialogue and exchange between these 2 agencies. An inter-agency task force would provide such a forum. In any cooperative effort, communication and education is of utmost importance. In essence, we have 2 groups looking at a problem through different lenses. It is important that each side understand and appreciate the viewpoint and major issues of the other. Educational programs to provide guidance to nurses when dealing with in-custody patients would be invaluable. As an example, an article published in Nursing in 2004 described some simple rules to follow when dealing with patients in police custody. 5 The establishment of lines of communication to explain purpose and status with frequent updates as regard
e22
JOURNAL OF EMERGENCY NURSING
to their prisoners may alleviate much misunderstanding by the officers involved. Conclusions
It would be the responsibility of such a task force, if established, to oversee the planning and implementation of mutually agreed upon changes to the system. One such change may be the designation of areas reserved for use in these instances. The local LE agencies also may agree on some common solution for guarding in-custody prisoners such as the presence of a permanent officer on high-incident nights that could be achieved through some type of revolving coverage, planned in advance. One area that may be addressed is in the use of restraints. The New York City Police Department uses plastic handcuffs on hospitalized patients. 6 This practice may provide enhanced security in areas or situations where metal cuffs are contraindicated such as magnetic resonance imaging and defibrillation procedures. This committee also may set guidelines to map the ethics involved in such collaboration similar to those in the UK, which set formal accountability and protocols. 7 From an emergency department viewpoint, it may be advantageous to restructure and revise triage polices and procedures to specifically address the issue of in-custody patients, perhaps by establishing a grading system to assess the level of threat to public and staff safety based on the nature of the arrest charges, the patient's medical condition, and other pertinent factors. This system may help in expediting handling of high-risk patients to assure the security of all involved. Finally, such a task force may provide a forum for further study and refinement of the process involved. It will serve as a “bridge of understanding” between LE and the hospital and provide for efficient health care with minimum risk for all when dealing with this type of inter-agency contact. The results of this survey were shared with the administrative bodies of local LE and the hospital emergency department. The immediate response to this proposal was the inclusion of LE representatives in monthly meetings with ED personnel, local EMTs, hospital security, and ED administration. The general consensus from concerned parties, to this date, has been positive. To fully assess the impact of this task force, this study may need to be repeated in the near future. REFERENCES 1. Arsenault M, Milkovits A, Mooney T. Worst nightmare. Providence Sunday Journal. 2005:1, 18-19. 2. Contente W. City of Revere v Massachusetts General Hospital: Government responsibility for an arrestee's medical care. Am J Law Med. 1983;9:359-73.
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3. Chandler Police Department. E-12 prisoner processing: sick & injured prisoners (general orders/policy). 2005. Updated July 2008. http:// chandlerpd.com/gos/E12-5pris-sick.pdf. Accessed February 6, 2013. 4. NSW Government Health. Memorandum of understanding between NSW health and the NSW police service. 2002. http://www0.health. nsw.gov.au/pubs/2002/mou.html. Accessed February 6, 2013.
March 2013
VOLUME 39 • ISSUE 2
5. Jones J. When your patient is in police custody. Nursing. 2004;34:23. 6. No author. Plastic handcuffs reduce bystander risks. Nursing. 1999;29:63. 7. Hunt G, Van Der Arend A. Treatment, custody, support: an exploratory qualitative dialogue to map the ethics of interagency co-operation in hospital emergency departments in the UK and the Netherlands. J Interprofessional Care. 2002;16:211-20.
WWW.JENONLINE.ORG
e23
BRIDGING
THE
GAP: INTERAGENCY TASK FORCE
Author: Cheryl A. Kowal, BS, RN, Warwick, RI
Admission of in-custody patients into an overtaxed emergency department is often frustrating for both law enforcement and ED staff. To facilitate collaboration between law enforcement and ED staff, it would be advantageous to initiate a professional interagency task force. To justify the need for such a task force, a random survey of hospital and law enforcement personnel was
undertaken. Result of this survey revealed major misconceptions by both sides concerning the other's role. One common area of overwhelming agreement between the agencies was the need for such a task force. The data suggest the urgent need for mutually agreed upon policies and procedures for in-custody patients for both agencies to provide a safe environment for all involved.
he citizens of any community rely on a variety of local government and private services; two of the most important are local law enforcement (LE) and the community hospital. They both are trusted and respected servants of the community that address entirely different public needs; however, at times, their spheres of interest overlap. The mission of LE is to protect and serve. The mission of our local community hospital is to provide compassionate, quality health care as part of an integrated delivery system serving community needs. The goals of these 2 agencies intersect when local law enforcement is required to utilize the hospital emergency department for medical treatment of persons in police custody. This interaction primarily poses safety issues for ED staff, LE officers, and most importantly, other ED patients. The recent death of a Providence Rhode Island police officer killed in the police station, in what is perceived as a secure environment for handling in-custody individuals, brings to the forefront the potential for violence. 1 This event could have just as easily taken place in a crowded, overtaxed emergency department with the possibility of far more dire consequences involving an extremely vulnerable population. Therefore it is obvious that there is a need for a collaborative effort between local LE and hospital personnel to minimize risk to all involved. This end may be achieved by establishing a process to improve admission and
treatment of individuals in police custody in a more organized and professional manner. The challenge is that 2 groups of professionals are looking at the same problem through different, highly polarized lenses, which leads to misconceptions and misunderstandings with regard to the role of the other agency in the process. Although safety is the primary consideration, many other factors must be brought into account. These factors include manpower demands from both hospital and LE perspectives, financial implications for both agencies, and the effect on the community left unprotected when resources are allocated away from normal patrol areas. LE's obligation is stated under the eighth and fourteenth amendments of the U.S. constitution. They require LE to provide medical attention to in-custody prisoners when claim of injury or sickness of such parties is known or suspected. 2 In addition, they are called upon to transport individuals in mental health, alcohol, or substance abuse crisis to the emergency department. This may occur even when those individuals may not be technically under arrest or in custody. This situation often leads to misconceptions that the police are just “dumping” patients on an already overtaxed emergency department. The misconceptions and misunderstandings that are part of this relationship can detract from the concept of an effective cooperative effort. Better communication and understanding of each other's roles would improve relations between LE and caregivers. To achieve this goal, it would be beneficial to establish a purposeful dialogue between LE and the hospital. The proposed improvement to the system would be the establishment of an LE–emergency department task force. This task force would address the problems in the current system and work to develop procedures and policies to address these issues. The theoretic basis for this idea is that effective cooperation between these professionals will provide efficient health care with minimum risk to
T
Cheryl A. Kowal is retired Post Anesthesia Care Nurse, Warwick, RI. For correspondence, write: Cheryl A. Kowal, 455 Toll Gate Rd, Warwick, RI 0288; E-mail: [email protected]. J Emerg Nurs 2013;39:e19-e23. Available online 26 December 2006. 0099-1767/$36.00 Copyright © 2013 Published by Elsevier Inc. on behalf of Emergency Nurses Association. http://dx.doi.org/10.1016/j.jen.2006.10.010
March 2013
VOLUME 39 • ISSUE 2
WWW.JENONLINE.ORG
e19
CLINICAL/Kowal
all involved. It is important to clarify the perceptions of the current process from both sides of the spectrum. This was achieved by conducting a random survey of LE and hospital staff (HS) to establish the current status of cooperation and misconceptions. Methods
A sample questionnaire was created that incorporated demographic information and 10 questions relating to the current processing of in-custody individuals brought to the local hospital emergency department. These questions were derived from personal conversations with both ED staff and LE personnel. The demographic questions focused on 4 areas, including (1) age, (2) sex, (3) occupation, and (4) years of experience in one's current job. The questions themselves were grouped into 2 main categories. The initial 7 questions dealt with opinions regarding the appropriate management of patients brought to the emergency department in the custody of local LE agencies. The final 3 questions dealt with the idea of establishing a task force composed of LE and ED representatives. There also was a space for additional comments to be added by the respondents, particularly in response to “no” answers. A letter attached to each questionnaire explained the purpose and scope of the survey. The survey was a random voluntary sampling of the respondents' views on the questions previously outlined. A total of 120 questionnaires were distributed equally among the 3 local LE departments servicing the area and ED staff. Approval for conducting the survey was obtained from senior LE officers in each department and the nurse manager of the emergency department. The questionnaires were collected after a week and compiled for evaluation and statistical analysis of demographic information. The demographics were subjected to descriptive statistical evaluation by Microsoft Excel to derive mean, range, and standard deviation. The questions were evaluated for percentages of positive (Yes) responses. For purposes of compilation, unspecified or sometimes responses were classified as a negative response. Results
Table 1 provides information on the demographics of the respondents. A total of 81 questionnaires were returned out of 120 distributed for an overall response rate of 67.5%. The response rate for LE and HS were similar, with 67.7 % (61/90) responding from LE and 66.7% (20/30) from HS. The age of respondents had a mean (SD) of 36.7 (9.8) years. When separated into job categories, the mean age of the HS
e20
JOURNAL OF EMERGENCY NURSING
TABLE 1
Demographic information Law Hospital enforcement (n = 20) (n = 61)
Age (y) 34.7 (6.9) Experience (y) 9.8 (7.3)
All respondents (n = 81)
43.4 (13.9) 36.7 (9.8) 17.3 (11.8) 11.7 (9.2)
was significantly higher than those of LE. The mean age (SD) of HS was 43.4 (13.9) as opposed to 34.7 (6.9) for LE. The mean (SD) experience in current position was also significantly higher in HS, 17.3 (11.9) as opposed to 9.8 (7.2) for LE (Table 1). Table 2 provides information specific to each of the 7 questions requiring a “Yes” or “No” response. Respondents from both disciplines had similar responses to 3 of the questions. In question No. 5, dealing with the presence of hospital security, and in question No. 7, concerning appropriate restraints, there was a significant positive response. In question No. 8, which was of utmost importance to making the vision for the facility a reality, there was an overwhelming positive response (88.9%) to the need for a interprofessional task force (Table 2). There were major disagreements between the disciplines with regard to prior notification (question No. 1), where LE felt notification was sufficient (70.5%), as opposed to HS (50%). In question No. 2, dealing with a designated area, HS believed it was appropriate (70%), as opposed to LE (47.5%). Question No. 3 dealt with a cooperative effort to expedite in-custody patients. HS (70%) believed it was cooperative, contrary to the perception of LE (45.9%). Finally, in question No. 7, which dealt with the feelings of rapport between LE and the hospital staff, the HS believed that the relationship was good (75%), whereas LE disagreed (45.9%). Questions 8-10 dealt with the idea of establishing a task force composed of LE and ED representatives, the goal of which would be to foster mutual cooperation and understanding. Question No. 9, “Who do you feel should be represented on such a committee?” dealt with respondents' perceptions of participants necessary for an effective task force to deal with the issues discussed. There was major agreement among all respondents that the task force should include ED nurse and physician representation as well as a representative of LE from each local community. The general consensus from the LE respondents was that those representatives should include line officers who have direct experience with the emergency department. To a
VOLUME 39 • ISSUE 2
March 2013
Kowal/CLINICAL
TABLE 2
Percentages of positive responses to survey questions Question
No. 1. Is prior notification of the pending arrival of in-custody patients timely and appropriate? No. 2. Is the designated area for treatment of in-custody patients appropriate at this time? No. 3. Is the admission process a cooperative effort designed to expedite the handling of in-custody patients? No. 5. Is hospital security notified and present upon admission of in-custody patients? No. 6. Do you believe that appropriate restraints are used in all areas involved in the care of in-custody patients? No. 7. Do you feel that there is a good rapport between local law enforcement and ED staff? No. 8. Do you feel that the establishment of such a task force would be beneficial?
lesser degree, administration from both the hospital and LE were suggested. In question No. 10, respondents were asked, “How often should such a committee meet?” The majority (56.8%) believed that quarterly meetings were needed. Many believed that monthly meetings were necessary (24.9%), whereas 18% of respondents suggested alternative schedules. One respondent suggested an initial meeting to discuss the problems, a follow-up meeting in 1 month to propose solutions, then a 6-month period to evaluate the impact of the solutions. Question No. 4, “Based on the assumption that timely and efficient handling and discharge of in-custody patients will minimize risk to ED staff as well as other patients, what do you feel is the greatest barrier to expediting this process?” was designed to elicit personal perceptions of the current process. The responses given varied from thoughtful to extremely critical and antagonistic to the other agency involved. However, there was a basic underlying tone to each group's responses. In general, ED staff believed that patient load as well the disruptive nature of the patients that the police brought in were the biggest obstacles. They also cited ancillary departments such as laboratory and radiology as being major contributors to delays. They made particular mention of alcohol intoxication and substance abuse patients as the major disruptive influences. Many persons believed that the police were “dumping” these patients on them and that the emergency department was becoming a “detox” center. The tone extracted from LE responses was
March 2013
VOLUME 39 • ISSUE 2
Hospital (n = 20) (%)
Law enforcement (n = 61) (%)
All respondents (n = 81) (%)
10 (50)
43 (70.5)
53 (65.4)
14 (70)
29 (47.5)
43 (53.1)
14 (70)
28 (45.9)
42 (51.9)
17 (85)
52 (85.3)
69 (85.2)
16 (80)
46 (75.4)
62 (76.5)
15 (75)
28 (45.9)
43 (53.1)
17 (85)
55 (90.2)
72 (88.9)
that the whole process took too much time and these patients were not expedited. Many respondents cited the fact that they are required to wait in areas with other patients before being seen. Their concern is the exposure of these sometimes agitated and disruptive patients to the general public. They also believe that the ED staff strongly resents their presence and tends to ignore their needs. One respondent referred to the fact that they were treated as “second-class citizens” by the ED staff. They note that there is a definite communication gap regarding where each side is coming from. One respondent stated that “The in-custody patients know the system and purposely delay the process, preferring to spend the night in a nice warm hospital bed as opposed to a cell.” Discussion
The results of this survey tend to suggest a general lack of understanding and appreciation among LE and HS for the other's role. There is an undertone of resentment and at times animosity by each group directed at the other. It is important that steps be taken to initiate a cooperative dialogue between these institutions to promote better communication between all involved. The fact that both groups overwhelmingly agreed that a task force is needed attests to this idea. The goals of this task force would include (1) establishing policies and procedures for both LE and the
WWW.JENONLINE.ORG
e21
CLINICAL/Kowal
hospital concerning in-custody patients, (2) establishing a line of communication and education for future problems, (3) planning and implementation of commonly agreed upon changes to the system, and (4) providing a forum for further study and refinement of processes. The most important goal will be to establish effective policies and procedures for the handling of in-custody patients. Many LE agencies nationwide have laid out specific protocols for handling sick and injured prisoners. The Chandler Police Department in Arizona has one such policy, which specifies action of police depending on the type of injury and provides for arrest response dependent upon pre-existing medical conditions such as intoxication or diabetes. 3 There must be multi-agency guidelines designed to provide protocols for both agencies. One such guideline exists in a memorandum of understanding between police and health care agencies in New South Wales, Australia. They have incorporated multi-agency brief risk assessment guidelines for handling prisoners based on factors agreed upon by both agencies. 4 The role of hospital security should also be examined. The current policy of many hospitals is that the prisoner is the sole responsibility of the local law enforcement.
Implications for Emergency Nurses
The emergency department typically is the focal point for the interaction between the associated hospitals and the LE agencies servicing the area. It is by nature the most vulnerable in respect to the potential for violence and disruption by incustody patients. When one factors in the tendency of the emergency department for overcrowding, confusion, and staffing shortages, it is apparent that compromises to public and ED staff security and safety may arise. To minimize these safety issues, it is important to ensure maximum cooperation between ED staff and LE. This may best be accomplished by opening a forum and mechanism for dialogue and exchange between these 2 agencies. An inter-agency task force would provide such a forum. In any cooperative effort, communication and education is of utmost importance. In essence, we have 2 groups looking at a problem through different lenses. It is important that each side understand and appreciate the viewpoint and major issues of the other. Educational programs to provide guidance to nurses when dealing with in-custody patients would be invaluable. As an example, an article published in Nursing in 2004 described some simple rules to follow when dealing with patients in police custody. 5 The establishment of lines of communication to explain purpose and status with frequent updates as regard
e22
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to their prisoners may alleviate much misunderstanding by the officers involved. Conclusions
It would be the responsibility of such a task force, if established, to oversee the planning and implementation of mutually agreed upon changes to the system. One such change may be the designation of areas reserved for use in these instances. The local LE agencies also may agree on some common solution for guarding in-custody prisoners such as the presence of a permanent officer on high-incident nights that could be achieved through some type of revolving coverage, planned in advance. One area that may be addressed is in the use of restraints. The New York City Police Department uses plastic handcuffs on hospitalized patients. 6 This practice may provide enhanced security in areas or situations where metal cuffs are contraindicated such as magnetic resonance imaging and defibrillation procedures. This committee also may set guidelines to map the ethics involved in such collaboration similar to those in the UK, which set formal accountability and protocols. 7 From an emergency department viewpoint, it may be advantageous to restructure and revise triage polices and procedures to specifically address the issue of in-custody patients, perhaps by establishing a grading system to assess the level of threat to public and staff safety based on the nature of the arrest charges, the patient's medical condition, and other pertinent factors. This system may help in expediting handling of high-risk patients to assure the security of all involved. Finally, such a task force may provide a forum for further study and refinement of the process involved. It will serve as a “bridge of understanding” between LE and the hospital and provide for efficient health care with minimum risk for all when dealing with this type of inter-agency contact. The results of this survey were shared with the administrative bodies of local LE and the hospital emergency department. The immediate response to this proposal was the inclusion of LE representatives in monthly meetings with ED personnel, local EMTs, hospital security, and ED administration. The general consensus from concerned parties, to this date, has been positive. To fully assess the impact of this task force, this study may need to be repeated in the near future. REFERENCES 1. Arsenault M, Milkovits A, Mooney T. Worst nightmare. Providence Sunday Journal. 2005:1, 18-19. 2. Contente W. City of Revere v Massachusetts General Hospital: Government responsibility for an arrestee's medical care. Am J Law Med. 1983;9:359-73.
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3. Chandler Police Department. E-12 prisoner processing: sick & injured prisoners (general orders/policy). 2005. Updated July 2008. http:// chandlerpd.com/gos/E12-5pris-sick.pdf. Accessed February 6, 2013. 4. NSW Government Health. Memorandum of understanding between NSW health and the NSW police service. 2002. http://www0.health. nsw.gov.au/pubs/2002/mou.html. Accessed February 6, 2013.
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5. Jones J. When your patient is in police custody. Nursing. 2004;34:23. 6. No author. Plastic handcuffs reduce bystander risks. Nursing. 1999;29:63. 7. Hunt G, Van Der Arend A. Treatment, custody, support: an exploratory qualitative dialogue to map the ethics of interagency co-operation in hospital emergency departments in the UK and the Netherlands. J Interprofessional Care. 2002;16:211-20.
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