IMPACT OF VIOLENCE AND THE EMERGENCY DEPARTMENT RESPONSE TO VICTIMS AND PERPETRATOR

VIOLENCE AMONG CHILDREN AND ADOLESCENTS

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IMPACT OF VIOLENCE AND THE EMERGENCY DEPARTMENT RESPONSE TO VICTIMS AND PERPETRATOR Issues and Protocols Christine M. Walsh-Kelly, MD, a n d Richard Strait, MD

Research on the current epidemic of violence and its victims is limited. In the past decade, however, considerable attention has been focused in the area of domestic violence. Cofnprehensive emergency department (ED) domestic violence protocols have been developed and evaluated that address identification, treatment, safety issues, legal reporting statutes, and medical and psychosocial intervention^.'^, 30 The development of similar protocols to address nondomestic ED violence is essential given the scope and impact of the current violence epidemic. This article focuses on victims, perpetrators, and the occurrence of violence in the ED and describes issues and strategies for identification, intervention, and documentation. INTERVENTIONS FOR VICTIMS AND PERPETRATORS

Emergency departments are the major site for medical contact with persons who are victims and perpetrators of Optimal emergency care for victims and perpetrators of violence includes identification and treatment of the acute injuries, assessment of emotional and psychosocial issues, crisis intervention, and provision of multidisciplinary follow-up.33 Initially the acute injuries are stabilized and definitive treatment is initiated. ~

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From the Division of Emergency Medicine, Children’s Hospital of Wisconsin (CMW); and the Department of Pediatrics and Emergency Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin (CMW, RS)

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Then a comprehensive psychosocial evaluation should be made, regardless of the patient’s status as a victim or perpetrator. Studies have demonstrated that the psychological and descriptive profiles of assailants and victims of intentional injury are quite similar; frequently the victims are the offenders in other assaults.26Identification of violence risk and previous violent activity permits an informed decision about appropriate interventions. PSYCHOSOCIAL INTERVENTION FOR VICTIMS

The psychological impact of traumatic violent experiences is devastating for victims. The goal of the initial psychosocial consultation is to provide crisis intervention. Strategies include patient debriefing, provision of emotional support, alleviation of guilt feelings, anticipatory guidance, education in coping strategies, and evaluation of preexisting emotional problems. Decisions for additional interventions for the victim are based on the traumatic experience, the child‘s response to this experience, identified premorbid psychosocial disturbances, family dynamics, and available resources. The goal of these interventions is to decrease the potential for posttraumatic stress disorder, chronic victimization, and the emergence of victims as assailants. Resources to support ongoing psychosocial recovery include comprehensive child-centered and family-focused mental health services; individual, family, or group therapy; victim support groups; social service agencies; churches; social organizations; and schools.4, 9, 38 Because a significant majority of victims are treated and discharged from the ED, intervention programs must be initiated in the ED. Project UJIMA, a violence intervention program operating in the Children’s Hospital of Wisconsin ED, provides on-site case managers to coordinate community and hospital resources prior to ED or hospital discharge. Other multidisciplinary violence projects that incorporate a hospital component include the Boston Violence Prevention Project and the Oakland program, Caught in the Crossfire. Resources for both medical and psychosocial follow-up should be clearly delineated at di~charge.2~ PSYCHOSOCIAL INTERVENTION FOR PERPETRATORS

An assessment of the underlying emotional and psychosocial attributes of patients who are perpetrators of violence is also essential. These patients should be screened for weapon carriage, alcohol and drug abuse, depression, family violence, risk-taking or antisocial behavior, criminal history, and gang membership, and appropriate strategies to address these behaviors developed. Seriously injured perpetrators have significantly lowered psychological defenses and may be most receptive to interventions at this point. Programs providing effective intervention with violent offenders use a multidisciplinary approach with representatives from parent groups; community-based organizations; criminal justice system; mental health and social service agencies; the education system; and local, state, and federal 26, 37 These programs provide an assessment of the characteristics of the individual offender, modification of these characteristics, promotion of self-esteem, and a change in the perception of Identification of alcohol or substance abuse requires a referral for substance abuse counseling and rehabilitation?, 29, 33 Social services should be arranged to assist with the devastating social problems, such as poverty and family violence,

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experienced by most violent offenders. Successful programs to teach anger management, conflict resolution skills, and nonviolent problem-solving techniques have been developed by school-based and peer-mediation programs and social-service agencie~.’~, l9 These programs, such as the Boston-based Violence Prevention Project, have been strongly advocated as a means of reducing the need for more expensive future rehabilitative efforts. The Violence Prevention Project, a service of the Boston Department of Health and Hospitals, provides a 10-session course for high school students that includes information on the risks of intentional injury, a philosophy of nonviolent response to anger, and instruction in alternative techniques for conflict Thriving mentoring programs for career development, academic tutoring, and positive role modeling have been developed in several cities.I6,19, 27 Community recreational facilities, job-training programs, and youth organizations are critical community resources that should be available to juvenile offenders?,27 Prior to discharge, patients who are violent offenders should receive a coordinated follow-up plan that includes the essential medical re-evaluation and appropriate mental health and community resources to facilitate prevention of further violent activity. These resources should be discussed with the parent or guardian who is given written instructions with phone numbers, addresses, and a contact person, if available. 1

EMERGENCY DEPARTMENT VIOLENCE

The ED is a prime environment for violence due to the high volume of acutely ill and injured patients, waiting times, availability of drugs and potential hostages, 24-hour accessibility, and risky psychiatric patients who present for medical In a survey of pediatric ED (PED) directors, 77% reported one or more physical attacks on staff per year, 75% identified one or more verbal threats per week, and 25% reported actual injury to staff. Half of surveyed PED directors reported confiscation of weapon^.^ In 1992, Wasserberger and colleagues%reported 25% of major trauma victims treated in their ED were carrying weapons. Between 1980 and 1988, 34 nurses were murdered at work in the United States, 60% as a result of gunshot The increasing presence of violent offenders as patients and the escalating incidents of violent confrontations in emergency departments are significant concerns for health-care professional^.^, 21 Potential targets of ED violence include patients, visitors, and ED personnel. Effective prevention and intervention require knowledge of specific risk factors, meticulous attention to safety issues, and training of all ED staff in the recognition and defusion of potentially violent situations. Potential risk factors include the presence of violence-prone individuals, staff attitudes and behavior, and ED systems and structure. Characteristics of violence-prone individuals include male gender, alcohol and drug abuse, gang membership, weapon carriage, psychiatric disorders, illiteracy, low self-esteem, accompaniment by law-enforcement officers, a history of violent behavior, early exposure to family violence, and a desire for revenge. Violence-prone patients may present as either the perpetrators or victims of intentional injury; however, patients are not the only perpetrators of ED violence. In one study, visitors accounted for 23% of violent incidents in the ED.’, 4, 7, 8, 17, 20, 21, 31, 35 The attitudes and communication styles of health-care personnel may precipitate violent responses from at-risk patients and visitors. Staff who are argu-

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mentative, abrupt, or condescending or who fail to provide requested patient services may trigger angry physical responses from violence-prone individual^.'^ Education of staff in multicultural diversity issues and effective communication skills reduces the likelihood of a violent confrontation with individuals already stressed by an acute medical crisis. Potential risks related to ED structure and systems include access, isolation, poor lighting, inappropriate examination room design and location, and prolonged wait times. Emergency department access should be limited by securitymonitored and locked entrances. The use of metal detectors to detect concealed weapons and installation of bullet-resistant glass in triage and reception areas are indicated for facilities with a significant prevalence of violent activity. Continuous video surveillance of the department can be used as a deterrent to assaultive behavior as well as a method to alert security personnel to developing or potentially violent confrontation^.^^ Waiting times should be reduced and clean and comfortable waiting areas pr~vided.’~, 21, 31 Examination rooms should be private but not isolated and should permit staff monitoring of activity. Furniture should be arranged to prevent patient anxiety and entrapment of staff. Light switches should be located outside the examination room. The examination room door should be accessible to allow both intervention and escape.25,27, 35 An atmosphere of privacy and a sense of security should be provided to both assailants and injured victims. The risk for retaliatory activity is significant; thus patients should be identified solely by an alias or code name. Access to patient examination rooms and release of information should be limited to health-care personnel, social-service staff, and law-enforcement officers directly involved in the patient’s care. ED staff can play a major role in the prevention of violence if they are trained to recognize and defuse potentially violent situations. Recognizable clues to impending aggression include angry demeanor, provocative behavior, agitation, pacing, loud or pressing speech, tense or frequent changes in posture, fist clenching, striking walls, or throwing f~rniture.’~, 20, 28 Optimal management of individuals displaying these characteristics requires skill in conflict resolution and aggression control techniques. Gang awareness, emphasizing identification of gang members and their cultural attributes, is essential to minimize the threat of gang-related violence in the ED. Recognition of local gangs by typical clothing and head gear, “colors,” tattoos, language, hand signals, and evidence of previous major injury permits appropriate security measures to be implemented. Emergency department staff interaction with gang members should avoid judgmental, challenging, or disrespectful communication styles because gang culture dictates physical confrontation of such challenges. Additional strategies to minimize risk for gang violence include protection of the gang member’s identity, restriction of visitors, and, if available, early involvement of community members or law-enforcement personnel with gang expertise to assist in maintaining a nonviolent environment. Patients or visitors displaying aggressive behavior should immediately be isolated in a quiet, secure location, and security personnel should be alerted. Panic buttons are an excellent method to activate the security response to a crisis. Hand-held buttons or buttons worn around the neck have the advantage of instantaneous access but only to those individuals wearing them. Permanently mounted buttons offer the advantage of universal access but must be strategically located to ensure immediate availability. Verbal placation should be attempted to diffuse violent or aggressive confrontations. Emergency department personnel should converse with a calm demeanor but should avoid eye contact,

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close positioning to the patient, arguments, and threats.', 5, 7, 22, 36 They should never enter into an escalating argument or physically position themselves between two fighting individuals. Confrontations that escalate despite verbal placation may require chemical or physical restraint, assistance from law-enforcement officials, or ED evacuation. In the event that the assaulting individual is a patient, restraint may be required to permit appropriate evaluation and treatment. Hospitals may elect to implement violence management teams such as described by Brayley and colleagues? These teams, with predetermined roles and responsibilities, effectively manage violent patients while minimizing the risk of injury to the patient and ED staff. At a minimum, emergency departments should develop written policies defining the rationale, indications, and standards for verbal intervention, physical detention, and chemical restraint.**3, The security service response to violent ED events should also be delineated by written policies and procedures for the response to, and containment of, a violent episode, physical restraint of violent individuals, management of a hostage situation, and police mobilization. Critical areas to address in the hostage procedure include notification of hospital security and law-enforcement officials, hostage isolation, evacuation, and designation of a negotiator. Guidelines for negotiation and hostage behavior should be clearly delineated.7,25 Health-care providers exposed to a violent event in the ED are victims themselves and may require psychological intervention. Crisis intervention for ED staff should include immediate critical incident debriefing and subsequent psychological support. Critical incident stress debriefing (CISD) is a technique initially designed by the dilitary to assist their personnel with processing and integrating details of combat to reduce their emotional reaction. CISD includes an analysis of the event; a discussion of the individuals' reactions to the incident; presentation of potential physical, stress-related, and grief symptoms; and education in stress management. Resources for ongoing psychological support and benefits for injured staff should be clearly identified.l0

LEGAL ISSUES

Emergency department staff are confronted with providing quality medical care to patients with violence-related injuries in an environment of complicated legal issues. The major legal considerations include consent for treatment, restraint, duty to warn, criminal reporting statutes, and documentation. Consent for treatment has been extensively reviewed elsewhere.%Emergency physicians have a duty to provide appropriate care to patients and to protect both the patient and others in attendance. For patients with violent behavior, the use of chemical or physical restraint may be considered essential to appropriately discharge this duty. During the course of ED treatment, a patient may indicate an intent to harm another individual. Legal experts generally agree that ED physicians have a duty to warn any intended victim of violence identified by their patients. Law-enforcement officials must also be notified. Finally, ED personnel must comply with all state criminal reporting statutes.', 6, 28 Well-documented patient records are essential because they provide concrete evidence of the violent event and may be crucial to the outcome of any legal case. Thorough documentation is also critical to demonstrate the appropriate compliance with legal reporting statutes and restraint detention policies. Table 1 lists the critical elements to document.

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Table 1. CRITICAL PATIENT DOCUMENTATION ELEMENTS History Includes the violent event in the patient's own words, past medical history, and social history. Physical examination Includes detailed description of injuries: type, number, size, location, stage, and an illustration via body chart or drawing. Results Results of diagnostic tests. Collection Collection and retention of forensic and evidentiary material. Restraints Include an explanation of indications, patient consent or nonconsent, type of restraint: chemical or physical, and a periodic examination of restrained areas. Diagnosis Referrals Information Informationconveyed to patient. Discharge Discharge instructions.

Table 2. EMERGENCY DEPARTMENT PROTOCOL-IDENTIFICATION AND MANAGEMENT OF VIOLENT PATIENT Definition: A violent patient is a patient who has intentionally used physical force against another person or oneself. 1. Identify violent patient (list criteria). 2. Initiate safety precautions for patient, ED staff, visitors, and other patients. Notify hospital security (describe notification procedure). Implement security plan (describe plan and implementation steps). 3. IInitiate patient confidentiality measures. No patient identifiers (list procedure for identification). Limit release of information (define parameters). Private examination room (identify specific room). Restrict or prohibit visitors. 4. ,Evaluate, stabilize, and treat medical conditions. 5. ICollect, retain, and safeguard specimens, photographs, and other evidentiary material (describe system and procedure). 6. Notify appropriate legal authorities per local and state statutes (define reporting requirements and procedures). 7 . Evaluate psychosocial status. 8. Provide resources for medical follow-up. 9. Refer to appropriate mental health, community, and social agencies. 10. Document: History Physical examination Treatment Notification of security, legal authorities Collection of specimens and evidentiary material Referrals Medical follow-up Disposition

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Protocols In January 1993, the American College of Emergency Physicians published a statement entitled Protection from Physical Violence in the Emergency Department. In that statement, emergency departments were advised to develop written ED protocols for violent situations occurring in the ED. The following protocols for victims and perpetrators of violence and eruption of extreme violence address this recommendation (Tables 2 4 ) . They are presented in outline format and are based on the information reviewed in the preceding pages. Each protocol should be viewed as a ”skeleton” requiring expansion and modification by individual hospital emergency departments based on existing policies and procedures and local and state criminal reporting statutes. Effective protocol development requires a cooperative effort by affected individuals to produce a customized document consistent with the individual ED philosophy, practice, and routine. Protocols for violence should include definitions, identification, medical and psychosocial treatment, safety interventions, referral procedures, legal reporting requirements, and documentation. The individual responsible for each action should be clearly identified in the protocol. Written staff expectations for protocol compliance and a monitoring tool must be developed.

Table 3. EMERGENCY DEPARTMENT PROTOCOL-IDENTIFICATION AND MANAGEMENT OF VICTIM OF VIOLENCE ~

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Definition: A victim of violence is a Datient who is the reciDient of intentional force. 1. Identify victim of violence (list criteria). 2. Initiate safety precautions for patient, ED staff, visitors, and other patients. Notify hospital security (describe notification procedure). Implement security plan (describe plan and implementation steps). 3. Initiate patient confidentiality measures. No patient identifiers (list procedure for identification). Limit release of information (define parameters). Private examination room (identify specific room). Restrict visitors. 4. Evaluate, stabilize, and treat medical conditions. 5. Collect, retain, and safeguard specimens, photographs, and other evidentiary material (describe system and procedure). Evaluate psychosocialstatus Evaluate and “stabilize” emotional status 6. Notify appropriate legal authorities according to state and local statutes (define reporting requirements and procedure). 7. Provide legal information, advocacy, and referral. 8. Refer to appropriate mental health, community, and social service agencies. 9. Provide resources for medical follow-up. 10. Document: History Physical examination Treatment Notification of security, legal authorities Collection of specimens and evidentiary material Referrals Medical follow-up Disposition

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Table 4. EMERGENCY DEPARTMENT PROTOCOL-MANAGEMENT

OF EXTREME

VIOLENCE Definition: A condition of extreme violence is present when a patient, visitor, or other individual threatens the life or safety of another patient, visitor, or person by physical force or the use of a weapon. 1. Identify risk factors for extreme violence (list criteria). 2. Initiate safety precautions for patients, ED staff, and visitors. 3. Notify hospital security (describe notification procedure, such as panic button). 4. Implement security plan (describe plan and implementation). 5. Notify law enforcement agencies (describe indications and notification procedure). 6. Implement hostage plan as appropriate (describe indications, plan, and implementation steps). 7. Defuse situation (describe indications and methods). Verbal placation Physical restraint Chemical restraint (choice of medication doses, contraindications, or side effects) a. Evacuate (identify indications for evacuation, evacuation plan, and method of implementation). 9. Medical treatment for injured patients, visitors, and staff. 10. Crisis intervention for affected staff: Immediate critical incident debriefing (define method of implementation) Resources for counseling (list Iesources and method of access) 11. Postmortem investigationof violent incident (identify individual responsible to coordinate).

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Address reprint requests to Christine M. Walsh-Kelly, MD Emergency Medicine Children’s Hospital of Wisconsin 9000 W. Wisconsin Avenue b MS 677 Milwaukee, WI 53226