That's more than I anticipated, so thank you very much.
The Canadian Association of Emergency Physicians is the national specialty society for emergency medicine in Canada, with over 2,500 members.
With the birth of our specialty approximately 40 years ago, our primary focus was on education and training to identify and treat life- and limb-threatening emergencies. Over the ensuing decades, our role has changed. Emergency physicians now bear daily witness to failed social policies that result in increasing visits to our departments by patients with substance abuse—including alcoholism—poverty, marginalization and violence. The latter, in particular, is of grave and increasing concern to both our members and our nursing colleagues.
Health care providers have a fourfold higher rate of workplace violence, and 50% of all attacks on health care workers occur in the emergency-department setting. Our nursing colleagues in particular bear the brunt of much of this violence. Most of the assaults on emergency department personnel were by patients or visitors, and the degree of physical violence has been increasing.
It is both under-reported and underappreciated. Studies have shown that only about 30% of violent incidents in the emergency department are reported to higher authorities.
The root causes and contributing factors to violence have been well described. There's a very extensive literature base. As with many problems that beset the emergency department, many contributors lie outside the department itself, and are societal and cultural in nature.
Chronic oppression, with racism, poverty, inequity and social exclusion, lead to substance abuse, mental illness and violent behaviour.
All are important, but substance abuse, and in particular the increasing incidence of crystal meth use in the western provinces, has many of our western colleagues particularly concerned.
As the population ages, complex presentations of the elderly in the emergency department, coupled with prolonged waits for care, as a result of crowded hospitals, lead to an increased risk of delirium and violent acts by the elderly.
While violence in the community is certainly a driver for violence in the ER, it is not the sole driver. There are factors intrinsic to our departments and to our hospitals, including overcrowding and increased wait times, that lead to immeasurable stress for our patients and their families, as they wait eight, 12 or 24 hours to be seen. We have insufficient—in our view—nursing staffing ratios, leading to poor communication and poor basic care of the patient who's been deemed to require admission. They wait in the hallways, and it's totally unacceptable.
We also have poor environmental design, all of which lead to an increased risk of violence in the emergency department.
With respect to the effects, multiple studies and reports have shown that exposure to violence in the ER has a deleterious and demoralizing effect on staff, most notably nursing staff. Occupational strain, impaired job performance, fear of patients and future assaults, decreased feelings of safety and reduced job satisfaction have all been commonly identified.
It also leads to absenteeism, lost-time injuries and prematurely shortened careers. Workplace violence in the health care sector also has a large and well-quantitated economic effect.
This is a national problem that requires a national solution. I know that many of you believe that health care is a provincial responsibility, and it largely is, although you're paying part of the health care tax dollar. However, you could be very helpful, I think, in helping develop a template of best practices to be shared with your provincial colleagues.
Violence in the emergency department, as I stated, is a symptom of a much bigger problem—broadly societal—with racism, poverty, substance abuse, gang and personal violence and inadequate upstream mental health resources for the mentally ill and, of course, those with substance abuse. This is a societal issue, and is beyond the immediate control of emergency physicians.
Within the hospital and the emergency department per se, however, we can consider the following. While individual staff members can contribute to safety through their practice and behaviours, ultimately, the legal and moral responsibility to provide a safe workplace falls to the employer, and thus to a hospital's administration, from board to departmental leadership.
These are a few of the major considerations and the literature is quite extensive, so I will keep this relatively short.
There should be an increased focus on appropriate facility design, with a limited number of controlled entry points to the emergency department with the capability to rapidly lock down the department.
Monitoring is often an afterthought, but there must be a visible security presence 24-7 with adequate backup available in response to an actual or potential incident. It's always the last thing to happen, usually after the incident has already happened.
Regarding skills and attitudes, all emergency department personnel should receive training in non-violent de-escalation to defuse the situation.
There should be clear policies and procedures in place with regular staff training to cover how staff should respond to a high-risk situation, including and regrettably, the active shooter protocol, which is now a part of many urban hospitals.
There should be care plans. Security as well as the clinical staff should have a system for tracking the high-risk individuals and identifying them on return, as well as ideally suggesting a safe approach individualized to a person's behaviours and known clinical issues.
There should be an incident reporting system, as well as a process for incident review. There needs to be a clear line of accountability for all aspects of emergency department safety for our nursing colleagues, patients and ourselves.
We hear the phrase zero tolerance. We believe that—and this is really quite important to stress—violence in the emergency department is first and foremost a medical symptom which requires an assessment to diagnose the etiology. Intoxication, psychosis and mania, dementia and delirium, brain trauma and tumours are all potential causes of violent behaviour.
Violence can also be reflective of a much bigger socio-economic problem, as previously discussed. We support zero tolerance of violence in the emergency department and every incident requires an institutional response, but the phrase “zero tolerance” cannot be used as an excuse to evict or ban patients who have not been properly assessed. This only makes us complicit in a culture of stigmatization and inequity. We believe violent patients deserve the very best possible assessment and care from their ED providers. Their individual social circumstances must be considered in their ultimate care plan. The zero tolerance lies with zero tolerance of an administration that turns a blind eye to the issue of safety in a department.
Thank you very much.