6.1 Governance

6.1.1 Service policies and procedures

The Hospital Executive must ensure that established policies, procedures and processes are in place to support all staff across the hospital to report all incidents, including where these incidents occur against ED staff. These elements include:

• Effective implementation of policies and workplace violence prevention programmes.
• Resourcing to enable policy requirements to be met.
• Ongoing monitoring of the policies, procedures and processes to ensure they are contemporary and reflective of lessons learned.
• Undertaking risk assessments in accordance with local procedures, with completed assessments (and control measures) communicated to staff.

6.1.2 ED policies and procedures

EDs must have specific, contemporary policies and procedures for the prevention, early identification, and proactive management of violence within a patient-care focused framework. All EDs should be provided with the resources and capability to mount a timely and appropriate response to any violent incident as it occurs, including prompt access to appropriately trained hospital security and/or police at all times.

6.2 Prevention

6.2.1 Staff training

ED staff must be aware of hospital policies and procedures for the management and reporting of violent incidents and have appropriate training in the recognition of early predictors of violence and its immediate management. Professionalism, cultural safety, cultural competency, and communication skills should be emphasised as key elements in fostering a safer environment for all parties, conducive to mutual respect and cooperation. This is especially important for staff in triage and front-of-house roles.

The hospital administration is responsible for ensuring that ED staff understand their legal responsibilities and medico-legal protections with respect to the circumstances under which treatment can be refused or withdrawn or violent people removed from the ED if they do not have an illness or injury requiring time critical care or they are accompanying a patient.

All ED staff, including ED security personnel and external stakeholder liaison contacts (for example, police and ambulance staff), should receive regular and ongoing violence prevention training that includes verbal de-escalation strategies to safely manage behavioural disturbances and/or aggression.

Training should help staff adopt best practice and understand:

• Risk factors for aggression and violence, including clinical and non-clinical characteristics
• Signs of escalation and imminent violence
• Effective ED communication strategies, including mediation, culturally safe, and culturally competent communication
• De-escalation strategies
• Trauma-informed practice
• Workplace violence prevention measures
• Workplace policies and procedures on violence prevention and management
• Appropriate use of sedation and restraint (where permitted)
• Emergency and post-incident responses
• Their right to withdraw to safety at any time (including security staff)²⁴
• Incident reporting procedures.

ED staff must receive adequate training in the hospital’s emergency and risk management systems, including initiating and responding to internal emergencies (for example Code Black responses or other hospital-wide standardised emergency management system). All staff members should have access to personal and/or fixed duress alarms at high-risk areas such as triage. Implementation of patient alert systems that generate a signal to warn staff of any potential risk to themselves and others, should also be encouraged.²⁵

6.2.2 Resourcing of ED security personnel

Dedicated, specifically trained hospital security personnel are an important ED resource that should be adequately funded by jurisdictional health system managers, and employed and trained by hospital EDs as an integrated part of the ED clinical team.²⁶ Well-trained, experienced hospital security personnel with strong, reassuring, and supportive physical presence, excellent communication skills, an aptitude for learning, a solid understanding of cultural safety and competency, and a positive ‘customer service’ attitude can be successfully utilised in the ED to problem solve and eliminate unnecessary conflict.²⁷ All ED security personnel must clearly understand the ‘rules of engagement’ within their individual workplaces and be ready at all times to protect staff, patients and accompanying others from physical assault.

All ED security personnel should operate as part of a multidisciplinary team that includes clinicians, with clearly defined roles. There must be opportunities for ED security staff to regularly train with ED clinical staff to build the skills of all those involved in responding to an incident.

It is important to note inconsistencies in resourcing of security personnel in Australian and Aotearoa New Zealand rural and remote EDs. Often, regional, rural, and remote EDs are not resourced to contract after-hours security personnel and instead rely on internal hospital staff contracted primarily in another role, such as wardsmen, or external agents such as on-call private security firms and/or local police. Security personnel and police are therefore unlikely to be able to respond to a violent ED incident in an appropriately short timeframe. In these contexts, specific local arrangements must be in place, including memoranda of understanding.

6.2.3 ED design

The ED entrance should be well lit and designed in such a way that optimises visibility. CCTV cameras may be installed both outside and inside the waiting room, noting that governance around the security of this footage is paramount.

The reception and registration desk serving the main entrance should allow for surveillance of all persons entering the hospital. A high and wide reception desk provides a level of protection for staff. Duress alarms should be installed at reception and triage.

The triage area should be easily identifiable, accessible and properly staffed. Clear signs and wayfinding should be utilised to indicate where patients report.¹ Triage areas should provide ED staff with a clear line of sight into the waiting room while still preserving patient privacy and confidentiality.

Waiting rooms should be designed to prevent unauthorised entry into the clinical area of the ED and provide staff with appropriate visibility of patients and accompanying persons in the waiting room.^{1 3} Consideration should be given to appropriate lighting, noise levels and distractions like art works, public television, magazines, and video entertainment for children in the waiting room. Comfortable seating arranged in conversational groupings, tables for food and drink, and charging stations for mobile devices should also be considered. These considerations can assist in reducing stress and agitation levels.

The ED environment must be adapted so that it is culturally safe. Providing private areas away from crowded waiting areas to discuss health information and take vital signs, may assist some patients, including Māori patients, feel less vulnerable and exposed. ED design can result in a culturally unsafe environment when there is limited space for family or community support.

Hospitals should provide separate rooms for the assessment and management of patients suffering from a behavioural disturbance. ACEM recommends an appropriately low stimulus area for patients suffering from an acute psychological or psychiatric crisis (such as a mental health short stay unit) and a behavioural assessment room (BAR) for the management of acutely disturbed or violent patients. These rooms should be designed to minimise the risk of injury to the patient and ED staff.

6.2.4 Liaison with other emergency services

It is essential that regular meetings occur with internal and external stakeholders to improve awareness of ED pressures and to ensure communication across impacted parties and the coordination of efforts for all involved in the care of emergency department patients. This includes broader hospital staff, ED staff, local police, ambulance service, mental health first responders and other community-based healthcare workers.

These meetings should regularly discuss systems and processes to prevent or manage violent incidents. A multi-disciplinary approach is essential as it acknowledges the respective strengths and limitations of each impacted service and the broader journey of the patient through the healthcare system.

Regular meetings will also provide scope to discuss known violent patients/offenders and put in place proactive alert systems to minimise the likelihood of an incident.

6.3 Risk assessment and planning

6.3.1 Risk alerts

Past behaviour is the best predictor of future behaviour. All EDs should have systems that alert staff of previous violent behaviour at future presentations. All staff should be trained to check alerts on arrival and before interaction and enter alerts after incidents of violence.

6.3.2 Risk screening

ACEM highly recommends the use of risk screening tools to improve objectivity in the assessment of violence risk and promote proactivity in its management. There are currently no validated tools specifically designed for EDs. The only validated tool in healthcare settings, the Bröset Violence Checklist, while not designed for or validated in EDs, is proving simple and effective within the ED environment.²⁸

Experienced ED staff rapidly pick up on subtle cues about a patient’s behaviour that suggests a potential for violence. This ability is powerful for early identification of potential problems but a screening tool should also be used to ensure that any response is objective.

6.3.3. Risk mitigation

Any alerts or screening tool should be aligned with a selection of multi-dimensional strategies to mitigate the risk, covering environment and location, as well as the responsibilities of security, nursing, and medical staff.

6.4 Incident management

6.4.1 Behavioural crises

All ED staff should be empowered to call for assistance when feeling their safety is being threatened. If least-restrictive methods fail, a rapid assessment is required to determine the clinical priorities and legal considerations under which a decision is made. Escalation to a senior medical or nursing staff member is essential when assessing and managing a behavioural emergency where there is an identified risk of violence or escalating aggression. The starting point for these assessments is that capacity is assumed, and staff should not place themselves at risk of harm to prove otherwise.

If a violent person is putting others at risk due to violent behaviour and is determined not to have a clinical problem requiring time critical emergency care, it may be appropriate for them to be removed from the ED with security and/or police assistance where required.

ACEM recommends a consistent and uniform approach to emergency management, including behavioural crises within hospitals and health care facilities in Australia and Aotearoa New Zealand.

6.4.2 Least-restrictive methods

The principle of least restrictive practice should be employed for every patient. ED staff should have training in de-escalation strategies, that should be employed in the first instance, together with utilisation of appropriately trained hospital security personnel. Mechanical, physical, or chemical restraint is a last resort measure that should only be used to facilitate assessment and/or treatment that will prevent imminent harm to the patient or others, and all other less restrictive means of management have been explored and found unsuitable.

Clinicians should acquaint themselves with the ACEM Statement on the use of restrictive practices in emergency departments S817 ²⁹, the legal requirements of their jurisdiction with respect to restrictive practices, and their workplace policies and procedures.

All NZ health service providers should meet Ngā Paerewa Health and Disability Services Standard NZS 8134:2021 that requires the allocation of resources to address actions that minimise restrictive practices. ³⁰ The Australian Commission on Safety and Quality in Healthcare Action 5.35 outlines the use of restraint where clinically necessary and strategies to improve health services to reduce the use of restrictive practices.³¹ Internal policies should include the aim of eliminating seclusion and restraint wherever possible.

ACEM supports a reduction in the use of restraint in the ED to manage patients exhibiting disturbed and/or aggressive behaviour wherever possible. Prevention strategies, such as engagement, rapport development and communication, situational awareness, and appropriate case management should be employed wherever possible. Addressing concerns, attending to needs, and keeping patients and visitors informed should be routine responsibilities of all ED staff. De-escalation strategies should be employed early. For certain patient groups, e.g., for acute mental health or withdrawal presentations, proactive use of pharmacotherapy to manage symptoms may be appropriate and prevent escalation.

6.4.3 Seclusion and restraint

When responding to violence, a team-based approach is best by staff who are trained and practised in verbal de-escalation, therapeutic sedation and physical restraint. If restraint is required, and meets all criteria set out in the ACEM Statement on the use of restrictive practices in emergency departments S817, appropriate sedation should be employed.²⁹ Physical restraint in the ED should occur as a last resort under medical supervision and for the shortest time possible and always documented. ED staff should be aware of the relevant legal frameworks governing the use of sedation and restraint in their jurisdiction, and these should be articulated clearly in local policies for the management of violence and followed.

Under NZ mental health guidelines, seclusion is still permitted as a last resort to prevent harm in emergency situations, and when providers have tried other less restrictive practices. All uses of locked seclusion rooms and areas that the patient/service user cannot freely exit must be recorded as seclusion events.³² Legislation varies between Australian states and territories, but all states and territories have legislation and associated regulations that includes criteria for when and where seclusion and restraint may be used.³³

6.5 Post-incident management

6.5.1 Responding to violent incidents

The hospital and the health system have a responsibility to act in response to violent incidents. Actions taken by the hospital and/or system resulting from violent incidents should be promptly and transparently reported to staff (including, importantly, those directly affected by the incident).

In instances where violent incidents need to be reported to police, the hospital administration should make the initial report. Hospital administration should provide support to ED staff in any police investigations that may arise as a result of violent incidents in the ED.

Hospital management are responsible for reporting all ‘reportable incidents’ to the relevant work safety authority.

6.5.2 Post-incident debriefs and support

ED staff are encouraged to routinely hold structured debrief sessions after all significant security events. All hospitals should provide appropriate psychosocial and legal support systems for ED staff during any investigation and/or legal proceedings. Support systems should be in place for ED staff who are returning to work after experiencing workplace violence.

6.5.3 Standardised reporting

Violent incidents should be reported to hospital administration and all incidents (including near misses) should be appropriately recorded and fully investigated. Each incident of violence should be reported through the hospital risk management system so that the true extent of violence in EDs can be understood and monitored over time.

Administrative and clinical leadership is necessary for a change in culture to empower clinicians to report violence incidents. Both the literature and anecdotal reports from ACEM members suggest that one of the barriers to violent incident reporting is the time required to enter data into the hospital risk management system. Hospital management should ensure that reporting processes are streamline so that reports can be made quickly and easily. Standardised systemwide reporting processes should be established to support improved reporting and to facilitate stronger responses.

ACEM recommends the following broad categories for inclusion in a whole-of-hospital violence surveillance system in accordance with jurisdictional practices:

1. Worker demographics (for example job title, department).
2. Workplace violence subtype (for example verbal abuse, threat of assault, physical assault).
3. Perpetrator characteristics (for example patient, visitor, gender).
4. Event setting (for example in person, telephone).
5. Hospital location (for example ED, intensive care unit).
6. Physical location (for example hallway, waiting room).
7. Hospital factors (for example emergency/acuity, long wait time, short staffing).
8. Perpetrator factors (for example receipt of bad news, mental and behavioural condition, alcohol intoxication).
9. Warning signs (for example frustration, anxiety, mumbling).
10. Weapon type (where relevant).
11. Involvement of others (for example co-workers, security personnel).
12. Intervention used (for example de-escalation, security, sedation).
13. Immediate consequences for worker (for example distress, injury).
14. Text description of the event (completed by worker).
15. Recommendations for future prevention efforts.

7. Related documents

• Quality Standards for Emergency Departments & Other Hospital-based Emergency Care Services
• G15 Emergency Department Design Guidelines
• S57 Statement on Emergency Department Overcrowding
• S43 Statement on Alcohol Harm
• S817 Statement on the use of restrictive practices in emergency departments
• P41 Access to care for patients with acute mental and behavioural conditions
• Relevant jurisdictional workplace health and safety legislation
• Relevant hospital and/or health care facility workplace health and safety policies/procedures
• Relevant jurisdictional medical indemnity legislation