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Don’t bleed before you are wounded, and if you can avoid being wounded…

…so much the better!

Part of me is wondering what took them so long to get to this point in the conversation.

In their latest Quick Safety utterance, our friends in Chicago are advocating de-escalation as a “first-line response to potential violence and aggression in health care settings.”  I believe the last time we touched upon this general topic was back in the spring of 2017 and I was very much in agreement with the importance of “arming” frontline staff (point of care/point of service—it matters not) with a quiver of de-escalation techniques. As noted at the time, there are a lot of instances in which our customers are rather grumpier than not and being able to manage the grumpies early on in the “grumprocess” (see what I did there?!?) makes so much operational sense that it seems somewhat odd that we are still having this conversation. To that end, I think I’m going to have to start gathering data as I wander the highways and byways of these United States and see how much emphasis is being placed on de-escalation skills as a function of everyday customer service. From orientation to periodic refreshers, this one is too important to keep ignoring, but maybe we’re not—you tell me!

At any rate, the latest Quick Safety offers up a whole slate of techniques and methods for preparing staff to deal with aggressive behaviors; there is mention of Sentinel Event Alert 57 regarding violence and health workers, so I think there is every reason to think that (much as ligature risks have taken center stage in the survey process) how well we prepare folks to proactively deal with aggressive behaviors could bubble up over the next little while. It is a certainty that the incidence rate in healthcare has caught the eyes and ears of OSHA (and they merit a mention in the Quick Safety as well as CDC and CMS), and I think that, in the industry overall, there are improvements to be made (recognizing that some of this is the result of others abdicating responsibility for behavioral health and other marginalized populations, but, as parents seem to indicate frequently, nobody ever said it would be fair…or equitable…or reasonable…). I personally think (and have for a very long time, pretty much since I had operational responsibilities for security) that de-escalation skills are vital in any service environment, but who has the time to make it happen?

Please weigh in if you have experiences (positive or negative are fine by me) that you’d feel like sharing—and you can absolutely request anonymity, just reach out to the Gmail account (stevemacsafetyspace@gmail.com) and I will remove any identifying marks…

An interesting security development: To arm or not to arm?

In a February 18 Joint Commission leadership blog post, Mark Crafton, TJC’s executive director of communications and external relations, focuses on the benefits of investigating different approaches for mitigating violence in hospitals. At least that’s where the conversation starts, but it ends up in kind of an interesting (and to my eyes, unexpected) direction: the question of whether hospital security officers are a more effective deterrent/mitigation strategy when they are armed. (N.B.: In Crafton’s post, he refers to security “guards”; call me whatever you like, but I think the term “guard” just doesn’t ring well with me. I’m okay with the terms “security staff” or “security officers,” but “guards” just gives me the vapors—metaphorically speaking, of course.)

In the course of the posting, Crafton points to an article in the Chattanooga Time Free Press that will likely generate some debate among healthcare security professionals, and I tend to agree with that thought. Apparently the article was the result of a healthcare system’s decision to disarm their security staff and adopt the “soft” uniform look (e.g., blazers, etc.) to more effectively emphasize the security officer’s role as a more customer-oriented (my description) countenance. Now we’ve touched on the subject of arming security officers in the past (it’s been a really long time) and it’s probably way past the time for looking at this topic, particularly as the good folks at CMS have some rather strong thoughts on the subject:

CMS does not consider the use of weapons in the application of restraint or seclusion as a safe, appropriate health care intervention. For the purposes of this regulation, the term  “weapon” includes, but is not limited to, pepper spray, mace, nightsticks, tazers, cattle prods, stun guns, and pistols. Security staff may carry weapons as allowed by hospital policy, and State and Federal law. However, the use of weapons by security staff is considered a law enforcement action, not a health care intervention. CMS does not support the use of weapons by any hospital staff as a means of subduing a patient in order to place that patient in restraint or seclusion. If a weapon is used by security or law enforcement personnel on a person in a hospital (patient, staff, or visitor) to protect people or hospital property from harm, we would expect the situation to be handled as a criminal activity and the perpetrator be placed in the custody of local law enforcement.

The use of handcuffs, manacles, shackles, other chain-type restraint devices, or other restrictive devices applied by non-hospital employed or contracted law enforcement officials for custody, detention, and public safety reasons are not governed by this rule. The use of such devices are considered law enforcement restraint devices and would not be considered safe, appropriate health care restraint interventions for use by hospital staff to restrain patients. The law enforcement officers who maintain custody and direct supervision of their prisoner (the hospital’s patient) are responsible for the use, application, and monitoring of these restrictive devices in accordance with Federal and State law. However, the hospital is still responsible for an appropriate patient assessment and the provision of safe, appropriate care to its patient (the law enforcement officer’s prisoner).

As you can well imagine, equipping security staff with weapons of almost any stripe can result in the classic slippery slope. My personal practice was to have a clear delineation between security staff and law enforcement responders. Security staff were provided ongoing crisis management education and worked closely with clinical staff to proactively manage at-risk situations. Law enforcement response was summoned when appropriate and the use of weapons was solely at the discretion of those responders. I know those lines can get pretty blurry in the heat of the moment, but specific roles are, I think, the best starting point for an effective security program.

At any rate, Crafton goes on to discuss the following: the cases for armed/not armed security staff; armed staff as authority figures vs. armed staff as a potential for raised anxiety of patients who are already distressed/stressed; and how do you make patients and staff safe, etc. There are, of course, good arguments on both sides, but ultimately (and this is one of the common threads when it comes to TJC standards and expectations), it is the responsibility of each organization to determine how best to manage, in this case, security risks. It doesn’t seem likely that peace, love, and understanding are going to be breaking out any time soon; the role of the security officer has never been more important.