Good afternoon. There is nothing that I can say that will be more important than what you just heard. You are remarkable. Thank you for being vulnerable. Thank you for sharing that with us. That's exactly right. Well done. You can all see yourselves in her talk. We're going to talk a little bit about danger signs. These are my disclosures, none of which are financial in nature, and you will be absolutely convinced there is no augmented intelligence in anything that I'm presenting to you today. These are our objectives. We're going to talk about hospital violence types, some drivers, the warning signs in particular, and what could be done, what should be done, and how to envision what that future will look like. You've heard some of this already. I intend to add to it. Violence is categorized by perpetrators. There's four different types. You can see far and away it's a customer or patient, or it's a current or former employee. This is more than 90% of all the hospital violence, and the categories of violence that have been perpetrated, this is since the 1970s, has been categorized in this way. You can see all the in-hospital pieces, verbal, sexual, emotional, but the out-of-hospital ones that you've heard about in terms of stalking and online harassment. We've had a detailed description of horizontal or lateral violence, but there are others. This is from ZDogg. I can't watch this. I've watched it too many times, and I cry every time. Hashtag silent no more. You should watch more than once. This is vertical violence. Dr. Michael Wong is stabbed 13 times by a patient. He just tries to make people's lives better, and you have met this woman today. This is lateral violence. The quote in there, I knew this would happen, suggests that the horizontal violence is perhaps more preventable, but it will not be prevented if we continue this trend where we under-report this in a robust fashion. You've heard it is not expected. I only need to report physical injuries. If I report, I'll be the target, and if I'm the team leader, well, that will alter my team dynamics. They won't respect me because I've now cried for help. This is all wrong, and it is aided and augmented by the lack of granular feedback when you submit a report. You don't know what has happened. What drives this? Well, there's a whole lot of things, and these are some key hospital violence triggers. The intersection of the emotional contact and framework, the care that's been received, the history of that person with the health care system, all of these may embrace things like moral emotion, such as anger, but you must be aware of all these because it is often underpinned by moral distress, a clash of bedrock values and beliefs. The things that make you who you are and that you hold near and dear are often presented in conflict with the clinical situation in front of you, and you should be aware of this. When you look at violence, and this is ED, violent escalations, and you look at triggers, what you'll see in blue is that there are adverse events that impacted staff. In orange, you'll see the influence of alcohol, but look at the gray bars. It has nothing to do with intoxication. Of course, this is Australia, and some of the weapons were a tomahawk, which we don't generally see in the U.S., but it challenges your assumptions. Everyone that does this has some psychiatric disease or some drug abuse, but that is not the case. In fact, when you look in other studies, time is a factor, and when you look at ICU length of stay, it's zero to two days, 2%. More than a week, 9% of individuals have some episode of hospital violence, and these are typical patients. You can see they may look like the people that come to your ICU. This awaits on your doorstep. When they looked at the contributing factors, confusion, delirium was one of them. The severity of medical illness had significant impact. Psychiatric illness, only about a third. So there are many other pieces to this that you should know about. This is a study from India. 85% of the clinicians, regardless of where they worked, said they had experienced hospital violence. Only one in five had been trained to deal with it in any way, shape, or form, leading the pack, poor communication. Everything related, and dissatisfaction with care was far behind. We own communication. Because you work in a complex care environment, you're very vulnerable. These are people with critical illness or critical injury. Conflict which has lots of different kinds of triggers intersects with care that is complex, and the person who's at the bedside bears the brunt of this. This is more than nurse practitioners and PAs, and all of them more than physicians. Warning signs, you've heard many of them. But there's a categorization. Behavior, prior emergency department violence before they got to your ICU. The difficult family, the one that won't engage or engages in a very hostile sort of way. People that make threats. People that stalk. I've had 36 death threats. Yep, six of them led to arrests. When I was president, I got a variety of emails that said, we know who you are, we know where you live, we're coming for you. That was the nicely worded one. Individuals that have a history of poor performance and behavior in your hospital that have a flag, those that are identified as carrying weapons into the facility that require the police to remove them. But there are also events. If only I can get to the most wonderful ICU, all will be well. We can't always guarantee that. Unexpected end of life. And if the individual dies before the family gets to visit, that is often a powerful trigger for vertical violence. But horizontal, I cannot give you a better description than what you've already heard. And I'm not going to dwell on it because you did a far better job than I would. But it overlaps with discrimination. You've seen this. This is an interesting model. When you look at workplace violence and discrimination, you can see all of the categories of discrimination. It strongly intersects with general and mental health, manifests in a variety of ways, and the most telling discriminatory aspect is gender. If you survey French intensivists, a reasonable sample, a little more than 370, half of them had gender-based discrimination, more than a third were bullied, and nearly half said this directly led to a poor quality of life. This is one of those never events. People should not have to deal with this at work. Well, those are things that are warning signs when they're present, but there are others when they're absent. And so, yes, this is a deliberately blank slide. If you do not have administrative support, it is very hard to change the culture. But there's other things. On one side, you see the old unit, that door never closed. As soon as we moved out of it, that door now closes. This is the new unit, brand new hospital, none of the doors lock. How can you be safe? Our unwell wellness room, at the end of each corridor is one of those wave your hand opening events. This is remotely located. No one will know if you have a problem there. It's not policed. It's not surveilled. You need to be protected where you work. There are standards. The Joint Commission, in particular, has all these articulated. If you have not been educated on them and you don't have a group that is working on them in your facility, its absence is a danger sign because it supports an unsafe environment. The domains that are addressed are staff. Do you go into a patient's room where there is the potential for conflict alone, or must you always have a buddy? Does your name badge have your last name on it? We have electronic ones that brings up our name and our picture so that everyone knows who's coming in the room. It's easy to find who you are, at least your social media profile. Is the room designed with all of the supplies on the other side of the bed where we put the family? And so that if there's an issue, you can't really get out? Is there an alarm system? Are your rooms surveilled digitally or not? Where are people allowed to walk? Do you have flow control? What kind of response do you have? Do you have a behavioral escalation support team or a behavioral emergency response team? Or are you left alone to fend for yourself? And have you been trained, not just in de-escalation, but physical safety? If your hospital doesn't do it, you should do it. Prevention and response are key areas. We'd love to prevent all of this, but you can't prevent all of it, therefore you must learn to manage conflicts that you can resolve it. This is training that's suitable for everyone in your ICU, including the people who deliver food. You'd be surprised who patients and family talk to. In order to help with this, you need to figure out not just what they want, but why they want it. Their interests, not just their positions. I need a free meal. Well, that's nice. I'd like a free meal also, but when you ask why they need a free meal, it's because they can't afford parking and therefore either they eat or they come visit their family member. If you do that, you break down barriers and you get to figure out what they need and why. There is particular language to support helping discover this. What I think I hear is, did I get that correct? You're allowed to be empathetic. You're allowed to identify and bond with them and acknowledge that their perspective is one that is reasonable, but you're going to help them through that now and you're sorry that we're in this situation. What can I do for you at this point? Everyone can be trained this way, because then you're collaborative and that wall comes down very easily. Some interventions, best teams we talked about, more security, sometimes it helps, a panic button is helpful, red flags in the electronic health record, but control, all of those are far inferior to training your staff, workplace violence prevention. We've put this in at our facility. This is the evolved system. You can't go through that with anything that has a whole lot of nettle in it, slows down access, but you will know whether people are coming in with tools or not. But you should be trained to do what you already know how to do better. This is one study looking at the run-hide-fight focused in the OR area and everyone with simulation training could perform better. How many people have been trained in de-escalation here? Show of hands. Not most of you. This is not an orientation event. This is an ongoing event, repeated event, yearly. But you should also prepare for rescue. This is the lobby of our trauma facility. Right next to the gift shop there's an AED, but there's also a stop-the-bleed kit and it's located on all of our floors, because if you have to wait for someone else to bring it to you, that's too late. And recovery? Well, we have lots of approaches for recovery, but you have to make sure the administration deploys them. And you can see a variety of them here and far and away a couple of things are important. Debriefs as a group, but also pets. This is Spartacus Cooch. Yes, he's an Akita. I have an Akita. Antonio has Akitas. He was there not for patients and not for visitors. He was there for us. And he was there during the debriefs and he was there around those debriefs. And everyone felt one important thing. They had hope that all that they saw, all that had happened, could in fact be better. So I'll leave you with these conclusions. There are unique aspects of patients and family. There are other structural aspects of the facility, but ultimately there's also you and how you best prepare. So with that, I think we'll have lots of time for questions and I will thank you for your attention. And this is a key topic and this is a session that you will all remember. Thank you.

hospital violence

healthcare workers

conflict resolution

emergency response

psychological support