All right. Good morning, everybody. I'm going to shift gears a little bit and talk about one of the challenges in the critical care workforce, which is violence against clinicians in the ICU. There we go. OK. I don't have any disclosures relevant to this topic. I should tell you, I do have two first degree black belts. I got them when I was a teenager. I don't know how well they would serve me now. I have not had to employ them in my practice. In the hospital, when I was in retail, that was a whole other story. But I figured it would be a fun disclosure in what will otherwise be a serious topic. And I have. There we go, okay. I just want to start with my story When I was a critical care resident in West, Virginia I was towards the latter end of my residency program, and I was working on the weekend. It was a routine weekend and All of a sudden there was this big commotion a woman had found out something unpleasant about her her husband And she she went home, and she got a gun and she came back to the ICU This is the days before security was there so you could just walk in and her husband was one of our patients He's I mean where's he gonna go. He's in the bed, and she shoots him just there We didn't know what was going on We didn't thankfully none of us were ever going to be her intended victim because she was only aiming for her patient for her husband She comes back out. She calmly puts the gun on the nurse's station, and she waits for the police to come But you know what's fascinating about that event is we know we talked about it jokingly. You know like oh, yeah I guess what happened today at work, but nobody ever set us down nobody debriefed us We never talked about it and looking back. That was probably not the healthiest of Reactions to it in our world if when violence occurs in the hospital about half the time It's in the critical care setting Unfortunately our nursing colleagues do bear the brunt of it just in our talk today two nurses will be assaulted a Few years ago SCCM actually sent out a survey to members some of you in the audience may have responded To this and about 86% of people said yeah I think it could occur in my ICU and 44% actually said they've been threatened in a similar number said they'd been attacked and most people who had actually been attacked had been Threatened before it and it sort of confirmed what we know you know nurses are Significantly more likely to be threatened and attacked than physicians and some of our other colleagues And so are our women those who are working in bigger ICUs than smaller Facilities, but you know what most of us have not had training and how to deal with this and unfortunately We're not very comfortable with our security at our institutions that they would be able to respond and keep us safe either There was a another study that came out just a couple of years ago. It's a big study 5400 professionals very similar data You see that Across the board you have a lot of verbal emotional physical even cyber Violence that is occurring against clinicians most of it is gonna be the patient or somebody accompanying them But it's also our colleagues we're getting it from our supervisors from the people we work with and I was astounded at how Frequent this is happening. There are people a third of over a third of people are dealing with this a couple of times a year a little under a fourth one to two times a quarter But there are people who were dealing with this every single day and some of you probably Have had to deal with that as well It takes a hit on your motivation and that trickles down to the type of quality that we can we can care But you know, we're also not reporting it. We're not telling hospital administration. We're not reporting it to the police Most people will have so they knew that there were reporting processes at their institution, but they're just not using them But again this sort of reiterated most people have not had training and how to deal with it But they're worried about what would happen if somebody comes into my ICU with a gun and shoots somebody. What do we do? That's stressful again. I don't know that I processed it at the time But certainly if this is something that was a one-and-done thankfully situation But what happens when it's repetitive and you work in a toxic environment that gets to you Emotionally, you don't want to work there that impacts the type of care that we provide to our patient And unfortunately, we're talking about shortages. That doesn't help the situation in terms of turnover We are a prime environment. You know, we are has been kind of pointed out. We're understaffed and overworked We don't have always the time that we know we need to provide in terms of Communication to our patients and to their families in times These are the sickest of the sick there the families and the patients tensions are running high Both individually and even between families, right? It's so it's just a ripe environment for this to occur not to mention the fact that our patients themselves Either come to us with issues that set them up for maybe behavior that leads to this or we're doing it to them Whether it's delirium and agitation they have cognitive disabilities. We have lots of patients with substance disorders So it is just a prime environment, which probably explains why half of the environments occur in our world Unfortunately, there's surprisingly little research out there about you know, that's evidence based on what do we do? How do we deescalate this? And I would say a lot of the solutions are really common sense I really want to advocate for educating the biggest statistic that we've seen is most of us don't know what to do if Something happens. We have to make sure that our clinicians know what to do. There are some programs out there Some of them are proprietary like the management of aggressive behavior I don't have any involvement within but I did think it was a very nice structured program There's also some simple behavioral coaching simulation is becoming very popular I know a lot of hospitals have done this with active shooting drills Maybe expand it more into what do you do when you have an aggressive patient? Who's raising a ruckus while you're also got a code in the background or you have a new? admission coming up or something along those lines so that people can You get over stimulated and being able to practice before it occurs in the real world There have been a couple of studies. I will go through them very briefly. One was a Sort of a PhD study where they took the English modified de-escalating scale and tailored it to the ICU Now this is a scale that sort of it's like a Leichhardt scale It rates you on how well you're doing, you know The best is you're you're really in tune with that patient and the worst is you were just as bad as they are That fight is probably half your fault And they took they had a database where they track all these incidents and they took what were they considered to be the most violent Incidents that happened frequently at their institution. I don't know what's going on there, but they made simulations and they did pre and post So they they put everybody through these simulations and then they went into the classroom Gave them good debriefing skills gave them resources like badge buddies on how to deal with it Put them back through the simulation later And as you would kind of expect their ability to de-escalate situations improve But of course say they sort of realize this is one study. We do need to do more work in this area There's some practice I mentioned before there's a lot of practical things You'd be surprised at the number of our colleagues even that don't realize you can't hit a person in the hospital You can't yell at them in the hospital. So just having little things like signage I think can be very helpful I would again going back to communication pause and listen Most of the time when we're talking about violence against clinicians It all boils down to communication people don't feel like they've been heard. They don't feel like they're They are important to you and sometimes they just want to be listened So stop and say something like, you know I just want to make sure I Understand what you're trying to say so that I can make sure that I help you as best as I possibly can Also be aware of how fast and how loud you're talking. I'm from the south. I tend to talk fast, right? I'm a little lower key, but I went to school in New Jersey. So I'm used to sort of that You have to remember it's not how you think you're coming across but how the patient or their loved one Particularly when they're stressed out, right? So try to take a deep breath Check yourself and just remember try to be as kind as you possibly can and always allow time for questions the other Really the only other big study that has been published in this area was something that where they actually developed a multidisciplinary Behavioral response team. We all have code teams. A lot of us have sepsis teams. This is a behavior team, you know that they can call They did disseminate it through four to our training sessions Just a heads up in terms of added workload that we don't have They did realize you have to go to all eight hours before it really was effective But I think some of their strategies were interesting. I apologize I know that that this is a little bit grainy. It's the best I could do They have a nice little algorithm that people can follow It I think take does a good job at taking into consideration Clinical aspects of you know, is this intentional does our patient have morbidities dealing so a very practical way of dealing with it They also have a box, you know, we have our code blue boxes They have a code gray everything you need to do to respond to these behavioral situations If if that's not enough They have a rapid sedation protocol for the most violent of patients to be able to safely sort of sedate them so that they don't Cause more harm and then one thing that I particularly like they added a new member to their ICU team They have a customer service representative in the ICU whose only job is to put out fires, right? They're there. They're watching. They're an extra hand to pretty provide the communication that we that we don't have Their resource for patients, so I thought that that was a really nice Addition some of the others practical consideration. We all if you can't have that case, you know that customer service represented We all have caseworkers in our hospital. We are we under utilizing them. Can we help use them in our ICU? I know we are using them in our ICU a lot more to provide Resources Compromise pick your battles, right? Not everything do we have to win as clinicians sometimes that we if it's not a deal-breaker Maybe we can meet the patient halfway. I maybe it's just because I'm in Alabama. We have found food works wonderful but sometimes again It's one of the things we found over the years is light and noise control and then from a protection standpoint a lot of facilities are starting to explore wearable techs or nurses and other clinicians can push a button if they really feel Uncomfortable To call security without it being so obvious and making the situation worse the other thing I just want to point out and I think this goes back to my own story debrief debrief everyone everyone that was involved the colleagues Like a med safety meeting almost but also don't forget their secondary victims the patient next door and their family members heard this, too And if you don't go address this with them, they're gonna also be left with some of those Aftermath situations It's also really important to make sure that there is a clear and expected reporting procedure Because remember most of us were we're just dealing with it We're just like oh this happened at work today and we that not that does not need to be the norm We need to make sure that we as a team feel supported encouraged. I'm very sorry this happened to you We're gonna work to make sure this doesn't happen again again much in the same way If we have a near miss with our patient care, we try to prevent that And then finally as I leave you today, we need to be our own advocates Most of you flew in here on a plane If you were to have messed with one of the flight attendants or the pilots, that's automatically a federal offense You could go to jail. There's big fines There is in while 40 states have laws on the books making this a felony not all do there's nothing at the federal level To advocate for us. There is a law. It's a Bipartisan law that's being proposed as we speak that would make it a federal offense I think you know, it's it's not political. It's it's just safety, right? And so again, we have to be able to speak up for ourselves So that we do have the type of environment that we want that will feel safe and will enjoy Coming to every day

violence against clinicians

critical care settings

de-escalation techniques

multidisciplinary response teams

healthcare worker safety