Before it even opened on April 7, St. Joseph Hospital’s new emergency department wing was the scene of TV-like drama when an armed patient pulled out a gun, sending medical staff into emergency response.
In the days leading up to the event, patients were notified via cards on their meal trays that it was going to happen — it being the hospital’s first ever active shooting simulation, an effort to help prepare staff for such situations and to deal effectively with the increasingly prevalent threat of violence in their workplace.
Hospital staff members are trained throughout the year to respond to a variety of emergencies. They practice drills for code blue — medical emergencies like cardiac arrest — and code red, which means fire. Last Wednesday, the St. Joseph leadership team created a scenario that started at code grey and escalated to code silver. Code grey is a violent situation, and code silver means a weapon is pulled.
Instances of violence against healthcare workers are not uncommon, especially in the emergency department, where emotions and tensions run high, said David Copson, chief of security for St. Joseph Hospital.
“We’ve had two incidents in St. Joseph for the month of March so far,” Copson said on March 24. “We can’t get into the details.”
Episodes of violence aren’t always caused by psychiatric patients. They can happen when ordinary people dealing with medical emergencies and other hardships become overstrained emotionally. But increasingly, the violent situations involve people in need of psychiatric care after their mental health has spiraled downward and they come into emergency rooms as a last resort.
A growing problem
The growing prevalence of violence in New Hampshire’s hospitals is a symptom of years of cuts to state funding for mental health care, said John Clayton, president of the New Hampshire Hospital Association. In 2011, the federal government deemed the state’s mental health care system “in crisis” and in violation of the Americans with Disabilities Act.
Increases in violence in emergency rooms are happening all over the state, Clayton said. He noted two recent high-profile occurrences at Elliot Hospital in Manchester. Last July a worker was attacked by a mentally ill emergency room patient. In October, another mentally ill patient paralyzed and broke the neck of a security officer at the same hospital.
“The patient population affected by mental illness has increased dramatically over the last several years,” said Dr. James Martin, emergency department director at St. Joseph. “I think part of that is due to the statewide deficiency of resources available to them.”
Emergency rooms have becomes safety nets — and that means resources like beds are scarce. Mental health patients sometimes stay for a week or more while hospital staff find proper arrangements. Not having the resources available to help patients is emotionally draining on staff, Martin said.
It’s a problem the state government is aware of and is beginning to respond to, Clayton said. Last year Gov. Maggie Hassan formed a committee that created the “Mental Health Sentinel Event Review.”
The report released in January stated that “suicidal” was the primary diagnosis for more than one in five patients, and one third reported major depression. It also said New Hampshire Hospital in Concord was the more frequent destination of patients following a visit to an emergency department.
In 2012, 196 sentinel events — unexpected instances that involved death or serious physical or psychological injury, or the risk of those — occurred in the state’s acute care facilities, and in 2013 there were 228, the report stated.
Training to respond
The report also stressed the importance of training hospital staff to respond to violent outbursts, but Clayton said that while it’s an important piece, it’s not going to solve the problem. Emergency rooms are not equipped to properly care for mental health patients, Clayton said.
“If you had a problem with your leg, you would not expect to go to the emergency room and say just sit there for four or five days. Unfortunately, that’s where psychiatric patients find themselves,” he said.
During St. Joseph’s simulation, many of the actors played their real-life roles. The hospital’s emergency department staff played the parts of emergency department staff. Nursing students were asked to play the parts of patients and victims. Once code silver was activated, members of the Nashua Police Department acted as police officers. They came in, did a sweep of the building, searched for the aggressor and contained him.
“When staff have an opportunity to practice, they get better at responding in real situations,” said Francine Dupuis, emergency operations manager. “It’s a good exercise for both departments to work in collaboration on how to handle these violent situations.”
The training hospital staff get at St. Joseph will benefit the state’s other hospitals too, Copson said. Most of its staff work per diem, cobbling together a handful of part-time jobs. Because every hospital in the state has the same 10 emergency codes, the skills are transferable anywhere they go.
While drills and training happen frequently, the active shooter training is the first of its kind for St. Joseph, and another of its magnitude and time commitment likely won’t happen again. The event was more than a year in the making. Staff have been preparing since June, taking classes and watching DVDs, Dupuis said.
“It is a very intensive drill to put together. Every department in the hospital is part of it,” she said. “We may well do department-wide drills [again], but not hospital-wide.”
Workplace violence can look like anything from verbal to physical assaults with or without weapons, but the leadership teams chose to simulate an active shooter scenario late last month because gun violence is increasingly pervasive.
“Active shooter situations are happening clear across the country, and some are very close to New Hampshire,” Copson said.
As seen in the April 17, 2014 issue of the Hippo.