Vanderbilt's Handle with Care initiative aims to reduce violence in emergency department

With violence toward health care workers from patients and visitors on the rise inside emergency departments, personnel with Vanderbilt's Adult Emergency Department are learning a new set of skills to keep them - and those they care for - safe. A training program called Handle with Care is the latest initiative in Vanderbilt's ongoing effort to reduce violence in the emergency department and protect staff, patients and guests.

According to the National Institute for Occupational Safety and Health, the nation's emergency departments are among the most dangerous work settings in health care due to assault from patients and visitors. Further, a study released in 2010 by the Emergency Nurses Association found more than half of emergency nurses have experienced physical violence on the job, including being pushed, spit on, scratched and kicked.

Brent Lemonds, M.S., R.N., administrative director of Emergency Services for Vanderbilt, said this data was eye-opening and wanted to respond in a positive way.

In April 2011, Vanderbilt's Adult Emergency Department launched Handle with Care, a crisis intervention and behavioral management program which teaches verbal and physical intervention methods. The course instructs staff on how to de-escalate an out-of-control patient and protect themselves if they feel threatened.

"We felt like it was a good idea to equip our staff with some new tools to use," Lemonds said. "This course really builds the staff's confidence to be able to respond positively in violent situations."

Emergency departments across the country are faced with overcrowding, and patients often use emergency services in lieu of primary care physicians, just a few of the issues which can heighten frustration and lead to violent behavior, Lemonds says. He also noted a connection to violence with an increase in psychiatric patients, as well as a high percentage of patients under the influence of alcohol and drugs.

When Handle with Care was proposed, Vanderbilt staff members Mike Malone, EMT, Anthony Locklayer, R.N., and Jacki Ashburn, R.N., and Quality Consultant, volunteered to become certified Handle with Care instructors and have since led nearly 100 employees through the program.

The majority of the four-hour course teaches verbal de-escalation techniques. Instructors stress that verbal de-escalation is powerful and the goal is to avoid physical restraint when at all possible.

Malone, a 10-year paramedic in the Department of Emergency Medicine, said the most important aspect is to recognize tension and assess where a person is in the tension cycle. If verbal de-escalation does not suffice, the course teaches the primary restraint technique (PRT). The PRT is an easy to teach, orthopaedically-sound physical hold that offers mechanical advantage without pain or injury.

"It's only when a person escalates up the tension cycle and is directly threatening that you engage in the PRT," Malone said.

Michelle Ingram, a mental health specialist in the Adult Emergency Department, recently experienced a situation where the PRT was necessary. Ingram had a self-abusing patient whose behavior escalated into a potentially dangerous state for the patient and staff. Ingram was able to administer the PRT hold and calmly escort the patient back to her room.

Ingram said this was the only time she has had to use the physical restraint portion of her Handle with Care training because the verbal technique is so effective.

"If you can master the verbal de-escalation, these instances of using physical restraint are few and far between," she said.

"It's encouraging to me that the managers decided to devote a whole class to this because it shows they care about our well-being to give us these tools."

All current emergency staff will complete the course by September, although Handle with Care classes will continue for new employees and recertification purposes.

"Participants leave the course saying it was fun and helpful and that now they have a lot of practical things they can use if they have a violent situation arise," said Marsha Price, M.Ed., operations manager for Emergency Services. "It's also been a morale booster because they can see that Vanderbilt is taking violence in the ED very seriously and that we are making the efforts to equip them with the knowledge and tools to de-escalate."

In addition to Handle with Care, Vanderbilt's emergency department has taken numerous actions to reduce the risk of violence, including installing a metal detector at the entrance, having a round-the-clock presence from Vanderbilt University Police Department, rapid movement of psychiatric patients to the Psychiatric Transition Unit and ongoing violence training for staff and managers.