Perils in Practice
ISBN 9789395264204

Highlights

Notes

  

Chapter 8: Safety Measures on the Ground for Healthcare Organisations

Ravisankar T. N. Alexander Thomas

Case Study

A booked obstetric case came in late at night with labour pain to the single-owner obstetric hospital with all the necessary facilities available 24x7. The patient was advised a caesarean section by midnight, but her relatives took time to give consent for the same.

The obstetrician noted the time and date when the consent for LSCS was requested. The delay of 25 minutes to receive the consent and another delay of 15 minutes for the arrival of the anaesthetic resulted in the loss of the baby.

Even before coming out of the surgical theatre, the obstetrician alerted the police and a patrol police jeep soon reached the spot, as the hospital had a good rapport with the nearby police station. The relatives refused to take the body of the dead baby, demanding an explanation. By early morning, a group of doctors (including paediatricians) reached the hospital, explained everything to the crowd repeatedly and answered all their questions, at the end of which the relatives finally accepted the body of the dead baby.

In the meantime, the case sheet was prepared with the help of the other doctors and handed over to the police. A group of doctors belonging to the association gave a media interview to clear doubts; this was broadcast on satellite channels chasing “juicy news” for their TRP ratings.

The above scenario is a classic case of how to properly handle a crisis using the following steps:

    1. Documenting the time when LSCS was advised.

    2. Calling the police and staff in preparation for a hostile response from the relatives.

    3. Making an SOS call to fellow colleagues.

    4. Using colleagues’ help to complete documentation, as it is difficult to document appropriately in a preoccupied frame of mind during a crisis.

    5. Conducting a public information session for the media organised by the association office-bearers.

    6. Wasting no time in handing over the dead body to prevent swelling of the crowd with multiple opinions that can flare up the situation.

Introduction

The uniqueness of healthcare is that it is the only labour-intensive sector working around the clock and involving all categories of staff from different backgrounds. In addition, it is a highly demanding vocation.

Violence is defined as any “behaviour involving physical force intent to hurt, damage or kill.” Violence in any form against anybody or anything is against universal law. In recent years, healthcare establishments and professionals are being exposed to violence at increasing rates. Sometimes, case outcomes can be unpredictable and unexpected. An unexpected outcome combined with inadequate communication on the part of the healthcare provider can be the cause of outrageous behaviour by the public. In the event of an unfavourable outcome for the patient, the violent events that follow despite offering the best of their expertise can lead to significant mental trauma for the concerned doctor or healthcare worker. Therefore, it is important that the mental health of the healthcare provider is accorded due importance.

Healthcare establishments are also unique in the fact that the majority of its employees are women, who are at higher risk for violence and harassment. It is all the more important that they are provided adequate security and work safety to perform to their best of ability. It would be advisable on the part of the government to announce hospitals as safe zones with zero tolerance for violence, and give top priority for immediate and swift action during incidents of violence.

Types of Violence against Healthcare Workers

Violence against healthcare professionals could range from harassment and verbal abuse to physical assault, even leading to death. They include acts of intimidation, blackmailing, cyber bullying, mob lynching and harassment. Acts of violence can be directed at healthcare workers, equipment and infrastructure. Violence could occur either as an immediate or delayed reaction. Mob psychology gives people the confidence to create violence in any form while feeling assured of no consequences since they are in a large crowd.

Studies have revealed that 50 per cent of violence takes place in the ICU, 45 per cent in the ER and 70 per cent of violence initiators are patient’s escorts. Another study in 2018 revealed that 50 per cent of attacks are reported during the night shift.

Causes and Consequences of Violence

The causes of violence against healthcare professionals have been explored in the previous chapters. They include inappropriate communication such as poor communication and body language by staff, arguments between hospital staff, unwillingness to refer or discharge patient on attender’s or patient’s request, demanding signatures repeatedly without proper explanations, repeated requests for information on patient’s status with no response. Other causes are unexpected events including death, unwillingness to pay the bill (out of pocket expenses), denial or delay in treatment in the ER, non-availability of consultants and other staff, and so on.1

There are several consequences of violence against healthcare workers, including physical injury, mental trauma, loss of trust in the doctor–patient relationship, social and financial loss, disturbed work environment (including the loss of work hours) and the rise of defensive medical practice. Long-term consequences include an increase in the cost of healthcare along with the likelihood of healthcare facilities shutting down, thus disadvantaging the local community.2

Early Signs of Violent Reactions

It is imperative that healthcare workers, security and other hospital staff be trained to identify relatives or attendants who are potential troublemakers. These are the people who walk around in the hospital premises, often having conversations about the patient and their progress. Employees must be taught to inform their immediate supervisors about any suspicious behaviour or provoking conversations, so that the management and doctors can take the requisite precautions while making the necessary efforts to talk to those attenders and clear their apprehensions in order to keep violent reactions at bay.

The cash counter and front-office employees will be able to identify these dissatisfied relatives/attendants from their non-cooperative attitude or reluctance to accept a consultant’s opinion or review. Quite often the consultant’s inability to communicate appropriately could contribute to the root cause for violence. Such events should be reported to the senior clinicians and management to be handled correctly.

It has to be ensured that during weekends and long holidays, appropriate and sufficiently detailed hand-overs are done, and provision for adequate staffing is made in order to respond to patients’ needs.

An ICU patient’s attendants are usually amongst the most demanding. It is recommended that an ICU with over six beds have a medical counsellor to communicate with the patient relatives as frequency demands. It is also necessary for the clinicians to meet the relatives of very sick patients at least twice a day to provide updates, and these meetings need to be recorded and documented.

Preventing Violence

The following pages provide guidance on steps to be taken to avert the possibility of violence, what can be done during an incident of violence and what should be done after such an incident. Many of the below-mentioned strategies were introduced and used in real-life situations at a well-known city hospital headed by one of the authors, and were found to be useful in averting many a crisis.

Strategies for Prevention

    1. All categories of staff are to be trained in communication. This is now a requirement of the National Accreditation Board of Hospitals and Healthcare Providers (NABH) certification. Healthcare communication has also been introduced into the medical education curriculum. It is important to remember that one should communicate firmly but sensitively, keeping in mind that the patients’ attendants are going through an emotional time. More details on communicating appropriately can be found in Chapter 3 titled The Importance of Effective Communication.

    2. Retired police personnel could be employed for purposes of security, training and liaising between the hospital and local police stations. This topic is expanded upon in Chapter 5 titled Law Enforcement.

    3. The presence of adequate staff is a must in order to attend to patients promptly, especially in emergency and critical care departments.

    4. A solid infrastructure with adequate availability of equipment (wheelchairs, stretchers, etc.) should be ensured for the quick and effective care of patients.

    5. The hospital entrances and exits should be designed in such a way that entry can be restricted by closing one or two entrances as and when required. Good lighting of the corridors and work place is essential.

    6. It is important to install CCTV monitoring for the entire hospital especially in areas such as ER, ICUs and OBG departments as a tool to pick up early signs of violence, as well to act as a deterrent to violence from patients and their relatives. If, in a situation where awareness of the CCTV camera and monitors can provoke a violent mob to destroy it, it is necessary to have a few hospital staff recording the event in hiding from close quarters.

    7. Attendants’ visits should be restricted after visiting hours, especially during night times.

    8. Security systems at night and during long holidays must not be compromised.

    9. Any untoward incidents or signs of impending violence must be reported to the management concerned.

    10. Women employees must always be accompanied by security personnel or male staff when they are shifting the patient to other establishments.

    11. Settling of bills on a periodic regular basis should be encouraged to avoid piling up of huge outstanding amounts.

    12. There should be prominent signage announcing that attacks on hospitals are non-bailable offences with stringent punishments.

    13. The hospital staff should have access to legal advice or be trained in basic and relevant legal aspects.

    14. A well-advertised, easily accessible and widely displayed round-the-clock patient redressal system/helpline, assuring a prompt response from a senior hospital official, will go a long way in building confidence among patients and averting any untoward incidents. The senior hospital official could, if necessary, personally interact with the complainant and resolve the grievance. The email address of the institution head can also be displayed to ensure that unresolved issues can be attended to.

    15. For times outside regular duty hours (including evenings, weekends and holidays), a resident administrator system can be set up. The resident administrator, preferably a senior nurse, posted on rotation is appointed to take overall charge of the hospital in relation to food quality, alertness and readiness of security, availability of ambulance, ensuring that telephonic queries are appropriately answered, being a point of contact for any sudden issues, and so on.

    16. The resident administrator can be supported by senior staff who can do night rounds on rotation.

    17. A daily report by the resident administrator (either by email or WhatsApp) to the core group of hospital officials every morning will be beneficial in understanding any day-to-day problems, areas of concern and the necessary remedial actions to be taken.

Handling a Violent Situation

1. All hospitals should become familiar with using Code Violet over the public address system.3 Code Violet is now accepted as the code for the hospital response when a violent incident is taking place. The phrase “Code Violet” is announced thrice over the local PA system to alert the staff to make their way to the place where the incident is taking place. Trained personnel should form a protective circle around the victim being subjected to violence. They should only protect the staff and equipment and should not retaliate or enter into an altercation with the mob.

Awareness regarding the Code Violet facility should be generated widely among the staff and hospital employees. Code Violet can be made effective only with mock drills at frequent intervals. The role of the individual must be predetermined, and only mock drills can reemphasise the responsibilities and identify the gaps to be closed on the next occasion. Mock drills are an effective way to keep the hospital staff alert. The steps include the following:

    1. Informing hospital administration

    2. Security staff or their supervisors calling for the police to counter the violent mob or persons

    3. Restricting entry into hospital

    4. The senior staff or medical superintendent gathering a team for discussions to defuse the crisis

With the assistance of the police force to defuse the crisis, the hospital management can attempt to initiate a dialogue with the violent mob. The primary aim should be to move the body or the patient away from the hospital premises rather than recovering payment for the treatment process or such related matters. The commercial aspect can be taken care of at a later time, or the hospital can use a legal forum to recover the same.

After a Violent Incident

The main steps are outlined here and examined in greater detail in Chapter 5 titled Law Enforcement.

    1. File FIR

    2. Follow up with the police station

    3. Follow up with the court

    4. Conduct a root cause analysis of the incident to prevent a reoccurrence

    5. Address the mental health of the victim through counselling, work back-ups, and so on.

Small Clinics or Individual Practitioners

In smaller clinics and individual private practice set-ups, the security systems are not as advanced as those in bigger healthcare facilities. Hence, violent persons and mobs need to be handled differently.

1. Effective communication with the patient and relatives is crucial.

2. Apart from seeking immediate police assistance, the clinic head should also seek the support of pre-determined groups (nearby clinics and local healthcare institutions) through WhatsApp groups or other mechanisms so that they can physically come to the clinic’s aid.

3. It is more likely that a family practitioner would have a more personal and deeper rapport with influential persons who may be patients at the clinic, and hence he/she should handle a violent situation with a call to those who may be able to defuse the crisis.

4. Recording of the event and training staff accordingly is advisable.

5. It is always necessary for a single clinic owner to have a referral hospital where they can refer patients who develop complications while providing treatment so that the hospital can also join the defense of their professional action.

Conclusion and Take-Home Messages

This chapter has explored the causes and consequences of violence against healthcare professionals, and provided guidance for on-the-ground safety measures that can be implemented in healthcare organisations (Flowchart 8.1).

Action Plan after a Violent Incident
Flowchart 8.1

Action Plan after a Violent Incident

    1. Prevention is better than cure: communication is key, and all hospital employees should be trained in effective communication.

    2. The mental health of healthcare workers should be given due importance.

    3. Develop a system through staff/CCTV to pick up signs of impending trouble and try to resolve it before it manifests in a violent outbreak.

    4. Set up an independent helpline for patients/attendees to reach administrators directly.

    5. Ensure the periodic settlement of bills.

    6. In case of an actual incident, put into practice a pre-determined SOP with the aim of protecting victim and hospital.

    7. Conduct mock drills frequently.

    8. Follow up with the police and courts to discourage future incidents of violence.

1. M. Kumar, M. Verma, T. Das, G. Pardeshi & J. Kishore, “A study of workplace violence experienced by doctors and associated risk factors in a Tertiary care hospital of South Delhi, India,” Journal of Clinical and Diagnostic Research. 10 (2016). DOI: . 10. LC06-LC10. 10.7860/JCDR/2016/22306.8895
2. Framework guidelines for addressing workplace violence in the healthcare sector. [2020 Jun.]; https://apps.who.int/iris/bitstream/handle/10665/42617/9221134466.pdf.
3. Dial Code Violet for Violence Against Doctors. Medical Dialogue. https://medicaldialogues.in/dial-code-violet-for-violence-against-doctors-guidelines?infinitescroll=1.