Continuing from Part I and from Part II.

–

Griffiths said CMS would not discuss whether hospital security should carry stun guns or other weapons because that is a “law enforcement” issue that falls outside CMS jurisdiction.^[1]

The CMS approach is dial 911 and hope that nothing bad happens before the police handle the violence, or dial 911 and hope that nothing bad happens because the police have been called to handle the violence.

Certainly, if a patient can survive the JCAHO/TJC (Joint Commission for Accrediting Healthcare Organizations/The Joint Commission) social services questionnaire, that patient must meet the definition of stable – even if that patient’s violent behavior does not meet any definition of stable.

A patient with a head injury would be better treated by the police, rather than by hospital staff.

A patient with hypoglycemia would be better treated by the police, rather than by hospital staff.

A patient with a brain tumor would be better treated by the police, rather than by hospital staff.

A patient with a psychiatric condition would be better treated by the police, rather than by hospital staff.

Trust CMS. Just seclude patients and call the police. Do not treat!

CMS spokeswoman Ellen Griffiths is making it clear that the approach of CMS is not to consider the ways their rules may affect the overall care of patients. CMS is just a rules organization that does not have to deal with reality.

–

Lehigh Valley’s actions ran afoul of patient protection rules meant to limit the ways patients can be restrained, said Holli Senior, deputy press secretary for the Pennsylvania Health Department. Weapons should not be used in the context of restraining a patient. If a physical confrontation goes beyond the point at which usual restraints are in order, then local police should be called, Senior said.^[1]

This is the problem.

The people making these rules are attempting to limit the ways patients can be restrained.

Perhaps they never heard the saying that when all you have is a hammer, then every problem looks like a nail.

How does the Pennsylvania Health Department come to these conclusions?

How will patients benefit from a rule that makes an arbitrary and binary distinction between patients and criminals?

I’m sorry, at this point you have crossed the line and are no longer a patient. You have been discharged according to Pennsylvania Health Department rules. We are attempting to barricade you away from people we still consider to be patients. We will wait for the police to come and take you away. Maybe the police can mange your blood sugar problems/head injury/psychiatric problems/et cetera better than the doctors and nurses can. All hail the omniscient PHD!

Welcome to the Pennsylvania Health Department. We are here to toggle you.

–

The health department, which has “deemed status” in Pennsylvania to carry out CMS rules for hospitals governed by Medicare rules, responded to a complaint about a specific incident in which a Lehigh Valley security officer used a stun gun on a patient. The resulting inspection led to a review of patient records, which showed 3 other incidents with stun guns during the previous few years. Lehigh Valley started using stun guns in 2007.^[1]

A single incident?

An average of one TASER use per year?

Recklessness!

Abuse!

What if we look at each use of a TASER?

The regulators found fault with Lehigh Valley, according to an October 2010 inspection report, because the stun guns were used without a preceding attempting to restrain or seclude the patients. The incidents involved the following:

•An agitated patient in the ED received multiple doses of Ativan, Haldol, and valium during about 2 hours and was still agitated. Security staff was called and the patient “came at” security, at which point the patient was stunned.

•A patient was asked to sign a transfusion consent and refused, becoming agitated, and began yelling at staff. The patient was using an intravenous pole as a weapon and barricaded himself in the restroom. Security talked to the patient, but he became more agitated and ultimately a stun gun was used. Police were called and took a report.

•An ED patient ran out of an examination room, slamming the door, hitting the wall, and yelling. Medical staff tried to calm the person, and eventually security was called. The patient attempted to punch a security officer, “who intercepted the patient’s punches and took the patient to the ground.” The patient began fighting with both officers, and one used a stun gun to subdue him.

•An upset patient left the ED, and security staff pursued the person for fear he would harm himself or others and called police. The patient pushed a security officer, striking the officer with his fist and grabbing for the officer’s belt containing pepper spray and a stun gun. Another officer warned the patient 3 times and then discharged a stun gun.

In each instance, the health department said, security staff should have followed policy and restrained or secluded the patient or waited for police to arrive.^[1]

the stun guns were used without a preceding attempting to restrain or seclude the patients. . . . received multiple doses of Ativan, Haldol, and valium

And we certainly wouldn’t want to consider multiple doses of Ativan, Haldol, and Valium as attempts to restrain (or seclude) the patient, since these are just chemical/medical restraints.

the stun guns were used without a preceding attempting to restrain or seclude the patients. . . . Security talked to the patient, but he became more agitated and ultimately a stun gun was used.

And we certainly wouldn’t want to consider talking with the patient as appropriate, since we only want the patient secluded while we wait for the police to show up to treat the patient..

the stun guns were used without a preceding attempting to restrain or seclude the patients. . . . Medical staff tried to calm the person, and eventually security was called. The patient attempted to punch a security officer, “who intercepted the patient’s punches and took the patient to the ground.”

And we certainly wouldn’t want to consider medical staff trying to calm the patient as attempts to restrain (or seclude) the patient. We also would not want to view security’s attempts to restrain the patient as attempts to restrain the patient.

the stun guns were used without a preceding attempting to restrain or seclude the patients. . . . security staff pursued the person for fear he would harm himself or others and called police. The patient pushed a security officer, striking the officer with his fist and grabbing for the officer’s belt containing pepper spray and a stun gun. Another officer warned the patient 3 times and then discharged a stun gun.

And we certainly wouldn’t want to consider attempts by security to keep the patient away from other patients as attempts to restrain (or seclude) the patient. We also would not want to view security’s attempts to restrain the patient as attempts to restrain the patient.

Better to let the patient harm himself or others. After all, JCAHO/TJC won’t have any problem with that, as long as the appropriate suicidal questionnaire has been filled out by this oh so cooperative patient.

If the patient does not try to kill himself, but tries to kill someone else, the regulatory agency will not be at fault for creating an environment that makes it likely that the violent patient will be able to harm/kill other patients.

There will probably be a rule created along the lines of permitting law enforcement activity in a hospital, even though the goal should be for the hospital to treat the violent patient.

–

I also wrote about the problems with violent patients in MedicCast – EMS and Health Care Workplace Violence on Federal Radar. Jamie Davie discussed this in the podcast EMS and Health Care Workplace Violence on Federal Radar.

–

Footnotes:

–

^[1] Patient Safety Versus Workplace Safety – Stun Gun Debate Illustrates Dueling Federal Mandates
by Jan Greene
Annals of Emergency Medicine
Volume 57, Issue 4 , Pages A20-A23, April 2011

Free Full Text from Annals of Emergency Medicine                 Free PDF from Annals of Emergency Medicine

.

Continuing from Part I.

–

CMS’s actions in Pennsylvania raise a question: Should all hospitals that must comply with CMS regulations stop using stun guns? According to a survey in Campus Safety Magazine, 26% of hospital security officers carry “less-lethal” weapons such as neuromuscular incapacitating devices (stun guns made by Taser International), 7% carry handguns, and 13% carry both.^[1]

CMS is the Centers for Medicare & Medicaid Services.

–

CMS spokeswoman Ellen Griffiths was careful not to extend the Lehigh Valley case into a national mandate for all hospitals. CMS, and any state agencies that act on CMS’s behalf, usually respond to complaints rather than actively inspecting hospitals for compliance with rules. But she did observe, as did a Pennsylvania Health Department spokeswoman, that the CMS rules strongly discourage use of weapons with patients. The rules state:

“CMS does not consider the use of weapons in the application of restraint or seclusion as a safe, appropriate health care intervention. For the purposes of this regulation, the term “weapon” includes, but is not limited to, pepper spray, mace, nightsticks, tazers, cattle prods, stun guns, and pistols. Security staff may carry weapons as allowed by hospital policy, and State and Federal law. However, the use of weapons by security staff is considered a law enforcement action, not a health care intervention. CMS does not support the use of weapons by any hospital staff as a means of subduing a patient in order to place that patient in restraint or seclusion. If a weapon is used by security or law enforcement personnel on a person in a hospital (patient, staff, or visitor) to protect people or hospital property from harm, we would expect the situation to be handled as a criminal activity and the perpetrator be placed in the custody of local law enforcement.”^1[1]

Therefore, having a bunch of people wrestle with the patient, raising the heart rate, blood pressure, respiratory rate, intracranial pressure, et cetera even higher than they would be with the use of a TASER, is less harmful to the patient because this more dangerous practice is not classified as using a weapon.

–

Griffiths said CMS would not discuss whether hospital security should carry stun guns or other weapons because that is a “law enforcement” issue that falls outside CMS jurisdiction.^[1]

This is entirely about CMS telling hospitals how to handle violent patients.

Dealing with violent patients is a patient care issue, even when law enforcement are needed to assist with managing the patient.

For the Pennsylvania Health Department to abandon these patients to law enforcement is not fair to those who treat violent patients in Pennsylvania.

For the Pennsylvania Health Department to abandon these patients to law enforcement is not fair to violent patients in Pennsylvania.

This may come as news to CMS spokeswoman Ellen Griffiths but –

–

I also wrote about the problems with violent patients in MedicCast – EMS and Health Care Workplace Violence on Federal Radar. Jamie Davie discussed this in the podcast EMS and Health Care Workplace Violence on Federal Radar.

To be continued in Part III.

–

Footnotes:

–

^[1] Patient Safety Versus Workplace Safety – Stun Gun Debate Illustrates Dueling Federal Mandates
by Jan Greene
Annals of Emergency Medicine
Volume 57, Issue 4 , Pages A20-A23, April 2011

Free Full Text from Annals of Emergency Medicine                 Free PDF from Annals of Emergency Medicine

.

There is an interesting article in Annals of Emergency Medicine about contradictory rules from conflicting agencies that affect patient care.

One emergency department (ED) gets cited by a federal agency for using stun guns to subdue violent patients. Another is fined for failing to provide a safe workplace. It is a federal catch-22, leaving ED administrators caught between seemingly contradictory mandates from federal bureaucratic silos.^[1]

Different agencies.

Different rules.

No communication.

Faulty logic.

If those of us taking care of patients were guilty of the same errors, we would expect to be fined, or shut down, although probably not for faulty logic.

Yet, when those who regulate us are guilty of these errors, we are expected to satisfy all of their demands and be grateful for the abuse attention.

–

Dr. Kane has the sense that violence in hospitals is getting worse. Statistics back up her perception. ED visits resulting in violence increased from 16,277 to 21,406 between 2005 and 2008, nearly a one-third increase, according to the federal Substance Abuse and Mental Health Services Administration. Visits to the ED for drug- and alcohol-related incidents increased during that time from 1.6 million to 2 million.^[1]

Do the federal, or state, regulatory agencies feel the need to do something to protect those taking care of the patients or to help those taking care of the patients to protect their patients?

No. These regulatory agencies just create more responsibilities for others. These regulatory agencies do not have any responsibility for the damage they cause.

–

The mayhem is having an influence on hospital staff. More than half of ED nurses are victims of physical or verbal abuse at work in a given week, according to a survey by the Emergency Nurses Association released in September 2010.^[1]

–

CMS’s actions in Pennsylvania raise a question: Should all hospitals that must comply with CMS regulations stop using stun guns? According to a survey in Campus Safety Magazine, 26% of hospital security officers carry “less-lethal” weapons such as neuromuscular incapacitating devices (stun guns made by Taser International), 7% carry handguns, and 13% carry both.^[1]

CMS is the Centers for Medicare & Medicaid Services.

In Pennsylvania, the use of TASERs on patients is not considered to be acceptable, because these weapons act by neuromuscular incapacitation. On the other hand, doctors may use paralytics, which are medicines that cause neuromuscular incapacitation, and that neuromuscular incapacitation is considered a treatment, rather than a weapon.

Anything can be a weapon. All that matters is the way that it is used.

Pretty much the same can be said for treatments.

Botulism is extremely poisonous WMD (Weapon of Mass Destruction), but it can be used as a treatment. Ditto radiation.

Just because something is generally perceived as a weapon does not mean that its use is always harmful.

The TASER can be an effective means of protecting patients, but this is something that the regulators do not seem to be capable of understanding in their overly simplistic view of the way the world works.

–

I also wrote about the problems with violent patients in MedicCast – EMS and Health Care Workplace Violence on Federal Radar. Jamie Davie discussed this in the podcast EMS and Health Care Workplace Violence on Federal Radar.

To be continued in Part II and later in Part III.

–

Footnotes:

–

^[1] Patient Safety Versus Workplace Safety – Stun Gun Debate Illustrates Dueling Federal Mandates
by Jan Greene
Annals of Emergency Medicine
Volume 57, Issue 4 , Pages A20-A23, April 2011

Free Full Text from Annals of Emergency Medicine                 Free PDF from Annals of Emergency Medicine

.