Podcast: Violence Prevention in the Emergency Room

A stethoscope and a mask laying flat.

Guest Biography
Dr. Sally Gillam is the Chief Nursing Officer at St. David's South Austin Medical Center in Texas, where she has been in her role for more than 25 years, managing all aspects of nursing care at the 328-bed tertiary acute care facility.

She recently earned her doctorate from the Texas Tech University Health Sciences Center. Dr. Gillam has served on the Board of the Texas Organization of Nurse Executives, the Concordia University Austin Nursing Advisory Board, and the Nursing Legislative Action Coalition.

Dr. Gillam recently authored a journal publication examining the cost and extent and timing of beneficial effects for employees in large hospital emergency departments who are provided Nonviolent Crisis Intervention® training. The study is an industry milestone, as it's the first quality improvement study published on workplace violence in the health care sector.

Podcast Highlights
Here are a few of the highlights from my conversation with Dr. Gillam.

On the police department policy of dropping violent offenders in the ER (2:54)
We saw local law enforcement actually introducing their efforts to increase their drop off of psychiatric cases at our facility, when a lot of these patients were, believe it or not, deemed too unpredictable for a standard incarceration environment such as jail or some type of holding cell. . . . I wouldn't believe that until I actually spoke with these officers myself and was actually told, "Dr. Gillam, these patients are too violent to go to jail. So therefore, we need them to either decompress, or we need them to rehab themselves long enough in your emergency department prior to us returning to see if we are going to take them to jail or not."

On the definition of events termed “code purples” at the hospital (4:48)
A code purple, that's what we use as our call for an emergency need of security assistance. We use that, and when that code is called, we have security run to that area. It's very similar to a code blue or any kind of cardiology code, those types of things. So this is for, strictly, an emergency call for security assistance. Anyone can call it. Anyone who feels fearful that they're in an environment that they need additional support, they can call it.

On selecting St. David’s South Austin Hospital for her study (4:22)
In our emergency department, we actually have multiple free-standing EDs that report into this ED, and the part that I selected for the study was one that I could actually contain, which is the primary ED. So that primary ED sees about 70,000 to 75,000 visits a year. And I felt that was a large enough population that I could utilize for measuring our training. 

On staff preparedness and the danger to staff from violent activity in the ER (6:00)
Our millennials are now coming out of the school, and they’re being hired into the workplace, ages 18 to 35 years old. And many of these nurses have not really been well-trained in their core classes for dealing with crisis intervention. So we see them trying to manage the clinical needs of these patients, but we do not see that they are adequately trained at all for managing escalating behaviors.

I believe that they are sitting ducks if they're not trained to de-escalate these problems. (7:38)

On why she chose Nonviolent Crisis Intervention® training for her study (8:24)
"Well, it's great to do that (crisis intervention training), but I need to study this. I need to know some truth. I need some facts. I need to back this up, so that I can prove to anyone that's questioning the return on investment, that our CPI training is actually effective," and I was able to do that with this study.

On the primary question of her scientific study (12:56)
This really is going to sound extremely simple, but I need to validate the effectiveness of training in an easy-to-understand manner. Sometimes you can get study questions that are a little complicated, and that's never good. So I wanted to come up with a simple question. And my question essentially was, "What benefits are derived from providing Nonviolent Crisis Intervention® training to ED personnel to reduce violent events that are manifested as code purples?"

I needed to definitely come up with a cost versus benefit analysis. (12:17)

On the results of the study (29:59)
Essentially what we saw is, for each 1% increase in staff Nonviolent Crisis Intervention®-trained in the previous 90 days, it resulted in a linear reduction of .045 code purples for 1000 ED visits. So it doesn't sound like a lot when you see it like that, but these numbers add up--as the staff are trained, and you pick an emergency department that sees about 75,000 patients, it adds up. In our case, it resulted in a 23% reduction in code purples over the study period. 

So I was able to prove that implementing this education, as it existed then, meaning the every-two-year training, I was able to reduce 23% of code purples over the study period, and that was a whole year.

On ROI (34:46)
I assigned 16 hours of employee time at their salary cost, and then I also looked at instructor time and their cost, and I arrived at a figure that was essentially 2% of payroll per year. That's what the cost was. That's very low. So we used percentages. I didn't use gross numbers, because that changes, depending on what your average salary costs are, and that doesn't change a lot. So I arrived at a figure that was 2% of payroll per year is used to achieve a benefit that was able to mitigate 23% of violence-related risk.

When you say investing 2% of annual payroll is going to mitigate 23% of workplace violence risk, that seems like a significant ROI. (39:23)

Dr. Gillam:
And that is what the study proves! So if someone needed to utilize or reflect on a     study to help ascertain whether or not they wanted to invest in Nonviolent Crisis Intervention® training for their staff, this study is actually what can prove that 2% of payroll reduces 23% of violence.

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