LEWISTON — Working in his old emergency room, Dr. M. Ed Kelley didn’t always feel safe.

Known for its mental health care, St. Mary’s Regional Medical Center’s Emergency Room is a frequent stop for people having mental health crises or struggling with substance abuse problems.

It can be a volatile group of people — manic adults, teenagers intent on hurting themselves, patients going through withdrawal and demanding drugs — and there were few safeguards against violence in the ER.

Agitated mental health patients were placed in the same curtained areas as children, the elderly and others there for illness or injury. Nurses tried to watch for signs of aggression, but they sometimes didn’t have the time or the ability. The whole ER was open, designed for patients with broken bones and the flu, not for patients bent on killing themselves and willing to go through any doctor or nurse who got in their way.

“I’ve personally had patients do the linebacker rush and hit me, run me over and run outside,” said Kelley, who is now working in a new, safer ER at St. Mary’s.

He isn’t the only mental health care worker in Maine who’s had something like that happen with a patient. For some, the altercations have been much worse.

A month ago, the federal Occupational Health and Safety Administration issued a report on serious work-related injuries at The Acadia Hospital, a mental health and substance abuse treatment facility in Bangor. Its months-long investigation found that at least 115 hospital workers were assaulted by patients between January 2008 and December 2010.

Of particular concern to investigators were five cases in the past year, including an admitting psychiatrist who was beaten and choked, a nurse who was choked and beaten and whose head was pounded into a wall, and psychiatric technicians who were either smashed in the face or kicked in the groin.

To fix Acadia’s safety problems, OSHA recommended that, among other things, the hospital assess its security risks, better configure its building for safety, teach staff how to de-escalate explosive situations and more quickly respond to violent situations. Acadia did not return phone calls seeking comment.

Those who care for patients with mental health or substance abuse problems say issues of violence are industry-wide.  

“It’s part of our field,” Kelley said. “You know when you do psychiatry you’re going to get hurt occasionally. That’s something we’re aware of.”

Tops for work-related injuries

In 2009, general medical/surgical hospitals and nursing care facilities were the top two industries in Maine for work-related injuries that caused employees to miss at least one day of work. They bested elementary and secondary schools, supermarkets and other grocery stores and ship building in the top five.

Of the 2,262 Maine health care workers hurt badly enough on the job in 2009 to miss at least one day of work, 144 were victims of violence. Of those, one-third worked in psychiatric and substance abuse hospitals, twice the number of incidents in general hospitals, according to the state. Another 17 percent worked in nursing care facilities, and 11 percent worked in residential mental health and substance abuse facilities. In general, there hasn’t been a lot of change in those numbers over the past five years.

Most of the time, workers were hurt by patients. And in most cases, the injured workers were on the front line of patient care as nursing aides, orderlies, psychiatric aides and registered nurses. Nearly half the time they were hit, kicked or beaten. Other times, they were scratched, pinched, bitten or otherwise assaulted.

Major incidents are rare, but they happen.

“Let me put it this way: If you’re not paying attention to it, you’re leaving yourself wide open to a big problem,” said Dennis King, CEO of Spring Harbor Hospital in Westbrook, a nonprofit inpatient facility for children, teenagers and adults with mental illnesses.

Workers are quick to point out that people with mental illnesses are not necessarily more violent than anyone else. That’s a stereotype, they say. But someone unstable or in crisis, someone who is out of control, overwhelmed or desperate, can lash out. And, often, those are the people who arrive at an emergency room or need the intensive services of an inpatient facility.

“People come in in handcuffs,” Kelley said. “They come in severely intoxicated; they come in extremely psychotic, and until we get some medicines to calm them, they can start off violent, even before we’ve had a chance to help them.”

Room for pacing, ranting

In recent years, many of Maine’s mental health care facilities have changed the way they do business in an effort to make things safer for their workers.

At St. Mary’s, one of the changes was physical. Kelley didn’t like the setup of the old ER. It wasn’t safe.

About 400 people a month — 4,500 a year — arrive at St. Mary’s ER looking for help with mental illness or substance abuse. About 2,500 a year are admitted.

“Literally, you could have a 50-year-old, severely manic, agitated, dangerous person right next to a 6-year-old. It was horrible. It was,” Kelley said. “And it wasn’t just us, it was everybody. In fact, most (hospitals) still have all their patients sort of mixed in together, or they may have one corner of the ER sort of called the psych section.”

A few years ago, St. Mary’s leaders began talking about ways to make the ER safer for patients and workers. Around the same time, they decided to expand and renovate the ER. The two ideas meshed.

“Traditionally, ERs were never designed well for behavioral patients,” Kelley said. “Even the more modern ones, where you’ve got a single little room for each patient, don’t do real well when the patient’s starting to get agitated and wants to pace and move and rant and rave and throw things, because you’re just stuck in a little box of a room. It makes them more agitated. So, we changed it.”

Now at St. Mary’s ER, mental health patients have their own waiting area, designed to be large enough to allow agitated patients to pace to relieve their anxiety. Children are separated from adults, and both have their own exam rooms with safety features that prevent patients from taking up items in the room and hurling them at medical personnel.

And in a simple but important change, the behavioral section of the ER is secured with locked doors. No more linebacker rush.

“It sounds funny,” Kelley said, “but locked doors are a big safety area that’s wonderful.”

And the area is now staffed at all times by a psychiatric nurse trained to look for troubling behavior.

“They know what’s happening before it gets bad, can intervene early and even offer medications, which the emergency room nurses may not even think about until (the patients) are already exploding, and then they get the sedatives to calm them down,” Kelley said. “But the psych nurses will give them something mild and calming before it even becomes an issue. As much as the physical plant, that was gigantic.”

Talk, not restraint

Hospitals, outpatient facilities and providers of in-home care all say training is key.

“We want to take a preventive approach,” said Timothy Richardson, chief of staff at Togas VA Medical Center in Augusta, where a rifle-carrying patient was shot and killed by police near the hospital grounds last summer. “We do not want to just deal with situations after they’ve occurred. We want to find ways to reduce the risk.”

In addition to panic buttons, specially designed rooms and security guards at Togus, staff members are taught how to talk to patients so they calm down, how to avoid situations that might put them at risk and how to react if someone tries to assault them. Special teams are trained to respond to and de-escalate explosive situations.

When patients are violent or threatening, their cases are brought to a disruptive behavior committee for consideration. If it’s a minor situation, the patient might be warned that such behavior is unacceptable. In more dangerous situations, the patient could be told that care will no longer be provided at Togus’ community clinics and the patient must be seen at the main hospital in Augusta, where security is stronger.

In rare cases, the hospital has refused to see dangerous patients.

“We generally bend over backwards to make sure we can continue to offer the services,” he said. “We might just offer them in a slightly different way.”

For many facilities, restraint is a last resort used only in extreme situations. They’ve found that it upsets patients more and increases the risk of harm to workers.

“You don’t want to hold somebody whose behavior is escalated by being held,” Spring Harbor’s King said. “If you have kids, you know that. When you hold them, they kick harder, and it gets to be a power struggle. You want to stay away from things like that. We try to use talk and reassurance.”

Sedatives are considered chemical restraint and are used only in extreme circumstances.

“It’s not about shooting them up and throwing them in a room,” King said.

If a patient is restrained, staff members hold a debriefing afterward to discuss how to avoid a similar situation in the future. It’s part of an ongoing culture of safety, King said. Once, the culture wasn’t considered so safe.

Several years ago, the hospital surveyed staff members about safety at Spring Harbor. They didn’t rave.

“It was actually a good learning experience for us because the staff had very specific concerns about what administration could do,” King said.

The hospital hired a full-time occupational health worker dedicated to resolving workplace hazards, including safety issues with patients. Administrators began walking the units more often and more regularly, inviting workers to talk to them about safety concerns. If someone brings up a concern, the situation is addressed.

Since then, Spring Harbor has seen fewer serious incidents overall, and the incidents it does see are less serious. Its staff surveys are more positive.

“We’ve redoubled our efforts, and it’s paid off,” King said.

Authorities at other facilities feel the same way. And they say it’s not only their staff members who are better protected.

“Almost every single patient I’ve talked to really appreciates the change,” St. Mary’s Kelley said. “They feel safer.”

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