Managing violent patients in hospitals is a growing concern, particularly in emergency departments where staff and physicians frequently encounter individuals in an agitated state or in distress due to medical, psychiatric or substance-related issues. The collaboration between hospitals, paramedics, and police is critical for safe transition of patients from pre-hospital settings to in-hospital care, knowing the receiving team is prepared for possible violence. Scarborough Health Network (SHN) is committed to a multi-disciplinary approach, where the hospital, paramedics, and police work together to ensure violent patients are managed safely in a controlled, secured environment.

In September 2024, a team including interprofessional staff and leadership from across SHN, Toronto Paramedic Services, and the Toronto Police Service, gathered at Birchmount Hospital for a Rapid Improvement Event (RIE). For SHN, it was all hands on deck, with representation from the Network’s emergency departments, admitting and registration, mental health, security, clinical informatics, professional practice, quality and patient safety, workplace health and safety, and senior leadership.

The team was asked to review and scrutinize root causes of violence in the emergency departments. Each key provider group often works in silos, which can lead to miscommunication and unsafe conditions. By adopting an integrated approach and collaborating more closely, hospitals can provide a safer environment for both staff,
physicians, and patients. 

“Coming to the emergency department is stressful for anyone. By enhancing communication, conducting joint training, and establishing clear protocols, healthcare settings can prevent and respond to violence more effectively, said Dr. Caroline Thompson, Interim Co-chief for SHN’s emergency departments. 

“The evidence suggests that the biggest impact in reducing violence in a healthcare setting is training to help identify when our patients are becoming frustrated or angry, and helping our staff respond in a validating and empathic way.”

“Exceptional quality care begins with maintaining a safe environment for patients and healthcare workers. Understanding and respecting each other’s perspectives can help create a safer and more compassionate
environment.”

By collaborating with community partners and gleaning insights about workplace violence prevention initiatives at other institutions, this RIE focused on enhancing SHN’s current ED processes and building on existing action plans to adopt innovative strategies for managing and preventing violent incidents. 

According to Dr. Ilan Fischler, Chief of Psychiatry at SHN, changing the culture to understand that violence occurs within a relationship is the key to minimizing friction and ultimately decreasing violent incidents in the ED. 

“The evidence suggests that the biggest impact in reducing violence in a healthcare setting is training to help identify when our patients are becoming frustrated or angry, and helping our staff respond in a validating and empathic way,” explained Dr. Fischler.

“Staff, patients, and families have an important role in helping to co-design a culture within hospitals that implements relationship-based care.”

Sergeant Giovanni Liggio from the Toronto Police Service agrees. His RIE presentation emphasized the powerful role of communication both between staff and patients, and between hospital staff and police officers. 

“If a patient with a violent history is brought in, this needs to be communicated effectively,” explained Sergeant Liggio. 

“When an officer escorts a patient to the hospital, it is important for the officer to stay with the patient until security arrives. This way they can prevent any incidents from occurring, and flag any previous incidents of violence to hospital staff before transferring responsibility for the patient to the hospital.” 

Communication is also necessary in de-escalation training for better managing violent situations, along with understanding the cues for when someone may be prone to violence. 

“Last year, there were 130 incidents of violence or threatened violence against paramedics at hospitals in Toronto,” stated Andrew Lock, Superintendent of Toronto Paramedic Services. 

“In my experience, consistent language and assessment skills, communication pathways, inter-agency cooperation, and more training in de-escalation techniques are the most impactful in reducing violence in emergency departments.”

During the RIE, participants worked together in groups to:

• Examine real case studies involving violence in Ontario EDs, to identify process gaps that may have contributed to the escalation of violence; 

• Discuss how systemic inequities and unconscious bias may impact a patient’s response to hospital staff and first responders; 

• Explore how to improve communication between staff, security, and community partners; and 

• Establish opportunities or interventions that could have been implemented to mitigate any
escalation.

While SHN has robust workplace violence prevention training in place, and ED leaders continuously engage their teams and other hospital departments to identify gaps and make improvements, collaboration with community partners like police and paramedics is driven by SHN’s strategic vision for a more integrated healthcare system.

“Bringing in outside perspectives from our partners who are also grappling with violence and harassment in their own roles is immensely helpful in thinking outside the box and exploring how we can adapt successful strategies inside the hospital,” said Morgan McNeil, Interim Director of Emergency Services at SHN.

“Our department is completing action planning and will regroup with the broader team in about six months to review accountabilities and fine tune any changes that may be necessary.”

The SHN team also looks forward to building new emergency departments at Centenary and Birchmount in the next few years to address the increase in ED visits. Research shows that higher throughput in the ED and shorter lengths of stay can decrease violence.

With support from government partners and generous donors, SHN is well on the way to solving this piece of the puzzle. New infrastructure will help address the issue of overcrowding and lead to better patient experiences and outcomes. 

By Melody Keshishian

Melody Keshishian is a Communications Specialist, Scarborough Health Network