EMed

Role Of Emergency Department Staff in Violence Prevention

EM involvement in Community Violence Prevention

  • Large numbers of violent offences which result in ED treatment are not detected by the gardaí
  • Information about location and time of assaults, which can easily be collected in EDs can help police and local communities target their resources much more effectively
  • ED professionals, particularly senior doctors, can be powerful and effective advocates for community safety
  • EDs act from the patient/victim perspective (most crime prevention activity is orientated towards offenders/offending)
  • Burdens on EDs can be reduced, particularly late at night at the weekend when services are stretched and alcohol-related disorder is commonplace, including in the ED itself
  • Involvement can lead to improvements in local transport services, pedestrian safety and alcohol licensing all of which are important in violence prevention
  • Involvement can help other agencies to realise the seriousness of violence from a health standpoint, particularly the numbers and seriousness of injury sustained
  • EDs are the only sources of information about serial (repeat) injury: a recognised precursor to homicide in the home and elsewhere
  • This approach can identify trends in weapon use: the use of glasses and bottles as weapons was first recognised not by police but by ED services
  • Even very serious violence, knife and gun crime, may not be reported to the gardaí, for example in drug – related gang crime
  • Data sharing provides a new objective measure of community violence which helps the public and the gardaí to understand the true size of the problem
  • ED staff can facilitate increased reporting of violence to the gardaí by those injured who are not in a position to report
  • ED doctors have an ethical responsibility, in the public interest, to report serious violence if the patient or other people are at continued risk, (eg with regard to knife and gun crime, with regard to people who have been injured several times previously at the hands of the same person and with regard to locations of violence such as particular nightclubs)
  • ED Patients who have been injured in violence support routine questioning about the circumstances of injury, police reporting and whether they need help to report or to prevent future harm

Who can contribute to community violence prevention?

  • Receptionists, who have been identified as in the best position to record electronically the necessary information
  • Managers and IT staff who can anonymise information, adjust local software and share data electronically with the police and crime reduction/community safety partnerships and the National Violence Observatory
  • Nurses, who can supplement information collected by clerical staff, act as powerful advocates in local communities, enquire routinely about the circumstances of injury, and contribute to secondary prevention, for example with regard to alcohol brief interventions. Doctors, who can contribute powerfully to local prevention, can be persuasive advocates for community safety acting as ambassadors in this regard for their hospital Trusts, can institute routine enquiry about the nature and cause of injury, and who can refer patients to agencies who can increase safety, for example refuges. ED doctors can be effective witnesses to injury risks in alcohol license hearings and can contribute effectively to conferences with other agencies such as transport and environmental health organisations all of which can increase community safety

When can EM contribute to community violence prevention?

  • During contacts with all assault patients
  • At attendance of every serial (repeat) assault patient/victim. Serial attendance should prompt enquiries about garda reporting, as well as referral to other agencies. A further example is when, during the night, several injured people attend from the same location, when this fact should be promptly reported to the gardaí
  • When those who have been injured in very serious violence attend: when patients are brought in unconscious or have been injured in gun or knife crime when the police should be informed promptly whether or not the patient’s consent can been obtained
  • Information should be shared with local police and crime reduction partnerships as agreed locally with the agencies involved

What can EM contribute to the prevention of community violence?

  • Data/Intelligence, with regard to location, time, weapon, and garda reporting
  • Advocates for local prevention and safety: particularly doctors and nurses
  • Expert witnesses and witnesses of fact in court hearings
  • Safe havens for patients to report to the gardaí and explain to them what has happened
  • Partners in local crime prevention: crime reduction and community safety partnerships want to work with EDs
  • Evidence based attitudes. The evidence based culture is more advanced in medicine than it is in crime prevention: ED doctors can bring greater objectivity to violence prevention effort
  • Commitment to safety in the town/city served by their ED

Misconceptions and barriers to ED contributions to community violence prevention

Patient confidentiality

There are many misconceptions about confidentiality: although it is important to respect the confidential nature of personal information, data protection and crime prevention legislation and General Medical Council guidance (UK practitioners) makes specific provision for data sharing to detect, investigate and prevent community violence, of which all violence which results in Emergency Medicine treatment can be considered from a lay perspective to be a serious example. Responsibility with regard to data, a key principle underpinning data protection legislation, means identifying repeat attenders, and responsible sharing of data with agencies able to increase community safety. It is important to find and prosecute offenders wherever possible and to ensure that patients have access to means of reporting violence to the police whilst in the ED. In the context of recent murder enquiries, public services have been heavily criticised for not sharing data when, potentially, lives and serious injury may have been prevented by so doing.

A blinkered attitude to injury which focuses only on treatment

Prevention and wider issues of justice and safety are also important. Involvement in community prevention has in the past even been criticised, wrongly, as ‘unacceptable medical paternalism’. EDs are central to local communities.

Unreasonable demands for evidence by gardaí

Some antagonism on the part of ED staff towards gardaí has been generated as a result of what appear to be unreasonable demands for evidence. Garda approaches should take account of the rights of the injured but responses by Emergency Medicine personnel should take account of the need to detect and prevent serious violence so that further violence can be prevented and offenders brought to justice.

Over-regulation

In the past, guidelines have been published which recommend disclosure of information only by senior Emergency Medicine doctors to senior police officers. In practice, most violence occurs late at night and at weekends when senior staff in both services are not present. Appropriate disclosure of information about the circumstances of violence should take place promptly, with regard for example to gun shot and knife wounds and all ED doctors should be ready to contact the gardaí when appropriate. In the past, over-restrictive local rules have led junior doctors to provide police informally with tip offs in relation for example to drug related offences.

Logistic barriers to collection of evidence

These include lack of appropriate software in the ED and absense of links with the gardaí and with crime reduction partnerships. These barriers can be overcome by receptionist training, simple adjustments to software, the introduction of new standard national datasets and establishment of formal links between Emergency Medicine consultants and local crime reduction partnerships.

Funding

Relevant data collection, IT support and links with crime reduction partnerships have been achieved at little extra cost to local Emergency Departments. Unjustified concerns about funding can get in the way of responsible practice. Solutions are however available from local crime reduction partnerships who are all funded to facilitate data sharing.

Time constraints

Evaluations indicate that whilst doctors and nurses may be too busy to collect information about the circumstances of violence, reception staff have opportunities during waiting room waits and also have access to appropriate IT systems. Data collection by reception staff obviates the need for clinical staff to collect information, but responsible clinical care should still include enquiry about cause of injury, police reporting and finding out whether one injury may be part of a series of attendances after injury at the hands of the same attacker.