Identification of Local Problem
Each year, over 40,000 Americans die from firearm injuries. It has become increasingly easy to access and carry firearms in many states. Self-protection is the main reason for the public carrying weapons and firearms outside the home. A weapon is defined as any device that could be carried, possessed, or used to inflict physical harm. Weapons are commonly encountered by healthcare providers, where trauma centers and behavioral health facilities are at highest risk. It is noted that 26% of major trauma patients are armed with lethal weapons with 16% being guns.5 According to the literature, accidental firearm discharges in the ED represent a real risk of injury to trauma team members and should be labeled as a “never event” especially if proper firearm handling processes are not implemented. The US Department of Labor Occupational Safety and Health Administration (OSHA) recommend screening for conventional weapons, as well as restricting items that can be used as weapons to prevent workplace violence1,2. Screening for dangerous weapons upon ED entry is an important aspect of safety and security for the ED staff and trauma team members. All staff should assume that every trauma patient transported by EMS has a hidden weapon until it is further screened.
Context of the QI Activity
Our goal was to develop a safe protocol for weapon screening, handling, firearm disarming, and documentation in the trauma bay as we encountered a few incidents where weapons were visualized on initial trauma x-rays.
What were the interventions?
A multidisciplinary team was created to develop a protocol for weapon screening, handling, and disarming firearms. A documentation process was created in the trauma narrator for trauma patients meeting activation criteria transported by EMS to our trauma center. Reference was made to the institutions’ policies on armed threat, weapon detection, and weapon search-seizure. When EMS transports the patients through the entrance of the ED, a Security Officer uses a hand-held metal detection screening wand to scan the patient in search of weapons. Once the patient is in the trauma bay, the protocol includes placing patient belongings on the trauma bay floor. A Security Officer inspects the patient’s belongings, and if a gun is found, they shout, “Gun” which alarms the trauma team to briefly halt patient care while the firearm is wrapped in a towel. The Security Office shouts, “We are Safe,” as the trauma team resumes patient care. The weapon is transported to a clearing station by a Security Officer and then stored in the Security Department. Weapon assessment fields were added to the EMR trauma narrator documentation template to include weapon screening, weapon found, and a comment section. ED nursing scribes were educated on the new weapon fields in the trauma narrator. Security personnel received training on hand-held metal detection wand and gun handling safety practices.
Costs and Funding Sources
Cost of a hand-held metal detector could range deom $20 to $250.
Overall Results and Analysis
After implementation, we measured the compliance of nursing documentation on weapon screening and presence of weapons located in the EMR trauma narrator section. One hundred activation charts were audited. Of these 45% were L1 and 55% were L2 activations. Documentation compliance was 82%. Weapons were noted in (9) 9% of the cases. Of these 3 were identified as knives and 6 were documented as unknown weapons.
The changes were sustained by developing and implementing an ED trauma protocol for weapon screening, handling, and firearm discharging. Categories for documentation were incorporated into the ED nursing EMR trauma narrator and ED nursing orientation. These categories included weapon assessment, weapon presence, and type of weapon confiscated by a Security Officer. We plan to continue using the weapon screening process and enhance our documentation efforts to near 100% compliance using a core group of trauma team leaders as one second is all it takes for an incident to occur. We plan to screen all EMS patients when entering the ED. Special thanks to the trauma team and ED staff for participating in this project.
Limitations
Continual education of new ED nurses, security, and new trauma staff on gun safe processes in the ED and trauma bay; cost of security metal detection wand; approval to develop fields in EPIC Trauma Narrator; possible lack of administrative support for gun screening.
Lessons Learned
Self-protection is the main reason for the public carrying weapons and firearms outside the home. Accidental firearm discharges in the ED represent a real risk of injury to trauma team members and should be labeled as a “never event,” especially if proper firearm handling processes are not implemented. Weapon screening is the least we can do to protect ED staff, trauma team members, and those seeking care. Patients and providers deserve access to a healthcare setting where they are free from preventable incidents. We will continue to support our theme #GUN-STOP-SAFE to find hidden weapons on trauma patients.
References
- Occupational Safety and Health Administration. Violent injuries resulting in days away from work by industry, 2002-2013; December 2015.
- Occupational Safety and Health Administration. Guidelines for preventing workplace for healthcare and social service workers. Publication /osha3148.pdf; 2016.
- Pourshaikhian M, et al. A systemic literature review: workplace violence against emergency medical service personnel. Arch Trauma Res March 2016;5(1):e28 734.
- Smalley, C, et al. Dangerous Weapons Confiscated after implementation of routine screening across a healthcare system. AJEM 36(2018); 1505-1507.
- Kelan, GD, et al. Hospital based shootings in the US: 2000 to 2011. Ann Emergency Med. 2012;60(6):790-798,e1.
