Hospital Emergency Departments are a truly unique environment. They are incredibly busy, emotional rollercoasters that are often overcrowded (especially on weekend nights), frequently understaffed and open 24-hours a day to anyone who might require their services. In fact, in the U.S. the Emergency Medical Treatment and Active Labor Act, or EMTALA, prohibits EDs from turning anyone away who requests to be treated, regardless of their ability to pay, including those with poor temperaments or openly hostile attitudes. If the ED were only visited by people who required straightforward medical diagnosis and treatment, this alone would be challenging enough. Add family members, acquaintances and “high-risk” patients to the equation, and you have the perfect recipe for potential disaster. This is why Emergency Departments should be considered a security-sensitive area in hospitals and should be provided specialized security countermeasures including specific education for staff who work in this highly charged environment (in both clinical and non-clinical roles).

While there are many types of “high risk” patients, here we will concentrate on two particular types, the behavioral health patient being boarded for extended periods of time and the forensic/prisoner patient. Each of these patients is very different yet each poses an increased risk for workplace violence issues and other security-related concerns.


Boarding of Behavioral Health Patients

Due to a number of complex issues which often include a lack of available dedicated psychiatric department beds, a growing population of persons with behavioral disorders and a decreased availability of treatment options due to budget reductions, boarding times of psychiatric or behavioral health patients in U.S. Emergency Departments has skyrocketed in recent years, with some patients being kept in an ED treatment room for as long as several weeks until a psychiatric department bed opens up for a transfer. A few of the negative results that such an inefficient system can create includes a loss of revenue for the time that a clinical bed is occupied by a boarded behavioral patient (could be hundreds of dollars per hour), increased wait times for others visiting the ED (resulting in negative patient satisfaction scores) and the perception of other patients and staff who have to deal with the escalating violent behavior of these patients (increasing anxiety for staff, other patients and visitors).

Another very real consequence of this extended boarding time is the increased risk for workplace violence and elopement attempts. The longer that these behavioral patients are boarded in areas not designed or resourced to meet their unique physical and emotional needs, the greater the likelihood of an elopement attempt or an incident of violent behavior. Because of this issue alone, healthcare facilities are seeing more and more need for a dedicated security presence in their Emergency Departments for much longer periods of time, for stand-by duty and patient watches, as well as an increase of patient restraints and the potential consequences of such interventions (i.e., increased scrutiny by regulatory agencies and the requirement for additional training for all staff involved in such procedures).

For example, on January 1, 2014, the Joint Commission (a regulatory agency which accredits healthcare facilities in the U.S.) introduced the following element of performance: “The hospital measures and sets goals for mitigating and managing the boarding of patients who come through the emergency department” (LD 04.03.11, EOP 6 and 9). Failure to meet this standard can result in significant penalties for the hospital or organization, including a threat to their Medicaid and Medicare funding (which most hospitals cannot function without). This issue is universal in the United States, and a recent in-depth news report from The Seattle Timesregarding behavioral health patients in the Seattle area gives some scope to the problem, stating in part:

  • “A lack of space forced those involuntarily detained to wait for treatment 4,566 times in the past 12 months – more than double the number in 2010, according to an analysis of state, county and hospital records.”
  • “In King County, boarding quintupled between 2009 and 2012. Now nearly two of every three detained patients spend time warehoused.”
  • “The patients wait on average three days – and in some cases months – in chaotic hospital emergency departments and ill-equipped medical rooms. They are frequently parked in hallways or bound to beds, usually given medication but otherwise no psychiatric care.”

So what can be done to combat this growing problem without the adding of more behavioral health facilities? One answer is providing specific training to all Emergency Department staff on how to recognize the warning signs of potentially violent behavior and proper de-escalation and intervention skills for managing such behaviors before they can manifest into physical displays of aggression. At our organization, we enrolled several of our security personnel in an instructors school of an internationally recognized de-escalation program, so that we can now certify our clinical teammates without the need for off-campus classes or expense (in fact, we certified over 1,200 nursing staff last year alone with a cost avoidance of several hundred-thousand dollars).

Another tactic is the creation of a behavioral health transport system, by which hospital security personnel transport behavioral health patients between facilities (so long as local, state and federal laws are met). Such a process can alleviate several of the issues that extended boarding can create, such as reducing wait times for patients and allowing local law enforcement (to whom such transport duties typically fall) free to concentrate on crime prevention and other police-related matters. Depending upon the volume of such transports at a facility, the additional revenue potential provided by freeing up an Emergency Department bed more quickly can result in the program paying for itself within the first few years of operation, not to mention the numerous intangible benefits that such a service can provide (improved patient experience, no stigma of being transported in the back of a police car, quicker response to transport requests, etc.). As long as a robust policy and procedure are created to govern such a process, a behavioral transport program can provide many benefits to the patient as well as the healthcare organization.


Forensic Patients

“Forensic patient” is the term commonly used for any patient that is under legal or correctional restrictions, also known as a prisoner patient. They typically require special supervision while being treated at a healthcare facility, usually provided by local, state or federal law enforcement officers or agents. The mere presence of such patients brings specific risks for a variety of reasons, including unpredictable behaviors, the presence of contraband and, of course, escape attempts.

In June 2011, the International Association for Healthcare Security and Safety (IAHSS) released the results of a comprehensive cross-sectional study regarding prisoner escape attempts from the healthcare environment. This scientific study was prompted by a 2010 International Healthcare Safety and Security Foundation crime survey’s results, which indicated that healthcare security professionals were concerned about the risks to hospital campuses and healthcare facilities that are engaged in the medical treatment of prisoner/forensics populations, and that such incidents seemed to be on the rise in both frequency and impact to the organizations where such attempts occurred. The results of the study were revealing, demonstrating in part that in the majority of cases where prisoners escaped, their restraints were partially or completely removed (sometimes removed for a medical procedure or when a prisoner was asked to change into a hospital gown or requested to go to the bathroom).

One disturbing fact that this study also uncovered was concerning the use of weapons during escape attempts. Of the 99 cases reviewed, the only weapons reportedly used by prisoners during their escapes were either the weapons of the law enforcement/corrections officers or healthcare security staff or the restraints placed on prisoners. Most escape incidents that involved injuries occurred when prisoners were able to wrest officers’ firearms, Tasers, pepper spray or batons from them. There were also a number of reported incidents where prisoners used their restraints to disable officers by hitting them with their own metal restraints. While there were a small handful of cases in which accomplices brought guns into the hospital to assist in prisoner escapes, the overwhelming number of incidents demonstrates the need for better training regarding weapon retention and defensive tactics by those charged with guarding such patients.

Several strategies can be employed to reduce or eliminate prisoner escapes from healthcare facilities including:

  • Developing and using standard procedures and policies for managing prisoner patients.
  • If necessary, increase training and/or the frequency of training to law enforcement/corrections officers and appropriate hospital staff members.
  • Hospitals should also consider a review of corrections custody protocols to reasonably assure an appropriate level of custody for prisoner patients, and those caring for large volumes of prisoners should evaluate the risks posed and weigh the need for additional security measures including conducting “prisoner escape” drills along with other emergency incidents (such as bomb threats and active shooter exercises).

Hospitals are unpredictable, complex powder kegs of excitement and drama, and no area better embodies this than the Emergency Department. No one visits an ED unless they have to, and when they do it is typically under extreme circumstances that result in them being at less than their best behavior. Be it for medical issues or behavioral health needs, certain patient populations present a higher security risk than others and appropriate countermeasures must be taken into consideration to ensure the safety of all patients, visitors and staff that interact with these specialized clients. Healthcare professionals have dedicated themselves to the care of others, but as security professionals we must first make certain that they are taken care of themselves.



Rosenthal, Brian. “Boarding Mentally Ill Becoming Epidemic in State.” The Seattle Times,5 Oct 2013, Accessed Jan 23rd, 2014


Miko-Porto, V. Smith, T. “The IHFSS 2011 Prisoner Escape Study.” Journal of Healthcare Protection Management27. 2 (2011) :38-58. Print


About the Author: Bryan Warren is Director of Corporate Security for Carolinas Healthcare System (based in Charlotte, N.C.). He has been a contributor to numerous publications including Security magazine, the Journal of HealthCare Protection Management and Health Facilities Management, and has authored chapters for the IAHSS Basic, Advanced and Supervisory Training Manuals as well as a Workplace Violence Prevention chapter for the IAHSS Healthcare Safety Certification program. He is a two-time recipient of the Russell Colling Medal for Literary Achievement in Healthcare Security and is a former President of the International Association for Healthcare Security and Safety (IAHSS). He is the Sector Chief for Emergency Services in the FBI’s Infragard program in the Charlotte region and is a member of the American Society of Industrial Security International (ASIS), the International Law Enforcement Educators and Trainers Association, and the Southeastern Security and Safety Healthcare Council.