When patients enter an emergency department or we begin our shifts, there is the expectation of safety. The American Society for Health Care Engineering’s 2018 Hospital Security Survey found more than half of our hospitals had an increase in violence against staff from the prior year. The rise in violence in emergency departments across the country is cause for great concern. And there is movement in the right direction. In November, the House of Representatives passed the Workplace Violence Prevention for Health Care and Social Service Workers Act, requiring employers to develop and implement a workplace violence prevention plan.
Explore This IssueACEP Now: Vol 39 – No 11 – November 2020
Some hospitals have installed walk-through metal detectors at the main entrance to their emergency departments as part of their overall safety initiatives. Is this good policy?
Let’s explore the consequences of metal detectors.
Cost is often one of the first concerns raised. The cost of the initial purchase of the metal detector is only a fraction of the total resources needed to operate it. The initial purchase is expensive, as is continued maintenance of walk-through metal detectors. Additional impacts include queuing, space, and additional staffing needs. Jon Huddy outlined the following concerns in the book Emergency Department Design: A Practical Guide to Planning for the Future.1
Space for equipment and searches: Adding metal detectors to your existing walk-in vestibule is not as easy as it sounds, even if you get the budget to cover the costs of the equipment and required personnel. You’ll need space for the machine itself, but you’ll also need space for patients and visitors to wait in line to walk through. You’ll need more space immediately beyond the detection equipment to be able to search bags and people. You’ll need to consider a different pathway out of the public area so that patients and visitors don’t have to pass back through the detection and search area when they leave.
Private search room: An additional consideration is a private search room near the metal detector that can be used for more intensive searching of people who set off the metal detector even after removing items most likely to cause problems. This takes up another room in the department, but it tends to be necessary when metal detectors are used.
X-ray equipment: Another space hog is the X-ray machinery used to scan bags, similar to what is used in airports to check carry-on items. I’ve worked with a few departments that have installed X-ray equipment, and it takes up at least another 160 square feet for the machine and personnel.
Surveying who’s in line: The largest drawback to the use of metal detectors is that it forces patients and visitors to wait in line. As a result, the queue must be staged so that clinical professionals from a reception desk, assessment area, or triage room can maintain visibility of everyone in line. At some facilities, planners have considered putting a paramedic or nurse outside the building to help with the queuing and allowing them to be close to arriving patients. This represents additional staff cost, but a risk management assessment might drive the need for it.
Reducing queuing: I’ve seen a couple of emergency departments with metal detectors come up with options to reduce the length of time people wait in the line. In one approach, a volunteer or staff member stands ahead of the metal detector, handing out bins, telling entrants to empty their pockets, and giving them instructions for passing through the metal detectors so they are ready to move through more quickly. Another option, although an expensive one, is to add a second metal detector. This doesn’t necessarily mean that another security guard is needed.
Staffing expense: Metal detectors are a huge operational expense. One security guard has to move entrants through the detector while another security guard searches bags. At any facility, implementing metal detectors with only one security guard will result in very long lines.
EMS patients: More emergency departments are stationing security guards at ambulance entrances to “wand” patients as they arrive to detect weapons.1
But more than this, metal detectors can provide a false sense of security. A 1999 study found that the implementation of an ED security system increased the number and percentage of weapons confiscated before patients were placed in patient care areas but did not decrease the number of assaults.2
The American Society for Health Care Engineering’s 2018 Hospital Security Survey found that 57 percent of respondents reported an increase in violent incidents against staff in the emergency department, and 52 percent saw an increase outside the emergency department. Controlling who is in the hospital is one of The Joint Commission’s Environment of Care standards and is a key security tactic. Visitor-management systems, which require each visitor to sign in, provide ID or be photographed, and wear a badge, can deter unauthorized visitors.
Those of us who work in emergency medicine know that the vast majority of violence in emergency departments is verbal. And much of the physical violence that does occur does not involve the use of a weapon.
We must continue to emphasize the importance of continued training of ED personnel in the management of violent patients and potentially violent situations. The needs and demands of each emergency department vary from hospital to hospital. Proactive safety measures for emergency departments are crucial for both patients and health care professionals. Because of the limitations and practical concerns surrounding the use of metal detectors, we should instead direct funds toward durable safety plans focused on the needs of each individual emergency department.
- Huddy J. Emergency Department Design: A Practical Guide to Planning for the Future, 2nd ed. Dallas, TX: American College of Emergency Physicians, 2017.
- Rankins RC, Hendey GW. Effect of a security system on violent incidents and hidden weapons in the emergency department. Ann Emerg Med. 1999;33(6):676-679.
Dr. Sanson is an emergency physician, professional speaker, and ED consultant.