Behind Maplewood incident, a rising trend of hospital violence

Why an elderly patient charged a nursing station at St. John's Hospital last Sunday — swinging a metal rod at anyone in his path — remains a mystery, but the assault reflects a clear trend of rising violence against hospital workers in Minnesota.

A record 46 workers' compensation claims have been filed by nurses who were assaulted or intentionally injured in hospitals, according to state data through September reviewed by the Star Tribune. At that pace, this year's injury claims will equal the total for 2012 and 2013 combined.

Those claims reflect the most severe cases, but the overall rise in hospital violence has captured the attention of Minnesota's hospital leaders, health department and nurses union. Now, a state health task force is trying to identify the causes and promote safety precautions for nurses and other medical workers.

"This is a crucial issue for [hospital workers]," said Diane Rydrych, director of health policy for the Minnesota Department of Health. "They do sometimes feel like they are in harm's way."

Video of Sunday's attack at the Maplewood hospital showed a typical overnight shift — nurses completing paperwork — when Charles Logan charged into view just before 2 a.m.

Swinging a yard-long metal rod, the St. Paul man struck nurses as they ran for safety, leaving one nurse with a broken wrist and another with a collapsed lung. Two others suffered injuries escaping.

Maplewood Police Chief Paul Schnell said that Logan — who was wearing a cap and a jacket — appeared to be under the delusion that he needed to fight his way out of the hospital. Logan later died from undetermined causes when apprehended near the hospital.

"He did exhibit some signs of paranoia. He did believe people were out to get him," Schnell said.

Hospital assaults can be diabolical because many nurses doing routine care have come to expect resistance from patients who are upset by dementia, medications, pain or the fear of hospital confinement, said Barb Martin, a board member for the Minnesota Nurses Association.

"The attitude is, when you get a black and blue mark from being hit, or a sore neck from being pulled by a patient, it's part of the job," said Martin, a member of the state's workplace violence task force.

Not all data point to a rising problem. The share of private hospital workers in Minnesota who lost even one day of work due to workplace assaults declined slightly between 2011 and 2012, according to the U.S. Bureau of Labor Statistics.

Still, the assault rate for private hospital workers was nearly three times higher than for the workforce generally.

Nurses and hospital officials point to several conditions that might be driving the increase.

As hospitals take on patients with more and more complex conditions, nurses and other caregivers have more demanding tasks, leaving them less time to watch for potential behavior problems, Martin said.

Even the nation's obesity epidemic could come into play: A heavier patient who resists being moved by a nurse might be more likely to cause injuries.

The 46 claims so far this year — indemnity requests by nurses who missed three or more days of work — exclude unintentional injuries, but include a couple of cases in which intent was undetermined.

The delicate challenge is teaching nurses the "tells" that suggest when a patient is volatile, without making them so jaded that they no longer provide compassionate care.

St. Cloud Hospital has been at the forefront of safety efforts since 2010, training all hospital staff members how to detect agitation in patients and de-escalate violent situations. The hospital marks patient doors and places notes in electronic medical records when patients present some risk.

The hospital's electronic medical record also lists options to soothe agitated patients. Some might be as simple as knocking before entering patients' rooms or leaving the patient's television on at night because that is how they fall asleep at home, said Joy Plamann, care center director for medicine at the CentraCare hospital.

"It seems very basic, but in today's health care environment, many people are very task-oriented. We have to take a blood pressure and a temperature, so we go do that. But we need to be more thoughtful sometimes."

Not all incidents involve patients — some involve relatives or even strangers — and many involve patients who aren't violent by nature.

"What about people coming into the emergency room high on drugs or alcohol?" Plamann said. "You have people coming in who are not in control of their emotions."

The rising toll mostly eluded state health officials until 2012, partly because the violence was not always intentional. The state's "adverse events" reporting system requires hospitals to report incidents in which patients or staff members are killed or severely injured due to assaults, but only those in which harm was intentional. Just 10 cases have been reported over the past decade.

Then, when state officials asked hospital leaders two years ago what else they could do to enhance safety, the broader picture of workplace violence emerged. Around that same time, the issue captured the public spotlight when a man entered a hospital and assaulted a woman in labor and her doctor.

Since that time, the Health Department has collected feedback from 90 hospitals and clinics about security gaps that leave health care workers vulnerable. Online safety training sessions are underway, and hospitals are sharing their success stories.

At Hennepin County Medical Center in Minneapolis, employees can learn verbal "judo" to calm patients, how to position themselves in rooms for a hasty exit and how to break the holds of people who grab them. Doctors even visited a paintball facility last year to simulate an emergency of a patient with a gun.

St. Cloud Hospital just added new safety measures, including a behavioral emergency response team that is called to any floors where patients appear threatening. Security staff members are alerted to rooms with high-risk patients, and hospital staff review patient rooms to remove equipment such as infusion pumps that are no longer needed, because clutter can create stress.

At HealthEast's St. John's Hospital, the 68-year-old attacker used a rod that connected his bed to medical equipment as his weapon. HealthEast and police are investigating what might have set him off. Logan had suffered delusions, according to police reports, which also noted a confrontation Saturday night between his relatives and an attorney at the hospital over his legal authority to make his own medical decisions.

Video of the rampage shows that nurses had little opportunity to defuse the attack: The patient emerged from his room swinging the metal rod and chased nurses out of their station in 12 seconds.

"One of the challenges … is that the vast majority of patients, just like the vast majority of people that police officers encounter, represent absolutely no danger," said Schnell, the Maplewood police chief. "But there are these unique circumstances."

Jeremy Olson • 612-673-7744