bridging the gap: interagency task force

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BRIDGING THE GAP:INTERAGENCY TASK FORCE Author: Cheryl A. Kowal, BS, RN, Warwick, RI Admission of in-custody patients into an overtaxed emergency department is often frustrating for both law enforcement and ED staff. To facilitate collaboration between law enforcement and ED staff, it would be advantageous to initiate a professional interagency task force. To justify the need for such a task force, a random survey of hospital and law enforcement personnel was undertaken. Result of this survey revealed major mis- conceptions by both sides concerning the other's role. One common area of overwhelming agreement between the agencies was the need for such a task force. The data suggest the urgent need for mutually agreed upon policies and procedures for in-custody patients for both agencies to provide a safe environment for all involved. T he citizens of any community rely on a variety of local government and private services; two of the most important are local law enforcement (LE) and the community hospital. They both are trusted and respected servants of the community that address entirely different public needs; however, at times, their spheres of interest overlap. The mission of LE is to protect and serve. The mission of our local community hospital is to provide compassionate, quality health care as part of an integrated delivery system serving community needs. The goals of these 2 agencies intersect when local law enforcement is required to utilize the hospital emergency department for medical treatment of persons in police custody. This interaction primarily poses safety issues for ED staff, LE ofcers, and most importantly, other ED patients. The recent death of a Providence Rhode Island police ofcer killed in the police station, in what is perceived as a secure environment for handling in-custody individuals, brings to the forefront the potential for violence. 1 This event could have just as easily taken place in a crowded, overtaxed emergency department with the possibility of far more dire consequences involving an extremely vulnerable population. Therefore it is obvious that there is a need for a collaborative effort between local LE and hospital personnel to minimize risk to all involved. This end may be achieved by establishing a process to improve admission and treatment of individuals in police custody in a more organized and professional manner. The challenge is that 2 groups of professionals are looking at the same problem through different, highly polarized lenses, which leads to misconceptions and misunderstandings with regard to the role of the other agency in the process. Although safety is the primary consideration, many other factors must be brought into account. These factors include manpower demands from both hospital and LE perspectives, nancial implications for both agencies, and the effect on the community left unprotected when resources are allocated away from normal patrol areas. LE's obligation is stated under the eighth and fourteenth amendments of the U.S. constitution. They require LE to provide medical attention to in-custody prisoners when claim of injury or sickness of such parties is known or suspected. 2 In addition, they are called upon to transport individuals in mental health, alcohol, or substance abuse crisis to the emergency department. This may occur even when those individuals may not be technically under arrest or in custody. This situation often leads to mis- conceptions that the police are just dumpingpatients on an already overtaxed emergency department. The misconceptions and misunderstandings that are part of this relationship can detract from the concept of an effective cooperative effort. Better communication and understanding of each other's roles would improve relations between LE and caregivers. To achieve this goal, it would be benecial to establish a purposeful dialogue between LE and the hospital. The proposed improvement to the system would be the establishment of an LEemergency depart- ment task force. This task force would address the problems in the current system and work to develop procedures and policies to address these issues. The theoretic basis for this idea is that effective cooperation between these professionals will provide efcient health care with minimum risk to CLINICAL Cheryl A. Kowal is retired Post Anesthesia Care Nurse, Warwick, RI. For correspondence, write: Cheryl A. Kowal, 455 Toll Gate Rd, Warwick, RI 0288; E-mail: [email protected]. J Emerg Nurs 2013;39:e19-e23. Available online 26 December 2006. 0099-1767/$36.00 Copyright © 2013 Published by Elsevier Inc. on behalf of Emergency Nurses Association. http://dx.doi.org/10.1016/j.jen.2006.10.010 March 2013 VOLUME 39 ISSUE 2 WWW.JENONLINE.ORG e19

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C L I N I C A L

Cheryl A. K

For correspoRI 0288; E-

J Emerg NuAvailable on

0099-1767/

Copyright ©Association.

http://dx.do

March 201

BRIDGING THE GAP: INTERAGENCY TASK FORCE

Author: Cheryl A. Kowal, BS, RN, Warwick, RI

Admission of in-custody patients into an overtaxedemergency department is often frustrating for both lawenforcement and ED staff. To facilitate collaborationbetween law enforcement and ED staff, it would beadvantageous to initiate a professional interagency taskforce. To justify the need for such a task force, a randomsurvey of hospital and law enforcement personnel was

owal is retired Post Anesthesia Care Nurse, Warwick, RI.

ndence, write: Cheryl A. Kowal, 455 Toll Gate Rd, Warwick,mail: [email protected].

rs 2013;39:e19-e23.line 26 December 2006.

$36.00

2013 Published by Elsevier Inc. on behalf of Emergency Nurses

i.org/10.1016/j.jen.2006.10.010

3 VOLUME 39 • ISSUE 2

undertaken. Result of this survey revealed major mis-conceptions by both sides concerning the other's role. Onecommon area of overwhelming agreement between theagencies was the need for such a task force. The datasuggest the urgent need for mutually agreed upon policiesand procedures for in-custody patients for both agencies toprovide a safe environment for all involved.

The citizens of any community rely on a variety oflocal government and private services; two of themost important are local law enforcement (LE) and

the community hospital. They both are trusted andrespected servants of the community that address entirelydifferent public needs; however, at times, their spheres ofinterest overlap. The mission of LE is to protect and serve.The mission of our local community hospital is to providecompassionate, quality health care as part of an integrateddelivery system serving community needs. The goals ofthese 2 agencies intersect when local law enforcement isrequired to utilize the hospital emergency department formedical treatment of persons in police custody. Thisinteraction primarily poses safety issues for ED staff, LEofficers, and most importantly, other ED patients.

The recent death of a Providence Rhode Island policeofficer killed in the police station, in what is perceived as asecure environment for handling in-custody individuals,brings to the forefront the potential for violence.1 Thisevent could have just as easily taken place in a crowded,overtaxed emergency department with the possibility of farmore dire consequences involving an extremely vulnerablepopulation. Therefore it is obvious that there is a need for acollaborative effort between local LE and hospital personnelto minimize risk to all involved. This end may be achievedby establishing a process to improve admission and

treatment of individuals in police custody in a moreorganized and professional manner.

The challenge is that 2 groups of professionals arelooking at the same problem through different, highlypolarized lenses, which leads to misconceptions andmisunderstandings with regard to the role of the otheragency in the process. Although safety is the primaryconsideration, many other factors must be brought intoaccount. These factors include manpower demands fromboth hospital and LE perspectives, financial implications forboth agencies, and the effect on the community leftunprotected when resources are allocated away from normalpatrol areas.

LE's obligation is stated under the eighth andfourteenth amendments of the U.S. constitution. Theyrequire LE to provide medical attention to in-custodyprisoners when claim of injury or sickness of such parties isknown or suspected.2 In addition, they are called upon totransport individuals in mental health, alcohol, or substanceabuse crisis to the emergency department. This may occureven when those individuals may not be technically underarrest or in custody. This situation often leads to mis-conceptions that the police are just “dumping” patients onan already overtaxed emergency department.

The misconceptions and misunderstandings that arepart of this relationship can detract from the concept of aneffective cooperative effort. Better communication andunderstanding of each other's roles would improve relationsbetween LE and caregivers. To achieve this goal, it would bebeneficial to establish a purposeful dialogue between LE andthe hospital. The proposed improvement to the systemwould be the establishment of an LE–emergency depart-ment task force. This task force would address the problemsin the current system and work to develop procedures andpolicies to address these issues. The theoretic basis for thisidea is that effective cooperation between these professionalswill provide efficient health care with minimum risk to

WWW.JENONLINE.ORG e19

TABLE 1Demographic information

Lawenforcement(n = 61)

Hospital(n = 20)

Allrespondents(n = 81)

Age (y) 34.7 (6.9) 43.4 (13.9) 36.7 (9.8)

CLINICAL/Kowal

all involved. It is important to clarify the perceptions ofthe current process from both sides of the spectrum. Thiswas achieved by conducting a random survey of LE andhospital staff (HS) to establish the current status ofcooperation and misconceptions.

Methods

Experience (y) 9.8 (7.3) 17.3 (11.8) 11.7 (9.2)

A sample questionnaire was created that incorporateddemographic information and 10 questions relating to thecurrent processing of in-custody individuals brought to thelocal hospital emergency department. These questions werederived from personal conversations with both ED staff andLE personnel. The demographic questions focused on 4areas, including (1) age, (2) sex, (3) occupation, and (4)years of experience in one's current job. The questionsthemselves were grouped into 2 main categories. The initial7 questions dealt with opinions regarding the appropriatemanagement of patients brought to the emergencydepartment in the custody of local LE agencies. The final3 questions dealt with the idea of establishing a task forcecomposed of LE and ED representatives. There also was aspace for additional comments to be added by therespondents, particularly in response to “no” answers. Aletter attached to each questionnaire explained the purposeand scope of the survey.

The survey was a random voluntary sampling of therespondents' views on the questions previously outlined. Atotal of 120 questionnaires were distributed equally amongthe 3 local LE departments servicing the area and ED staff.Approval for conducting the survey was obtained fromsenior LE officers in each department and the nurse managerof the emergency department. The questionnaires werecollected after a week and compiled for evaluation andstatistical analysis of demographic information. The de-mographics were subjected to descriptive statistical evalua-tion by Microsoft Excel to derive mean, range, and standarddeviation. The questions were evaluated for percentages ofpositive (Yes) responses. For purposes of compilation,unspecified or sometimes responses were classified as anegative response.

Results

Table 1 provides information on the demographics of therespondents. A total of 81 questionnaires were returned outof 120 distributed for an overall response rate of 67.5%.The response rate for LE and HS were similar, with 67.7 %(61/90) responding from LE and 66.7% (20/30) from HS.The age of respondents had a mean (SD) of 36.7 (9.8) years.When separated into job categories, the mean age of the HS

e20 JOURNAL OF EMERGENCY NURSING

was significantly higher than those of LE. The mean age(SD) of HS was 43.4 (13.9) as opposed to 34.7 (6.9) for LE.The mean (SD) experience in current position was alsosignificantly higher in HS, 17.3 (11.9) as opposed to 9.8(7.2) for LE (Table 1).

Table 2 provides information specific to each of the 7questions requiring a “Yes” or “No” response. Respondentsfrom both disciplines had similar responses to 3 of thequestions. In question No. 5, dealing with the presence ofhospital security, and in question No. 7, concerningappropriate restraints, there was a significant positiveresponse. In question No. 8, which was of utmostimportance to making the vision for the facility a reality,there was an overwhelming positive response (88.9%) to theneed for a interprofessional task force (Table 2).

There were major disagreements between the disci-plines with regard to prior notification (question No. 1),where LE felt notification was sufficient (70.5%), asopposed to HS (50%). In question No. 2, dealing with adesignated area, HS believed it was appropriate (70%), asopposed to LE (47.5%). Question No. 3 dealt with acooperative effort to expedite in-custody patients. HS(70%) believed it was cooperative, contrary to theperception of LE (45.9%). Finally, in question No. 7,which dealt with the feelings of rapport between LE and thehospital staff, the HS believed that the relationship wasgood (75%), whereas LE disagreed (45.9%).

Questions 8-10 dealt with the idea of establishing a taskforce composed of LE and ED representatives, the goal ofwhich would be to foster mutual cooperation andunderstanding. Question No. 9, “Who do you feel shouldbe represented on such a committee?” dealt with re-spondents' perceptions of participants necessary for aneffective task force to deal with the issues discussed. Therewas major agreement among all respondents that the taskforce should include ED nurse and physician representationas well as a representative of LE from each local community.The general consensus from the LE respondents was thatthose representatives should include line officers who havedirect experience with the emergency department. To a

VOLUME 39 • ISSUE 2 March 2013

TABLE 2Percentages of positive responses to survey questions

QuestionHospital(n = 20) (%)

Law enforcement(n = 61) (%)

All respondents(n = 81) (%)

No. 1. Is prior notification of the pending arrivalof in-custody patients timely and appropriate?

10 (50) 43 (70.5) 53 (65.4)

No. 2. Is the designated area for treatmentof in-custody patients appropriate at this time?

14 (70) 29 (47.5) 43 (53.1)

No. 3. Is the admission process a cooperative effortdesigned to expedite the handling of in-custody patients?

14 (70) 28 (45.9) 42 (51.9)

No. 5. Is hospital security notified and present uponadmission of in-custody patients?

17 (85) 52 (85.3) 69 (85.2)

No. 6. Do you believe that appropriate restraints areused in all areas involved in the care of in-custody patients?

16 (80) 46 (75.4) 62 (76.5)

No. 7. Do you feel that there is a good rapport betweenlocal law enforcement and ED staff?

15 (75) 28 (45.9) 43 (53.1)

No. 8. Do you feel that the establishment of sucha task force would be beneficial?

17 (85) 55 (90.2) 72 (88.9)

Kowal/CLINICAL

lesser degree, administration from both the hospital and LEwere suggested. In question No. 10, respondents wereasked, “How often should such a committee meet?” Themajority (56.8%) believed that quarterly meetings wereneeded. Many believed that monthly meetings werenecessary (24.9%), whereas 18% of respondents suggestedalternative schedules. One respondent suggested an initialmeeting to discuss the problems, a follow-up meeting in 1month to propose solutions, then a 6-month period toevaluate the impact of the solutions.

Question No. 4, “Based on the assumption that timelyand efficient handling and discharge of in-custody patientswill minimize risk to ED staff as well as other patients, whatdo you feel is the greatest barrier to expediting this process?”was designed to elicit personal perceptions of the currentprocess. The responses given varied from thoughtful toextremely critical and antagonistic to the other agencyinvolved. However, there was a basic underlying tone toeach group's responses. In general, ED staff believed thatpatient load as well the disruptive nature of the patients thatthe police brought in were the biggest obstacles. They alsocited ancillary departments such as laboratory and radiologyas being major contributors to delays. They made particularmention of alcohol intoxication and substance abusepatients as the major disruptive influences. Many personsbelieved that the police were “dumping” these patients onthem and that the emergency department was becoming a“detox” center. The tone extracted from LE responses was

March 2013 VOLUME 39 • ISSUE 2

that the whole process took too much time and thesepatients were not expedited. Many respondents cited thefact that they are required to wait in areas with otherpatients before being seen. Their concern is the exposure ofthese sometimes agitated and disruptive patients to thegeneral public. They also believe that the ED staff stronglyresents their presence and tends to ignore their needs. Onerespondent referred to the fact that they were treated as“second-class citizens” by the ED staff. They note that thereis a definite communication gap regarding where each side iscoming from. One respondent stated that “The in-custodypatients know the system and purposely delay the process,preferring to spend the night in a nice warm hospital bed asopposed to a cell.”

Discussion

The results of this survey tend to suggest a general lack ofunderstanding and appreciation among LE and HS for theother's role. There is an undertone of resentment and attimes animosity by each group directed at the other. It isimportant that steps be taken to initiate a cooperativedialogue between these institutions to promote bettercommunication between all involved. The fact that bothgroups overwhelmingly agreed that a task force is neededattests to this idea.

The goals of this task force would include (1)establishing policies and procedures for both LE and the

WWW.JENONLINE.ORG e21

CLINICAL/Kowal

hospital concerning in-custody patients, (2) establishing aline of communication and education for future problems,(3) planning and implementation of commonly agreedupon changes to the system, and (4) providing a forum forfurther study and refinement of processes.

The most important goal will be to establish effectivepolicies and procedures for the handling of in-custodypatients. Many LE agencies nationwide have laid outspecific protocols for handling sick and injured prisoners.The Chandler Police Department in Arizona has one suchpolicy, which specifies action of police depending on thetype of injury and provides for arrest response dependentupon pre-existing medical conditions such as intoxicationor diabetes.3 There must be multi-agency guidelinesdesigned to provide protocols for both agencies. Onesuch guideline exists in a memorandum of understandingbetween police and health care agencies in New SouthWales, Australia. They have incorporated multi-agencybrief risk assessment guidelines for handling prisoners basedon factors agreed upon by both agencies.4 The role ofhospital security should also be examined. The currentpolicy of many hospitals is that the prisoner is the soleresponsibility of the local law enforcement.

Implications for Emergency Nurses

The emergency department typically is the focal point for theinteraction between the associated hospitals and the LEagencies servicing the area. It is by nature the most vulnerablein respect to the potential for violence and disruption by in-custody patients. When one factors in the tendency of theemergency department for overcrowding, confusion, andstaffing shortages, it is apparent that compromises to publicand ED staff security and safety may arise. To minimize thesesafety issues, it is important to ensure maximum cooperationbetween ED staff and LE. This may best be accomplished byopening a forum and mechanism for dialogue and exchangebetween these 2 agencies. An inter-agency task force wouldprovide such a forum.

In any cooperative effort, communication and educa-tion is of utmost importance. In essence, we have 2 groupslooking at a problem through different lenses. It isimportant that each side understand and appreciate theviewpoint and major issues of the other. Educationalprograms to provide guidance to nurses when dealing within-custody patients would be invaluable. As an example,an article published in Nursing in 2004 described somesimple rules to follow when dealing with patients in policecustody.5 The establishment of lines of communication toexplain purpose and status with frequent updates as regard

e22 JOURNAL OF EMERGENCY NURSING

to their prisoners may alleviate much misunderstanding bythe officers involved.

Conclusions

It would be the responsibility of such a task force, ifestablished, to oversee the planning and implementation ofmutually agreed upon changes to the system. One suchchange may be the designation of areas reserved for use inthese instances. The local LE agencies also may agree onsome common solution for guarding in-custody prisonerssuch as the presence of a permanent officer on high-incidentnights that could be achieved through some type ofrevolving coverage, planned in advance.

One area that may be addressed is in the use ofrestraints. The New York City Police Department usesplastic handcuffs on hospitalized patients.6 This practicemay provide enhanced security in areas or situations wheremetal cuffs are contraindicated such as magnetic resonanceimaging and defibrillation procedures. This committee alsomay set guidelines to map the ethics involved in suchcollaboration similar to those in the UK, which set formalaccountability and protocols.7

From an emergency department viewpoint, it may beadvantageous to restructure and revise triage polices andprocedures to specifically address the issue of in-custodypatients, perhaps by establishing a grading system to assess thelevel of threat to public and staff safety based on the nature ofthe arrest charges, the patient's medical condition, and otherpertinent factors. This systemmay help in expediting handlingof high-risk patients to assure the security of all involved.

Finally, such a task force may provide a forum for furtherstudy and refinement of the process involved. It will serve as a“bridge of understanding” between LE and the hospital andprovide for efficient health care with minimum risk for allwhen dealing with this type of inter-agency contact.

The results of this survey were shared with theadministrative bodies of local LE and the hospital emergencydepartment. The immediate response to this proposal was theinclusion of LE representatives in monthly meetings with EDpersonnel, local EMTs, hospital security, and ED adminis-tration. The general consensus from concerned parties, to thisdate, has been positive. To fully assess the impact of this taskforce, this study may need to be repeated in the near future.

REFERENCES1. Arsenault M, Milkovits A, Mooney T. Worst nightmare. Providence

Sunday Journal. 2005:1, 18-19.

2. Contente W. City of Revere v Massachusetts General Hospital:Government responsibility for an arrestee's medical care. Am J Law Med.1983;9:359-73.

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Kowal/CLINICAL

3. Chandler Police Department. E-12 prisoner processing: sick & injuredprisoners (general orders/policy). 2005. Updated July 2008. http://chandlerpd.com/gos/E12-5pris-sick.pdf. Accessed February 6, 2013.

4. NSW Government Health. Memorandum of understanding betweenNSW health and the NSW police service. 2002. http://www0.health.nsw.gov.au/pubs/2002/mou.html. Accessed February 6, 2013.

March 2013 VOLUME 39 • ISSUE 2

5. Jones J. When your patient is in police custody. Nursing. 2004;34:23.

6. No author. Plastic handcuffs reduce bystander risks. Nursing. 1999;29:63.

7. Hunt G, Van Der Arend A. Treatment, custody, support: an exploratoryqualitative dialogue to map the ethics of interagency co-operation inhospital emergency departments in the UK and the Netherlands.J Interprofessional Care. 2002;16:211-20.

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