Policies,Clinical,UWHC Clinical,Department Specific,Emergency Department

Maintaining a Safe and Secure Environment (40.5)

Maintaining a Safe and Secure Environment (40.5) - Policies, Clinical, UWHC Clinical, Department Specific, Emergency Department



To establish guidelines for changing the security status in the ED, define how Security will secure the ED in response to
escalating tension, and describe how a change in status may affect ED patients and visitors.

The Emergency Department (ED), by its very nature is a dynamic, tension filled environment. It is susceptible to quick and
sometimes unsafe temperament changes that bring with them a potential for loss of environmental control. This policy
addresses the real possibility of these changes and works hand-in-hand with the Emergency Department Green/Yellow/Red
Stages of Escalation Grid (see Appendix A). It creates an awareness of the changing conditions within the department.

A. ED Stages of Escalation Grid:
1. Green – Described as business as usual.
2. Yellow – Described as an environment having the potential for escalating disruptive behavior.
3. Red – Described as an environment where escalating disruptive behavior has resulted in a risk for violence
or the potential for the loss of control of any area of the ED (parking lot, waiting room, patient care areas).
Red status will be utilized if there has been an introduction of weapons or threats of violence made against
any person in the ED or the ED as a department.
B. Responsible persons for determining ED stage- There should be open dialogue between all parties before the
decision is made to change status if the situation allows. In almost all situations the decision to change the ED
Security Status is a joint decision made by the ED Care Team Leader (CTL)/ Nurse Manager, a Security
Supervisor or Officer in Charge (OIC), the ED Administrative Attending Physician and the Nursing Coordinator.
a. If there is any delay in making the determination to change to Red status, the change to red will be made
while additional information is gathered.
b. In the event there is not agreement to change to Red status, the ED CTL and Administrative Attending
Physician or the ED Nurse Manager (NM) or ED Director will make the final decision.
c. If the decision is made NOT to change the security status to red, and there has been a risk of violence or
the potential for the loss of control of any area of the ED, the ED NM or ED Director will still be notified
of the situation regardless of the day/ time. If the ED NM, after discussion with the ED Director feels the
status should be changed to red, the status will be changed to red.
d. Security leadership may also assist with the decision. Call Security at 890-5555 or contact the paging
operator to contact the Director of Security.
e. The Hospital Administrator on-call will be notified when the ED is in Red status.

C. Staffing:
1. Green
a. One Security officer will be assigned to the ED at all times.
b. This position is assigned to the entire workspace including the parking lot, waiting rooms and
patient care areas.
c. The officer will remain active within the space and should work closely with other members of
the ED team.
d. Officers should be relieved for breaks/meals in the ED, thus creating seamless security coverage.
e. From 1900-0300, a University of Wisconsin Police Department (UWPD) officer or second
Security officer will be assigned daily.

Effective Date:

June 1, 2015

 Administrative Manual
 Nursing Manual
 Other _Emergency Department


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Maintaining a Safe and Secure


f. Officers assigned to the ED will be allowed leave the area without security coverage in order to
respond to emergent situations in other parts of the facility when requested by the OIC.
i. The ED Security Officer will advise the ED CTL/ Charge Nurse that he is leaving for
another emergent situation and the ED will be without an officer present. Upon
returning, the security officer will check in with the CTL. Security will contact
UWPD if additional resources are needed.

2. Yellow
a. One officer is assigned to the ED at all times.
b. Duties are the same as described above, with the exception that the officer’s attention may be
directed at a very specific problem.
c. It is possible, depending upon the situation, that there will be multiple officers assigned to the ED.
d. There may be officers assigned to attend to a specific problem, while another officer takes over
the general security of the ED.
e. The officer assigned to the ED will not leave when the ED is in Yellow status.
f. All staffing changes are made in the ED.
g. If there is the need for additional security elsewhere in the hospital and clinics, the UWPD will be
i. They will either relieve the ED Security Officer or respond directly to another area in
the hospital and clinics.
ii. The decision on how and when to use UWPD resides with the Security Supervisor or
the Officer in Charge.

3. Red
a. At least two Security Officers are assigned to the ED.
b. It may be necessary to have officers assigned in teams depending upon the situation.
c. UWPD will also be notified of the Red status and will either be on close stand-by or in the ED.
i. In the event of a direct threat of violence made against any person in the ED or the
ED as a department, UWPD presence will be requested.
ii. They will assist in assessing level of risk and directing appropriate safety measures
for the staff and patients.
d. The Shift Supervisor or OIC may, after discussions with the Director of Security or his designee,
decide to call in additional staff.
e. The officers assigned to the ED will not leave when the ED is in Red status. All staffing changes
are made in the ED. If there is a need for additional security elsewhere in the hospital and clinics
the Security Director, Supervisor or Officer in Charge will coordinate coverage.

Effective Date:

May 1, 2015

 Administrative Manual
 Nursing Manual
 Other _______________


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Emergency Department- Stages of
Escalation Response Plan

D. Access Control:
1. Green – All access controlled doors operate as intended during normal operations.
2. Yellow – All doors are secured, no doors are allowed to be propped for any reason unless they are
attended by someone, and then only momentarily. Staff is directed to use non-public entrances into the ED
patient care area.
Red – All doors are secured. No remote access is allowed. All visitors are escorted into the secured patient
care areas. Some points of entry, such as the main public entrance into the ED patient care area, may be
manned with a security/police officer. Staff is directed to use non-public entrances into the ED patient care
area. Depending upon the situation, Security and Police may decide to limit access at the street.

E. Visitors:
1. Green – Visitors will be admitted by Emergency Department Clerks (EDC), per guidelines established by
the ED.
2. Yellow – Somewhat restricted status based on circumstances. Restrictions may be limited to parties
involved in the particular situation, or status change may affect everyone. This decision will be made by
the ED CTL/ Charge Nurse in concert with Security.
3. Red – Depending upon circumstances, the entire patient care area may be off -limits to visitors. The
decision process is as above. Two passes per family may be used as appropriate, but never more than two
people per patient in the ED patient care area at any one time.
a. Difficult parties- Difficult parties will be separated and moved as necessary to de-escalate
potentially difficult/dangerous situations. Moves can be from one side of the waiting room to the
other side, or they can be completely outside of the ED waiting room. How these situations are
handled will depend upon situational circumstances and the size of the party involved. In extreme
situations, some people may be asked to leave the hospital. This will only be done as a last resort
and more than likely will require the presence of the UWPD or other police agency in
coordination with hospital Security.

F. Notification:
1. The Security Supervisor, OIC or the Security Dispatcher will notify Paging (2-0000) of the change in
status, who will send a notification to the individuals on the ED Security Status paging list. Refer to the
Stages of Escalation Matrix (Appendix A) for the list.
a. The message will include the ED Security Status and a brief explanation as to why the change in
b. Notification includes all changes in status, including a return to Green status.
2. All other notifications will be handled by Paging and will follow established protocols.
3. A scrolling message will be added to the ED track board by the ED CTL/ Charge nurse for internal
notification of any status changes.
a. The ED CTL/ Charge nurse will attempt to notify all ED staff of the situation.
4. The CTL will contact the Help Desk (5-7777) to have a scrolling message added to all desktops.
a. Message will read: ED Security status is RED. Please refer to policy ____ for more information.
5. The control switch for the light color change and the audible alarm system will be activated.
a. Strategically placed colored strobe lights inside the ED patient care area alert staff to the security
status in the ED.

Effective Date:

May 1, 2015

 Administrative Manual
 Nursing Manual
 Other _______________


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Emergency Department- Stages of
Escalation Response Plan

G. Documentation:
1. All unusual events/situations will result in the completion of a Security Incident Report by Security. All
normal incident writing protocols will be followed.
2. The ED CTL or charge nurse will complete a Patient Safety Net (PSN).

H. All clear
1. There will be an ongoing huddle to share updated information and address any changes in concerns.
2. Once the threat of violence or risk of loss of control has passed, Paging will be notified of the “all clear”
by Security.
a. A page will be sent to the paging list that was notified of the original change.
b. The ED CTL will contact the Help Desk to have the scrolling message removed.

I. Tracking:
1. Security is tasked with monitoring and tracking any change in ED Security status. Security will create a
log entry every time the ED changes to Yellow or Red status.
a. The entry will include the time the status was initiated, why it occurred, who made the decision to
escalate, when the status was de-escalated, by whom and why.
b. It is possible to have multiple log entries for the same incident if the incident goes from green to
yellow to red, back to yellow and then to green. This particular scenario would require three log
entries (two yellow and one red).
2. All instances of Security status changes to Red will be reviewed by the ED Steering Committee with a
Security presence for the discussion.
J. Testing:
1. Monthly tests of the control switch for the light color change and audible alert will be coordinated by
K. Training:
1. All staff working in the ED will complete the Safe ED training program upon hire and annually.


Director, Emergency Services
Division Chief, Emergency Medicine
Medical Director, Pediatric Emergency Medicine
Nurse Manager, Emergency Department


Tami Morin, RN, MS Dr. Azita Hamedani
Director Emergency Services Division Chief, Emergency Medicine

Chris Corrigan
Director, Security

Effective Date:

May 1, 2015

 Administrative Manual
 Nursing Manual
 Other _______________


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Emergency Department- Stages of
Escalation Response Plan

Appendix A- STAGES OF
Copyright © 2007 by the University of Wisconsin Hospitals
and Clinics Authority Revised: 05/26/2015
Potential for, or
actual loss of
control of any
portion of the ED
(parking lot, waiting
room, patient care

(May only be
initiated by the ED
Admin MD, ED
Care Team Leader
(CTL), Security
Supervisor or the
Preferably it’s a
joint decision. If
there is a
disagreement, the
ED CTL has final
- Everything listed in
yellow with the addition
of precipitating factors.
This could be any
combination of factors
that elevate tensions
and stress resources.
- Introduction of
- Acts of physical
- Large numbers of
visitors or family
-Verbal threats toward
staff or police
- Security will notify the Paging and
Message Center to send a group
notification page. Those
on the group page include:
Hospital admin on call
Nursing admin on call
ED Social Worker
EDC Supervisor
Security Director
ED Nurse Managers
Emergency Services
Security Supervisors
Niemuth and Schulz
Security 1-9
Security Officer Wilson
Nursing Coordinators
ED Night Pharmacist
Access Center
Peds Trauma Surgeon
Peds Trauma Coordinator
EM Physician leadership
- Security will alert visitorsduring the
distribution of visitor passes, using
scripted message.
- The ED CTL will notify Dane
County Comm Center (911)
(Notification by blast page and
visual recognition upon arrival)
- Controlled traffic &
pedestrian flow
- Perimeter can be
moved to the
street as
- Establish exterior &
- Visitor parking
restricted away
from ambulance
staging areas
- Security/ UWPD in
charge of crowd
- All department
entrance points
secured with no
remote entry allowed
- Visitors routed to
controlled points of
- 2 visitors per room
- Visible security &
police presence in
parking, waiting and
patient care areas
- Employees directed to
enter through non-
public areas
- All staffing decisions based
on situational
circumstances as
determined by Dept.
-Increased awareness of
movement through the
- Security present and
cannot be sent away
- UWPD is primary police
back-up and will be
actively involved in event
- Nursing Coordinator will
work with group to
determine and fill any
additional staffing needs
- All non-essential staff
directed to stay away
from the area
-EMS is notified during
ambulance report that
the ED is in red status

- There is always a point-
person (identify at time
of event)
- As time permits, key
personnel from the ED,
ED leadership, Security,
Social Work, Nursing
Coordinator, UWPD
and Hosp.
Administration will
huddle and develop an
immediate plan of
- The established
leadership group, will
re-conference routinely
throughout the event to
make sure that the plan
stays fluid and
appropriate for the
circumstances at hand
- ED Admin MD and ED
Director, will assess
need to go on diversion
- Consider how events in the
ED affect other areas of
the hospital
- Communication with
- Accurate and timely
information flow is critical
- Determine who, how &
when to initiate and
downgrade a Level Red
- Assess the need to activate
the command center
- Staff understand and can
implement evacuation
- Determine presence of
media and have plan for
appropriate interaction
-Turn TVs in WR off or
change to a non-local
- Debrief after the event;
timeliness is important
Potential for
disruptive behavior

(Decision to
activate, same as
- Behavioral issue(s)
- Victim of violent crime(s)
-Non-accidental trauma
(NAT), gunshot
wound (GSW) or
- Surge capacity issues
- Gang related activity
- High profile community
event (Halloween)
- Multi-victim trauma
- Police involved events
- Security
- UWPD (heads-up)
- ED Staff
- Nursing Coordinator
- Social Work, Case Managers,
Child Life
- Interpreter(s)
- Hospital Paging and Message
- Patient visitors
- EDC’s
(Notification, same as above)
- Follow
- Ambulance
parking only at
Entrance”- no
- All doors secured
-Door from WR to triage
closed at all times
- Follow established
- Security to provide
additional coverage
- Officer may not leave ED
- UWPD may be required
- There will be dialog
between departments
involved (30 second
huddle) so that
everyone knows who is
doing what and what is
being done.
- As lesser version of items
listed under red.
Business as usual
- Business as usual - Business as usual - Business as Usual - Follow established
- Security presence 24/7
- Officer may leave for
emergencies outside ED
- Business as usual - Business as usual