University of Iowa Hospitals flag 'disruptive' patients
With hospital violence increasing nationwide, more see it as necessity
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IOWA CITY — With her arm outstretched for a blood draw at a University of Iowa clinic, Tara Armstrong focused her attention on something appearing on the phlebotomist’s computer.
“I asked her what the issue was,” she recalled of that February day.
A red box popped up in the 33-year-old patient’s medical record, and the phlebotomist was trying to make it disappear. But a curious Armstrong asked her to bring it back up.
“Disruptive patient alert,” the note read — entered by Lance Clemsen on Nov. 30, 2016.
Clemsen is a social work specialist for UI Hospitals and Clinics and chair of its 4-year-old “Disruptive Patient and Visitors Program.”
Armstrong’s experience highlights the tight rope health care providers like the UIHC walk in their commitment to serve a diverse and growing population at a time of increasing hospital violence nationally.
It also illustrates some of the ethical and logistical challenges of “disruptive patient” programs — which, while not widely known to the public, are becoming more common across the country.
PATIENT REFUTES ALLEGATIONS
The red box wasn’t Armstrong’s first encounter with Clemsen.
He got involved in her health care in 2014 after her treatment team leveled a series of complaints against her — including that she made inappropriate social media posts about clinic staff; followed or waited for providers in hallways; wandered the clinic after hours; and kept contacting staff members after they’d repeatedly answered her questions, according to March 23 letter from UIHC Deputy Counsel Nike Fleming.
Armstrong provided that and other records she has received from the UI to The Gazette.
Clemsen and other administrators met with Armstrong to discuss the concerns. In a 2015 email, Armstrong’s surgeon informed her “you have been labeled by them as disruptive.” But the behavior escalated, according to Fleming’s letter.
Among other things, she wrote, Armstrong showed up outside her surgeon’s home, “which we understand is not near her own home and is in a secluded area.”
In January, the hospital’s Disruptive Patient and Visitor Committee placed an alert in Armstrong’s chart and sent her a letter telling her so, according to Fleming.
But Armstrong said she didn’t get that letter until Feb. 14 — the day after she snapped a photo of the alert on her phlebotomist’s screen. And, Armstrong noted, the alert indicated Clemsen had entered it months earlier in November.
Armstrong refutes many of the allegations, including purposefully showing up near her surgeon’s house — saying she has walked the route for years, not knowing he lived nearby. And she questioned whether some of the other complaints should qualify her as disruptive.
Armstrong has no criminal record in Iowa, records show.
PATTERNED AFTER SIMILAR VA PROGRAM
The UI modeled its program off those that have been used by the Veterans Affairs Health Care System for years. UI administrators worked with the Iowa City VA hospital to launch their program under the charge of maintaining a safe environment for staff, patients and visitors “while assuring the alleged offender is treated fairly, consistently, and in compliance with federal, state, and local laws.”
“We try to respond and provide guidance to our staff and some of our patients and visitors when there are events that end up interfering with us being able to provide care — disruptive events,” Clemsen said. “What we’re talking about are kind of repeated, deliberate, more egregious kinds of things that happen over and over and over.”
At the center of the program is a 17-member committee of representatives from an array of disciplines — psychiatry, legal affairs, nursing, emergency medicine, safety and security, quality and operations improvement and the Office of Patient Experience.
The group meets monthly and reviews referrals from the hospital’s medical team. Committee members weigh in on how to proceed — sometimes convening meetings aimed at resolving issues before they escalate.
“We are able to provide some real-time guidance, feedback and everybody lives happily ever after,” Clemsen said. “Those are the people who, maybe out of their frustration, say ‘Well, I’m going to kill you guys or blow up the place’ — one-time kinds of things like that.”
Repeat offenders are the ones the committee follows and potentially flags. For the past two years, the committee has followed 65 patients, “plus or minus,” a hospitals spokesman said.
Considering the university sees nearly 1 million patients on its main campus and across its more than 200 outpatient clinics annually, that’s minuscule, Clemsen said.
All flagged patients are notified, Clemsen said. And, “if somebody feels they’ve been mistreated or this is inappropriate,” he or she may appeal. Flags that are not appealed typically remain at least two years.
Training on how to handle disruptive patients and process the flags is not required, but university officials said it’s encouraged.
“We try to coach our staff on ‘this works, that doesn’t’ so that, again, we take care of the patient, we get them well treated, but also we do it in a safe manner,” Clemsen said.
Although alerts pop up in the disruptive patient’s electronic medical record, officials said, the university does not share the information with other institutions.
“That information is only available to UI Health Care faculty and staff,” according to UIHC spokesman Tom Moore.
Clemsen said the university has a special need for such a committee.
“Every other hospital in the state can say, ‘We’re done. You’re too big of a nuisance. It’s too problematic. You cause too many problems. You’re too dangerous,’” Clemsen said. “But we don’t have that luxury. Because we are the state’s hospital.”
Moore said the institution is not legally prohibited from denying care. But, he said, under the statute that established UIHC, “our mission is to serve all Iowans.”
“We take that commitment to provide high-quality, compassionate care very seriously,” he said.
UIHC officials declined to discuss specific patients — including Armstrong — but Clemsen cited generic examples of those who have been labeled disruptive — including patients who brought weapons, made threats or turned violent.
“We have had a number of patients who come in to the ER, who are intoxicated, and during the course of their stay become extremely belligerent and violent,” he said. “We’ve had people that have assaulted other patients that are waiting in the ER. We’ve had those patients destroy property in the ER — urinate on the floor.”
In 60 percent of the flagged cases, Clemsen said, the university identified no events after the intervention.
“It went from problem to zero — happily ever after,” he said. “The other 40 percent, what we noticed was a sharp decline in the number of ‘code greens’ — which are disruptive response team security involvement.”
‘VIOLENCE IN HOSPITALS IS REAL’
The Iowa City VA hospital — similar to UIHC — has 63 patients with disruptive flags.
UnityPoint Health-St. Luke’s Hospital reported it does not have a similar program or committee, but Mercy Medical Center in Cedar Rapids said it does — a newly formed “Workplace Violence Prevention Committee.”
Noting the need for having a disruptive patient and visitor program, Clemsen cited instances of violence in hospitals nationally.
“It used to be that hospitals were almost like sanctuaries, cathedrals — and across the country there’s more and more extreme, aggressive, violent, hostile behaviors that are happening … It’s everywhere,” he said.
Doug Vance, with UIHC Safety and Security and a member of the disruptive behavior committee, said the public is aware that “violence in hospitals is real.”
“So when people make those comments today, what they really need to realize is everybody around them is hearing those comments and increasing their anxiety and fear,” Vance said.
That, perhaps, is part of the reason disruptive behavior — and the hospital response — is “one of those things that we don’t talk about very often,” according to Janis Orlowski, chief health care officer for the Association of American Medical Colleges.
But Orlowski, who leads several groups including the Council of Teaching Hospitals and Health Systems, said disruptive patient and visitor behavior has surged in the last 25 years.
Research and literature supports the notion that — where violence used to be less common — nurses today often are pushed, slapped, punched and berated, according to Orlowski.
Most teaching hospitals have processes to deal with disruptive behavior, and a growing number have committees. One of their tools — although not ideal — is denial of care.
“It’s something we try to avoid at all costs,” Orlowski said.
And the potential for discrimination that might arise from a notification that a patient has a mental health condition or a history of disruptive behavior “is a concern you have to guard against,” she said.
Marjorie Smallwood, program manager for the Workplace Violence Prevention Safety Office at the University of California San Francisco Medical Center, said California is leading the country in how it deals with hospital violence — recently passing a law requiring hospitals to maintain logs of violent incidents and establish an oversight structure, among other things.
Her institution has had a behavior oversight committee — now called a “workplace violence prevention committee” — for more than a decade. Smallwood said it doesn’t use flags to identify problem patients. Rather, it documents in treatment notes past concerns and best practices for handling the patient.
“We don’t flag patients,” Smallwood said. “But we do identify any behavior precautions that we need to apprise our staff on … It’s more like documented in their record and interventions that will help, rather than flags.”
At UIHC, Clemsen said the committee doesn’t flag everyone who comes to its attention and tries to work through a variety of solutions before reaching that point.
“Our goal in all of this is not to bias anyone or to prejudice anybody,” he said.
But Armstrong said she feels that’s what has happened to her, and believes the “disruptive” label has hurt her care.
Armstrong’s saga began in July 2013, when she underwent a preventive bilateral mastectomy with immediate reconstruction. In the months that followed, she reported concerns about her healing and emailed staff often with lengthy questions.
In October 2013, according to Armstrong, a nurse declined to take any more of her emails — leading to a meeting with a patient representative, a therapist and others. In December, Armstrong filed a complaint against the nurse, who she felt discriminated against her.
In June 2014, Armstrong received a message she was asking too many questions. And in July 2014, the disruptive behavior committee received a report from the plastic surgery clinic that she was making Facebook posts about staff, writing short stories about them and their families, appearing in public settings frequented by staff and delivering gifts to staff, according to documents.
In August 2014, Clemsen met with Armstrong and sent her a letter summarizing their concerns and outlining required changes.
“If you do not abide by these guidelines, we will take additional actions which may include terminating this UIHC specialty care,” according to the letter.
After years of back and forth, Armstrong in February received official notification that a “disruptive behavior risk alert has been added to your medical record,” according to documents.
“This means every time you present for care at the UIHC, all health care staff involved in your care will be forewarned of your disruptive behavior history,” according to the letter. “This alert will provide instructions regarding how to best intervene.”
Armstrong said she continues to receive treatment in the dermatology clinic and believes her plastic surgery care is incomplete.
But the letter warns her, “In the event you enter the University of Iowa Hospitals and Clinics campus or facilities for any reason, please be advised that security may be called and remain present throughout your visit.”
“If necessary, we may also involve the university police for appropriate support or arrest,” according to the letter.
Armstrong has logged several complaints with the university over the years and filed a complaint with the Iowa Board of Medicine. An attorney, on her behalf, sent a “cease and desist” letter to the university.
Armstrong, who said she’d love a peaceful resolution, said the warnings have deterred her from attempting to schedule follow-up appointments to complete her reconstruction.
“I’m terrified,” she said.
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