Experts say hospitals must plan for providing care after an attack

Cybersecurity and patient safety

Experts offer advice for hospitals on protecting systems and patients

Tips and tough love

Criminals know smaller systems are vulnerable to cyberattacks

Targeting small hospitals

Many angry encounters in hospitals, including those that end in violent episodes, stem from failures in communication.

Some violent attacks arise because patients or family members don’t feel as if healthcare workers are hearing them, says Marisa Randazzo, executive director of threat management at Ontic, a security firm that works with hospitals and health systems.

“So often, when we are in our interaction with someone who is getting agitated, it is because the person on the other side of that interaction doesn't feel heard,” Randazzo says.

How hospitals can reduce the risk of violence

Doctors and nurses have been assaulted with alarming frequency

 in recent years. Over half of emergency physicians say they have been physically assaulted. Even before the COVID-19 pandemic, 

clinicians dealt with more workplace violence than other industries

. But doctors, nurses, and healthcare workers have all said 

 about the role that better communication can play in reducing the risk of violence to healthcare workers.

As Randazzo says, “Bad things can happen when there isn't good communication.” 

(In this video, Marisa Randazzo shares some communication tips with Chief Healthcare Executive. The story continues below.)

After woman shoots terminally ill husband in Florida hospital, questions persist

There’s no reason a patient, family member or loved one should assault a healthcare worker. But clinicians need to understand people aren’t at their best if they are in the hospital or caring for a loved one who has been hospitalized.

They’re worried about their health, or the recovery of a loved one, and those concerns are intensified if the patient is a spouse or a child. They may be worried about the costs of the hospital stay.

In those situations, Randazzo says healthcare workers can help defuse tensions by making sure that the patient or loved one knows that someone is listening.

“When I'm in an interaction where I feel like it's getting volatile or heated, I tried to stop talking and listen more, and ask them … ‘Can you repeat that? I want to make sure I understand what you're saying’,” Randazzo says. “The more I understand what you're saying, the more I may be able to do to help. You're not over-promising, but you are trying to take the temperature down.”

Healthcare workers and managers should also pay attention to how loud they are talking to the patients, noting that it’s human nature to match the volume and intensity of the other person or people in a conversation.

So if the patient or loved one is getting agitated, the healthcare worker is likely getting irritated as well.

“In a situation that's starting to escalate, one tactic I've learned to do is to try to slow down the pace of my talking, take the volume of my voice down, and just try to slow things down a bit,” she says. “And oftentimes, the person on the other side will take a breath, and start to match that pace as well.”

Hospitals and health systems should train their staff in de-escalation techniques, Randazzo says, and she stresses the training shouldn’t be limited to security personnel. Doctors, nurses, custodians, and even volunteers could benefit from de-escalation training.

 aimed at emergency departments and inpatient psychiatric facilities. Those steps include maintaining a clear, calm voice, using non-threatening body language, and expressing support for issues and problems.

Health systems should encourage practicing and discussing de-escalation techniques, the Joint Commission advises.

All staff should be trained in recognizing if patients or family members are getting angry or agitated, and express those concerns to nurses so there’s an opportunity to reduce tensions, Randazzo says.

Many doctors and nurses do their best to talk to patients and loved ones, but they have limited time because they are caring for other patients. As some nurses have left hospitals during the pandemic, those who are still working in health systems say they are picking up more patients, adding to their considerable workload.

Nursing profession is ‘beyond burnout,’ and needs greater attention

Family members of patients understandably get anxious, and angry, when they are trying to get information but their doctors and nurses are being pulled in different directions.

In some instances, doctors and nurses sometimes communicate in medical jargon that patients and family members don’t grasp.

In reviewing some difficult situations, Randazzo says, “One of the key culprits is insufficient communication in non-medical terms with family members.”

In one situation at a health system where tensions rose, Randazzo said the organization discovered that while the medical team members were all on the same page with the treatment plan and timeline, the patient and family members didn’t receive that information.

“It was communicated with medical terms rather than non-medical terms, or insufficient timeline, or families didn’t feel they could ask questions or weren’t given time to ask questions,” she says.

Hospitals can look at ways to improve communication to patients and family members, and give them more mechanisms to ask questions and raise concerns, Randazzo says.

Hospitals could consider assigning case workers to help families with questions or to translate complex health information and treatment plans in ways those without medical degrees can understand.

Case managers can give patients a resource to direct their questions, and may be easier to reach than physicians, Randazzo says.

“Doctors are there to give medical information and often have to do it quickly,” Randazzo says.

“If hospitals or healthcare facilities can look at who do we have that might be here to translate that information, help explain what a patient and their family just heard, help to be a bridge for follow up communications, all of those simple tools and tactics can help to enhance communication, and then reduce the likelihood that lack of communication or frustrated communication could lead to hostility or even violence.”

Healthcare workers can run into difficulty when communicating with patients and family members who don’t speak English, or it’s not their most comfortable language.

It’s yet another reason why hospitals must strive to build diverse staffs, Randazzo says.

“Diverse staff can help in any employment setting for a whole variety of reasons and diversity around language fluency can be particularly helpful for hospitals and healthcare facilities,” she says.

If there aren’t workers on staff or on shift who speak the language used by a patient or family member, healthcare workers can still use translation tools such as Google Translate to help facilitate a conversation, Randazzo says.

Case managers can also use translation tools to provide written explanations of the care that was delivered and treatment instructions in the patient’s native language.

“Any effort and any tool that can help to reduce communication, misunderstandings and barriers is going to be particularly helpful in situations where there is concern about life and about well-being, and people who may be operating at a level of real stress around those issues,” Randazzo says.

 offers standards on workplace violence prevention

Articles

Some patients get agitated, and aggressive, when they don’t feel heard. Marisa Randazzo of Ontic shares some advice on easing tensions before they escalate. 

Better communication can curb anger and violence in hospitals

Two decades after hospitals began charging “trauma activation fees,” health systems are taking wildly different approaches, with fees differing by tens of thousands of dollars.

Researchers found that hospitals are charging anywhere from $1,000 to more than $61,000, according to a study published in 

The fees were first approved in 2002, and they are designed to cover the costs of mobilizing the medical personnel who are part of the trauma team. Hospitals argued such fees were necessary to sustain the high costs of operating trauma centers. However, they have also gained growing scrutiny, particularly given the wide variation in costs at some providers.

Trauma centers in the west charged the highest fees, while hospitals in the northeast typically imposed lower fees. For-profit hospitals for the most part charged higher fees.

The researchers suggested a more standard approach should be considered.

“These findings suggest that some patients with serious traumatic injuries will incur disproportionately high trauma activation fees depending on the trauma center to which they are brought. Therefore, standardization of trauma activation fees is warranted,” the authors wrote.

Black patients more likely to be flagged as aggressive in emergency departments

The trauma activation fee policies are significant. Patients being brought to trauma centers aren’t going to be in the position to do comparison shopping with other hospitals, the study’s authors noted.

Researchers from Mount Sinai Medical Center in Miami Beach Florida and Florida International University examined the prices of the activation fees at more than 500 hospitals.

The researchers found dramatic differences in the pricing and said their analysis, to their knowledge, is the most comprehensive of trauma activation fees to date. The data was collected between January 2 and March 11, 2022. Here are some key findings from the study.

The median trauma activation fee was $9,500.

Hospitals in the west had the highest activation fees, with a median of $18,099. By contrast, the median activation fee in the northeast was $5,841.

For-profit hospitals imposed higher activation fees, the researchers said. The HCA Healthcare system, the large for-profit organization based in Nashville, Tenn., operates 43 trauma centers in the analysis, with a median activation fee of $29,999. HCA owns the majority of the nation’s for-profit trauma centers. However, HCA barely eclipsed the TENET Healthcare system, which had a median activation fee of $29,924 at seven trauma centers.

The Providence system had the highest median trauma fee of any non-profit hospital system ($23,680), the study found. The NYC Health + Hospitals system, a government-run system, had the lowest median trauma activation fees of any hospital system with a minimum of 5 trauma centers ($1,817).

Nevada had the highest median activation fee at $27,544. In California, the median activation fee was $24,057. While researchers noted California is a more expensive place to live, they also pointed out that New York, which doesn’t exactly have a modest cost of living, had a median activation fee of $6,047.

The lowest median activation fee was found in West Virginia: $1,782. Massachusetts had a median activation fee of $3,491, the lowest among the 10 states with the most trauma centers.

The researchers said they couldn’t explain such a wide variation in the trauma fees between different states. California, for example, had a median trauma fee about seven times higher than Massachusetts.

Trauma centers have proven to be successful in improving the survival rates of patients who have been seriously hurt, the researchers noted. A 2006 

 found the mortality rate was substantially lower at care provided in a trauma center.

However, the researchers of the new study also pointed out that some research suggested that more than one-third of patients who are taken to trauma centers don’t meet the triage guidelines and could be treated at local hospitals.

Those patients, or their insurers, are paying higher costs that may not be needed, the authors noted.

“Given that patients who sustain severe injuries have little choice about the trauma center to which they are brought, standardization of trauma activation fees, allowing only for small variations by region to allow for differences in cost of living, is warranted,” the researchers wrote.

Researchers found facilities run the gamut, ranging from $1,000 to more than $60,000, according to findings published in Jama Network Open. The authors called for standardization of the fees.

Hospital trauma fees vary by tens of thousands of dollars: Study

The final quarter of 2022 didn’t provide a rebound for digital health.

Digital health in the fourth quarter of 2022 fell to the lowest level of any quarter since 2017, according to an 

Overall, digital funding dropped to $25.9 billion in 2022, according to the report. While 2021 was a record year with $59.7 billion, funding dropped 57% in 2022.

In the final quarter of 2022, digital deals dropped 33% year-over-year, the report stated. There were only 21 digital health mergers and acquisitions in the fourth quarter, which was also the lowest number in five years.

Digital health mergers and acquisitions basically fell in half in the past year, falling from 611 in 2021 to 305 in 2022.

investors are expecting to see more mergers in healthcare and the life sciences

Analysts are expecting to see more hospital mergers and partnerships

Still, it’s been a trying time for digital health.

The report notes there were no new “unicorns” to arrive in the fourth quarter, marking the first quarter since 2018 without the birth of a unicorn. A unicorn is a startup with a valuation that surpasses $1 billion. Even with the quiet fourth quarter, there were 107 startups that emerged as unicorns in 2022, second only to 2021, according to CB Insights.

Funding for telehealth and digital mental health both dropped by more than half in 2022, the report stated.

, funding dropped from $17.5 billion in 2021 to $7.5 billion in 2022, a 57% decline, according to the report. The number of deals dropped from 655 to 455.

, funding fell from $5.5 billion in 2021 to $2.6 billion in 2022, a 53% drop. The number of deals fell to 289 in 2022, down from 354 the previous year.

The digital health market is in a state of correction

, investors said during a panel discussion at the HLTH Conference in Las Vegas. Investors are more careful about putting their money in digital health startups and want to be convinced of sound business plans.

Cheri Mowrey, head of U.S. healthcare investment banking for Morgan Stanley, said during the panel, “This is a pendulum that swings. It will swing back again.”

Investors “are going to do much more diligence” before putting money into digital health companies, Mowrey said.

During the HLTH panel, Michael Yang, managing partner of OMERS Ventures, said the pendulum has swung too far in digital health. While investors may have been too lax in doing their homework before investing a couple of years ago, Yang said investors are now being too cautious.

“We’ve overcorrected,” Yang said. “Now it’s nuts on the other side.”

Yang said founders are still going to be able to find investors if they have novel technologies and solid business plans to produce profits.

“If you as a founder believe in your mission, you’ve got to do whatever it takes to get to the other side,” Yang said.

After a spectacular 2021, funding dipped sharply in 2022, according to an analysis by CB Insights. The number of mergers and acquisitions also tumbled. 

Digital health funding plunges to 5-year low in Q4

Doctors and nurses have repeatedly sought to call attention to the increased level of violence they are facing in hospitals.

 at a medical building on the campus of the Saint Francis Health System in Tulsa, Okla. in June. Two doctors, a receptionist and a patient lost their lives.

A nurse and a social worker were fatally shot

 in the maternity unit at Methodist Dallas Medical Center in Dallas, Texas in October. The suspect had been assaulting his girlfriend before shooting the healthcare workers, police said.

a woman shot and killed her terminally ill husband

 inside AdventHealth Daytona Beach Hospital. No one else was injured, but the woman pointed her weapon at three other individuals, and she remained in the room for hours before a SWAT team took her into custody, police said.

Healthcare workers are dealing with enormous stress as they find themselves being assaulted by patients or family members, says Marisa Randazzo, executive director of threat management of Ontic, a security firm that works with health systems.

“They are continuing to experience a high level of violence, particularly patient-directed violence, but also family-directed violence targeting their healthcare providers, the nurses, the techs, the doctors,” Ranazzo told 

In addition, healthcare workers are also dealing with increased violence, or at least hostility, from fellow co-workers, she says. After nearly three years of dealing with the COVID-19 pandemic and growing staff shortages, doctors, nurses and other healthcare workers have been pushed to the limit.

Hospital and healthcare executives can take important steps to improve the safety of their workplaces and at least reduce the risk of violent encounters, Randazzo says.

Better communication can curb violence in hospitals

Healthcare leaders need to make sure employees know about those safety measures. And they need to be listening when doctors and nurses say they don’t feel safe at work.

“So much of good security and violence prevention work goes on without employees knowing it, but right now, hospitals and healthcare are facing a situation where so many employees feel unsupported, and therefore feel unsafe,” Randazzo said.

“It’s not enough to just do the work,” she said. “It’s really important to make sure that all employees at these hospitals and healthcare facilities know of all the violence prevention work that’s going on.” 

(See part of our conversation with Marisa Randazzo in this video. The story continues below.)

Doctors and nurses haven’t been shy about describing their frustrations with increasing violence in hospitals. 

Most emergency doctors said they have seen rising violence

, and many said they are frustrated their organizations aren’t doing more to prevent it, according to a September survey by the American College of Emergency Physicians.

Doctors and staff at children’s hospitals have also faced 

threats and harassment for providing gender-affirming care

Healthcare leaders can tackle one aspect of security by simply reaching out to employees and asking about their concerns, Randazzo says. Executives should consider taking surveys of staff to gauge their perceptions of safety and workplace violence.

Even if those surveys don’t offer good news, organizations would send a message to employees that their opinions matter.

“It can be tremendously helpful to do a survey of all of your staff around their current concerns,” Randazzo says. “How safe does this place feel? They may be scared or reluctant to do a survey like that, thinking the results are not going to be good.”

“If the results are not good, you can turn it into an opportunity,” she adds.

If healthcare workers don’t feel safe, then the hospital or health systems can start initiatives to improve safety.

Organizations that take such a step will also send a message that they are paying attention to their workers’ concerns. 

Nurses have frequently said they don’t think their hospitals care about their safety

“The fact that you’re willing as an administration to ask for that input is very important and can really demonstrate care for your employees’ well-being and safety,” Randazzo says.

Healthcare leaders also must strive "to communicate effectively, and frequently, all the different things that the hospital or healthcare facility may be doing," she adds.

“Whatever you are already doing around workplace violence prevention, you may be doing a tremendous amount, but if it’s not known to the employees, it’s important to find ways to communicate those efforts,” Randazzo stresses.

Hospitals can include reminders about resources in company newsletters, or include signs in bathrooms or break rooms to indicate where employees can turn if they need assistance or to report aggressive behavior from patients, families, or fellow employees.

“The perception of safety is a really important component to workplace violence prevention,” she says.

Some doctors have said they are frustrated that the individuals attacking healthcare workers haven’t been prosecuted.

Organizations can be in a bind if law enforcement agencies or prosecutors opt against pressing charges, which commonly happens in incidents that don’t result in serious injuries, Randazzo says. A hospital does not decide if an assailant is prosecuted, but that doesn’t stem the bitter feelings of employees who have been attacked.

And that underscores why healthcare executives need to be talking regularly about safety and protecting workers.

“I think the perception that employers aren’t doing enough is very real,” Randazzo says.

Health systems shouldn’t simply assume that violent incidents are going to happen and they can’t be avoided.

“A common misperception or misunderstanding within hospitals and healthcare is that there’s nothing you can do to prevent violence, particularly targeted violence,” Randazzo says.

In the spirit of busting myths, Randazzo also wants to address another commonly held view that violence prevention is the sole domain of security.

‘There is a mistaken belief that this is just a problem for their security departments and security personnel to solve,” she said. “The reality is workplace violence is minimized across different industries most effectively when it’s a multidisciplinary effort.”

“It’s security, it’s HR, it’s looking at your counseling services that may be available for employees,” she adds. “Getting input from front-line personnel in the emergency department, in accounts payable, in different departments that often get those more irate interactions.”

Health systems should also look at training of all healthcare workers, from clinicians to custodians, in de-escalating strategies. “Those are skills that all staff, including volunteers, can benefit from having,” she says.

Workers should be encouraged to take notice of patients or family members who may be upset, and to flag a nurse or supervisor to inform them about a potential problem, she said.

Hospitals need to track violent incidents so they can learn from them and also take additional steps to protect workers and patients, Randazzo says. Systems can learn if they need to add security or make other changes to improve working conditions.

“I can’t emphasize enough, this ability to capture and store incidents in a database or some sort of software format is vital for healthcare and hospitals,” Randazzo says.

Healthcare organizations can conduct periodic reviews of violent incidents to determine trends. Seeing data year over year can provide hospitals valuable insight.

“That can really help hospitals and healthcare facilities learn about where their high-risk areas are, or high-risk practices may be in place, and to help put mitigation measures around those as well,” Randazzo says.

Health systems should take a “trauma-informed approach” to supporting employees, Randazzo says. Organizations can help workers who have been through trauma by providing more choices, she says.

Some companies outside of healthcare have tried to help workers by giving them more freedom to work remotely or to pick different shifts. Hospitals and health systems don’t necessarily have that luxury: most doctors and nurses can’t work remotely, for the most part.

But giving some choices, such as when they work, could help workers who are struggling with the stress after an attack, or simply dealing with the ongoing threat of violence.

“The flexibility over when, the flexibility to be able to exert some control over your preference, over aspects of your job, any ability to exert some control over their situation can really help people who have experienced trauma, and help them to return to more productive levels,” Randazzo says.

“The more that you can take as an employer a trauma-informed approach, the more you can increase the positive climate of the workplace, where employees feel like the employers care about their well-being and care about their safety.”

Doctors and nurses have been attacked far too often. Marisa Randazzo of Ontic discusses steps health systems can take to protect their workers.


How hospitals can reduce the risks of violence

Despite the challenges of running hospitals in the COVID-19 pandemic, chief executive officers were less likely to depart for greener pastures over the past year.

In 2022, 103 hospital CEO changes were reported, according to a 

 from Challenger, Gray & Christmas, a firm that tracks executive departures. That’s down a bit from the 112 hospital CEO changes in 2021, the firm said in the report published Jan. 19.

Companies in the healthcare and health products industry announced 111 CEO departures in 2022, which is a drop from the 124 reported in 2021. Across all industries, CEOs were more likely to stick around in 2022, the report said.

How women can improve their chances of becoming CEOs

Still, the hospital and healthcare industries were among the sectors with the most CEO exits, according to the report. Given the 

 hospitals have faced, it’s understandable that some chief executives would want to consider other opportunities.

“The pandemic changed how many hospitals and health care companies operated. The industry was plagued by staffing issues and burnout at all levels,” Andrew Challenger, senior vice president of Challenger, Gray & Christmas, Inc., said in a statement accompanying the report.

Hospitals should expect a difficult 2023, but ‘there’s light at the end of the tunnel’

The pharmaceutical sector witnessed more executive exits. Among drug companies, there were 34 CEO changes in 2022, up from 24 in 2021.

Fewer CEO changes were reported across all sectors.

In 2022, companies reported 1,235 CEO exits, a 8% drop from the 1,337 CEO exits that occurred in 2021. It’s the lowest number of CEO departures since 2017, according to the report.

“Companies appear to be holding steady with their leadership after years of leadership changes and unprecedented uncertainty,” Challenger said in a statement.

The government/non-profit sector experienced 271 CEO changes, the most of all sectors, while the technology sector was a distant second, with 137 announced changes at the top.

Many CEOs (308) chose to retire in 2022, while 272 chief executives stepped into other positions in the company, usually in a board or other C-suite role.

Some hospital CEOs left for other opportunities. 

 took over his new role as CEO of CommonSpirit Health in August after leading Henry Ford Health for several years.

Paul Rothman, CEO of Johns Hopkins Medicine

Intermountain Healthcare CEO Marc Harrison

 stepped down last fall to accept a new position to run a healthcare platform business for General Catalyst. The organization, now known as Intermountain Health, named 

Across all sectors, the number of CEOs who were terminated rose slightly, moving from 9 in 2021 to 12 in 2022.

The Hospital for Special Surgery names a CEO for its Florida operations, and more | MED MOVES

Even with the drop, the number of changes was among the highest of all sectors, according to a report tracking executive exits.

Hospital CEO departures dropped in 2022

A woman is in prison after fatally shooting her husband in a hospital in Daytona Beach, Florida, and some questions remain about the incident.

It remains unclear how she managed to get a firearm in the hospital, and police said she declined to answer questions from investigators.

Police say Ellen Gilland, 76, shot and killed her terminally ill husband, who was being treated at AdventHealth Daytona Beach Hospital. The woman initially intended to take her own life after shooting her husband, Jerry Gilland, 77, but she couldn’t go through with it, Daytona Beach Police Chief Jakari E. Young said, according to a 

Authorities said nobody else was injured in the incident, which took place Jan. 21. She remained in the room for hours after shooting her husband, police said.

Gilland has been charged with murder and aggravated assault, police said. 

Daytona Beach police provided more details on the incident Monday and also released body camera footage, which shows officers shouting at her to drop the gun. One member of the team implores her, "We don't want to hurt you ... Talk to me." Police eventually are seen removing her from the hospital, in a wheelchair. 

(You can watch part of the police video; the story continues below.)

The hospital staff had to evacuate patients, which police described as a “logistical nightmare,” according to reporting by 

. Most of the patients on that floor are on ventilators, police said.

Daytona Beach police released the arrest report Monday, which provided more details on the incident.

Two witnesses entered the hospital room after the shooting, according to the report. Police said Gilland pointed the firearm at the two individuals and ordered them to leave the room, and they did.

Another witness entered the room after hearing the firearm, and recognized the suspect as the victim’s wife. Gilland pointed the weapon at the witness’ chest and told the witness to get out of the room, the witness told police. The witnesses were not identified in the police report.

More than four hours after the shooting, police used a “flashbang” distraction device and a SWAT team entered the room.

The SWAT team used a stun gun, which was unsuccessful in subduing Gilland, police said. As the stun gun was fired at her, Gilland shot a round from her handgun, which struck the ceiling above her husband’s bed, police said. She then dropped the gun and the SWAT team apprehended her without further incident, according to the arrest report.

A detective attempted to interview Gilland but she declined to answer questions and asked for a lawyer, police said.

The incident comes after fatal shootings at medical facilities in 

 last year. Doctors and nurses complained that 

they are encountering more violence from patients and families members in the COVID-19 pandemic

The police chief said, "Obviously, we're unsure how she brought that gun into the hospital, but this was planned,” WESH reported.

In a statement about the incident Monday, Daytona Beach police said, “We worked together as a team and accomplished the best possible outcome given the situation.”

While no staff were injured, hospital employees were told to remain in place, and one doctor told CNN he stayed in a supply closet.

Hospitals need to train staff to deal with threats

, including someone with a weapon, Brine Hamilton, then-president of the 

International Association for Healthcare Security and Safety

“The big thing is training,” Hamilton said, and he added, “Not just security staff but all staff.”

Healthcare systems should consider forming multidisciplinary teams, including members of clinical and security staff, to address workforce violence and assess threats, Hamilton said.

Authorities say it’s unclear how she was able to bring a gun into the hospital. She remained in the room for hours, forcing patients to be moved.