According to the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), one element of performance by which a hospital's environment of care is measured is that "the hospital controls access to and egress from security-sensitive areas, as determined by the hospital. Ambulatory and Ambulance entrances should be separate, with electronically operated locks, and glass should have high impact resistance. Access from the waiting areas to the treatment areas should be controlled. There should be restricted access from the remainder of the hospital into the ED.

The physical layout of the ER should conform to a large extent to the guidelines set out in “Guidelines on Emergency Department Design” from the Australasian College for Emergency Medicine or “The impact of the built environment on care within A&E Departments” from NHS Estates in the UK.

Often, access control is lacking in Trauma Centre / Emergency Departments, however it is one of the primary areas for improving security mentioned in the literature.  It is often also the focus of many staff comments, particularly those who have experience of Emergency Department environments where there is a greater degree of security overall.

The route by which a patient, staff member or visitor enters the department affects the locations they can access. As the ambulance entrance leads directly to resuscitation and the major injury area, it is important that access through the entrance is tightly controlled.  The routes by which visitors enter and leave the department should be tightly controlled so that privacy and dignity of patients is not compromised and to ensure that visitors do not access sensitive areas. 

Access control starts with physical barriers and the enforcement through these of a perimeter of privileged access.   Only those authorised to be in certain spaces can get to them.

As part of controlling patient visitors, some hospitals have implemented a visitor management system which enables security officials to track who is in the building and ensures visitors are only allowed access to certain areas of the hospital. Hospital security staff and/or volunteers can scan the visitor's driver's license. The visitor's information is automatically entered into a database and a visitor pass is printed on a label, which is then worn by the visitor for the duration of their visit. The system can also be integrated onto the hospital's network for continual update with the patient data system to verify that the patient is registered. A system restricting movement of visitors in a New York City hospital used identification badges and color-coded passes to limit each visitor to a specific floor. The hospital also enforced the limit of two visitors at a time per patient. Over 18 months, these actions reduced the number of reported violent crimes by 65%.

With the use of ID badges, key-fobs, keycards, keypads and so on, it is possible to effectively create areas within a facility that are accessed only by those authorised people. In addition to physical barriers as described above, an effective and competent security team will normally be empowered to enforce access control within a facility by using visible visitor and/or patient badges in addition to the staff badges already worn by hospital staff.

Despite hospitals' growing interest in beefing up their security hardware, some security professionals urge health facility professionals to focus on training staff how to assess and de-escalate potentially violent situations. "The best camera in the world can't reach out and stop a bad guy from hitting you - we need more training for security and professional staff in how to handle these violent people, more than we need cameras to record the event."

  ---------------------------------------------- Gerard O’Dea is a conflict management, personal safety and physical interventions training consultant.  He is the training director for Dynamis, a specialist provider of personal safety and violence management programmes and the European Adviser for ‘Verbal Defense and Influence’, a global programme which addresses the spectrum of human conflict.  www.dynamis.training