Hospital officials say the number of nurses and aides injured by patients or visitors spiked last year, and the St. Cloud Hospital shooting is the second hospital assault in 12 months that ended in a fatality. None had been reported by hospitals in 11 prior years.
In the case of Danny Hammond, who wrestled a gun from Aitkin County deputy Steve Sandberg and shot him on Oct. 18, federal regulators found errors in patient care by St. Cloud Hospital. But hospital and health officials around the state say they worry that a similar tragedy could befall them even under the best of circumstances.
“For many hospitals, it’s more, ‘Oh, thank God that wasn’t us,” said Carrie Mortrud of the Minnesota Nurses Association, a nursing union.
The St. Cloud shooting also laid bare frictions between hospitals and law enforcement officials over who’s responsible for security when police bring unstable detainees to hospitals. The Minnesota Hospital Association is considering a task force to clarify expectations in handling such patients.
A deadly encounter
Hammond had a history of domestic violence and an arrest warrant when he was brought to St. Cloud Hospital after a drug overdose. After regaining consciousness, Hammond expressed suicidal and homicidal desires and was placed on a 72-hour observational hold -- meaning he was not free to leave the hospital -- in a medical unit where he was monitored by a nursing aide and a deputy.
Upon learning he would be jailed after being discharged, Hammond reportedly charged the deputy and shot him. Security forces then used a stun gun to subdue Hammond, who died afterward.
A subsequent review by federal regulators faulted the hospital because a physician assistant ordered the 72-hour hold but no psychiatric care. That decision also perplexed mental health advocates.
“It’s like identifying someone with a heart attack and saying, ‘Eh, I don’t think we’ll do anything about it,’?” said Sue Abderholden of the Minnesota chapter of the National Alliance on Mental Illness.
But hospital officials said the incident underscores broader risks in mental health care in Minnesota. Even when psychiatric care is ordered, they noted, a widespread shortage of psychiatric beds can leave volatile patients waiting for care in emergency rooms or medical floors -- often for hours or days.
These risks have worsened in the last two years, following a change in state law that gives mentally ill jail inmates priority for admission to the state’s long-term treatment facility in Anoka, said Dr. Steven Miller, who directs inpatient adult psychiatry at the University of Minnesota Medical Center.
“That’s caused problems throughout the system,” he said, “and it’s especially these very high-risk, very aggressive patients that are the most difficult for hospitals to manage.”
Violent patient-on-staff incidents at University’s psychiatric unit in Minneapolis increased nearly 60 percent from 2013 to 2014, according to figures provided to the Star Tribune. An ER unit in North Memorial Medical Center reported more assaults to staff last year than in the prior three years combined, a physician stated at a recent conference.
Use of tie-down restraints to subdue unruly patients also has increased, Miller said, after years of success in switching to safer alternatives such as verbal de-escalation.
Patient placement
Hammond’s case also underscores the risks of placing dangerous patients in medical wards rather than locked psychiatric units, Mortrud said.
When he arrived at the hospital, Hammond needed intensive medical care, according to a federal Medicare report on the incident released last week. But at the time of the shooting, he was simply receiving an intravenous antibiotic, which could have been administered in a psychiatric unit, Mortrud said.
“The staff on psychiatric units are trained a lot differently and a lot more extensively on de-escalation techniques or takedowns,” she said.
A similar dilemma arose at the U’s hospital earlier this year, when a hallucinating patient on a 72-hour hold in an unlocked medical unit left her room and fondled a patient in another room until staff intervened. Like the St. Cloud Hospital, the U subsequently faced a review by federal regulators.
Yet it can be difficult for a hospital to move a mentally ill patient with complex medical needs into psychiatric units, which are often full and ill-equipped to address those needs, said Matt Anderson of the Minnesota Hospital Association.
“Many times those patients have to be placed on a medical unit to deal with medical issues first because they are often more life-threatening,” he said.
Who will pay?
Anderson said the fact that Hammond wasn’t under arrest at the time he entered St. Cloud Hospital underlines an ongoing tension with law-enforcement agencies. Hospital officials suspect that law officers don’t arrest mentally ill detainees before bringing them to hospitals because that would make their departments responsible for the cost of their care.
Yet leaving unstable detainees at hospitals without arresting them limits the security options, Anderson said. Law enforcement officers in hospitals have more discretion to handcuff threatening patients who are under arrest compared with hospital workers, who can restrain patients only in extreme clinical situations.
“There’s a functional difference between being under arrest and not being under arrest,” Anderson said.
Whether that would have made a difference in St. Cloud is unclear; hospital officials declined to comment for this story. However, the hospital adopted policy changes following the federal regulatory review that include an expectation that police will guard any patient who is going to be arrested upon discharge.
James Franklin of the Minnesota Sheriffs’ Association denied that financial interests affect arrest decisions made by front-line officers.
“Once you’ve got [a patient] secured at a hospital, then you go sit down and say, ‘OK, what’s the process? Do I have sufficient probable cause? Do I have all the evidence? Do I have all the paperwork?’ These are all factors that are difficult to ascertain at 2 o’clock in the morning,” Franklin said.
Many times, he said, “an officer will, what we call ‘stuff and cuff’ -- hold them [at the hospital] until we can get all this figured out.”
Law enforcement officials, in turn, express their own frustrations with hospitals. In some instances, they say, police bring in unstable patients -- with plans to arrest them later -- only to have hospitals release them without notice because they don’t meet medical criteria for psychiatric care or 72-hour holds.
Making hospitals safer
Efforts to improve hospital security emerged in the Legislature last year following a November 2014 incident at St. John’s Hospital in Maplewood. An enraged patient stormed through a ward, swinging a metal pole at nurses and chasing them. Three nurses were injured, and the patient died after police subdued him with a stun gun.
New laws require hospitals to write violence response plans, tally assaults, and train all staff on skills to identify and verbally de-escalate agitated patients or visitors.
Broader training is a good idea, Miller said, as aggressive incidents have popped up in obstetrics or orthopedics, not just the psychiatry unit. The state appears on pace this year to match the record 134 workers’ compensation claims filed in 2014 by nurses or aides injured intentionally by hospital patients or visitors, according to the state Department of Labor and Industry.
Abderholden said the St. Cloud case demonstrates the need to provide concurrent psychiatric and medical care to patients with these dual needs -- and not to let mental health issues fester.
“Within a hospital, they argue whether they have a mental health patient or a regular patient. The reality is people often are coming in with both,” she said. “You need to treat the whole person.”
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