The Manitoba Nurses Union is calling for heightened security in Winnipeg emergency departments to manage an increase in violence they say is related to a more than 1,200 per cent surge in meth-related visits in the past five years.

In 2013, emergency departments across the city had an average of 15 meth-related visits per month, according to data gathered by the Winnipeg Regional Health Authority. So far this year, that number has climbed to an average of 207 visits per month.

The WRHA tracked the data across seven sites based on patients who either disclosed their drug use or provided a urine sample.

According to the nurses union, while not all patients who present with meth-induced psychosis are violent, the rates of violence against staff have risen with the patient numbers.

"The really volatile, violent, erratic behaviour — these patients are very unpredictable and when they are in the midst of a meth-related psychosis, they can be very anxious, very paranoid and very volatile," said MNU president Darlene Jackson.

"We know that in many facilities, and the majority of facilities, security is inadequate and in many many facilities in this province it is absent. There is no security."

Rates of meth-related emergency department visits in Winnipeg have been steadily rising since 2013, when the WRHA first started tracking the data.

Jackson cited two recent incidents in which nurses were injured by a patient who was in a meth psychosis, causing a concussion in one case and a head injury in the other.

In June, a patient high on methamphetamine at the Health Sciences Centre broke through the ceiling, crawled into a ceiling vent and had to be removed "kicking and screaming," according to the union.

A memo circulated to staff at Concordia Hospital in January reported a nurse was hit with a garbage can lid and an overall increase in the number of code whites — an alert signifying a violent patient — tied to the meth crisis.

"It's a very risky area and very risky time for those patients," said Jackson.

"It's not just a concern for the patient but also for the staff and family and visitor safety."

Not all security staff are peace officers

Although emergency departments across Winnipeg have security personnel on site, they're not all peace officers, said Jackson. Peace officers can physically intervene if a patient becomes violent and have a higher level of training than other officers.

According to a spokesperson for the health authority, the HSC is the only hospital in Winnipeg where at least 40 per cent of the security staff have "special constable" status, which gives them the same powers and protections as a peace officer under the province's Police Services Act.

That means they can use physical force to restrain someone or make arrests.

"All security staff in the region have the authority to intervene in a situation with a potentially violent person if they pose a threat to themselves, the staff or the patients in our care," said the spokesperson.

We need to have a good robust security system in this province, with individuals that are trained and have the ability to deal with these patients, physically if necessary. - MNU president Darlene Jackson

However, security staff who don't have special constable status don't have the same powers as a peace officer and can only use force under specific circumstances.

Jackson acknowledged that de-escalation training and other methods of managing violence are important, but staff are still getting hurt on the job as they wait for the police to respond to aggressive patients.

'Mixed messages' for security staff: MGEU

The union representing other health-care workers in the emergency department said they're also facing more violent situations on the job due to the meth crisis.

"Every employer has a moral and legal responsibility to ensure that workers have the protections, training, equipment and authority to safely deal with any violent outbursts by people who are high or have meth-induced psychosis," said Manitoba Government and General Employees' Union president Michelle Gawronsky in a statement.

MGEU also represents the HSC security personnel.

The Manitoba Nurses Union is calling for heightened security in Winnipeg emergency departments to manage an increase in violence they say is related to a more than 1,200 per cent surge in meth-related visits in the past five years. 2:44

"Unfortunately, too many of our members are getting mixed messages from their employers — they are feeling pressured to intervene in potentially dangerous situations but often don't have the protections, training, equipment or authority to do so safely," Gawronsky said.

"I believe that more than anything we need to have a good robust security system in this province, with individuals that are trained and have the ability to deal with these patients, physically if necessary," said Jackson.

By comparison, all hospitals run by Alberta Health Services in Edmonton have protective services staff who can act as peace officers and are "available to to assist with any violent patients or visitors," according to a spokesperson for AHS.

Security 'not the first option': WRHA

"Safety is obviously a concern when people present to emergency with psychosis and associated symptoms," said Gina Trinidad, who oversees continuing care and community services as the health authority's chief health operations officer.

But she said security is only part of the solution when it comes to dealing with aggressive patients.



"It's not the first option. We want to make sure that we're doing a proper assessment on the particular individual and looking at things how we triage," she said.

The region has made a number of recent changes at hospitals across the city to address safety concerns, she said. The Crisis Response Centre at the Health Sciences Centre altered its intake area to the front, rather than the rear of the facility, and the WRHA has enhanced non-violent crisis intervention training for staff throughout the region.

I think there's lots of room for improvement. - Dr. Jitender Sareen, U of M department head of psychiatry

All Winnipeg hospitals have security personnel on site, she added, and they have on occasion helped restrain patients who were a threat to others.

Trinidad said the WRHA also tracks when patients are aggressive, so that the team can take a proactive stance involving security to deter the behaviour on subsequent visits.

More psychiatric consultations

About half of the people visiting the ER high on meth had been there for the same reason in the past year. About half of those people had also been to an ER for a meth-related reason in the month before their latest visit. Data provided by the WRHA for the past three months shows that about half of the patients involved in meth-related emergency department visits had been to the ER for the same reason in the year prior. About half of those patients had been there in the month prior to their latest visit.

The medical director for the WRHA mental health program said that the increase in patients coming to emergency rooms with meth-induced psychosis has brought an increase in psychiatric consultations.



"It's still important to keep in mind that those presentations, although they've gone up, they're still a minority of the overall number of presentations for other mental health issues," said Dr. Jitender Sareen, department head of psychiatry at the University of Manitoba.



In the absence of an antidote for meth psychosis, he said, care is focused on medications to manage the symptoms and keep patients safe.

"Many people, the vast majority, clear within four to eight hours in the ER from crystal meth intoxication but a substantial proportion have psychotic symptoms beyond 12 hours," he explained.

"Less than five per cent require inpatient psychiatric admission."

While there is an increased risk of violent behaviour from patients arriving to emergency departments in meth-induced psychosis, the risk is best managed by a careful assessment, a collaborative team, the involvement of the patient and family in care and early administration of medications, Sareen said.

He also said supports and close observation are important, as paranoia is a major risk factor for violence.

"Many people with psychosis have also experienced trauma and violence against them and we really work on trauma-informed practices to engage people in care," he said.

"The good news about psychosis is the vast majority clear very quickly. They often are remorseful of any sort of incidents that have occurred so it's important to work on the relationship with the person and the family, and to be active in managing," he said.

Nowhere to go but emergency departments: MNU

Jackson said the "sad fact" remains that there is nowhere except the emergency department for patients in a psychosis to be treated.

"I believe that our best interest is to talk about security and to talk about how we can provide a safer environment to these patients and the nurses that are caring for them," she said, adding the union has discussed the issue with the province and is "heartened" to have had "some response."

"We're cautiously optimistic to move in the right direction," she said. "We need to start supporting those emergency departments, getting the security in, getting the staff in before we move into further change."

Both Trinidad and Sareen are eager to keep following recommendations made in a report on mental health care and addictions treatment in Manitoba by Virgo Planning and Evaluation Consultants which was released earlier this year.

That report called for the province to improve the entire mental health and addictions strategy through bolstering community and primary care programs to address the meth crisis.

"We're not the only jurisdiction that is grappling with this particular issue," said Trinidad.

"It is across the nation, across Canada in terms of the issue and so I think from a provincial perspective, we certainly are interested in working with government in terms of what Virgo has identified."

"I think there's lots of room for improvement," said Sareen.