Management of the Violent Patient
Management of a violent patient is particularly challenging for a number of reasons. The primary issue in the management of the violent patient is safety of both the patient and the ED staff. This includes physical and medical safety. Each ED should have policies and procedures in place for the care of the violent patient that emphasizes safety of all concerned.
Management of the violent patient should begin with an assessment that identifies the risk of violent behavior. Patient care situations that may indicate the potential for violence include previous violent behavior in the ED, physically aggressive or threatening behavior, hallucinations, delusions, suicidal or homicidal ideation, reported personality changes, patients in police custody, and intoxicated patients.42 Table 23-2 contains a summary of additional factors and characteristics that may contribute to violent behaviors.43
Table 23-2 Factors and Characteristics of Violence |Favorite Table|Download (.pdf)
Table 23-2 Factors and Characteristics of Violence
Factors That May Influence Violent Behavior
Characteristics of Violent People
Excessive or constant noise
Lack of information
Lack of understanding about the intake process in the ED
Perceived negative staff attitudes toward the patient
<30 years of age
Previous history of violent behavior
Problems with authority
Organic brain disease
Traumatic brain injury (TBI)
Patient assessment should always begin with safety. Both the patient and the staff need to be in a safe environment. There should be a room or dedicated area where violent patients can be placed with adequate personnel. Often a “show of force” can reduce the risk of violence in a patient or visitor. A brief history of the event should be obtained to set a context as to what may be the cause of the violent behavior. There may be a correctable medical etiology of violent or aggressive behavior that once addressed can allow the patient to act in more acceptable way. Box 23-1 lists a mnemonic to assist in determining some of the reasons for a patient's violent behavior.44
Box 23-1 Diagnoses to Be Considered for Violent Behaviors in the ED |Favorite Table|Download (.pdf)
Box 23-1 Diagnoses to Be Considered for Violent Behaviors in the ED
Trauma—traumatic head injury
Vascular—stroke or hemorrhage
Seizure—postictal or status epilepticus
Pacing, hostility, and anger can be behavioral indicators of possible aggression. Shallow rapid respirations, avoiding eye contact, excessive perspiration, and dilated pupils may be physical signs of hostility.
The cause(s) of the violent behaviors will drive the management of the patient. If there is a physical cause to the behaviors such as hypoxia or hypoglycemia, appropriate interventions should be initiated. Laboratory and other diagnostic tests such as CTs may be needed to determine or confirm the diagnosis.
If the violence is the result of a psychiatric disorder or intoxication, several interventions may be used. There are a variety of medications commonly used in the management of the violent patient. These include benzodiazepines, typical antipsychotic agents, and atypical antipsychotics. Medications are selected based on the desired effect and route of administration. It can often be difficult to obtain intravenous access in an agitated patient and an alternative route of medication administration would have to be used. The intramuscular route offers the advantage of accessibility in most patients, rapid absorption of the agent, and a low risk of injury to both patient and staff.
All of the medications used to control behavior can have potentially serious side effects such as respiratory depression and hypotension. It is also important to be aware of drug interactions especially if the patient is already on psychiatric medications. No matter what medication or combinations of medications, those ordering and administering them must be familiar with the pharmacology and dangers of the drugs being used. Table 23-3 lists some of the frequently used agents in the ED.43,44
Table 23-3 Medications Used in the Management of the Violent Patient
The use of physical restraints is common in the management of the violent patient. The Joint Commission has established standards for the restraint and seclusion of patients with behavioral emergencies. Each ED should have a protocol that describes the indications for physical restraints, what type of physical restraints should be used, time intervals for patient reassessment, and what documentation should be completed while the patient is in restraints. Documentation should include frequent reassessment of the patient including vital signs, medical and behavioral status, and readiness for the discontinuation of the restraints. There are time limits on the use of restraints and when the order should be renewed.45
Physical restraints have the potential for serious complications including neurovascular injury at the site of restraint application, aspiration if a patient cannot protect their airway should they vomit, and rhabdomyolysis. One suggestion to prevent injury is that when a patient is in restraints, a patient safety attendant (PSA) should be assigned to the patient to ensure that the patient is closely monitored.
There is an erroneous perception that hospitals are “safe-havens” from violence that plagues society as a whole. In the best of all possible scenarios that is exactly what hospitals and its front door, the ED, should be. However, reality has a way of intruding into the very institution that devotes its resources to provide care for those who come to its door.
This dichotomy of perceptions was underscored at one of the noted medical centers in the US, Johns Hopkins University Medical Center, when one September morning in 2010 the son of an elderly cancer patient shot a surgeon outside his mother's hospital room because he was upset at a poor outcome. That shooter was 50 years old, had no criminal record, was employed, and had a license to carry the weapon.19
The perception of violence toward healthcare workers as being a problem of the inner city, high-crime neighborhoods is a myth. One need only access the news to see that the society-at-large is severely challenged to protect its citizens from violence up to and including murder. Studies of the experience of both physicians and nurses who work in EDs give ample testimony to the fact that violence in a wide variety of forms is commonplace in all EDs in many different countries regardless of location or size. Essential questions that must be addressed are
- What obligation does a healthcare institution and ED have to provide a safe working environment for those who work within its confines?
- What standards should those institutions hold to establish security for both those who provide healthcare and for those who seek it?
This issue is particularly relevant to the ED where security must be balanced against access. These are goals that can be dichotomous. Hospital administration as well as ED management first needs to acknowledge the fact that violence in the ED is common and that a serious incident can occur. Verbal abuse is so pervasive in the ED that it is shrugged off as part of the familiar background noise. Such an attitude increases the chance of more serious forms of violence being perpetrated and prevents a more comprehensive and careful look at preventing violence toward staff and patients.
In Great Britain this issue was addressed with a “zero-tolerance” program with posters placed right in their accident and EDs advertising that fact.15 The effect such policies and notifications have at curbing violent behavior is not known but it certainly demonstrates a recognition of the issue. Similar policies have yet to be instituted in American EDs.
The Joint Commission has commented on this issue by acknowledging that violence in the ED is a difficult problem. It recommends controlling access to the ED and “layering” security with lighting so there are no dark areas, barriers so only authorized personnel and authorized visitors have access to the ED, inspections of visitors that can include metal detectors, and having “strategically” placed security personnel.46 The problem of violence in the ED has come to the attention of criminal justice authorities who have recommended that applied practical applications of criminology theory at preventing situational crime might have some value in addressing violence in EDs.
One suggested means of addressing that violence and the obligation to provide a safe workplace is through education programs for the ED staff. In one study at a Canadian high volume, tertiary care, urban medical center, a survey of the physicians and nurses addressing the incidence of violence was performed before and after an educational program. The program was known as the Prevention and Management of Aggressive Behavior Program (PMABP) and was a 4-hour presentation designed to teach assessment and prevention of aggressive behavior in order to establish a safer environment for staff and patients. It was required that all staff in the ED should participate. The result was an initial decrease in reported violent incidents at 3 months but the violence rate rose in the second survey 6 months after the program had been presented. However, the overall level of violence from baseline did decrease and the perception of feeling safe in the department increased.47
State and Federal mandated violence guidelines have also attempted to address violence in the healthcare setting. In 1993 California passed the Occupational Safety and Health Association's (OSHA) Guidelines for Security and Safety of Health Care and Community Service Workers. The Federal OSHA workplace violence guidelines introduced hospital specific guidelines in 1994. Comparing EDs in California with its state and Federal guideline mandates to EDs in a state that had only Federal guidelines showed that the California departments did better in training, written policies, and procedures.
However, there was little correlation among the components of a violence prevention program such that some departments had very strong training programs but did little to address policy and procedures and vice versa. Numerous gaps in creating a comprehensive program to address ED violence were found even in hospitals that recognized the problem, were mandated by state and Federal law to address ED violence, and made some steps to address the issue.1