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Violence in the emergency department

Managing aggressive patients in a high-stress environment

W. Kuhn, MD

VOL 105 / NO 1 / JANUARY 1999 / POSTGRADUATE MEDICINE


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Preview: The growing trend of violence in America's emergency departments (EDs) has the medical community on alert. Many hospitals have implemented security protocols, but the very nature of the ED environment makes it vulnerable to violence that jeopardizes the safety of staff and patients. Dr Kuhn discusses management of violent patients as well as safety measures and prevention of dangerous situations.


Violence is a significant social problem in the United States. Violence in our homes, schools, and streets has become an urgent and shameful issue (1) that is spilling over into hospital emergency departments and trauma centers. The emergency department (ED) is no longer a safe haven in the midst of violence. The eruption of violence in waiting rooms and treatment areas is becoming increasingly common and dangerous, compromising the safety of medical staff and patients. The medical community is alarmed, and occurrences of serious harm or death receive widespread media coverage (2,3). Understandably, improved security measures are being demanded to protect staff and patients. Some personnel are even taking safety measures into their own hands by carrying weapons to work.

Incidence of violence

Hostage situations, gunshot wounds, and assaults on staff in the ED are increasingly common (4-6). In 1988, Lavoie and associates (7) surveyed ED directors in 170 US teaching hospitals with a volume of about 40,000 patient visits per year. Of the 127 responding hospitals, 41 (32%) reported at least one verbal threat daily and 23 (18%) reported at least one threat with a weapon monthly. During the 5 years preceding the survey, 72 (57%) of the ED staff members had been threatened by a weapon; 55 hospitals (43%) reported that a physical attack on a staff member occurred at least once each month. Staff injuries had occurred in 102 (80%) of the EDs in the previous 5 years, while 9 hospitals (7%) reported violence resulting in death. Thirty-two (25%) of the hospitals reported at least one patient per day required restraint; 16 (13%) of the hospitals reported that patients sustained injuries from the restraint. Several of the hospitals in the study were involved in lawsuits brought by patients who were injured from restraint. Clearly, the safety of both emergency staff and patients is at risk (8).

Why are EDs vulnerable?

Many EDs, especially at major trauma centers, are located in inner-city or urban settings, where the incidence of violence is high, and emergency staff are sometimes innocent victims of drug- or gang-related vendettas. Violence often ensues in the ED when injured combatants find themselves in close proximity to enemies, police, and medical personnel only minutes after leaving the streets.

By nature, EDs are high-stress areas. Recently, a patient representative at our facility was injured by an irrational individual who was grieving for a family member. Long waiting times and delays in care can also increase hostility (7). Even normally pleasant, well-adjusted people can become irritable after a 3- or 4-hour wait, and those who are already unstable may become dangerous. In addition, patients and staff can be easily provoked by disagreements, discourteous remarks, and unnecessary roughness.

The 24-hour accessibility of drugs and potential hostages makes EDs particularly vulnerable to violence. A person experiencing drug withdrawal symptoms may seek drugs at an ED and become violent when denied. In addition, the policy of deinstitutionalization that was initiated some years ago has made America's EDs a safety net for psychiatric patients. Deinsti-tutionalization relies on 24-hour, "open door" access to emergency care. Emergency personnel are now responsible for much of the care that was once provided by psychiatric facilities, and they often must give medical clearance for psychiatric patients.

Characteristics of violent people

Violent behavior is most often linked to young age (under 30 years), male sex, access to weapons, and alcohol or substance abuse problems. Risk factors include absent roots, problems with authority, multiple arrests (often for assault), and dishonorable military discharge (9). Although some people habitually demonstrate violent behavior, others become violent depending on the circumstances.

Medical or psychological problems are also factors that influence violent behavior. Patients who are delirious from medical problems may suddenly strike out. Depressed patients who are suicidal may feel as though they have nothing to lose by also taking the lives of others. The incidence of violent behavior in psychiatric patients is no higher than in normal patients; however, paranoid patients are especially worrisome, particularly when they shift from generalized paranoia ("they are after me") to a specific person or group ("John is after me").

Causes of violent behavior

Emergency staff need to establish whether a patient's violent behavior stems from organic or psychiatric illness to determine the appropriate course of action (eg, medical admission, psychiatric admission or commitment, discharge).

Organic illness
It is a common assumption that all violent behavior is psychiatric in origin (10). However, violence caused by organic illness can occur without warning and be more severe than violence caused by psychiatric illness. Rapid onset of psychotic, agitated, or violent behavior in a patient without a prior history of psychiatric disease may indicate an organic disorder. Other clues include confusion or slow mentation, intellectual or cognitive deficits, slurred speech, visual hallucinations, and disorientation. Organic causes should be suspected in patients who are older than 40 years of age and have no history of psychiatric illness. Carefully evaluate all patients with abnormal vital signs; no patient should be discharged without an explanation or understanding of each abnormality.

Psychiatric illness
Psychiatric patients may present with violent behavior. Such patients typically are under 45 years of age, are alert and oriented, and have normal vital signs. They tend to avoid drug abuse. Patients with paranoid schizophrenia are the most common cause of ED violence, followed by those with personality disorders. However, healthcare workers often underestimate the potential for violence in patients with bipolar affective disorders. Manic patients may give staff a false sense of security but can quickly become hostile when demands are made. A previous history of psychiatric illness, auditory hallucinations, and logical, yet bizarre, thought process are all risk factors for violent behavior in psychiatric patients.

Anticipating violent behavior

The best way to control violence in the ED is to seek help before an incident occurs. A personal sense of uneasiness, or "gut feeling," may be a warning sign of impending violence and should be taken seriously (11). Take additional precautions if attending staff members also express uneasiness regarding a patient. Physical violence may be preceded by a period of mounting tension characterized by a tense, threatening posture or loud, profane speech accompanied by increased motor activity or restlessness (12). Recognizing the signs and taking appropriate precautions may prevent a violent outburst. Unfortunately, violence may be sudden and unpredictable, especially in patients with medical conditions that cause delirium or confusion (13).

Dealing with violence

Several safety measures can help control patients who suddenly become violent (table 1). Minimize eye contact and maintain a safety, or "buffer," zone about four times larger than normal. Agitated patients should be approached directly, because they are especially attuned to an incursion of their body space from the rear. If a patient retreats from you (14), ask where you should stand so that he or she is most comfortable. If necessary, let the patient know that his or her actions frighten you.

Table 1. Safety measures for dealing with violent patients

When a patient suddenly becomes violent
Alert staff and security personnel if you feel threatened or uncomfortable; take "gut feelings" seriously
Minimize eye contact with the patient
Make sure you and the patient have equal access to a door for escape
Maintain a safe distance from the patient (at least an arm's length) and stay to one side
Do not run or fight unless assured of success

When interviewing or examining a potentially violent patient
Request security personnel to search the patient and remove any weapons
Position security personnel inside the examination room or just outside with the door open
Use an examination room with 2 doors if possible
Remove potential weapons from the examination room
Remove personal accessories that can be used as weapons
Maintain a safety zone about 4 times larger than normal
Never approach the patient from behind


Deal immediately with threatening behavior. Alert other staff or security personnel at your first sense of uneasiness and enforce limits. Never bargain or compromise personal safety or that of patients or staff.

Emergency physicians often must interview and examine potentially dangerous patients to determine the degree of danger they represent or to provide medical clearance for commitment due to violent behavior. There are several ways to make this encounter safer (table 1).

Ideally, the examination room should have two doors, providing an escape route for both physician and patient if the situation escalates. If there is only one door, physician and patient should be equidistant from it. Blocking the exit increases the risk of harm if a violent patient feels the need to escape. Security personnel should be present and the examination room should be free from all objects that could be used as weapons (eg, trays, hot drinks, scalpels, needles, instruments, electrical cords). In addition, remove all personal accessories that could serve as potential weapons (eg, stethoscope, scissors, jewelry, pocket knife, belt). Even certain articles of clothing, such as a necktie, can be used as a weapon. (I was once held down for several minutes by a patient holding onto the knot of my favorite tie.)

Maintain a safe distance (at least an arm's length) and position yourself to one side of the patient, because a side blow can be dodged more easily than one from straight on. If you are choked, tuck in your chin to protect your carotids (9,15). If you are bitten, push toward the patient and hold the nose closed, which forces the mouth open. If a weapon is displayed, comply with demands but try not to show fear. Do not argue, cry, or whine, and never run or fight unless you are certain of success. Attempt to establish an emotional human relationship, because hostages are seldom killed when such a relationship has been established.

Dealing with armed patients

During a 14-year period, 26.7% of major trauma victims presenting to the ED at a major Los Angeles trauma center carried lethal weapons (16). Interestingly, female trauma patients were more likely to be carrying lethal weapons (36%) than male trauma patients (25%). At least one weapon per month was confiscated in 58 (46%) of the EDs surveyed by Lavoie and colleagues (7). During 1 month, metal detectors at one hospital identified and led to the confiscation of over 300 weapons, including shotguns, .357-magnum handguns, and automatic military weapons (7,16).

Although psychiatric patients are more likely to be carrying weapons, they are not the sole offenders. During a 20-month study conducted at the Oregon Health Sciences University (17), ED security personnel searched 500 (1.3%) of 39,000 patients. Weapons were found in 89 individuals; 24 (15.7%) were medical patients, compared with 60 (17.3%) psychiatric patients.

Physicians should not attempt to examine armed patients (18). Ideally, patients should be disarmed by security personnel before entering the ED, and any patient who is suspected of carrying a weapon should be questioned. If a patient is armed or if a weapon is discovered during an examination, the weapon should be checked with security at the front desk. Assure the patient that evaluation will continue after the weapon is checked and that it may be retrieved at discharge. It is unwise to attempt to take the weapon yourself. Instead, ask the patient to lay the weapon down and then call security to retrieve it. Weapons, whether legal or illegal, are personal property and should be returned after the examination unless the patient is committed for potentially violent behavior.

Managing violent patients

Three methods for controlling potential or actual violence are verbal management, physical restraint, and pharmacologic restraint.

Verbal management
In some cases, verbal management of violent patients is considered to be as effective as pharmacologic restraint. Minimize hostility by avoiding direct confrontation. Empathize with the patient's concerns and involve other staff members if necessary. An offer of food and drink may encourage cooperation in an agitated patient. Avoid direct confrontation, but enforce limits and outline the consequences of violent behavior.

Verbal management is not effective in patients with florid psychosis, delirium, severe intoxication, or agitation secondary to manic episodes. Such patients may be asked if they would like to be restrained; sometimes they agree because they feel that they are a part of the decision process, which gives them a sense of control (13).

Physical restraint
In many EDs, application of physical restraints is a daily occurrence. Lavoie and associates (7) found that 32% of EDs applied physical restraint on a daily basis. When physical restraints are required for safety, do not offer or negotiate (19); if the patient disagrees, he or she will no longer trust emergency personnel. Physicians are legally and ethically required to clearly state the reason for restraint, even if the patient may not hear or understand (20). All orders for physical restraint must be in writing and state the time and the reasons restraints were applied (21). Once restraints are applied, any injury or harm to the patient is de facto evidence of negligence. Table 2 (not shown) lists the American Psychiatric Association's criteria for application of physical restraint (22).

Patients can be injured or killed in the restraint process; therefore, restraint should never be used punitively, for convenience, or to control a mildly obnoxious patient. Ideally, five people (one for each of the patient's extremities and one for the head), including security officers, should be present to properly apply restraints using the least amount of force. The restraint team should include at least one woman when restraining female patients. To prevent aspiration, four-point, padded restraints should be used with the patient lying supine or on the side. A Philadelphia collar can be applied to control head banging, spitting, and biting. Any additional straps should be placed over the pelvis or knees, because chest straps may interfere with respiration. A healthcare worker must be in attendance at all times while the patient is restrained, and peripheral perfusion, mobility, posture, and mental status should be monitored every 15 minutes.

Pharmacologic restraint
Pharmacologic (chemical) restraint is considered by many to be more humane than physical restraint. Opiates, barbiturates, neuroleptics, benzodiazepines and, in extreme cases, neuromuscular blockade have been used (23-26).Medications may be given orally, intramuscularly, or intravenously alone or in combination and adjusted as needed. No one medication is appropriate for every situation. An oral benzodiazepine may be appropriate in patients with mild to moderate agitation or cocaine or alcohol withdrawal. Use of an intravenous benzodiazepine or parenteral neuroleptic is appropriate in cases where agitation is an immediate threat to safety. However, more extreme measures may be necessary in trauma patients with multiple injuries who are combative and whose injuries require transfer to the operating room. In such situations, the best solution may be total paralysis using neuromuscular blockade and intubation in the ED prior to surgery (24-26). This procedure ensures the safety of patients and staff and prepares patients for anesthesia.

Benzodiazepines and neuroleptics are the drugs most commonly used for chemical restraint or rapid tranquilization. Diazepam (Valium, Zetran) or lorazepam (Ativan) is recommended for use in incremental dosing depending on the situation. Initially, 2- to 10-mg doses of diazepam or 2- to 4-mg doses of lorazepam may be given and adjusted up as needed. The primary adverse effects are sedation and respiratory depression.

Haloperidol (Haldol) and droperidol (Inapsine) are neuroleptics that may be given alone or in combination with benzodiazepines. Both neuroleptics work well in patients with acute psychosis resulting from multiple causes and relieve agitation regardless of the cause (27). Either drug should be considered as a first-line agent, except in patients with drug withdrawal or sympathomimetic-induced symptoms, such as cocaine intoxication, where the benzodiazepines are preferred. Haloperidol and droperidol can be given intramuscularly or intravenously; haloperidol is also effective when given orally. Response occurs within minutes, and patients remain awake and alert. Haloperidol and droperidol are relatively safe with minimal adverse respiratory or hemodynamic effects (eg, transient hypotension with droperidol) and no lowering of the seizure threshold. Extrapyramidal side effects occur in less than 10% of patients and are more common with haloperidol. Such effects are not dose-related and usually occur outside the ED at least 12 hours following administration.

Protecting emergency staff and patients

Despite the requirements set forth by the Joint Commission on Healthcare Accreditation Organizations (28), many EDs are simply unprepared to deal with violent patients. Lavoie and colleagues (7) reported that nursing staff in many EDs received no specific training in management of aggressive patients.

Obviously, people cannot be denied access to emergency healthcare (29). However, controlled access can make EDs safer. The risk of injury to medical staff and patients can be significantly decreased with protected entrances, metal detectors, protective acrylic windows, 24-hour on-site security, and perimeter doors that allow staff to exit but remain locked and secure from the outside (30). In addition, emergency personnel should be trained to quickly recognize and appropriately manage violent patients.

Conclusion

A safe workplace is the right of every worker, yet emergency medical staff are exposed daily to violent patients who can jeopardize the safety of everyone in the ED. Despite official recommendations, many hospitals have yet to implement security protocols. Therefore, training emergency staff to anticipate and appropriately manage violent patients may be the best way to ensure a safe emergency healthcare environment.

References

  1. Pardes H. An overview of violence. Resident Staff Physician 1982;Nov:60-70
  2. Allison EJ Jr. Violence in America: a shameful epidemic. ACEP News 1992;March:4-5
  3. Smith M, McCabe J. Violence in the ED is a concern across nation, part 1. ACEP News 1993;May:8-9
  4. Foust D, Rhee KJ. The incidence of battery in an urban emergency department. Ann Emerg Med 1993;22(3):583-5
  5. Anderson AA, Ghali AY, Bansil RK. Weapon carrying among patients in a psychiatric emergency room. Hosp Community Psychiatry 1989;40(8):845-7
  6. Armed patients belie stereotypes. ED Management 1991; Mar:39-40
  7. Lavoie FW, Carter GL, Danzl DF, et al. Emergency department violence in United States teaching hospitals. Ann Emerg Med 1988;17(11):1227-33
  8. Pane GA, Winiarski AM, Salness KA. Aggression directed toward emergency department staff at a university teaching hospital. Ann Emerg Med 1991;20(3):283-6
  9. Rockwell DA. Can you spot potential violence in a patient? Hosp Physician 1972;10:52-6
  10. Tintinalli JE, Peacock FW 4th, Wright MA. Emergency medical evaluation of psychiatric patients. Ann Emerg Med 1994;23(4):859-62
  11. Reid WH. Clinical evaluation of the violent patient. Psychiatr Clin North Am 1988;11(4):527-37
  12. Dubin WR. Evaluating and managing the violent patient. Ann Emerg Med 1981;10(9):481-4
  13. Young GP. The agitated patient in the emergency department. Emerg Med Clin North Am 1987;5(4):765-81
  14. Perry S. Effective management of the violent patient. ER Rep 1983;4(6)31-6
  15. Tardiff K. Management of the violent patient in an emergency situation. Psychiatr Clin North Am 1988;11(4):539-49
  16. Ordog GJ, Wasserberger J, Ordog C, et al. Weapon carriage among major trauma victims in the emergency department. Acad Emerg Med 1995;2(2):109-13; discussion 114
  17. Goetz RR, Bloom JD, Chenell SL, et al. Weapons possession by patients in a university emergency department. Ann Emerg Med 1991;20(1):8-10
  18. Rice MM, Moore GP. Management of the violent patient: therapeutic and legal considerations. Emerg Med Clin North Am 1991;9(1):13-30
  19. Tupin JP. The violent patient: a strategy for management and diagnosis. Hosp Community Psychiatry 1983;34(1):37-40
  20. American College of Emergency Physicians. Policy statement: use of patient restraint. Dallas: American College of Emergency Physicians, 1991
  21. Lydon DR, Miller CS. Violent and suicidal patients: special handling required. Emerg Med Rep 1991;2(2):9-15
  22. Lavoie FW. Consent, involuntary treatment, and the use of force in an urban emergency department. Ann Emerg Med 1992;21(1):25-32
  23. Dubin WR, Feld JA. Rapid tranquilization of the violent patient. Am J Emerg Med 1989;7(3):313-20
  24. Kuchinski J, Tinkoff G, Rhodes M, et al. Emergency intubation for paralysis of the uncooperative trauma patient. J Emerg Med 1991;9(1-2):9-12
  25. Rotondo MF, McGonigal MD, Schwab CW, et al. Urgent paralysis and intubation of trauma patients: is it safe? J Trauma 1993;34(2):242-6
  26. Redan JA, Livingston DH, Tortella BJ, et al. The value of intubating and paralyzing patients with suspected head injury in the emergency department. J Trauma 1991;31(3):371-5
  27. Clinton JE, Sterner S, Stelmachers Z, et al. Haloperidol for sedation of disruptive emergency patients. Ann Emerg Med 1987;16(3):319-22
  28. Lehmann LS, Padilla M, Clark S, et al. Training personnel in the prevention and management of violent behavior. Hosp Community Psychiatry 1983;34(1):40-3
  29. Ordog GJ, Wasserberger J, Ordog C, et al. Violence and general security in the emergency department. Acad Emerg Med 1995;2(2):151-4
  30. American College of Emergency Physicians. Behavioral Emergencies Committee. Emergency department violence: prevention and management. Dallas: American College of Emergency Physicians, 1988


Resources on emergency department safety and security

American College of Emergency Physicians
PO Box 619911
Dallas, TX 75261
http://www.acep.org
Publications include Protection From Violence in the Emergency Department Policy Statement (No.4148) and Emergency Department Violence: Prevention and Management, 2nd edition.

International Association for Healthcare Security and Safety
PO Box 637
Lombard, IL 60148
Training programs, certification, educational seminars, newsletters, survey data, and journals.

Occupational Safety and Health Administration (OSHA)
US Department of Labor
OSHA Publications,
POB 37535
Washington, DC 20213-7535
http://www.osha.gov
Federal regulations on protection requirements in the healthcare environment.


Dr Kuhn is associate professor of emergency medicine, assistant professor of pediatrics, and former program director of emergency medicine residency, Medical College of Georgia, Augusta. Correspondence: W. Kuhn, MD, Department of Emergency Medicine, Medical College of Georgia, 1120 15th St, Augusta, GA 30912-2800. E-mail: tkuhn@mail.mcg.edu.


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