Epidemiology

The goal of caring for a violent patient is first to protect everyone involved and also to diagnose and treat important medical and psychiatric conditions (see the “Priority Actions” box). These goals are best achieved if warning signs of violence are recognized and the safest and most effective means of behavioral control are used.

The epidemiology of violence in the emergency department (ED) is inexact; past surveys suggest that as many as 80% of events are unreported.¹ Still, clear evidence indicates that most EDs experience violent patients routinely. Of greater concern, ED caregivers are often victims. More than 70% of ED nurses have reported being the victim of physical violence during their career.² The rate of assault on health care workers is 8 per 10,000, as compared with 2 per 10,000 for all private-sector industries, with the ED being one of the highest-risk areas.³

Violence may range from verbal threats to physical assault. Of reported events in one survey, 90% of cases involved the patient and 10% involved family or visitors. A few staff members may be confronted by former patients outside the ED or may become victims of stalking.

Nearly 60% of EDs in the United States have reported an armed threat on a staff member within 5 years.⁴ Weapons may be carried by patients, family members, visitors, or even staff members. Patients most likely to carry weapons include those with schizophrenia or paranoid ideation and individuals who have been the victims of gunshot wounds. Many violent patients are intoxicated with alcohol or drugs.

Violence threatens the career longevity of ED staff. Violent events should be regularly reported to police and hospital administration to raise awareness of this societal problem and to encourage safer practice environments.

How to Predict Violence

Violent behavior rarely erupts without warning. Risk factors for violence include an escalating psychiatric illness (e.g., schizophrenia, personality disorders, mania), alcohol and drug abuse, a previous history of violence, arrival at the ED in police custody, and male gender (Box 195.1). The use of risk factors to predict violent behavior has not been tested in cohorts of emergency physicians; psychiatrists have been only 60% accurate in predicting violence when using risk factors alone.⁵

Verbal and nonverbal clues provide evidence of impending violence. As patients become more agitated, the level of their voice may rise and their hand gestures may be more pronounced and expressive. Patients may exhibit restlessness on their gurney or may pace. Providers should trust their instincts when they become uncomfortable with an agitated patient. Emotional stress, prolonged waiting times, and gaps in communication create a provocative and unsupportive environment.

Interventions

Standardized methods should be used to confiscate concealed weapons. Metal detectors are used in some EDs and are recommended when possession of weapons by patients or visitors is frequent. For patients, a policy of routine undressing and gowning will minimize the likelihood of using hidden weapon when performed in an unbiased manner, regardless of the chief complaint.

Preparation of the examination room can facilitate safety. As many objects as possible should be removed from examination rooms that routinely hold violent or agitated patients. Panic buttons should be available for use by staff in any room where agitated patients are interviewed. Ideally, examination rooms should have two exits so that neither the clinician nor the patient feels trapped. Restless patients may become more agitated when physical outlets are constrained, so both the patient and caregiver must have unobstructed, rapid egress. Staff members should remove personal objects that could be used to cause injury by an assaultive patient. Such objects include neckties, large dangling earrings, and stethoscopes kept around the neck.

Deescalation Techniques

Early attention and preferential treatment may defuse anger born of impatience. If at triage, an agitated patient should be taken directly to a treatment room. Volatile patients should be removed from contact with other persons to decrease stimuli and avoid tension.

Essential violence prevention techniques include interpersonal skills that convey respect and unconditional positive regard. Improper behavior does not have to be accepted by ED staff, but no disrespect to the person should be conveyed. Start by stating explicitly that “this emergency department is a safe place” and the patient will be cared for well. Make the patient physically comfortable. Offer food or drink both as an expression of caring and also to minimize irritability. Do not surprise the patient; announce your arrival with a knock on the door or a verbal greeting. Ask permission to touch the patient before doing so. When speaking to the patient, use a calm and soothing voice. Listen attentively and intuitively to overt words and actions while attempting to assess underlying motivations and driving impulses. Additionally, listening will reassure the patient, and it is a caring act. Use straightforward speech and always be honest.

Even as the person receives genuine, unconditional care, boundaries of acceptable behavior should be set and consequences must be consistent. Inappropriate behavior is unacceptable and patients should be told the ramifications. Some patients do not have the ability to cope with the stressful environment and become verbally or physically uncontrolled. Other patients respond to limit setting and rules. Most require anxiolytics. Early use of a low-dose benzodiazepine often helps patients cope and prevents later escalation. No action or treatment should ever be punitive. Chemical restraint, physical restraint, seclusion, and arrest are predictable consequences of inappropriate behavior, but early medical therapy is compassionate and usually prevents escalation.

Health care providers can escalate a patient’s behavior through their own instinctive, impulsive, natural human conduct.⁶ Anger or frustration should never inspire unprofessional behavior or decisions. Physical and emotional distance may minimize the emotional reactions. A buffer zone of at least four body widths between the provider and the patient is recommended.

When a caregiver feels the urge to shout, argue, or engage in a staring match with a patient, the caregiver is inadvertently reciprocating the violence of the patient. Controlling these natural instincts is an important professional skill that for many requires cultivation and practice. Other caregivers must cultivate a willingness to engage sufficiently because their instinct is to disengage. Too much distance can be equally detrimental. Finding the optimal emotional and physical distance to be effective and caring is a practiced art. If caregivers are too distant, they will be aloof, condescending, or disengaged. If caregivers are too close, they may become stimulated by the patient’s disorder. The right distance enables control and effectiveness.

Medical Clearance

Agitated or violent behavior is frequently caused by treatable medical conditions. Reversible causes of altered mental status and violent behavior should be considered during the initial evaluation of the patient. Such causes include substance abuse, intoxication, glucose abnormalities, hypoxia, trauma, abnormal temperature (hypothermia and hyperthermia), infection, stroke, hypertension, and seizures. Older adults with new agitated behavior, delirium, or psychosis should undergo an extensive inpatient medical evaluation before a first-time psychiatric unit admission.

Treatment

Physical Restraint

Rationale

The use of restraint is indicated when verbal attempts have failed and action must be taken to prevent injury to the patient or staff. Restraint should be used only to facilitate diagnosis and treatment. It is inappropriate to use restraint as punishment or simply to quiet a disruptive patient.⁷

The Supreme Court case Youngberg v. Romero 1982 provided exception from assault statutes for physicians who restrained patients to protect the patient or others. This physician decision must be made carefully, as rarely as possible, and only under compelling circumstances to ensure safety.

The Joint Commission has published clear guidelines regarding monitoring, documentation, and the application of physical restraint (Box 195.2). Protection of the patients’ rights, dignity, and well-being is of utmost importance. The decision to apply physical restraint should be assessment driven; the provider must evaluate the individual patient in some way before a restraint is applied. It is inappropriate to maintain standing protocols. The selection of restraint should be individualized, and the least restrictive method is preferred; for instance, it is not necessary to restrain an agitated elderly patient with dementia in the same manner as an aggressive, muscular patient with cocaine intoxication. Hospitals must provide adequate training such that competent staff members are available for the safe application of physical restraint at all times.

Box 195.2

Guidelines for the Application of Physical Restraint

Protect the patient’s rights, dignity, and well-being.

Use of restraint is assessment driven.

Use the least restrictive method.

Trained, competent staff should provide safe application of restraint.

A time-limited order must be noted on the chart.

Document why restraint is necessary—be specific.

Protect yourself and others.

Act in the best interests of the patient.

Use restraints to facilitate medical evaluation or treatment.

Nursing documentation should be very thorough.

Monitoring and reassessment of the patient’s clinical condition and needs are essential.

Adapted from The Joint Commission: 2006-2007. Comprehensive accreditation manual for behavioral health care. Oakbrook Terrace, Ill: Joint Commission Resources; 2006.

Documentation

Documentation differs for physicians and for nursing staff. A time-limited order for restraints must be written on the chart before or shortly after restraints are applied. Providers must document why physical restraints were necessary and must cite that verbal techniques failed to calm the patient. Be specific about the patient’s condition and reasons for restraint, including potential danger to the patient or others, the planned medical evaluation or treatment, and assessment of the patient’s decision-making capacity. Nursing responsibilities include monitoring, frequent reassessment, and documentation of the patient’s condition and personal needs. The advent of electronic medical records and computerized physician order entry presents an opportunity to direct documentation that better meets regulatory requirements.⁸

 Documentation

Restraint*

Physician

Document why physical or chemical restraint was chosen and necessary. Cite that verbal techniques failed to calm the patient.

Record specific information about the patient’s arrival, the reasons for restraint, the potential danger to self or others, the planned medical evaluation, and an assessment of the patient’s decision-making capacity.

Record the initial evaluation by a licensed, independent provider within 1 hour of the patient’s arrival and restraint.

A time-limited order should be charted within 1 hour of the patient’s arrival.

Update restraint orders every 4 hours for adults, 2 hours for adolescents aged 9 to 17 years, and 1 hour for children younger than 9 years.⁹

Nursing

Frequently reassess the patient’s vital signs, condition, and personal needs.

Patients should then be reassessed every 15 minutes for the following:

• Signs of injury associated with the application of restraint

• Nutrition and hydration

• Circulation and range of motion in the extremities

• Vital signs

• Hygiene and elimination

• Physical and psychologic status and comfort

• Readiness for discontinuation of restraint

^* Refer to www.jointcommission.org for more information.

Technique

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