VIOLENCE IN THE EMERGENCY DEPARTMENT

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Violence in the emergency department (ED) is a problem that is poorly documented, inadequately researched, and often not managed optimally. Although well-compiled data on the overall incidence of ED violence are lacking, it is obvious from a variety of reports that violent behavior is neither uncommon nor decreasing in frequency.12, 17, 16, 21, 24, 25, 27, 28 This trend reflects both a 10% annual rise in the number of psychiatric emergencies as well as an increase in violence in society in general, with a doubling of the murder rate in the United States in the last 20 years.4, 17 Despite this trend, many hospitals do not have 24-hour ED security, and most provide inadequate staff education.

Section snippets

EPIDEMIOLOGY

A 1995 summary from the International Association for Healthcare Security and Safety of 221 hospitals in America and Canada reported 42 homicides, 1,463 physical assaults, 67 sexual assaults, and 165 robberies, and 47 armed robberies.20 The ED was the commonest hospital location for physical assaults, and the second commonest site of homicide.25, 28, 36 Between 1980 and 1990, according to the US Department of Labor, 26 physicians, 18 registered nurses, 27 pharmacists, 17 nurses' aides, and 18

ORIGIN

A study in the Journal of Clinical Psychiatry retrospectively analyzed a variety of clinical and demographic variables for every patient who presented to a single psychiatric ED over a 14-month period and was found to have a weapon.27 Although many predictors of subsequent violent behavior had been postulated, this study found no differences related to age, education, ethnicity, occupation, marital status, diagnosis, or extent of psychiatric impairment. The only variables that did correlate

RECOGNIZING THE VIOLENT PATIENT

Emergency physicians are traditionally not adept at addressing the issue of violence in the ED setting. In general, a physician does not expect that a patient seeking treatment will react violently to a caregiver. Many doctors are simply in denial of the threat of violence in the ED because of fear or a feeling of lack of control.23 As a result, most residencies do not offer formal violence training programs that teach physicians how to both recognize and manage the violent patient.

The approach

INITIAL APPROACH TO THE VIOLENT PATIENT

Once these signs are recognized, the next step is to attempt to diffuse the mounting violent behavior. Violent patients should not have to wait for long periods. Waiting may precipitate aggressive behavior, particularly in patients with underlying medical histories of mental illness.14, 30 The patient also should not be ignored by staff because this can make him or her become paranoid about perceived covert, adverse activity against him. It is better that a violence-prone person not be

Medications

Patient not responding to less invasive means may need to be medicated. Several medications can be used alone or in combination to manage violent behavior. Antipsychotics and benzodiazepines are among the most commonly used. Depending on the original cause of aggressive behavior, therapy can be tailored to treat any underlying causes. For example, if a patient is aggressive secondary to pain, an opioid or other analgesic can be the most appropriate and effective therapy.38

In the ED, rapid

CREATING A SAFE ED ENVIRONMENT

The best defense for the assaultive patient is to provide training for staff well in advance of potential situations. Trained, well-prepared ED staff are calmer and better able to deal with a violent patient before the situation escalates. An evaluation of a three-phase training system of staff at a psychiatric treatment center, consisting of training in verbal techniques, physical protection methods, and proper application of restraints, showed a significant reduction in assaults. The group

LEGAL CONSIDERATIONS

No discussion of management of the violent patient is complete without examining the legal issues. The process of interaction with the violent patient has many potential interfaces with the legal system, ranging from restraint use to third-party risk. The emergency physician must be adept not only at personal protection but also at ensuring that the violent patient and other patients are protected as well.

The key to reducing liability is documentation. Although usage of restraints was

FUTURE DIRECTIONS

There is a great need for more research in the field of violence in the ED, as evidenced by the paucity of up-to-date studies published in the emergency medicine literature. There is also a particular need for greater education of physicians and staff in EDs about the proper approaches to aggressive patients, including methods of chemical and physical restraint. Given the documented frequency of verbal and physical assaults that occur in EDs, such education and research may allow EDs to be

CONCLUSION

ED violence is a common occurrence, affecting a large percentage of staff in the form of both verbal and physical threats. An awareness of the comorbid conditions that frequently characterize the violent patient, such as certain personality disorders and substance abuse, is the first step toward preventing assault in the ED. Further steps include adequate training of department personnel and providing a safe physical setting so that attacks can be avoided. In the event that intervention is

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  • Cited by (30)

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    • Violence in the Emergency Department: A national survey of emergency medicine residents and attending physicians

      2011, Journal of Emergency Medicine
      Citation Excerpt :

      Our findings echo similar studies on ED violence: more needs to be done in the way of violence prevention measures such as increased security and training for ED staff (1,4–6,12,14,16). Several studies have examined and reported results related to violence in the ED (1,4–6,12,14,16). Unfortunately, all of these previous studies used different definitions of violence and surveyed a wide variety of ED staff ranging from only physicians to, for example, physicians, nurses, social workers, and registration staff.

    • Physical and Chemical Restraints

      2009, Emergency Medicine Clinics of North America
      Citation Excerpt :

      Do not reach for any weapon the patient may be holding.55 Various environmental, administrative, and behavioral preventative measures can be implemented to help make the ED a safer environment.56,57 Certain environmental designs can strategically minimize violence in hospitals.

    View all citing articles on Scopus

    Address reprint requests to Janice C. Blanchard, MD MPH, UCLA Medical Center, Robert Wood Johnson Clinical Scholars Program, Factor Bldg. Rm. B–537, 10833 LeConte Avenue, Los Angeles, CA, 90095–1736

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