The trusted source for
healthcare information and
You may miss potentially violent patients at triage
Stressful situations increase risk
If a patient presents visibly intoxicated and announces his or her intent to harm others, it's easy to make the decision to involve security. However, any ED patient or visitor has the potential to become physically violent, warns Gordon Lee Gillespie, PhD, RN, PHCNS-BC, CEN, CCRN, CPEN, FAEN, assistant professor and director of population-focused care at University of Cincinnati (OH) College of Nursing.
"I recommend that ED nurses apply universal violence precautions during all interactions with patients and visitors," he says. Patients and visitors are more likely to become violent when being told of a psychiatric admission, the death of a family member, or a new diagnosis of a terminal illness, says Gillespie.
"Other stressful situations are new smoking restrictions and limitations for visitor access," Gillespie says. "Crowded environments, long wait times, and ignoring patients and visitors are contributors to outbreaks of physical violence." Gillespie recommends these practices:
Don't leave individuals at risk for becoming physically violent in the general waiting room.
"Some ED nurses have reported that expediting patient care is not fair to other waiting patients," Gillespie says. "However, keeping a 'toxic,' escalating person in the lobby raises the anxiety and stress of all persons." This could result in aggression and violence from other individuals, he says, and lead to poor patient satisfaction related to their personal safety perception.
Contact the charge nurse.
He or she can then inform both staff and the ED physician of the person's risk for physical violence, says Gillespie. "Care can then be tailored to prevent further patient or visitor escalation," he says. "The triage nurse can also contact security, a hospital chaplain, or a patient liaison to provide support." (See related story below on steps to prevent violence.)
Take these steps, prevent violence by ED patients
ID signs of escalation
Is your patient pacing in the room or hallway, avoiding eye contact, mumbling, yelling or talking too loud, constantly staring, or avoiding eye contact? These are all signs that a person is escalating toward physical violence, says Gordon Lee Gillespie, PhD, RN, PHCNS-BC, CEN, CCRN, CPEN, FAEN, assistant professor and director of population-focused care at University of Cincinnati (OH) College of Nursing. He gives these tips to reduce risks with potentially violent patients:
Knock on the door when entering to prevent the patient and visitors from being startled.
"Introduce yourself when entering," Gillespie says. "Sit at least four feet away from the patient, providing distance in case the patient attempts to swing or throw an object at you."
Have quick access out of the patient treatment room.
Do not sit in a corner in the back of the room where a patient or visitor can block you from leaving, advises Gillespie.
Attempt de-escalation techniques.
"Ask the person what is wrong. Meet this need if possible," Gillespie says. "If you are not able to meet the need, explain your rationale."
If the patient continues to escalate, Gillespie says to leave the room and get assistance. "Someone else may be able to make a personal connection and resolve the stressor," he says.
Alert the rest of your team that the patient may become physically violent.
Have another nurse or technician assist you in the room while performing your assessment or intervention, advises Gillespie. "If this is not possible, then at least have someone outside the patient door in case you call for help," he says. "Have someone come to the room after five minutes, if you have not checked back in that you are okay."
Security should be aware of your concern, adds Gillespie, so that they are in the department and immediately available if called. "They don't necessarily need to be outside the door, as this can also escalate the situation," he adds.
For more information on potentially violent ED patients, contact: