Learn to recognize the signs of impending conflict and the people who cause it

Any person is potentially violent under the right circumstances, but there are definite red flags to watch for. "There are certain types of patients who are more likely to become abusive or violent," says Rob McFarland, a health care safety and security consultant based in Orange County, CA. Here are some patients to pay extra attention to, with strategies to reduce the possibility of violence:

Intoxicated patients. "The No. 1 problem patient is the intoxicated patient," says McFarland. "They’re time-consuming, demanding, and have no impulse control because they’re drunk, but they’re a fairly significant population served in the ED."

McFarland recommends "fast-tracking" these patients out the door. "Nurses object to that because there are more critically ill people," he notes. "It’s true that if you’re doing straight triage by medical necessity, these people are at the bottom of the list. But, the longer you keep them, the more likely you are to have an incident with them, so it’s best to get them in and out."

It’s a good idea to have a secluded room for intoxicated patients. "If you’ve got someone who’s vulgar, drunk, and screaming, you can’t have him disrupting all the other patients," says McFarland. "It could even be a closet-sized room, but you’ve got to have somewhere to isolate a disruptive patient."

Patients who have been waiting for hours. Even if a patient shows no outward signs of violence, he or she is likely to be extremely anxious. "If someone has been waiting for three hours sitting in the corner, it’s a good idea to go over and make contact with that patient," says Craig Ewing, director for the Southern California operations of Healthcare Security Services, based in Denver. "The idea is to keep the violence from happening in the first place."

"These patients are less likely to throw something at you, but they will often launch into verbal attacks," says McFarland. One strategy is to be as honest as possible about the waiting time. "On a busy Saturday afternoon, when a patient asks how long they’ll have to wait, show them the list, and say, ‘You are here, and the person at the head of the list came here two hours and 20 minutes ago.’"

It also helps to point out life-threatening emergencies. "If people in the waiting room can’t see the ambulances coming in, it’s useful to tell a roomful of folks that two ambulances just rolled up to the back door with some critically ill people," suggests McFarland.

Psychiatric patients. South Coast Medical Center’s ED in Laguna Beach, CA, regularly sees patients from the hospital’s psychiatric unit who frequently become aggressive. "Many of these patients are seeking treatment specifically because they’re having trouble controlling their behavior," notes Joni Taylor, RN, CEN, director of emergency services. "We’re sometimes notified in advance, but often we’re not." If a patient becomes aggressive, security is paged overhead to respond immediately, she says.

Parents with children. "Bringing a child to the ED is stressful, and a hurting child will often make a parent verbally abusive," says McFarland. ED managers should consider ways to support the parents during times of crisis, he recommends.

When an IV was started in a seriously ill toddler and the procedure didn’t go well, the father lashed out angrily at the staff. "It was a traumatic, bloody affair, and the dad was already stressed, but the staff wasn’t sensitive to that," McFarland recalls. "As a result, he started accusing them of hidden agendas." After McFarland bought the distressed father a cup of coffee and calmly explained the situation, the man calmed down.

"I call that my ‘coffee cup intervention,’ he says. "When someone is agitated, it’s amazing how quickly they will calm down if you walk up to them, and just say, ‘You’re really unhappy, why don’t we get you a cup of coffee and figure out how to make it better for you.’"

Deranged individuals. Patients with altered mental status can become combative, while other individuals may arrive at the ED with a specific target in mind. "If they come in angry, with a weapon and a plan, they’re really hard to stop," says McFarland. "Still, because they’re deranged, at least temporarily, they get frustrated and discouraged easily." De-escalation techniques can help to dissuade violent individuals, he says.