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(Editor’s Note: This is the second of a two-part series on violence in the ED. Last month’s ED Nursing covered reporting and documentation of assaults. This month, we tell you how to prevent assaults.)
When a belligerent 32-year-old man came to the ED at Community Medical Center in Missoula, MT, demanding Percocet for ear pain, the ED physician refused to give him the medication. "He had been to our facility three times in less than two weeks and had an extensive work-up, including a CT of the head. All tests and exams were normal, and a cause for his continued pain could not be found," explains Dianne Rallis-Peterson, RN, CEN, charge nurse for the ED.
When the ED physician offered an alternative pain medication, the patient became hostile and started shouting obscenities. "The patient’s anger escalated to the point where he started throwing things onto the floor and verbally threatened to harm us," says Rallis-Peterson. "While the physician calmly interacted with him, we activated our response team’ and called the police."
Within one minute, the patient was surrounded by several individuals from the response team. By the time the police arrived, the patient had left the ED. "When he saw the number of men who were closely watching him, the patient realized that he couldn’t continue to intimidate us," says Rallis-Peterson. She points to the scenario as the type of proactive approach you’ll need to take to increase your safety.
Here are other ways to prevent assaults:
• Form a "response team." At Community Medical Center, the ED has no security guard, but a "response team" is called by dialing "2222" when staff members feel threatened by a patient. The members on the team are all men from various areas throughout the hospital and include male nurses on the floors, maintenance workers, the orderly, and the house supervisor.
"The idea is that people who are out of control or threatening to the staff will settle down once they see they are outnumbered," Rallis-Peterson explains. "The number may vary, but generally we have four to seven men come to the ED in less than a minute," she says. She notes that the response team is not allowed to touch the patient in a threatening manner. "If the patient is truly threatening with a weapon, we call 911 and get law enforcement to respond," she says.
• Have at least one area that is secure. Community Medical Center’s ED has a unit that is behind a locked door. "It’s not only the patients that can be violent. Their friends and family members have also been a threat to us on occasion," says Rallis-Peterson. "It’s good to have a barrier between us and them if needed."
• Determine what’s causing the patient to be violent. Treatment may depend on your finding the underlying reason for the patient’s behavior, says Rallis-Peterson. "This may require all the skill we have, and a large amount of intuition," she notes. For example, the root of the problem might be pain, fear, drug-induced behavior, or a psychosis or delirium from a metabolic disorder, she says. "For instance, it does no good to treat a patient with an antipsychotic medication if their behavior is the result of an insulin reaction," she says.
• Realize that any patient can become violent. Any patient may cause physical harm, says Rallis-Peterson. "It’s not just the gang members packing heat. It could be the 5-year-old who doesn’t want his lab work drawn and delivers a swift kick to the nurse’s rib cage, or the demented 80-year old who grabs the nurse by the hair and bites and claws at her hands," she says.
Any individual put in the right situation might become violent, stresses Tracy G. Sanson, MD, FACEP, assistant medical director for the department of emergency medicine at Brandon (FL) Regional Medical Center. "Patients at risk for violence include the executive with a migraine who will miss a meeting, the parent with a child about to get off a school bus, the consultant again dealing with malfunctioning equipment," she says. "The list goes on and on and fills our EDs every day."
All patients need to be assessed for their potential for violence at each visit, Rallis-Peterson stresses. "Co-workers need to be aware and listening for escalating tension," she adds.
• Don’t allow a patient’s agitation to become "contagious." Let your calm demeanor soothe a distraught patient, advises Rallis-Peterson. "I try to stay in control, so that the patient can get in control," she says.
• Never say exactly what you are thinking if you are getting angry. "That can be very hard, especially if the patient is verbally abusive," admits Rallis-Peterson. "But anything said that inflames the patient further can escalate a trend toward violence." She recommends avoiding accusatory phrases such as: "Your problem is worse because you are a noncompliant patient," or "What happened to your last prescription? You just received 20 Percocet yesterday."
Don’t patronize or be condescending, she advises. "Often, agitated patients are highly sensitive to what the nurses are saying and doing," she notes. "They get very upset if they see the nurses off in a group talking about them."