Dr. Welch was the quality improvement director in the emergency department at LDS Hospital in Salt Lake City for 10 years. She is on the faculty at the Institute for Healthcare Improvement in Boston and speaks internationally on emergency department quality improvement. She also has served as a quality consultant for VHA, is a member of ACEP's quality improvement and patient safety section, and is a member of the Emergency Department Benchmarking Alliance. She has been published in numerous journals, and just finished her second book, “Quality Matters: Creative Solutions for the Efficient ED” to be published by Joint Commission Resources Publishing.
Part 1 in a Series
According to OSHA, 45 percent of workplace violence occurs in health care settings. While workplace violence is reported at a rate of two cases per 10,000 workers, in health care the rate is five times higher and grossly underreported. (Guidelines for Preventing Workplace Violence for Health Care and Social Workers. OSHA Publication 3148-01R, 2004; www.osha.gov/Publications/osha3148.html.) Health care workers are five to 12 times as likely to file a workers' compensation claim for violence than workers in any other industry. (Dying for a Job: Health-care Workers Beware. CBC News Online, April 24, 2006; www.cbc.ca/news/background/workplace-safety/sick-workplace.html.) Some 9000 nurses and health care workers will be injured or threatened every day in the United States (OSHA Regional News Release. Region 4, June 6, 2006), and the ED and psychiatric ward are the most common locations for workplace violence in health care.
Despite these statistics, most emergency departments have been haphazard in approaching this problem. Policies and procedures for identifying and managing potentially violent patients and training for staff have been slow to evolve. The number of incidents and injuries can be reduced by identifying patients with a high risk of violent behavior, developing action plans for such patients, and educating the team. (J Psychiatr Ment Health Nurs 2004; 11:595.) This series focuses on identifying high-risk patients and developing strategies for managing violent patients in the ED.
Risk Factors for Violence
The literature is replete with articles identifying the characteristics of patients that are likely to behave aggressively or violently. (Emergencies in Mental Health Practice: Education and Management. New York. Guilford Press, 1998; J Med Pract Manage 2007;23:86.) The most important factor in predicting whether a patient will be violent is a past history of violence. Sadly, most health systems have no mechanism for identifying patients who have been violent, and this information is more difficult to obtain than traditional medical records because of HIPAA. Because the ED is one of the most common sites of violence in health care, this information is important to frontline workers, and mechanisms for rapid identification of these high-risk patients should be a priority.
Historical elements such as recent incarceration, probation, police arrest, or elopement from a mental health facility increase the risk of violent behavior in mental health patients. If these facts are not known, a few questions can get at the propensity for violence in a patient: “What is the most violent thing you have ever done? Have you ever owned a weapon?”
Other patient characteristics also have been associated with violent behavior:
▪ History of violent behavior (strongest indicator).
▪ Talks loudly, uses profanity, makes sexual comments.
▪ Blames others.
▪ Demands unnecessary care, threatens staff, holds grudges.
▪ Accuses staff of being against him.
▪ States he is losing control.
▪ Throws or punches inanimate objects.
▪ Rapid pacing, sweating, head down, furrowed brow.
▪ Challenges authority, makes intimidating comments.
▪ Interest in weapons.
▪ Appears tense and angry.
▪ Appears intoxicated or under the influence of drugs.
▪ Romantic obsession with someone.
▪ Multiple life stressors: divorce, death, financial problems.
Another tool appearing in the literature during the past year is the Broset Violence Checklist. The BVC is a short-term violence prediction instrument assessing confusion, irritability, boisterousness, verbal threats, physical threats, and attacks on objects. It has been shown to be highly predictive of violence in the short term when used by nurses. (Acta Psychiatr Scand 2006;113:224.)
High Risk for Violence
Many institutions are educating staff to identify risk factors at intake and then to initiate a procedure for managing the patient. At the very least, such patients should be taken to a safe place, placed in a gown or hospital scrubs, and have all possessions confiscated. Because between four and eight percent of patients presenting to a psychiatric ED will bring weapons with them to the department, this policy is prudent.
At Intermountain Healthcare, patients identified in triage as having risk factors for violence are put in the safe room. They are identified as emergent, and are assessed by the physician or the crisis worker as high-, medium-, or low-risk. High-risk patient identification activates the Violent, Self-Destructive or Suicidal Behavior Procedure. High- to medium-risk patients remain in seclusion with the physician renewing the order every four hours. A patient safety attendant is assigned to observe the patient and keep documentation. (Note: The Joint Commission has been citing facilities that seclude patients without a mechanism for observation.) Typically physicians may order pharmacologic adjuncts to treatment that lower the risk for violence, allowing the patient's status to be downgraded. Low-risk patients can be monitored by family, friends, or staff, and may not need seclusion or restraints.
Next month: Characteristics of the workplace and the facility that increase risk.