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Emergency Medicine News:
doi: 10.1097/01.EEM.0000342733.39531.f7
Quality Matters

Preventing ED Violence Starts in Triage

Welch, Shari J. MD

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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 2 in a Series

Although 45 percent of all workplace violence occurs in health care settings, most commonly in emergency departments and psychiatric wards, emergency staff has been haphazard in approaching this problem. As I outlined last month, identifying patients at risk for violence should start in triage. If a patient's records don't reveal a history of violence (and they usually don't because of HIPAA), staff can ask a few questions to assess for potential violence: “What is the most violent thing you have ever done? Have you ever owned a weapon?”

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Besides a history of violence, which is the strongest indicator, a host of other patient characteristics are associated with violent behavior, including talking loudly and using profanity, blaming others, demanding unnecessary care, threatening the staff, throwing or punching inanimate objects, rapid pacing, challenging authority, making intimidating or sexual comments, interest in weapons, and appearing tense, angry, or under the influence of alcohol or drugs. Emergency staff also can use the highly predictive Broset Violence Checklist to assess confusion, irritability, boisterousness, verbal and physical threats, and attacks on objects. (Acta Psychiatr Scand 2006;113[3]:224.)

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Workplace Risk Factors

Besides the characteristics relevant to the patient that increase the risk of a violent episode, there are characteristics of the workplace and the facility that also increase risk. Organizations that have had periods of turmoil or where leadership is in flux seem to have an increased risk of these types of encounters. Organizations that have not crafted policies or procedures to manage violence or those where verbal hostility is tolerated are also at risk. In addition, understaffing, high activity, long waits, and the transporting of patients are high-risk conditions for violent outbursts.

Restricting a patient's freedoms, such as eating, drinking, and smoking (a regular practice in the ED), can put a patient over the edge because of power struggles and lead to violent outbursts. Overcrowded departments with uncomfortable spaces, conditions where staff work alone, and institutions with no training or procedures for patients who become violent put staff workers at increased risk.

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Facility Risk Factors

Facility factors also can help or hinder the management of violent episodes in the ED. One important and low-cost innovation is distributing temporary name badges to identify all visitors and patients and where they should be trafficking. An adhesive badge that tells the visitor or patient's name and which room he is in is a great innovation. It is practical for tracking movement (Mrs. Wilson's visitor doesn't belong in the trauma suite watching the show!), and it shows that the staff are paying attention to the flow of visitors. Staff also should be empowered to ask the name and business of anyone they don't recognize in the ED.

A host of measures can improve overall safety in the ED, including bright lighting, curved mirrors, visible security staff, closed circuit television, enclosed nurses' areas, silent alarm systems/panic buttons, metal detectors, and security escorts. Be sure to keep in mind that furnishings themselves can be used as weapons.

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Communication Training

Part of the training that staff members receive in this area should include communication and behavioral training. Though it must be emphasized that many patients who are under the influence of alcohol and drugs or are acutely psychotic can't be “managed,” no matter what communication and behavioral training the staff member has.

Active listening can often diffuse a situation. If the patient or upset family member perceives that the caregiver is concerned and involved, this may diffuse the situation. Using first person expressions (I or we) is less inflammatory than second person (you) statements. Here is where scripting can help in dealing with volatile situations.

It is worth remembering that 80 percent of communication is nonverbal, and body language can escalate a difficult encounter. Experts recommend that you adopt a very open posture as opposed to closing your arms across the chest or standing with hands on hips. They also caution against pointing at an angry individual. The best stance is with arms at your sides, looking the person in the eye but at a slight angle, not dead-on, because it is less confrontational.

A technique for disengaging from an angry encounter also can be taught. Experts recommend scripting such as:

▪ Acknowledge: “I can see that you are furious with me.”

▪ Commit involvement: “We will talk more about this.”

▪ State your needs: “I need to consult with Dr. X.”

▪ State your intention to return: “I will be back in five minutes.”

Our specialty needs coursework in anger management, not so much our own but rather the anger of the people we interact with in our emergency rooms. We need to acknowledge that we work in a dangerous environment and we need policies to protect us all. The ad hoc approach used for decades needs work, and there are data and research out there to show us the way.

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Security and Safety Changes for the ED

▪ Install closed circuit video and curved mirrors

▪ Limit access from outside

▪ Install bright lights

▪ Create employee “safe rooms”

▪ Enclose nurses' areas

▪ Install silent alarms, panic buttons, and metal detectors

▪ Ensure furniture cannot be used as weapons

▪ Ensure access to emergency exits

▪ Make security escorts available

▪ Flag violent patients' records

© 2008 Lippincott Williams & Wilkins, Inc.

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