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Reducing risks from combative patients



Combative patients

Jane Perry is director of communications and Janine Jagger is director of the International Health Care Worker Safety Center at the University of Virginia in Charlottesville.

The safety center and its quarterly journal, Advances in Exposure Prevention, are devoted to the prevention of occupational exposures to bloodborne pathogens. For more information, call 434-924-5159 or point your browser to The Web site includes an exposure prevention checklist that can aid you in your compliance efforts.

VANESSA BURKHART, an ED nurse for 13 years, was working the night shift when the police brought in a woman who'd taken an overdose of pills with alcohol. Initially, the woman seemed fairly cooperative.

But as Burkhart started an I.V. line with an 18-gauge, nonsafety catheter, the patient suddenly tried to hit her. As Burkhart blocked the blow, the needle came out of the catheter. The patient grabbed it and jammed it into the nurse's finger.

She then shocked Burkhart by saying, “You'd better get your blood tested; I have hepatitis.” Testing confirmed that the patient was positive for hepatitis C virus (HCV). Four months after Burkhart's needle-stick injury, follow-up testing revealed that she'd been infected with HCV.

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Biting, spitting, and scratching

Your risk of exposure to blood and body fluids increases when patients bite, scratch, spit, and behave aggressively in other ways. Bites and conjunctival exposures to blood and body fluids are documented transmission routes for HIV, HCV, and other bloodborne pathogens.

Data on bite and scratch injuries from the Exposure Prevention Information Network (1993 to 2001) show that nurses experience the highest proportion of bite and scratch injuries (49%). In 34% of cases, a health care worker was trying to restrain a patient; in 20% of cases, the injury involved broken skin and bleeding. Fifty-one percent of injuries were to the arms; 37%, to the hands. In a 1996 study, 50% of bite injuries were caused by combative patients, 36% by children, and 11% by psychiatric patients.

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Handling combative patients safely

Burkhart, now a director of nursing, stresses the importance of using safety-engineered sharp devices. “If I'd been using a safety I.V. catheter, my needle stick and HCV infection would have been prevented. After my stick, my hospital completely converted over to safety devices.” She offers these additional tips:

  • Always use personal protective equipment, including goggles and face shields when appropriate. Because almost 90% of bites and scratches affect the arms or hands, gloves and long-sleeved gowns are particularly important.
  • If you're starting an I.V. line and a patient becomes agitated or hostile, immediately back the needle out of the vein and activate the safety mechanism. Then get assistance before starting any other procedures.
  • If a patient is suicidal or under the influence of drugs or alcohol, be sure to have at least two health care workers at the bedside for any procedures.
  • When you feel you're losing control of a situation or your presence is upsetting the patient, ask for assistance or have someone else take over (with assistance) and leave.
  • Don't get so caught up in the mechanics of care that you forget to pay attention to the patient's body language. Signs of high anxiety include darting eyes, staccato speech, and jerky body movements.
  • Figure


  • Before you perform any procedure, tell the patient what you'll be doing and why, and ask her to hold still. If she refuses the procedure, don't insist. If a patient pulls away or asks angrily, “Why are you doing this to me?” stop what you're doing and take time to explain. Burkhart says, “Sometimes patients are physically aggressive because they feel they've lost control of their situation. You can help them regain a sense of control by using a quiet voice and giving clear, concise information about what you're going to do and the expected outcome.”
  • Learn more about nonviolent crisis intervention by taking courses offered by such organizations as the Crisis Prevention Institute (
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Ippolito, G., et al.: “Simultaneous Infection with HIV and Hepatitis C Virus following Occupational Conjunctival Blood Exposure,” JAMA. 280(1):28, July 1, 1998.
Tereskerz, P., et al.: “Risk of HIV-1 Infection after Human Bites,” Lancet. 348(9040):1512, November 30, 1996.
Vidmar, L., et al.: “Transmission of HIV-1 by Human Bite,” Lancet. 347(9017):1762-1763, June 22, 1996.
© 2003 Lippincott Williams & Wilkins, Inc.