The agitated patient: Steps to take, how to stay safe

,; ,

Applied Evidence

The agitated patient: Steps to take, how to stay safe

J Fam Pract. 2018 March;67(3):136-141,144-147

PDF Download

References

1. Occupational Safety and Health Administration. Workplace violence in healthcare: understanding the challenge. December 2015. Available at: https://www.osha.gov/Publications/OSHA3826.pdf. Accessed February 8, 2018.

2. Occupational Safety and Health Administration. Guidelines for preventing workplace violence for healthcare and social service workers. 2016. Available at: https://www.osha.gov/Publications/osha3148.pdf. Accessed February 8, 2017.

3. Mortimer DS, Berg W. Agitation in patients recovering from traumatic brain injury: nursing management. J Neurosci Nurs. 2017;49:25-30.

4. Wilson MP, Nordstrom K, Vilke GM. The agitated patient in the emergency department. Curr Emerg Hosp Med Rep. 2015;3:188-194.

5. Bogner JA, Corrigan JD, Bode RK, et al. Rating scale analysis of the Agitated Behavior Scale. J Head Trauma Rehabil. 2000;15:656-669.

6. Gaynes BN, Brown CL, Lux LJ, et al. Preventing and de-escalating aggressive behavior among adult psychiatric patients: a systematic review of the evidence. Psychiatr Serv. 2017;68:819-831.

7. Nordstrom K, Zun LS, Wilson MP, et al. Medical evaluation and triage of the agitated patient: consensus statement of the American Association for Emergency Psychiatry Project Beta Medical Evaluation Workgroup. West J Emerg Med. 2012;13:3-10.

8. Sands N. Mental health triage: towards a model for nursing practice. J Psychiatr Ment Health Nurs. 2007;14:243-249.

9. Sim MG, Wain T, Khong E. Aggressive behaviour - prevention and management in the general practice environment. Aust Fam Physician. 2011;40:866-872.

10. Swift RH, Harrigan EP, Cappelleri JC, et al. Validation of the behavioural activity rating scale (BARS): a novel measure of activity in agitated patients. J Psychiatr Res. 2002;36:87-95.

11. Ng J, Pan CX, Geube A, et al. Your postop patient is confused and agitated—next steps? J Fam Pract. 2015;64:361-366.

12. Vorderwülbecke F, Feistle M, Mehring M, et al. Aggression and violence against primary care physicians—a nationwide questionnaire survey. Dtsch Arztebl Int. 2015;112:159-165.

13. Bell HS. Curbside consultation—a potentially violent patient? Am Fam Physician. 2000;61:2237-2238.

14. Taylor H. Patient violence against clinicians: managing the risk. Innov Clin Neurosci. 2013;10:40-42.

15. Munsey C. How to stay safe in practice. APA Monitor. 2008;39:36.

16. Reus VI, Fochtmann LJ, Eyler AE, et al. The American Psychiatric Association practice guideline on the use of antipsychotics to treat agitation or psychosis in patients with dementia. Am J Psychiatry. 2016;173:543-546.

17. Accreditation Council for Graduate Medical Education. ACGME Program Requirements for Graduate Medical Education in Family Medicine. Revised July 1, 2017. Available at: http://www.acgme.org/Portals/0/PFAssets/ProgramRequirements/120_family_medicine_2017-07-01.pdf . Accessed October 30, 2017.

18. Phillips JP. Workplace violence against health care workers in the United States. N Engl J Med. 2016;374:1661-1669.

19. Hanson GC, Perrin NA, Moss H, et al. Workplace violence against homecare workers and its relationship with workers health outcomes: a cross-sectional study. BMC Public Health. 2015;15:11.

20. Unwin BK, Tatum PE 3rd. House calls. Am Fam Physician. 2011;83:925-938.

21. Victor P. Safety tips for home visits from a veteran NYC social worker. National Association of Social Workers, New York. Available at: http://www.naswnyc.org/?489. Accessed June 1, 2017.

22. Kansagra SM, Rao SR, Sullivan AF, et al. A survey of workplace violence across 65 U.S. emergency departments. Acad Emerg Med. 2008;15:1268-1274.

23. Meagher D, Agar MR, Teodorczuk A. Debate article: antipsychotic medications are clinically useful for the treatment of delirium. Int J Geriatr Psychiatry. 2017 Jul 30. doi: 10.1002/gps.4759. [Epub ahead of print].

24. Lanctot N, Guay S. The aftermath of workplace violence among healthcare workers: a systematic literature review of the consequences. Aggress Violent Behav. 2014;19:492-501.

25. Edward KL, Stephenson J, Ousey K, et al. A systematic review and meta-analysis of factors that relate to aggression perpetrated against nurses by patients/relatives or staff. J Clin Nurs. 2016;25:289-299.

26. Laposa JM, Alden LE. Posttraumatic stress disorder in the emergency room: exploration of a cognitive model. Behav Res Ther. 2003;41:49-65.

27. Mills LD, Mills TJ. Symptoms of post-traumatic stress disorder among emergency medicine residents. J Emerg Med. 2005;28:1-4.

28. Laposa JM, Alden LE, Fullerton LM. Work stress and posttraumatic stress disorder in ED nurses/personnel. J Emerg Nurs. 2003;29:23-28.

29. Occupational Safety and Health Administration. Workplace violence in healthcare: understanding the challenge. 2015. Available at: https://www.osha.gov/Publications/OSHA3826.pdf. Accessed June 1, 2017.

30. Zafar W, Khan UR, Siddiqui SA, et al. Workplace violence and self-reported psychological health: coping with post-traumatic stress, mental distress, and burnout among physicians working in the emergency departments compared to other specialties in Pakistan. J Emerg Med. 2016;50:167-177.

31. de Boer J, Lok A, Van’t Verlaat E, et al. Work-related critical incidents in hospital-based health care providers and the risk of post-traumatic stress symptoms, anxiety, and depression: a meta-analysis. Soc Sci Med. 2011;73:316-326.

32. Shah L, Annamalai J, Aye SN, et al. Key components and strategies utilized by nurses for de-escalation of aggression in psychiatric in-patients: a systematic review protocol. JBI Database Syst Rev Implement Rep. 2016;14:109-118.

33. Rose S, Bisson J, Churchill R, et al. Psychological debriefing for preventing post traumatic stress disorder (PTSD). Cochrane Database Syst Rev. 2002;(2):CD000560.

34. Tuckey MR, Scott JE. Group critical incident stress debriefing with emergency services personnel: a randomized controlled trial. Anxiety Stress Coping. 2014;27:38-54.

35. Pack MJ. Critical incident stress management: a review of the literature with implications for social work. Int Soc Work. 2012;56: 608-627.

36. Forneris CA, Gartlehner G, Brownley KA, et al. Interventions to prevent post-traumatic stress disorder: a systematic review. Am J Prev Med. 2013;44:635-650.

37. Warner CH, Warner CM, Appenzeller GN, et al. Identifying and managing posttraumatic stress disorder. Am Fam Physician. 2013;88:827-834.

38. Johnson B. Code lavender: initiating holistic rapid response at the Cleveland Clinic. Beginnings. 2014;34:10-11.

De-escalating the situation. General tenets of de-escalation apply across practice settings. Among them:

Stay calm. Avoid aggressive postures and prolonged eye contact.
Be nonconfrontational. Acknowledge the patient’s frustration/perceptions and ask open-ended questions.
Assess available resources such as clinical team members, family members, and silent alarms.
Manage the situation and the patient’s underlying issues/diagnoses. This includes mobilizing other patients to avoid collateral damage and exploring solutions with the patient.

For more on de-escalation tools, see (TABLE 3^4,6,9,11).

Your setting matters. It’s worth noting that the settings in which clinicians practice greatly influence the resources available to de-escalate a situation and ensure the safety of the patient and others.⁷ The review that follows provides some issues—and tips—that are unique to different practice settings.

Ambulatory settings

Sim and colleagues⁹ noted that aggressive behavior in the general practice setting may stem not only from factors related to the patient’s own physical or psychological discomfort, but from patients feeling that they are being treated unfairly, whether it be because of wait times, uncomfortable waiting conditions, or something else. A number of international studies have shown high rates of abuse toward FPs.^9,12 Of 831 primary care physicians surveyed in a German study, close to three-quarters indicated that within the last year, they had experienced aggression (ranging from verbal abuse and threats to physical violence and property damage) from a patient.¹² This statistic increased to 91% when it included the length of their career.

Between 2011 and 2013, 7 out of 10 workplace assaults occurred in health care and social service settings.

Bell¹³ suggests that physicians be aware that transference and countertransference issues are often at play when dealing with hostile or potentially violent patients. Suggestions to prevent aggression include some practice-level approaches (eg, providing waiting room distractions, making patients aware of potential delays), as well as being aware of nonverbal cues suggesting increased agitation (eg, clenched fists, crossed arms, chin thrusts, finger pointing).⁹

Group practice

An FP who practices with other health care providers and clinical staff has a built-in team that can assist with de-escalation. When meeting with a patient who has a history of violence or agitation in an exam room or office, try to ensure that you can get to an exit quickly if necessary. Also, alert staff to any concerns, and have a system for at least one staff member to check in periodically during the visit.

It is also helpful to develop an evacuation plan and create a “panic room” or “safe zone” for emergencies.^14,15 Such a space may be nothing more than an area or room for staff to gather. It should have access to the police or other emergency services via a land and/or cell phone line.

Solo practice

If you practice alone, institute safeguards whereby a colleague (at a different practice, building, or location) can be alerted if concerns arise. In addition, consider the following precautions: locking the door when alone after hours, screening potential patients, having a way to call for help (keep the number for the local police station and ED readily available), prohibiting potential weapons (as some states allow them to be carried), and learning some form of self-defense.¹⁵

Ensure that agitated patients are not positioned between you and the exit so that you can quickly escape if necessary.

Resources exist that offer guidelines for developing policies and procedures, checklists, and sample incident forms (eg, the International Association for Healthcare Security and Safety; iahss.org). Other organizations that can help with the development of a preparedness plan include the Occupational Safety and Health Administration (https://www.osha.gov/SLTC/workplaceviolence/evaluation.html), the Department of Homeland Security (https://www.dhs.gov/sites/default/files/publications/ISC%20Violence%20in%20%20the%20Federal%20Workplace%20Guide%20April%202013.pdf), and The Joint Commission (https://www.jointcommission.org/workplace_violence.aspx).