Epidemiology

The goal of caring for a violent patient is first to protect everyone involved and also to diagnose and treat important medical and psychiatric conditions (see the “Priority Actions” box). These goals are best achieved if warning signs of violence are recognized and the safest and most effective means of behavioral control are used.

The epidemiology of violence in the emergency department (ED) is inexact; past surveys suggest that as many as 80% of events are unreported.¹ Still, clear evidence indicates that most EDs experience violent patients routinely. Of greater concern, ED caregivers are often victims. More than 70% of ED nurses have reported being the victim of physical violence during their career.² The rate of assault on health care workers is 8 per 10,000, as compared with 2 per 10,000 for all private-sector industries, with the ED being one of the highest-risk areas.³

Violence may range from verbal threats to physical assault. Of reported events in one survey, 90% of cases involved the patient and 10% involved family or visitors. A few staff members may be confronted by former patients outside the ED or may become victims of stalking.

Nearly 60% of EDs in the United States have reported an armed threat on a staff member within 5 years.⁴ Weapons may be carried by patients, family members, visitors, or even staff members. Patients most likely to carry weapons include those with schizophrenia or paranoid ideation and individuals who have been the victims of gunshot wounds. Many violent patients are intoxicated with alcohol or drugs.

Violence threatens the career longevity of ED staff. Violent events should be regularly reported to police and hospital administration to raise awareness of this societal problem and to encourage safer practice environments.

How to Predict Violence

Violent behavior rarely erupts without warning. Risk factors for violence include an escalating psychiatric illness (e.g., schizophrenia, personality disorders, mania), alcohol and drug abuse, a previous history of violence, arrival at the ED in police custody, and male gender (Box 195.1). The use of risk factors to predict violent behavior has not been tested in cohorts of emergency physicians; psychiatrists have been only 60% accurate in predicting violence when using risk factors alone.⁵

Verbal and nonverbal clues provide evidence of impending violence. As patients become more agitated, the level of their voice may rise and their hand gestures may be more pronounced and expressive. Patients may exhibit restlessness on their gurney or may pace. Providers should trust their instincts when they become uncomfortable with an agitated patient. Emotional stress, prolonged waiting times, and gaps in communication create a provocative and unsupportive environment.

Interventions

Standardized methods should be used to confiscate concealed weapons. Metal detectors are used in some EDs and are recommended when possession of weapons by patients or visitors is frequent. For patients, a policy of routine undressing and gowning will minimize the likelihood of using hidden weapon when performed in an unbiased manner, regardless of the chief complaint.

Preparation of the examination room can facilitate safety. As many objects as possible should be removed from examination rooms that routinely hold violent or agitated patients. Panic buttons should be available for use by staff in any room where agitated patients are interviewed. Ideally, examination rooms should have two exits so that neither the clinician nor the patient feels trapped. Restless patients may become more agitated when physical outlets are constrained, so both the patient and caregiver must have unobstructed, rapid egress. Staff members should remove personal objects that could be used to cause injury by an assaultive patient. Such objects include neckties, large dangling earrings, and stethoscopes kept around the neck.

Deescalation Techniques

Early attention and preferential treatment may defuse anger born of impatience. If at triage, an agitated patient should be taken directly to a treatment room. Volatile patients should be removed from contact with other persons to decrease stimuli and avoid tension.

Essential violence prevention techniques include interpersonal skills that convey respect and unconditional positive regard. Improper behavior does not have to be accepted by ED staff, but no disrespect to the person should be conveyed. Start by stating explicitly that “this emergency department is a safe place” and the patient will be cared for well. Make the patient physically comfortable. Offer food or drink both as an expression of caring and also to minimize irritability. Do not surprise the patient; announce your arrival with a knock on the door or a verbal greeting. Ask permission to touch the patient before doing so. When speaking to the patient, use a calm and soothing voice. Listen attentively and intuitively to overt words and actions while attempting to assess underlying motivations and driving impulses. Additionally, listening will reassure the patient, and it is a caring act. Use straightforward speech and always be honest.

Even as the person receives genuine, unconditional care, boundaries of acceptable behavior should be set and consequences must be consistent. Inappropriate behavior is unacceptable and patients should be told the ramifications. Some patients do not have the ability to cope with the stressful environment and become verbally or physically uncontrolled. Other patients respond to limit setting and rules. Most require anxiolytics. Early use of a low-dose benzodiazepine often helps patients cope and prevents later escalation. No action or treatment should ever be punitive. Chemical restraint, physical restraint, seclusion, and arrest are predictable consequences of inappropriate behavior, but early medical therapy is compassionate and usually prevents escalation.

Health care providers can escalate a patient’s behavior through their own instinctive, impulsive, natural human conduct.⁶ Anger or frustration should never inspire unprofessional behavior or decisions. Physical and emotional distance may minimize the emotional reactions. A buffer zone of at least four body widths between the provider and the patient is recommended.

When a caregiver feels the urge to shout, argue, or engage in a staring match with a patient, the caregiver is inadvertently reciprocating the violence of the patient. Controlling these natural instincts is an important professional skill that for many requires cultivation and practice. Other caregivers must cultivate a willingness to engage sufficiently because their instinct is to disengage. Too much distance can be equally detrimental. Finding the optimal emotional and physical distance to be effective and caring is a practiced art. If caregivers are too distant, they will be aloof, condescending, or disengaged. If caregivers are too close, they may become stimulated by the patient’s disorder. The right distance enables control and effectiveness.

Medical Clearance

Agitated or violent behavior is frequently caused by treatable medical conditions. Reversible causes of altered mental status and violent behavior should be considered during the initial evaluation of the patient. Such causes include substance abuse, intoxication, glucose abnormalities, hypoxia, trauma, abnormal temperature (hypothermia and hyperthermia), infection, stroke, hypertension, and seizures. Older adults with new agitated behavior, delirium, or psychosis should undergo an extensive inpatient medical evaluation before a first-time psychiatric unit admission.

Treatment