Epidemiology of unarmed threats in the emergency department

One year cumulative incidence and risk factors associated with workplace violence within the ambulance service in a Swedish region: a prospective cohort study

OBJECTIVE

To measure the 1 year cumulative incidence of and analyse the risk factors associated with workplace violence directed towards the ambulance service in a Swedish region.

DESIGN

Prospective cohort study.

SETTING

The ambulance services in Örebro County Council (Sweden) contain approximately 300 000 inhabitants.

PARTICIPANTS

All ambulance missions during the period of 12 months (n=28 640) were assessed.

PRIMARY AND SECONDARY OUTCOME MEASURES

The primary outcome measure was workplace violence together with the associated risk factors.

RESULTS

The 1 year cumulative incidence of workplace violence within the ambulance service was 0.7%. Non-physical violence was most common. There was an increased odds for violence when the patient was under the influence of alcohol or drugs or suffering from mental illness. There was an association between the dispatch categories intoxication, unconsciousness or mental health problems and workplace violence against ambulance personnel. The offenders were mostly men aged 18-29 and workplace violence was more likely to occur in public places.

CONCLUSIONS

The 1 year cumulative incidence of workplace violence within the regional ambulance service was low in comparison to that of previous research. The overall regression model had low explanatory power, indicating that the phenomenon is complex and that additional variables need to be taken into account when trying to predict when workplace violence will occur. Additional research is needed to fully understand why workplace violence within the ambulance service occurs and how to mitigate such situations.

Analysis of Violent Incidents at Five Regional and Remote Australian Emergency Departments: A Retrospective Descriptive Study

Introduction

Workplace violence is endemic, destructive, and escalating in frequency and severity in healthcare. There is a paucity of research on workplace violence in regional and remote hospital emergency departments (EDs).

Objective

The aim of this study was to identify the perpetrator and situational characteristics associated with violent incidents in the ED across five regional and remote Australian sites.

Method

This study audited hospital summary data, incident reports, and medical records for a 12-month period in 2018 to examine the perpetrator and situational characteristics of workplace violence incidents in five regional and remote Australian EDs.

Results

Violent incidents were evenly spread throughout the week and across shifts. Most incidents were triaged as urgent, occurred within the first 4 hr, and had multidisciplinary involvement. Almost one in every six incidents resulted in an injury. Perpetrators of violence were predominantly young and middle-aged males and almost always patients, with most presenting with mental and behavioral disorders, or psychoactive substance use.

Conclusions

Understanding the characteristics of perpetrators of violence can help in seeking to tailor interventions to reduce further violent behaviors. These findings carry implications for optimizing patient care, staff safety and resource management.

Perpetrator and situational characteristics associated with security alerts in regional Australian emergency departments

Background

Workplace violence is a regular feature of emergency departments (ED) and reported to be increasing in frequency and severity. There is a paucity of data from regional EDs in Australia. The aim of this study was to identify the perpetrator and situational characteristics associated with security alerts in regional emergency departments.

Methods

This retrospective descriptive study was conducted in two regional Australian hospital EDs. All incident reports, hospital summary spreadsheets, and patient medical records associated with a security alert over a two-year period (2017 - 2019) were included. The situational and perpetrator characteristics associated with security alerts in the ED were recorded.

Results

One hundred fifty-one incidents were reported in the two-year period. Incidents most frequently occurred on late shifts and in an ED cubicle. Most incidents included multiple disciplines such as ED staff and paramedics, police and psychiatric services. One hundred twenty-five incidents had sufficient information to categorise the perpetrators. Mental and behavioural disorders (MBD) were the most frequent perpetrator characteristic present in security alerts (n = 102, 81.6%) and were associated with increased severity of incidents. MBDs other than psychoactive substance use (PSU) were associated with 59.2% (n = 74) of incidents and 66.7% (n = 18) of injuries. PSU was associated with 42.4% (n = 53) of incidents. Following PSU and MBDs other than PSU, repeat perpetrators were the next most prominent perpetrator category (24.8% n = 31) and were almost always associated with an MBD (93.5% n = 29).

Conclusions

Violence incidents in the ED are often complex, patients present with multiple issues and are managed across disciplines. Interventions need to extend from one size fits all approaches to targeting specific perpetrator groups. Since MBDs are one of the most significant perpetrator factors, interventions focussing on this characteristic are needed to address workplace violence in EDs.

Factors associated with paediatric and adolescent Emergency Department presentations involving acute behavioural disturbance events

AIM

Studies reporting factors associated with paediatric/adolescent acute behavioural disturbance (ABD) in the Emergency Department (ED) are lacking. The aim of this study is to describe paediatric/adolescent ED presentations involving ABD events.

METHODS

A retrospective chart review of presentations involving ABD events, identified via hospital security log, to a tertiary referral paediatric ED during the 2017 calendar year. Data reported included: cause of presentation, use of sedation/physical restraint, ED/inpatient length of stay (LOS) and time requiring security staff presence.

RESULTS

From 280 reported ABD episodes 26 were excluded leaving 254 events involving 150 patients across 233 presentations of whom 38 (25.3%) presented on multiple occasions. Median age was 14 years (interquartile range (IQR): 13-16), 132/233 (56.7%) were female, 167/233 (71.7%) primary mental health complaints, 30/233 (12.9%) deliberate self-harm, 18/233 (7.7%) deliberate self-poisoning, 11/233 (4.7%) acute intoxication and 7/233 (3.0%) other. Transport to hospital involved police and ambulance in 124/233 (53.2%), ambulance only 71/233 (30.5%), police only 16/233 (6.9%), relative or carer 20/233 (8.6%), with self-presentation in 2/233 (0.9%). Sedation or physical restraint was used in 81/233 (34.8%), both 38/233 (16.3%), restraint only 26/233 (11.2%) and sedation only 17/234 (7.3%). Intra-muscular droperidol accounted for 57/96 (59.4%) sedations, IM/IV benzodiazepines 15/96 (15.6%), IM/IV ketamine 5/96 (5.2%) and 19/96 (19.8%) other. Discharge from ED occurred in 171/233 (73.1%) with median ED LOS 5.1 h (IQR: 3.5-7.7) and median hospital LOS 92.4 h (IQR: 47.5-273.4) for those admitted. The Mental Health Act was utilised in 183/233 (78.5%) presentations. Median security staff time requirement per presentation was 2.4 h (IQR: 1.0-3.9).

CONCLUSIONS

Paediatric/adolescent ED presentations involving ABD are primarily due to mental health complaints. Less than half require the use of sedation/physical restraint. Time requiring security staff involvement is a significant resource consumption.

Antipsychotics and Risk of Neuroleptic Malignant Syndrome: A Population-Based Cohort and Case-Crossover Study

BACKGROUND

Neuroleptic malignant syndrome (NMS) is a rare and acute adverse drug reaction associated with antipsychotic therapy. However, few data on the risk and epidemiology of NMS are available.

OBJECTIVES

The aim of this study was to ascertain the incidence risk and all-cause mortality of NMS associated with antipsychotic use, and to assess the association of recent antipsychotic exposure and NMS.

METHODS

We did a population-based study using data from the Hong Kong Hospital Authority's Clinical Data Analysis and Reporting System database. Cases had a first diagnosis of NMS between 1 January 2004 and 30 November 2017. A case-crossover analysis was used to compare antipsychotic exposure 30 days before the diagnosis of NMS (index date) and a reference period 91-120 days before the index date. To adjust for potential time trends in antipsychotic exposure, we sampled from cases to match current cases and future cases, and further adjusted for select medications and acute medical conditions.

RESULTS

297,647 patients were prescribed antipsychotics, and the incidence risk of NMS was 0.11%. Of the 336 cases included in the case-crossover analysis, 20 (6%) died within 30 days after the index date; only one case had NMS recorded as the primary cause of death. When compared with the reference period, cases were more frequently prescribed multiple antipsychotics (15.8% vs 26.8%; standardized mean difference [SMD] 0.27) and short-acting injectable antipsychotics (3.6% vs 13.7%; SMD 0.37) during the 30 days prior to the diagnosis of NMS. Odds ratios for antipsychotic exposure in the case-crossover, case-crossover adjusted for time trend, and case-crossover adjusted for time trend and potential confounders analysis were 8.00 (95% confidence interval 3.42-18.69), 5.88 (2.46-14.04), and 4.77 (1.95-11.66).

CONCLUSIONS

Our results suggest that recent use of antipsychotics is associated with NMS. Although a case-only design inherently controls for confounding by time-invariant factors, residual confounding by acute medical conditions with similar presentations to NMS cannot be fully excluded.

Prevalence of the use of chemical restraint in the management of challenging behaviours associated with adult mental health conditions: A meta-synthesis

WHAT IS KNOWN ON THE SUBJECT?: The use of chemical restraint in emergency situations is to control aggression or violence to protect consumers and staff and is to be used as a last resort when all other behavioural control alternatives have been exhausted. Chemical restraint involves the use of medication. WHAT THE PAPER ADDS TO EXISTING KNOWLEDGE?: This is the first paper to systematically review the prevalence of the use of chemical restraint. The use of chemical restraint is common across emergency departments and acute psychiatric inpatient units worldwide. Consumers who are restrained are also likely to receive chemical restraint. The studies reviewed demonstrate that there is a need for more standardized data collection so that clearer comparisons can be made between healthcare settings and countries. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: Implications of practice include the need to report adverse events post-chemical restraint as these can deleteriously affect a person's physical health. Identification of and staff education about first-line management techniques before chemical restraint is administered are significant to reduce its use. ABSTRACT: Introduction Chemical restraint is used to manage uncontrolled aggression, agitation or violent behaviours of consumers with mental health disorders admitted to acute psychiatric or emergency settings. Aim This systematic review aimed to synthesize the international prevalence of chemical restraint for non-consenting adults. Method PsycINFO, CINAHL, MEDLINE/PubMed and Google Scholar databases were searched for peer-reviewed literature published between January 1996 and July 2018. This paper reports on data extracted from retrospective audits of chemical restraint practice. Results Forty-eight papers were included. The median prevalence of use of any restraint was 21.2% (25th% 8.0 to 75th% 36.3). Median prevalence of people who were chemically restrained, of all people restrained in any manner, was 43.1% (25th% 22.9% to 75th% 70.7%). Of all people admitted to facility(ies), the median prevalence of chemical restraint was 7.4% (25th% 2.7 to 75th% 17.6). There was no statistically significant difference in any prevalence measure considering healthcare setting or country. There was a significant decrease over the review period in the use of any restraint, including chemical restraint. Discussion and implications for practice This is the first known comprehensive meta-view of chemical restraint use worldwide, highlighting the need for standardized data collection to enable comparisons between healthcare settings and countries. Relevance statement There is an international imperative to reduce or eliminate the use of coercive practices, such as physical and chemical restraint, in mental health care. This study provides important information for mental health nursing by synthesizing the international prevalence of chemical restraint for non-consenting adults. This meta-view of the worldwide use of chemical restraint can inform ongoing efforts to reduce its use.

International research into 22 years of use of chemical restraint: An evidence overview

BACKGROUND

Chemical restraint (CR) (also known as rapid tranquilisation) is the forced (non-consenting) administration of medications to manage uncontrolled aggression, anxiety, or violence in people who are likely to cause harm to themselves or others. Our population of interest was adults with mental health disorders (with/without substance abuse). There has been a growing international movement over the past 22 years towards reducing/eliminating restrictive practices such as CR. It is appropriate to summarise the research that has been published over this time, identify trends and gaps in knowledge, and highlight areas for new research to inform practice.

AIMS

To undertake a comprehensive systematic search to identify, and describe, the volume and nature of primary international research into CR published since 1995.

METHODS

This paper reports the processes and overall findings of a systematic search for all available primary research on CR published between 1 January 1996 and 31 July 2018. It describes the current evidence base by hierarchy of evidence, country (ies) producing the research, CR definitions, study purpose, and outcome measures.

RESULTS

This review identified 311 relevant primary studies (21 RCTs; 46 non-controlled experimental or prospective observational studies; 77 cross-sectional studies; 69 retrospective studies; 67 opinion pieces, position or policy statements; and 31 qualitative studies). The USA, UK, and Australia contributed over half the research, whilst cross-country collaborations comprised 6% of it. The most common research settings comprised acute psychiatric wards (23.3%), general psychiatric wards (21.6%), and general hospital emergency departments (19.0%).

DISCUSSION

A key lesson learnt whilst compiling this database of research into CR was to ensure that all papers described non-consenting administration of medications to manage adults with uncontrolled aggression, anxiety, or violence. There were tensions in the literature between using effective CR without producing adverse events, and how to decide when CR was needed (compared with choosing non-chemical intervention for behavioural emergencies), respecting patients' dignity whilst safeguarding their safety, and preserving safe workplaces for staff, and care environments for other patients. The range of outcome measures suggests opportunities to standardise future research.

Analysis of patient related violence in a regional emergency department in Victoria, Australia

BACKGROUND

Emergency Departments (ED) have been identified as high-risk areas for patient related violence (PRV). The aim of the present study was to analyse recorded events of violence in a regional Victorian hospital ED, and examine the association these events had with substance abuse.

METHODS

A retrospective cohort study was undertaken to establish the incidence of PRV. Data were obtained from the hospital's incident management system, RiskMan, over a five and a half year period for all violent events categorised as Code Grey (CG) and Code Black (CB). The Haddon Matrix attached to the individual incident record was also reviewed.

RESULTS

A total of 548 violent events were analysed. The incident rate was 3.4 per 1000 ED presentations. Intoxication was the primary reason for violent escalations. There was no association between the frequency of CG events and the day of the week, month of admission, or shift of the day. Intoxicated men (110, 64.3%) were more likely to be the instigator of a violent event compared with intoxicated females (61, 35.7%) (OR 1.5, 95% CI: 1.19-2.02, p<0.001). A form of restraint, chemical, physical or both, was used in the majority of violent events (376, 68.6%).

CONCLUSION

This study demonstrated an increasing frequency of violent events in the regional ED. Rates of PRV were comparable to those reported in metropolitan hospitals. Intoxication was the most frequently observed underlying factor for PRV. Regional hospitals are in need of additional resources to instigate policies and procedures that will maximise patient and staff safety.

Intravenous Olanzapine for the Management of Agitation: Review of the Literature

Objective: The purpose of this review is to summarize the current evidence of the off-label use of intravenous (IV) olanzapine and discuss its risks versus benefits for the management of agitation. Data Sources: A literature search was conducted to gather relevant data regarding IV use of olanzapine for the management of acute agitation. PubMed, EMBASE, MEDLINE, and IPA were searched using the keywords and MESH terms: olanzapine, intravenous, IV, off-label, and agitation. Study Selection and Data Extraction: All case reports, and retrospective and prospective studies evaluating the efficacy and safety of IV olanzapine administration for agitation from January 2004 to December 2018 were analyzed. Data Synthesis: Doses from 2.5 to 10 mg given as an IV bolus (maximum dose of 30 mg/d) have been administered. Rescue medications such as droperidol or parenteral benzodiazepines are sometimes coadministered to assist with achieving adequate sedation. Prospective studies demonstrate efficacy similar to droperidol in achieving adequate sedation within 10 minutes and similar time to onset of sedation. Rates of respiratory depression and airway obstruction are low and similar to that of comparative agents, including intramuscular olanzapine. Relevance to Patient Care and Clinical Practice: This review evaluated the off-label use of IV olanzapine to manage agitation based on case reports, and retrospective and prospective data. Conclusions: The use of IV olanzapine remains controversial in the absence of clear evidence evaluating safety and efficacy. Future studies are warranted comparing IV olanzapine with more commonly utilized and Food and Drug Administration–approved treatment modalities for acute agitation in the emergency department and other settings.

Impact of acutely behavioural disturbed patients in the emergency department: A prospective observational study

OBJECTIVE

The present study describes patients with acute behavioural disturbance presenting to the ED, the impact they have on the department and any complications that occur.

METHODS

We performed a prospective observational study of adult patients (>17 years old) requiring parenteral sedation for acute behavioural disturbance over a 13 month period. Demographic data, mode of arrival, indication, drug type and dosing used for sedation were collected. Departmental data were recorded including the staff type and numbers involved and the condition of the department. The main outcomes were complications from sedative medication and injury sustained to patients or staff.

RESULTS

Over the study period 173 patients met inclusion criteria, the majority (n = 104, 60%) were men with a mean age of 38.5 years (standard deviation 14.4); 51% of patients had more than one indication for sedation (n = 89), the commonest being mental health related plus drug intoxication (n = 30, 33.7%). Intoxication was frequently from either alcohol (n = 62, 47%) or methamphetamine (n = 41, 31%). The median number of staff involved was 10 (interquartile range 8-12). Staff members received an injury in 12% (n = 20) of sedations, with only 1% (n = 2) of patients receiving any physical injury; 12% (n = 20) had a minor complication from the sedation medication. No patient had any major complication (apnoea, intubation, arrhythmias or cardiac arrest).

CONCLUSION

Patients with acute behavioural disturbance often have a history of mental illnesses and are commonly intoxicated. These patients have impacts on healthcare resources and pose risks to staff safety, but significant complications to patients do not occur frequently.

Economic Evaluation of Midazolam-Droperidol Combination, Versus Droperidol or Olanzapine for the Management of Acute Agitation in the Emergency Department: A Within-Trial Analysis

BACKGROUND

The combination of midazolam and droperidol has proven superior to droperidol or olanzapine monotherapy in the management of acute agitation in emergency departments (EDs).

OBJECTIVE

This is the first economic analysis to evaluate the cost-benefit and cost effectiveness of the midazolam-droperidol combination compared with droperidol or olanzapine for the management of acute agitation in EDs.

METHODS

This analysis used data derived from a randomised, controlled, double-blind clinical trial conducted in two metropolitan Australian EDs between October 2014 and August 2015. The economic evaluation was from the perspective of Australian public hospital EDs. The main outcomes included agitation management time and the agitation-free time gained. Sensitivity analyses were undertaken.

RESULTS

The midazolam-droperidol combination was the least costly regimen (Australian dollars [AU$]46.25 per patient) compared with the droperidol and olanzapine groups (AU$92.18 and AU$110.45 per patient, respectively). The main cost driver for all groups was the cost of the labour required during the initial adequate sedation. The combination afforded an additional 10-13 min of mean agitation-free time gained, which can be translated to additional savings of AU$31.24-42.60 per patient compared with the droperidol and olanzapine groups. The benefit-cost ratio for the midazolam-droperidol combination was 12.2:1.0, or AU$122,000 in total benefit for every AU$10,000 spent on management of acute agitation. Sensitivity analyses over key variables indicated these results were robust.

CONCLUSIONS

The midazolam-droperidol combination may be a cost-saving and dominant cost-effective regimen for the treatment of acute agitation in EDs as it is more effective and less costly than either droperidol or olanzapine monotherapy.

Excited Delirium: A Systematic Review

OBJECTIVE

We aimed to clarify the definition, epidemiology, and pathophysiology of excited delirium syndrome (ExDS) and to summarize evidence-based treatment recommendations.

METHODS

We conducted a systematic literature search of MEDLINE, Ovid, Web of Knowledge, and Cochrane Library for articles published to March 18, 2017. We also searched the gray literature (Google Scholar) and official police or medical expert reports to complete specific epidemiologic data. Search results and full-text articles were independently assessed by two investigators and agreements between reviewers assessed with K statistics. We classified articles by study type, setting, and evidence level.

RESULTS

After reviewing the title and abstract of 3,604 references, we fully reviewed 284 potentially relevant references, from which 66 were selected for final review. Six contributed to the definition of ExDS, 24 to its epidemiology, 38 to its pathophysiology, and 27 to its management. The incidence of ExDS varies widely with medical or medicolegal context. Mortality is estimated to be as much as 8.3% to 16.5%. Patients are predominantly male. Male sex, young age, African-American race, and being overweight are independent risk factors. Pathophysiology hypotheses mostly implicate dopaminergic pathways. Most cases occur with psychostimulant use or among psychiatric patients or both. Proposed treatments are symptomatic, often with rapid sedation with benzodiazepines or antipsychotic agents. Ketamine is suggested as an alternative.

CONCLUSION

The overall quality of studies was poor. A universally recognized definition is lacking, remaining mostly syndromic and based on clinical subjective criteria. High mortality rate may be due to definition inconsistency and reporting bias. Our results suggest that ExDS is a real clinical entity that still kills people and that has probably specific mechanisms and risk factors. No comparative study has been performed to conclude whether one treatment approach is preferable to another in the case of ExDS.

Don't Label Me: A Qualitative Study of Patients' Perceptions and Experiences of Sedation During Behavioral Emergencies in the Emergency Department

OBJECTIVES

Behavioral emergencies are commonly seen in emergency departments (EDs). Acutely agitated patients can be difficult to manage and sedation may be required to decrease dangerous behavior and to ensure the safety of both the patient and the staff. While the experience of staff caring for this population has been reported, patients' experiences with their overall management remains unknown. We aimed to describe the perceptions and experiences of patients regarding the use of sedation during acute behavioral emergencies.

METHODS

Face-to-face semistructured interviews were conducted with adults aged 18 years or older, who had received parenteral sedative medication for the management of a behavioral emergency and were deemed capable to participate. The participants were asked about their experiences of receiving care in the ED during the episode and their perceptions of sedation. All interviews were transcribed verbatim and analyzed thematically.

RESULTS

Data saturation was reached after 13 interviews. Two broad themes emerged: trusting relationships and needs or wants following sedation. A trusting relationship is built through 1) confidence in care, 2) sedation as an appropriate treatment, 3) insight into own behavior, and 4) humane treatment. Four subthemes of needs or wants were identified: 1) empathy, 2) debrief, 3) addressing concerns, and 4) follow-up.

CONCLUSIONS

A trusting relationship was identified as crucial to minimize the negative impact of coercive measures used to manage behavioral emergencies. Participants expressed similar needs to patients presenting with medical problems. This study illustrates their needs for compassionate communication, adequate information about the treatment provided, and follow-up care.

Occupational Disappointment: Why Did I Even Become a Nurse?

INTRODUCTION

The aim of this study was to identify patterns of feelings and behavior of ED RNs who have experienced verbal workplace violence.

METHODS

Twenty-eight registered nurses from across the state of California were recruited. Data were collected, using in-depth interviews, and were recorded. The tapes were transcribed and analyzed using Glaserian grounded-theory methodology.

RESULTS

The main experiences of participants included occupational disappointment, peer support, lack of preparation by mandatory violence prevention classes, and unrealistic patient expectations.

DISCUSSION

These findings can help staff, managers, and future educators of ED RNs examine feelings, mitigate the profound and pervasive effects of VWPV, and improve patient care. Contribution to Emergency Practice.

Managing Acute Behavioural Disturbances in the Emergency Department Using the Environment, Policies and Practices: A Systematic Review

INTRODUCTION

Effective strategies for managing acute behavioural disturbances (ABDs) within emergency departments (EDs) are needed given their rising occurrence and negative impact on safety, psychological wellbeing, and staff turnover. Non-pharmacological interventions for ABD management generally fall into four categories: environmental modifications; policies; practice changes; and education. Our objective was to systematically review the efficacy of strategies for ABD management within EDs that involved changes to environment, architecture, policy and practice.

METHODS

We performed systematic searches of CINAHL Plus with Full Text, PsycINFO, MEDLINE, and EMBASE, as well as reference lists of relevant review articles to identify relevant studies published between January 1985 - April 2016. We included studies written in English, which reported management of behavioural disturbances in adults associated with the ED through the use of environmental modifiers (including seclusion, restraint, specialised rooms, architectural changes), policy, and practice-based interventions excepting education-only interventions. Efficacy outcomes of interest included incidence, severity, and duration of ABD, incidence of injuries, staff absenteeism, restraint use, restraint duration, and staff and patient perceptions. Two reviewers independently screened titles and abstracts, and assessed the relevancy and eligibility of studies based on full-text articles. Two authors independently appraised included studies. A narrative synthesis of findings was undertaken.

RESULTS

Studies reporting interventions for managing ABDs within the ED are limited in number and quality. The level of evidence for efficacy is low, requiring caution in conclusions. While there is preliminary evidence for environmental change in the form of specialised behavioural rooms, security upgrades and ED modifications, these are not supported by evidence from controlled studies. Many of these "common sense" environmental changes recommended in many guidelines have been widely implemented in EDs.

CONCLUSION

There is an unambiguous gap in the literature regarding the efficacy of interventions for ABD management in EDs involving environmental, policy or practice-based changes. With growing demand on EDs, and with increasing numbers of ABDs, identification of robust evidence-based interventions for safe and effective ABD management is vital.

Review article: Workplace violence in the emergency department: A systematic review and meta analysis

Patient or visitor perpetrated workplace violence (WPV) has been reported to be a common occurrence within the ED. No universal definition of violence or recording of such events exists. In addition ED staff are often reluctant to report violent incidents. The true incidence of WPV is therefore unclear. This systematic review aimed to quantify WPV in EDs. The association of WPV to drug and alcohol exposure was explored. The databases MEDLINE, Embase, PsycInfo and the Cochrane Library were searched from their commencement to 10 March 2016. MeSH terms and text words for ED, violence and aggression were combined. A meta-analysis was conducted on the primary outcome variable-proportion of violent patients among total ED presentations. A secondary meta-analysis used studies reporting on proportion of drug and alcohol affected patients occurring within the violent population. The search yielded a total of 8720 records. A total of 7235 were unique and underwent abstract screening. A total of 22 studies were deemed relevant according to inclusion and exclusion criteria. Retrospective study design predominated, analysing mainly security records and incident reports. The rates of violence from individual studies ranged from 1 incident to 172 incidents per 10 000 presentations. The pooled incidence suggests there are 36 violent patients for every 10 000 presentations to the ED (95% confidence interval 0.0030-0.0043). WPV in the ED was commonly reported. There is wide heterogeneity across the study methodology, definitions and rates. More standardised recording and reporting may inform preventive measures and highlight effective management strategies.

Chemical agents for the sedation of agitated patients in the ED: a systematic review

OBJECTIVE

Chemical agents commonly used to sedate agitated patients in the emergency department include benzodiazepines, antipsychotics, or a combination of the 2 classes. Our objective was to determine if a class or combination therapy is (1) more effective, as measured by the proportion sedated at 15-20 minutes and the need for repeat sedation, and (2) safer, as measured by the proportion of reported adverse events.

METHODS

Systematic literature review and meta-analysis of studies comparing 2 or more chemical agents for sedation of agitated patients in the emergency department were carried out in PubMed, PsycINFO, Embase, and the Cochrane database. Meta-analyses for pairwise comparisons of drug class (benzodiazepine, antipsychotic, or combination) were carried out for each outcome: proportion sedated, need for repeat sedation, and adverse events.

RESULTS

Seven studies with 1135 patients were included. At 15-20 minutes, the proportion of patients sedated was greater with combination therapy than benzodiazepines alone (risk ratio [RR] = 1.31, P < .0001). Antipsychotics and combination agents required significantly less repeat sedations than benzodiazepines alone (RR = 0.49, P < .0001 and RR = 0.64, P = .002). There was significant heterogeneity in adverse event data, with respiratory system adverse events (desaturation, and need for airway and ventilatory support) being the most commonly reported. Benzodiazepines were associated with a higher incidence of adverse events than antipsychotics or combination therapy.

CONCLUSION

Combination therapy sedated a greater proportion of patients at 15-20 minutes than benzodiazepines alone. Antipsychotics and combination therapy were more effective, requiring less repeat doses for sedation than benzodiazepines. The risk of any adverse event was higher with benzodiazepines.

Rates of workplace aggression in the emergency department and nurses' perceptions of this challenging behaviour: A multimethod study

INTRODUCTION

Over the last 10 years, the rate of people presenting with challenging behaviour to emergency departments (EDs) has increased and is recognised as a frequent occurrence facing clinicians today. Challenging behaviour often includes verbal aggression, physical aggression, intimidation and destruction of property.

AIM

The aim of this research was to (i) identify the characteristics and patterns of ED-reported incidents of challenging behaviour and (ii) explore emergency nurses' perceptions of caring for patients displaying challenging behaviour.

METHODS

This was a multi-method study conducted across two metropolitan Sydney district hospitals. Phase 1 involved a 12-month review of the hospital's incident management database. Phase 2 involved a survey of emergency nurses' perceptions of caring for patients displaying challenging behaviour.

RESULTS

Over 12 months there were 34 incidents of aggression documented and the perpetrators were often male (n=18; 53.0%). The average age was 34.5 years. The majority of reported incidents (n=33; 90.1%) involved intimidation, verbal assault and threatening behaviour. The median time between patient arrival and incident was 109.5min (IQR 192min). The median length of stay for patients was 302.5min (IQR 479min). There was no statistical difference between day of arrival and time of actual incident (t-test p=0.235), length of stay (t-test p=0.963) or ED arrival to incident time (t-test p=0.337). The survey (n=53; 66.2%) identified the average ED experience was 12.2 years (SD 9.8 years). All participants surveyed had experienced verbal abuse and/or physical abuse. Participants (n=52) ranked being spat at (n=37; 71.1%) the most difficult to manage. Qualitative survey open-ended comments were analysed and organised thematically.

THEMATIC ANALYSIS

The survey identified three themes which were (i) increasing security, (ii) open access and (iii) rostering imbalance.

CONCLUSION

The study provides insight into emergency nurses' reported perceptions of patients who display challenging behaviour. All emergency nurse participants reported being regularly exposed to challenging behaviour and this involved both physical and verbal abuse. This was in contrast to a low incident hospital reporting rate. ED clinicians need to be better supported with targeted educational programmes, appropriate ED architecture and reporting mechanism that are not onerous.

Challenges of managing pediatric mental health crises in the emergency department

Children with mental health problems are increasingly being evaluated and treated in pediatric clinical settings. This article focuses on the epidemiology, evaluation, and management of the 2 most common pediatric mental health emergencies, suicidal and homicidal/aggressive patients, as well as the equally challenging population of children with autism or other developmental disabilities.

Feasibility and need for violence risk screening at triage: an exploration of clinical processes and public perceptions in one Australian emergency department

BACKGROUND

Research on patient aggression in hospital emergency departments supports the development of a systematic process for identifying individuals at risk of becoming violent. The feasibility and community acceptance of this approach is unknown. In this study, we determine the feasibility and explore the need for a violence risk screening process in one Australian emergency department.

METHOD

We used a descriptive exploratory design that involved semistructured interviews and observations of practice. The setting was an adult tertiary referral hospital and major trauma centre located in Melbourne, Australia. A convenience sample of nine triage nurses were observed assessing patients to explore how risk screening was undertaken in practice. Semistructured interviews were conducted with emergency department (ED) service users (N=19) to explore community perspectives on the process of violence risk screening.

RESULTS

Observations of practice revealed that nurses used observed and reported information to screen for potential risk of violence rather than employing a direct questioning approach. Interviews with community members in the emergency department waiting room highlighted a public expectation that nurses screen and accurately identify patients at risk of violence on arrival to the ED.

CONCLUSIONS

Consistent with local prevalence data, public expectations of emergency care supported the need to adopt a uniform approach to identifying people at risk of becoming violent on arrival to hospital. Observations of triage nurses interactions with patients revealed that the existing violence risk screening approach was not being consistently used by triage nurses. An integrated approach to determining violence risk during triage assessment is recommended.

Pediatric mental health emergencies and special health care needs

Children with mental health problems are increasingly being evaluated and treated by both pediatric primary care and pediatric emergency physicians. This article focuses on the epidemiology, evaluation, and management of the 2 most common pediatric mental health emergencies, suicidal and homicidal/aggressive patients, as well as the equally challenging population of children with autism or other developmental disabilities.

Expectations of Care, Perceived Safety, and Anxiety following Acute Behavioural Disturbance in the Emergency Department

Objective. We explored perspectives of emergency department users (patients and visitors) regarding the management of acute behavioural disturbances in the emergency department and whether these disturbances influenced their levels of anxiety. Methods. Emergency department patients and visitors were surveyed using the State-Trait Anxiety Inventory, and a purpose-designed questionnaire and semistructured interview. The main outcome measures were themes that emerged from the questionnaires, the interviews, and scores from the state component of the State-Trait Anxiety Inventory. Results. 70 participants were recruited. Users of the emergency department preferred behaviourally disturbed people be managed in a separate area from the general emergency department population so that the disturbance was inaudible (n = 32) and out of view (n = 40). The state anxiety levels of those that witnessed an acute behavioural disturbance were within the normal range and did not differ to that of ED patients that were not present during such a disturbance (median, control = 37, Code Grey = 33). Conclusions. Behavioural disturbances in the emergency department do not provoke anxiety in other users. However, there is a preference that such disturbances be managed out of visual and audible range. Innovative design features may be required to achieve this.

A retrospective analysis of intramuscular haloperidol and intramuscular olanzapine in the treatment of agitation in drug- and alcohol-using patients

OBJECTIVE

The treatment of agitation in drug- and alcohol-using emergency patients is understudied.

METHOD

We performed a retrospective chart review of 105 agitated emergency department patients who received either intramuscular (IM) haloperidol or IM olanzapine, comparing prescribing patterns, level of agitation, response to treatment and side effects in patients positive for drugs or alcohol [D/A(+)] and patients negative for drugs or alcohol [(D/A(-)].

RESULTS

The haloperidol-benzodiazepine combination was the most frequently prescribed treatment in both groups, although alcohol(+) status biased clinicians toward using haloperidol alone. Overall, D/A(+) and D/A(-) patients responded to the initial intervention at similar rates, although D/A(+) patients were rated as more agitated and had more posttreatment sedation than D/A(-) patients. In D/A(+) patients, haloperidol+benzodiazepine and IM olanzapine performed better than haloperidol alone. There were no serious adverse events with any treatment.

CONCLUSION

Findings support the generalization of efficacy data from more rarified agitated samples to populations with high rates of substance use and highlight the need for prospective, inclusive, randomized trials comparing the commonly used haloperidol-benzodiazepine combination with newer injectable antipsychotics.

Randomized Clinical Trial Comparing Intravenous Midazolam and Droperidol for Sedation of the Acutely Agitated Patient in the Emergency Department

STUDY OBJECTIVE

We compare intravenous midazolam and droperidol for the onset of sedation of acutely agitated patients in the emergency department (ED).

METHODS

This was a double-blind, randomized, clinical trial set in the ED of a university teaching hospital. Subjects were adults, acutely agitated because of mental illness, intoxication, or both, who received midazolam or droperidol, 5 mg intravenously, every 5 minutes until sedated. We analyzed time to sedation using survival analysis, median times to sedation, and proportions sedated at 5 and 10 minutes.

RESULTS

Seventy-four patients received midazolam; 79 patients, droperidol. Survival analysis showed no difference in time to sedation (hazard ratio 0.86; 95% confidence interval [CI] 0.61 to 1.23), P=.42. Median time to sedation was 6.5 minutes for midazolam (median dose 5 mg) and 8 minutes for droperidol (median dose 10 mg), P=.075 (effect size 1.5 minutes; 95% CI 0 to 4 minutes). At 5 minutes, 33 of 74 (44.6%) patients from the midazolam group were adequately sedated compared with 13 of 79 (16.5%) patients from the droperidol group, a difference of 28.1% (95% CI 12.9% to 43.4%; P<.001). By 10 minutes, 41 of 74 (55.4%) from the midazolam group were sedated compared to 42 of 79 (53.2%) from droperidol, a difference of 2.2% (95% CI -14.9% to 19.3%; P=.91). Eleven adverse events occurred in the midazolam group and 10 in the droperidol group. Three patients required active airway management (3 patients with assisted ventilation and 1 patient intubated); all received midazolam.

CONCLUSION

There is no difference in onset of adequate sedation of agitated patients using midazolam or droperidol. Patients sedated with midazolam may have an increased need for active airway management.

Violence in emergency departments: under‐reported, unconstrained, and unconscionable

Violence in emergency departments (EDs) has reached a level that requires concerted action and a shift in attitude - to eradicate a socially and professionally unacceptable peril. In some EDs, violence is a daily occurrence, with nursing staff reporting several episodes each week. Increased societal violence results in an increase in presentations for injury. Anger and pain and the influence of alcohol and drugs contribute to violence spilling over into the ED. The well known "system blockers" to reporting adverse events in hospitals result in under-reporting of violence episodes. Violence in EDs is different from other forms of violence - the aggressor has no overt dominance or power status and, in a setting of care, victims are likely to excuse the behaviour. Strategies to curb violence in EDs include modifying building design, providing security systems and personnel, and training staff in aggression management. The key to successful intervention is a strong preventive orientation that looks for high-risk indicators, and may extend to active physical and behavioural screening.