Management of the aggressive emergency department patient: non-pharmacological perspectives and evidence base

Protecting Frontline Workers: Strategies for Preventing and Mitigating Violence in the Emergency Department

Violence in the emergency department (ED) has been escalating for decades worldwide. High-stress situations are commonplace in the ED and can lead to intentional and unintentional aggression from patients. Staff must be educated on the signs of violence and escalation to recognize potentially dangerous situations early. Staff must also identify underlying medical conditions as the source of unintentional violence. Both situations would require different approaches to management. ED violence negatively affects patient care and leads to long-term harmful outcomes for staff. Multiple strategies for mitigation and prevention have been explored in the literature. Among those, weapon detection systems, de-escalation training, and violence prevention programs have demonstrated improved staff outcomes and decreased violence. Formalized procedures and policies should clearly assign roles for each staff member in the event of a violent patient. Training programs should be instituted and may include self-defense classes or crisis intervention courses. Emergency medicine residency programs and EDs around the country must address the rising incidence of violence within EDs through interdisciplinary policy, procedure development, and prevention and mitigation programs.

Formative evaluation of an emergency department clinical decision support system for agitation symptoms: a study protocol

INTRODUCTION

The burden of mental health-related visits to emergency departments (EDs) is growing, and agitation episodes are prevalent with such visits. Best practice guidance from experts recommends early assessment of at-risk populations and pre-emptive intervention using de-escalation techniques to prevent agitation. Time pressure, fluctuating work demands, and other systems-related factors pose challenges to efficient decision-making and adoption of best practice recommendations during an unfolding behavioural crisis. As such, we propose to design, develop and evaluate a computerised clinical decision support (CDS) system, Early Detection and Treatment to Reduce Events with Agitation Tool (ED-TREAT). We aim to identify patients at risk of agitation and guide ED clinicians through appropriate risk assessment and timely interventions to prevent agitation with a goal of minimising restraint use and improving patient experience and outcomes.

METHODS AND ANALYSIS

This study describes the formative evaluation of the health record embedded CDS tool. Under aim 1, the study will collect qualitative data to design and develop ED-TREAT using a contextual design approach and an iterative user-centred design process. Participants will include potential CDS users, that is, ED physicians, nurses, technicians, as well as patients with lived experience of restraint use for behavioural crisis management during an ED visit. We will use purposive sampling to ensure the full spectrum of perspectives until we reach thematic saturation. Next, under aim 2, the study will conduct a pilot, randomised controlled trial of ED-TREAT at two adult ED sites in a regional health system in the Northeast USA to evaluate the feasibility, fidelity and bedside acceptability of ED-TREAT. We aim to recruit a total of at least 26 eligible subjects under the pilot trial.

ETHICS AND DISSEMINATION

Ethical approval by the Yale University Human Investigation Committee was obtained in 2021 (HIC# 2000030893 and 2000030906). All participants will provide informed verbal consent prior to being enrolled in the study. Results will be disseminated through publications in open-access, peer-reviewed journals, via scientific presentations or through direct email notifications.

TRIAL REGISTRATION NUMBER

NCT04959279; Pre-results.

Using body-worn cameras in emergency departments: a pilot project

Nurses and other emergency department (ED) staff often experience verbal and physical abuse as part of their everyday work. Body-worn cameras are one tool that ED staff can use to try to reduce workplace violence and abuse and have been shown to be effective in other healthcare environments, such as mental health units. This article describes a pilot service evaluation which used a survey to assess the effectiveness of using body-worn cameras for staff in the author's ED. Findings suggest that nurses believed the cameras provided support when they were confronted by abusive or aggressive patients or relatives and in some instances diffused potentially violent situations.

Mental Healthcare workers' experiences in managing psychiatric patients' aggression in Maseru

Background

Aggression and violence in psychiatric clinical facilities are a common case, and mental healthcare workers utilise various management strategies to combat it. It is therefore crucial for mental healthcare workers to acquire skills for the management strategies of aggressive behaviour of psychiatric patients.

Aim

The aim of the study was to describe mental healthcare workers' experiences in the management strategies of aggressive and violent behaviour by psychiatric patients in Maseru district.

Setting

A psychiatric hospital situated to the south in Maseru in the rural countryside and general hospital located in the western lowlands of Lesotho in the village of Morija were used.

Methods

This study adopted a qualitative, exploratory, descriptive and contextual research design. There were two focus group interviews conducted per clinical facility, which consisted of six members in each group. There were four participants for individual interviews from psychiatric clinical facility and three individual interviews from general clinical facility.

Results

Thematic analysis of the data resulted in themes and sub-themes. These were psychological intervention strategy, physical strategy, chemical strategy, empowerment strategy and policy strategy. Participants viewed various management strategies of aggressive and violent behaviour of psychiatric patients they utilise in clinical facilities as effective.

Conclusion

The mental healthcare workers' experiences in managing aggression and violent behaviour of psychiatric patients were expression of psychological, physical, chemical, empowerment and policy strategies.

Contribution

The study will enhance the knowledge, skills and attitudes regarding management strategies that mental healthcare workers can utilise in managing aggressive and violent behaviour of psychiatric patients.

"I think we still do too little": measures to prevent violence and aggression in German emergency departments - a qualitative study

BACKGROUND

Healthcare workers employed in emergency departments (EDs) are particularly affected by physical and verbal violence. Violent assaults can be committed by both patients and their attendants. Research on interventions for violence prevention is limited and previous studies report that ED employees feel unprepared for violent incidents. Thus, the current study aims to explore ED staff's perceptions regarding available prevention measures, their effectiveness, barriers, and further needs in terms of violence prevention.

METHODS

In accordance with the qualitative study design, 27 semi-structured interviews were conducted via telephone with doctors and nurses working in direct contact with patients in German EDs. Main subjects were advantages and disadvantages of currently available measures, barriers regarding their implementation, their perceived effectiveness, as well as further needs concerning violence prevention. The transcribed interviews were analysed according to Mayring's qualitative content analysis.

RESULTS

Participants described environmental (e.g., alarm systems), organisational (e.g., security service), and individual-focused measures (staff training, verbal de-escalation). Measures perceived as effective were, for instance, communication and security service. Both demands and barriers were often related to financial constraints, e.g., staff shortage led to higher workloads and less time to consider violence prevention. In most cases, guidelines or standard operating procedures (SOPs) regarding violence prevention were missing, unknown, or not perceived as helpful in their current form. Furthermore, screening tools were not applied in any of the EDs.

CONCLUSIONS

The workload in EDs needs to be decreased in order to enable violence prevention, e.g., by reducing patient inflow or by increasing personnel. In addition, violence prevention guidelines tailored to the requirements of the respective ED need to be developed. Hospitals should supply ED staff with such guidelines, e.g., in the form of SOPs, but more importantly, prevention measures have to be practiced and communicated. Furthermore, there is a need for research on the implementation of screening tools for violent behaviour, so that the focus would shift from managing violence to preventing violence.

Putting out the welcome mat-A qualitative exploration of service delivery processes and procedures as barriers to treatment-seeking for people who use alcohol and other drugs

INTRODUCTION

There are a range of models and structures that determine features of alcohol and other drug treatment. Despite some structures being long-established, less is known about how specific aspects of service delivery impact treatment-seeking for people who use alcohol and other drugs. This Australian qualitative study explored both people with lived experience of problematic alcohol and other drug use, and health care staff's experiences of service delivery.

METHODS

Thirty-nine semi-structured interviews with people with lived experience and staff from either alcohol and other drug specialist, or broader health-care services, explored experiences of service delivery processes and procedures. Transcripts were thematically analysed and guided by a broad interest in barriers to treatment-seeking.

RESULTS

Within alcohol and other drug specialist services (i) time spent on wait lists; and (ii) poor implementation of assessment processes were identified barriers to treatment-seeking and engagement. Within broader health-care services (i) organisational expectations around behaviour and engagement; (ii) alcohol and other drugs viewed as separate to service role; and (iii) limited opportunities to informally engage were identified barriers to treatment-seeking.

DISCUSSION AND CONCLUSIONS

Results suggest opportunities to engage and undertake needs-based care planning are yet to be fully realised, particularly at the intake and assessment stages of alcohol and other drug service delivery; with frequent reassessment resulting in people repeatedly recounting traumatic experiences, often to different people, only to be placed back on wait lists with no support. Within broader health-care services aspects of service delivery may perpetuate stigma that places such people outside the purview of health care.

Caring for behaviorally challenging patients in nonpsychiatric settings

This article discusses a pilot study on the use of a behavior support plan to safely address patients who exhibit disruptive behaviors in the ED and nonpsychiatric medical settings while respecting their autonomy.

Nonpharmacological interventions for agitation in the adult intensive care unit: A systematic review

BACKGROUND

Person-centred nonpharmacological strategies should be used whenever possible to reduce agitation in the intensive care unit due to issues related to an overreliance on physical restraints and psychoactive drugs. However, the effect of nonpharmacological interventions to reduce agitation is unclear.

OBJECTIVES

The objectives of this study were to systematically review studies that evaluate the effectiveness of nonpharmacological interventions designed to prevent and minimise or manage patient agitation in the adult intensive care unit.

METHODS

This systematic review was conducted following the Joanna Briggs Institute's Systematic Review of Effectiveness method and a priori PROSPERO protocol. Quantitative studies were identified from seven databases, including MEDLINE, EmCare, CINAHL, Web of Science, PsycINFO, Scopus, and Cochrane Library. In addition, grey literature from several repositories and trial registers was searched. The primary outcome of interest was the effect on prevention, minimisation, and management of agitation. The quality of the evidence was assessed using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE).

RESULTS

Eleven studies were included (n = 882). Meta-analyses of two studies demonstrated significantly lower levels of agitation (measured with the Richmond Agitation Sedation Scale) in the group receiving a multicomponent nonpharmacological intervention than in those receiving usual care. Individual studies showed a significant effect of nature-based sounds, music, foot reflexology, healing touch, and aromatherapy. The type of the endotracheal suction system did not affect levels of agitation. Overall, the certainty of the findings was rated very low. Harms and adverse effects were not reported in any studies.

CONCLUSIONS

Nonpharmacological interventions have the potential to reduce levels of agitation in the intensive care unit. However, inconsistencies in reporting, low quality of methodological designs, and small sample sizes impact the certainty of the results. Future trials must include larger sample sizes, use rigorous methods to improve knowledge in this field, and consider a range of other outcomes.

Mitigating Pediatric Inpatient Aggression: A Quality Improvement Initiative

BACKGROUND

Patient aggression in the health care workplace has increased significantly, and the impact of workplace violence can be profound, including psychological trauma and lost productivity. We suspect these safety events are often unreported, leading to missed opportunities to design interventions to reduce harm. The primary aim of the interdisciplinary quality improvement team was to increase staff reporting of safety events utilizing our event reporting system related to the care of verbally and/or physically aggressive pediatric patients by 10% over a 12-month period.

METHODS

An interdisciplinary quality improvement team addressed existing gaps in the care of pediatric inpatients with escalating behavior. Interventions included a survey of staff knowledge, use of the care guideline for management, updates to the electronic medical record, patient aggression screening tool, an electronic order set, and an online education module. The primary outcome measure was the number of reported staff safety events related to the care of aggressive patients. Compliance with the use of the pediatric aggression risk screening tool was tracked as a process measure.

RESULTS

The reporting of safety events related to the care of aggressive patients increased from just <1.0 events per 1000 patient days to 3.0 with special cause variation observed on a statistical process control chart. The compliance with the use of the pediatric aggression risk screening tool improved during the time of the project, nearing 90%.

CONCLUSIONS

A variety of interventions aimed to address pediatric inpatient aggression can improve the reporting of events related to workplace violence and foster a culture of employee safety.

Management approach of patients with violent and aggressive behaviour in a district hospital setting in South Africa

Aggressive and violent behaviour is very common in the hospital setting. Simple agitation may unpredictably progress to overt aggression and violence by any patient in the emergency centres (ECs). Aggressive behaviour often manifests in forms of verbally abusive language, verbal threats and intimidating physical behaviour. Violent behaviour comprises the intentional use of physical force or power, threatened or actual, against self (suicidal), or another (homicidal) or properties, group or community, that could potentially result in injuries, death, psychological harm or deprivation. Therefore, individuals with unusual agitation and aggression should be treated as an emergency in both the community and healthcare settings in order to mitigate the progression to physical violence. Whilst the incidence and prevalence of aggressive and violent behaviour are higher in individuals with an underlying mental disorder, substance use disorder or comorbid mental disorder and substance use disorder, other individuals can also present with these behaviours in the ECs. Therefore, the front-line clinicians must be knowledgeable and competent in managing patients with aggressive behaviour with a view to de-escalate the situation and preventing or curtailing violence. This paper presents an evidence-based approach for managing patients with aggressive and violent behaviour, including a review of the steps for admitting patients for assisted or involuntary care.

Addressing and Recognizing Pediatric Inpatient Aggression Utilizing an Interprofessional Quality Team Approach

Children’s Hospitals’ Solutions for Patient Safety (SPS) is a network of over 140 children’s hospitals who share the vision of working together to eliminate serious harm across all pediatric hospitals. The SPS network is built on the fundamental belief that by sharing successes and failures transparently and learning from one another, children’s hospitals can achieve their goals more effectively and quickly than working alone. Each year, SPS hosts National Learning Sessions to which members are invited to submit abstracts describing relevant safety research or improvement work. The following abstracts were among the top submitted for the SPS Spring 2021 National Learning Session.

Addressing Workplace Safety in the Emergency Department: A Multi-Institutional Qualitative Investigation of Health Worker Assault Experiences

OBJECTIVE

This study aims to identify interventions to address workplace violence in the emergency department based on direct evidence from experiences of patient assault.

METHODS

We performed de novo coding and thematic analysis of datasets from two geographically distinct institutions and five different sites that contained interviews with 80 health workers.

RESULTS

We identified concepts that corresponded to the micro (workers and patients), meso (organizations and clinical units), and macro (society at large, worldviews, and values) levels of the healthcare system. Within each level, potential interventions fell into the prevention, response, and recovery phases of emergency preparedness.

CONCLUSION

Efforts to address workplace violence should consider interconnected influences from individual workers, organizations, and society at large. Comprehensive approaches at multiple phases of preparedness are needed to have sustained impact on safety.

Workplace Aggression and Burnout in Nursing-The Moderating Role of Follow-Up Counseling

The aim of this study is to obtain a better understanding of the association between the frequency of nurses’ exposure to workplace aggression from patients and their levels of burnout. In particular, we seek to shed light on the role of the availability of follow-up counseling in organizations after critical incidents in mitigating the adverse relationships between physical and verbal aggression and nurses’ burnout. A total of 582 nurses reported how frequently they had experienced physical and verbal aggression from patients in the last 12 months and whether they had the opportunity to receive follow-up counseling in their organization. In addition, nurses rated the extent to which they experienced each of the three dimensions of burnout (i.e., emotional exhaustion, depersonalization, and personal accomplishment). The results showed that both physical and verbal aggression were substantially related to the burnout dimensions. Furthermore, we found that the availability of follow-up counseling in organizations attenuated the relationships between physical aggression and all three burnout dimensions. While we found that the availability of follow-up counseling moderated the relationship between verbal aggression depersonalization, the moderating effects were not significant for emotional exhaustion and personal accomplishment. The findings indicate that the availability of follow-up counseling might help minimize the adverse impact of exposure to aggression from patients on nurses’ mental health.