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managing violence or the aggressive patient in the ED

general principles

  • aim for patient co-operation where possible and provide respectful, professional clinical practice
  • aim to de-escalate and administer harm minimization strategies
  • use pharmacologic agents as adjuncts according to behavioural escalation level (see under sedation)
  • clinical assessment to exclude treatable causes, manage ABCs, and to monitor vital signs
  • multi-disciplinary approach with senior ED doctors, nurses and mental health team +/- security as needed
  • regular medical review
  • be aware of statutory requirements (eg. Mental Health Act)

causes of aggressive behaviour

prevention and risk mitigation

  • ensure all patients and visitors are aware of zero tolerance policy to aggressive behaviour
  • consider TV surveillance cameras with screens visible to patients and visitors so they are well aware that all behaviour is being monitored and recorded
  • ensure the ED is designed for patient and staff security in the event of incidents
  • ensure there is an appropriate security response system in place
  • all staff should have adequate training on managing the agitated or violent person
  • ensure timely and appropriate communication, particularly to those waiting long periods and to those in high stress situations
  • be caring, calm, empathetic and professional in your approach to patients and their relatives, but be assertive early when their behaviour is becoming inappropriate.
  • address unrealistic expectations early
  • be cogniscent of cultural variations in behaviours, expectations and attitudes
  • be aware of past aggressive behaviour patterns of the patient
  • drug-affected patients can be very irrational and become rapidly agitated without warning, particularly with drugs such as metamphetamine / meth / ice.
  • be alert for clinical deterioration and treat pain or agitation early and adequately
  • ensure an adequate security response is attended for the expected arrival of agitated patients brought by police or ambulance, and ensure a timely initial clinical assessment to risk manage them
  • call security response EARLY before it gets out of hand
  • avoid presence of hand guns being carried by hospital security as this may escalate severity of some incidents whilst having little additional benefits.
  • nursing staff should document Behaviours of Concern (on a BoC chart) along with normal vital signs for all patients and escalate any rise in level of concern to medical staff.

initial Mx of the aggressive patient

  • alert other staff in area
  • do not approach alone
  • approach cautiously from the side
  • maintain a safe distance and avoid encroaching personal space which may escalate agitated state
  • do not allow the person to block a safe exit path
  • do not trap the person in a corner
  • adopt a calm, caring, professional manner, and introduce yourself
  • ask the person's name and use it
  • ask what the problem is and how you can help
  • ask the person to calm down so that you can help them
  • if feel unsafe or physically threatened, withdraw and press local duress button if available or call a security code
  • high risk incidents may warrant immediate call to police for assistance (phone 000)

physical intervention

  • often, the security team will need to forcibly restrain the person to attain control of the situation and safety of both the person, other patients and staff
  • the level of force applied must be justifiable, appropriate, reasonable and proportionate to a specific situation and should be applied for the minimum possible amount of time.
  • every effort should be made to utilise skills and techniques that do not use the deliberate application of pain.
  • the deliberate application of pain has no therapeutic value and could only be justified for the immediate rescue of staff, service users and/or others.
  • sudden death can occur when physical intervention is used, although this is a rare event.
  • one team member should be responsible for protecting and supporting the head and neck,where required.The team member who is responsible for supporting the head and neck should take responsibility for leading the team through the physical intervention process, and for ensuring that the airway and breathing are not compromised and that vital signs are monitored.1)
  • seclusion or rapid tranquillisation in a resuscitation area may be considered to reduce the length of duration of physical intervention.

further Mx of persisting agitated state

  • when safe to do so, clinically assess, looking for a cause
    • consider basic obs, temp, SaO2, BSL, blood alcohol level if appropriate and safe
    • in the elderly, consider a bladder scan to exclude urinary retention
    • look for head injury - may need CT brain if history or evidence of head trauma
    • history or evidence of drug or alcohol intoxication, or, particularly in the elderly, iatrogenic medication causes
    • assess mental state - orientation, memory, evidence of psychosis
  • treat the cause if possible
    • give oxygen if hypoxic
    • give glucose if hypoglycaemic
    • give diazepam if alcohol withdrawal state (may require doses up to 60mg/day in divided oral doses)
    • relieve urinary retention
    • if septic Rx as for sepsis / septicaemia
    • if delirium, then Mx as for delirium
    • if acute psychosis, give antipsychotics (eg. olanzapine wafer or im)
  • consider mechanical restraint in a resuscitation area to control the situation if all else is likely to fail and patient or others are at risk
  • consider further investigations eg. FBE, U&E, glucose, blood alcohol level

consider sedation

  • sedation should be considered if:
    • de-escalation and other approaches fail;
    • to relieve distress or agitation;
    • when there is a clear need to protect patient or others from harm;
    • to allow adequate clinical assessment and treatment of an underlying condition;
  • sedation may be given without patient's consent if the doctor believes it is required as a matter of urgency:
    • to save the patient's life;
    • to prevent serious harm to patient's health, or,
    • to prevent patient suffering or continuing to suffer significant pain or distress 2) ))

podcasts and other resources

other papers

Section 42A, Guardianship and Administration Act 1986(Vic
violence_in_ed.txt · Last modified: 2021/11/16 20:49 by gary1

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