Violent Behaviour in the ED

Introduction

Addressing the challenges associated with violent behaviour is an integral part of the workload of members of the Emergency Department (ED).

You should:

• Learn common causes of aggressive behavior in the ED
• Recognise potentially dangerous behaviour
• Understand how to defuse the situation and manage violent behaviour
• Learn how to differentiate between medical and mental health conditions
• Recognise that the priority is the safety of the patient and of other ED staff

Most People

It is important to anticipate and recognize violent or aggressive patients in order to keep health care providers and the staff safe. Patients visit the ED because something bad has happened to them, or to someone for whom they are concerned. They may be stressed because of this unexpected visit. They may also be in pain or feeling ill. Other issues that may cause them stress are difficulties parking, not being able to smoke, or being asked not to use their mobile phones. Many patients are frustrated by waiting times in the ED.

Most patients usually respond positively to good customer care and courteous communication. Provision of appropriate, timely and accurate information may often prevent initiation or escalation of aggressive behavior.

Learning bite

If not addressed appropriately, stress and anxiety can develop into frustration, aggression and violence.

Effects on Staff

Violence occurs in all areas of life. However, it is commonly directed towards medical providers. Assaults against health care providers is not uncommon. One of the most difficult situations physicians face is being threatened, abused, or physically harmed by one of their patients. Such assaults have been shown to be associated with staff sickness, absence, turnover, and loss of productivity, loss of commitment, fear, anxiety and loss of confidence.

Aggression

Violence directed toward health care providers can occur in the emergency department.

The average physical fight between two individuals lasts for only seven seconds. In this short time span, up to 15 violent acts (punches, kicks, etc.) may be exchanged, with injury tending to occur within the first three seconds [1].

Because these incidents occur so quickly, one cannot rely on panic buttons, security staff, or hot lines to police stations to address violent outbursts in the ED.

Emergency providers should be able to recognise and address a potentially aggressive behavior before it escalates and causes harm.

Which common medical emergencies may make a patient aggressive?

Always consider medical conditions as potential causes of agitation.

Aggressive, or violent behavior is not a diagnosis; but it may occur due to many underlying medical, toxicologic, or mental problems, or a combination of these conditions. The more important issue for the emergency physician is to identify medical problems that may cause the patients violent behavior. One must not overlook emergency medical conditions, such as the following: hypo/hyperglycaemia, head injuries, hypoxia, drugs, alcohol, or sepsis. Many psychiatric conditions may also present with aggression. Where possible, these causes need to be carefully considered, and addressed. Even if the history and presentations are suggestive of a psychiatric condition, medical causes should still be considered. It is possible that patients may be prematurely labeled as psycho, especially if they have a history of mental health issues.

Reversible causes should be considered during the initial evaluation. The mnemonic FIND ME (Functional, Infectious, Neurologic, Drugs, Metabolic, and Endocrine) may be helpful in the identification of a serious underlying medical cause. A rapid bedside blood glucose determination and pulse oximetry should be obtained for all potentially violent patients.

Medical

• Hyperthyroidism
• Hypoglycemia
• Traumatic Brain Injury
• Delirium

Psychiatric

• Depression
• Conduct Disorder
• Attention Deficit Hyperactivity Disorder
• Bipolar Disorder
• Impulse Control Disorder
• Psychosis
• Impulsive Behavior
• Substance Intoxication/ Withdrawal
• Post-Traumatic Stress Disorder

Keeping Yourself Safe

When dealing with a disturbed patient we need to consider our own personal safety.

We need to:

• Risk assess the patient
• Ensure there is an available exit route
• Advise other staff of our location
• Determine the need for an escort, chaperone or security officer
• Conduct the consultation in an area that has no potential weapons of opportunity (furniture, crockery, instruments, oxygen tubing etc.)

Legal Principles

Evaluation of the combative or violent patient begins with attention to safety measures. First providers must ensure the safety of the patient, patients family, and the ED staff during the evaluation process.

Legal Principles

There are a number of legal principles that apply to staying safe and managing aggression and violence at work.

The Health and Safety at Work Act [2]

This requires that workers and other persons should be provided with the highest level of protection that is reasonably practical against harm to their health, safety and welfare.

What does the law allow?

The law allows us to use reasonable force to protect ourselves and others in certain circumstances.

The Human Rights Act [3]

In the UK, human rights are protected by the Human Rights Act of 1998. This determines any use of force not only to be perceived as reasonable; but also, to be proportionate and necessary, as determined by the person at the time.

Subjects behaviour

Aggressive or violent behavior includes a wide spectrum of behaviours.

1. Calm and nonthreatening: Frustration only without overt signs of agitation.
2. Verbal agitation, wherein speech patterns indicate irrational
3. Verbal hostility, wherein more aggression is suggested
4. Verbally threatening, wherein actual threats are conveyed
5. Physically threatening: Patient assumes a fighters stance and makes a fist.
6. Physically violent: Patient physically attacks

A subject’s behaviour, and the increasing level of threat (coloured from blue, warning, to red, danger) can be described in the following ways:

Table 1: Subjects behaviour and level of threat
Subjects behaviour	Level of threat to staff
Compliant/non-threatening	Complies with our requests
Verbal and non-verbal indicators of threat/violence	See warning and danger signs
Active aggression	Subject strikes
Assaultive/aggression/violence	Repeated and focused attempts at assault
Serious/aggravated violence	Production of a weapon with the intent to use it in an assault

Within this range of behaviours we can recognise various warning signs or danger signs.

Warning Signs

Warning signs include:

Provocative behavior

• Shouting, loud voice
• Angry demeanor
• Tense posture; holding arm rails tightly, clenching fist
• Pacing, frequent change in body position
• Aggressive behavior; pounding walls, throwing objects, hitting or kicking

Appropriate posturing and communication skills are likely to enableyou to avoid trouble and bring about a satisfactory resolution of the situation.

Learning bite

People displaying warning signs can usually be mitigated and de-escalated by careful and thoughtful communication, conveying a sense of calm.

Danger Signs

Danger signs include:

• Fist clenching
• Facial pallor
• Lips tightening over bared teeth
• Eyebrows and chin drop
• Hands above the waist
• Target-acquisition glances (looking at a body part as a prelude to striking that area)

Signs such as these usually herald an imminent physical threat.

At this stage, communication is unlikely to help. It is time to exit immediately, or perform a physical intervention.

Learning bite

Once a subject displays danger signs, a physical attack is more or less inevitable and mere communication may not be adequate at this stage. It is time to leave immediately, or to prepare to intervene physically.

Impact Factors

While interpreting the subject’s behaviour, one should consider impact factors (situational factors that render a situation more or less dangerous).

Table 1: Impact Factors
Impact Factors	Description
Gender/age/size/strength	Relative size compared to yours
Previous knowledge/history	Someone who has been violent before is more likely to be violent again
Alcohol/drugs	Reduces the subject’s ability to reason. It may cause a loss of control making an assault more likely
Special skills	A martial arts practitioner or boxer will know how to respondmore efficiently and with greater effect
Imminent danger	Behaviour indicating imminent assault
Position of disadvantage	No route of escape, or a barrier between you and the aggressor
Environment	Difficulties in access and egress, no other support available
Weapons	Production of weapons or availability of weapons of opportunity

The Conflict Resolution Model

A model widely used to determine the lawful response to aggression and violence is the Police Conflict Resolution Model. This model requires us to assess the subjects behaviour and also to consider the impact when deciding upon our response.

The following animation reinforces the importance and relevance of the Police Conflict Resolution Model.

In 1996, the New York State Office of Mental Health issued a policy requiring all State-operated psychiatric facilities to develop and implement a proactive violence-prevention program based up on guidelines issued by the US Occupational Safety and Health Administration. This Psychiatric Management of Crisis Situations (PMCS) is provided to train staff on how to de-escalate potential crisis situations. It includes guidance on the use of to language, body posture and a discussion of potential warning signs All these can help alert the staff to potential dangers.

In the United Kingdom, the National Institute Health and Care Excellence (NICE) presents guidelines for the short-term management of the disturbed patient. These clinical guidelines were updated in 2015 to NICE guideline 10 [4] to incorporate pediatric patients and patients outside of acute-care settings. This document provides resources that can be used in a variety of clinical settings to create a safer environment for patient care in the event of possible aggression or violence.

Response Options

Having considered both the subjects behaviour and situational impact factors, we now need to determine our response. The following are options for a response to any kind of threat to safety: Disengage depart and call for help, put barriers between you and the aggressor (This is the best option for any serious threat) Two communication strategies: Verbally de-escalate the situation with communication skills Every effort should be made to first determine whether the aggressive behaviour can be managed at the verbal or behavioral level, without employing other means of restraint. The agitated but cooperative person may be amenable to verbal de-escalation techniques alone. This allows for the opportunity to assess the subjects mental status and comprehension, as well as his or her perception of the current situation. There are two communication strategies that allow us to verbally de-escalate and manage challenging situations. For subjects exhibiting warning signs we can adopt the LEAPS approach. The tone of our voice and intonation are very important during this process. Table 1: Key principles of LEAPS

Key principles of LEAPS
Action	What you should do
Listen	Ask open questions example: ‘What seems to be the problem?’ Listen actively and let subjects have their say. Do not try to predict what theyre going to say; Dont interrupt them; remain objective.
Empathise	From time to time indicate empathy even though you may not agree. Example. ‘That sounds terrible’, ‘I see’.
Ask	Question them to clarify their concerns
Paraphrase	‘Reading back’ key parts of their concerns indicate that you are listening and have engaged with them.
Summarise	Summarise their concerns and try developing a course of action.

Tips and ground rules which may be helpful in confronting situations

• Create a calm, polite, respectful environment. The American College of Emergency Physicians recommends that the ED should contain at least one secure examination room for the evaluation of psychiatric patients.
• Respect a patients personal space: Maintain a safe distance (at least two arm lengths) and provide space for easy exit, for all involved.
• Avoid touching an angry or agitated person
• Stay on the same physical level as the patient; do not look down on them; Avoid sudden movements
• Keep your posture neutral and maintain a non-confrontational body posture
• Do not stare at the patient; eye contact should convey sincerity

Establish a verbal contact in a calm and clear voice

• Use concise yet simple language
• Example: Asking, “How can we help you?” This display of compassion on the part of the treating provider or other ED staff may serve to calm the patient.

Active Listening Restate what the patient has said. This may help to improve a mutual understanding (Example: Tell me whether I have this right) Avoid confrontation; offer to help solve the problem Acknowledge their frustration Aligning goals

• Emphasize common interests
• Focus on the big picture
• Find ways to make small concessions

Monitoring

• Be aware of progress
• Know when to disengage
• Do not insist on having the last word
• Have a staff member sit with the patient

Agree or agree to disagree: (a) Agree with clear specific truths; (b) Agree in general (e.g., “Yes, everyone should be treated with respect.”); (c) Agree with unusual situations (e.g., “There are others who might feel like you.”). Refer to rules of common decency and set clear limits: Inform the patient that violence or abuse cannot be tolerated. Offer alternate choices for optimism: Patients feel empowered if they have some choice in the outcome. Debrief the patient and staff: Be sure to include opportunities for both the patient and the staff member (s) to speak Activate hospital security to ensure the safety of the patient and of the staff (if these conservative measures fail). In these situations, consider the following security measures:

• The security staff should not rush to the patients bedside but rather they should gather outside the door or close by, within eye contact of the patients room.
• A strong show of force may calm a potentially violent patient without the need for restraint
• Directly address the issue of violence

Inquire about

• Suicidal, or homicidal ideation or plan
• Possession of weapons: their belongings should be searched for any weapons or objects that could be used as weapons
• Current use of medications
• Acknowledge the obvious (e.g., “You look angry.”)
• If the patient becomes more agitated, it may be helpful to speak in a conciliatory manner. Offer supportive statements such as, “You obviously have a lot of will power and are good at controlling yourself.”

Assertions using different communication skills For subjects who display a higher-level threat (warning signs), but without signs of imminent violence (danger signs), we may need to escalate our communication strategy to assertion. There is a need to clearly indicate any offensive behaviour, to offer clear options, to provide boundaries and to confirm expectations. Here are some good examples:

• ‘I want to help you; but I need you to stop shouting/swearing.’
• ‘This is what we can offer you’
• ‘If you remain calm we will be able to help you’
• ‘If you cant control your behaviour then the only option we have is to ask you to leave.’
• ‘You tell me what it is that you want to do.’

Offer a reasonable, proportionate and necessary physical response when no other options remain, when there is a need to establish control or to prevent harm to anyone.. When standing outside the fighting arc it is best to adopt a stance which allows us to communicate; it also confers some protection to the upper body and serves as a starting position to a number of physical intervention skills, including blocks or restraint techniques. Adopt a stance, which affords minimal body exposure and protection, and shows a readiness to communicate.

The Fighting Arc

An assault can only be delivered within the so-called ‘fighting arc’ – the zone in which a fist or kick can be delivered. It follows, therefore, that we need to conduct communications with a potentially challenging subject outside the fighting arc.

The Stance

When standing outside the fighting arc it is best to adopt a stance which allows us to communicate; but also confers some protection to the upper body and serves as a starting position to a number of physical intervention skills, including blocks and control techniques. Adopt a stance, minimal body exposed and protected, ready to communicate.

Lawful Physical Intervention

For a physical interventionskill to be lawful, it must be used appropriately and in context. Physical skills include breakaway skills, blocks, pre-emptive strikes and restraint.

Physical skills can be used:

1. To defend yourself and protect others from immediate threat
2. To restrain an agitated and at-risk individual

You do not have to be certified to exercise your lawful right to intervene physically.

Clearly, appropriate training is a huge advantage and you should seek appropriate training that reflects the risk of violence in your work environment. Physical skills training needs to address the risks of restraint, including positional asphyxia and excited delirium.

Learning bite

Any physical intervention must be reasonable, proportionate and necessary in order to be lawful.

Restraint

The behavior that poses any safety risk should be managed before a medical and psychiatric examination can be performed. Indications for emergency sedation and restraint include the prevention of imminent harm to the patient, to others or to the immediate environment. This should be implemented in a systematic manner. Ideally it should follow a predetermined ED protocol that can beimplemented when the examiner leaves the room after simple verbal strategies proveare unsuccessful

Restraint must be carefully applied in any situation, in order to minimise restrictions on chest wall movement, and to assure no negative impact on respiration or other vital functions.

Practical training is recommended. Restraint is a unique problem associated with individuals in an excited state of delirium. Once again, care needs to be taken in order to avoid interference with vital body functions.

Excited Delirium

In this state, an individual displays bizarre and aggressive behaviour, often associated with drug abuse Example. Such behaviour may involve cocaine or amphetamines

The subjects may feel no pain, are abnormally strong and oftentend to rip away their clothings.

They are frequently brought into the hospital ED by the police.

These people are at great risk because they are:

• hyper-pyrexial
• dehydrated
• acidotic
• hypoglycaemic
• fatigued

It is essential to rapidly intervene to prevent physical or mental deterioration; Hence, restraint and rapid tranquillizing will be needed, in order to facilitate immediate treatment.

Rapid Sedation

Chemical sedation alone, or in conjunction with physical restraint, may assist in the safe management of an agitated or violent patient who seems unresponsive to verbal de-escalation strategies.

Rapid tranquillizing may be useful in managing acute, disturbed and psychiatric patients who are seriously agitated.

Rapid tranquillizing is warranted for patients who are:

• Without capacity
• Agitated
• Pose a risk to themselves
• Pose a risk to others

Recommended dosage: (Using NICE guideline)

Rapid tranquilization involves a neuroleptic agent such as haloperidol either alone or in combination with a low-dose benzodiazepine such as lorazepam or midazolam.

• For most patients 2 mg lorazepam orally, is recommended

For very challenging situations in which urgent control is required. IM haloperidol (5-10 mg) and/or IM lorazepam 2 mg can be administered. This is a potent cocktail which is commonly used.

Note that appropriate patient monitoring is required. IM drugs may take up to 30 minutes to begin to have an appreciable effect. Intravenous drugs should be used only in exceptional circumstances.

Investigations

Safety for all is of paramount concern. In some situations, this will call for someone to restrain the patient and/or restrain in order to obtain the following:

1. Background information is helpful and may have to be obtained from a variety of sources, e.g. hospital records, GP, family and friends
2. History of drug use both prescribed and illicit information should be sought
3. Vital signs and blood glucose level are important for all patients to help identify any underlying medical causes

Where excited delirium is suspected, the analysis of blood gases is indicated, following the safe management of the patients behavior.

Further investigation should depend upon the information obtained during initial assessment and observation.

• Failure to recognise underlying medical causes for the behaviour, e.g. Hypoxia or head injury. Beware that acute changes in behavior are a medical condition until proven otherwise.
• Failure to disengage, when danger signs are present i.e. not recognizing the need for physical restraint in an appropriate and timely fashion.
• Dismissing challenging patients from the department, before excluding significant medical or psychiatric causes.

1. Northants Police: Personal safety training. 1994.
2. The Health and Safety at Work Act, 1974
3. The Human Rights Act, 1998.
4. National Institute for Health and Clinical Excellence. Clinical Guideline 25. Violence. 2005; London; NICE.
5. National Institute for Health and Clinical Excellence. NICE Guideline 10. Violence and Aggression: Short-term management in mental health, health and community settings. 2015; London; NICE
6. NHS security management
7. Karas S. Behavioral Emergencies: Differentiating Medical from Psychiatric Disease. March 2002; Volume 4, Number 3: EB Medicine
8. American College of Emergency Physicians Clinical Policies Subcommittee (Writing Committee) on the Adult Psychiatric Patient, Nazarian DJ, Broder JS, Thiessen MEW, Wilson MP, Zun LS, Brown MD. Ann Emerg Med. 2017 Apr;69(4):480-498
9. Violence prevention in the mental health setting: The New York State experience. [accessed Sep 26 2018]
10. World Health Organization (WHO). Violence Prevention Alliance. Global Campaign for Violence Prevention: Plan of Action for 2012-2020.Geneva: World Health Organization; 2012. [Last accessed on 2018 August 18].
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12. Richmond JS, Berlin JS, Fishkind AB, Holloman GH Jr, Zeller SL, Wilson MP, Rifai MA, Ng AT. Verbal De-escalation of the Agitated Patient: Consensus Statement of the American Association for Emergency Psychiatry Project BETA De-escalation Workgroup.West J Emerg Med. 2012 Feb;13(1):17-25.