Coordination, communication, and continuity among all members of a hospital team are crucial to minimize conflict, avoid chaos, and reduce risks. By being armed with information and skills, hospitalists are less likely to isolate themselves from other team members or react in a nonproductive way when crisis situations emerge. —Judith Schubert, president, Crisis Prevention Institute, Milwaukee, Wis.
How Bad Is It?
According to the Emergency Nurses Association’s Institute for Emergency Nursing Research, violence is especially prevalent in the ED; about 11% of ED nurses report being physically assaulted each week. The agency states that the data is most likely grossly underreported, since reporting is voluntary.1
Healthcare workers in psychiatric wards are the most likely to suffer an injury caused by an agitated patient, Dr. Zeller says. Of those, nurses are the ones most commonly affected, followed by physicians.
“But agitation-related assaults and injuries can happen just about anywhere in a hospital,” he adds.
According to a study conducted by the Emergency Nurses Association, pushing/grabbing and yelling/shouting were the most prevalent types of violence. Eighty percent of cases occurred in the patient’s room.2 Dr. Zeller says that the most common injuries are those resulting from being struck, kicked or punched, or knocked down. Injuries include heavy bruising, sprains, and broken bones.
Dr. Zeller says it’s difficult to quantify exactly what types and costs of injuries occur. Injuries related to agitation are known to cause staff to miss work frequently. “That can cost a lot in terms of lost hours and replacement wages, as well as medical care for the injured party,” he says.
The Most Dangerous Circumstances
According to a series of 2012 articles on best practices guidelines for the evaluation and treatment of agitation published in Western Journal of Emergency Medicine, two-thirds of all staff injuries occur during the “takedown,” which is when staff attempt to tackle and restrain an agitated patient.3
“If interactions with a patient could help the person to regain control without needing the takedown or restraints, there would be fewer injuries and better outcomes,” says Dr. Zeller, who co-authored the article. “To help these patients in a collaborative and noncoercive way, and avoid restraints, verbal de-escalation is the necessary approach.”
As part of the study, a team of more than 40 experts nationwide was established to create Project BETA (Best practices in Evaluation and Treatment of Agitation). Participants were divided into five workgroups: triage and medical evaluation, psychiatric evaluation, de-escalation techniques, psychopharmacology of agitation, and use and avoidance of seclusion and restraint.
The guidelines were intended to cover all aspects of working with an agitated individual, with a focus on safety and outcomes, but also had a goal of being as patient-centric, collaborative, and noncoercive as possible.
“Every part of Project BETA revolves around verbal de-escalation, which can be done in a very short amount of time while simultaneously doing an assessment and offering medications,” Dr. Zeller says.
As a result of incorporating the guidelines in Project BETA, the psychiatric emergency room at Alameda Health System—which deals with a highly acute, emergency population of patients with serious mental illnesses—restrains less than 0.5% of patients seen. Dr. Zeller points out that this is much lower than the numbers restrained at other institutions. For instance, an article published in October 2013 reported several studies showing that 8% to 24% of patients in psychiatric EDs were placed into physical restraints or seclusion.4
What’s Required of Hospital Administration?
Under its Environment of Care standards, The Joint Commission requires accredited healthcare facilities to address workplace violence risk. The requirements mandate facilities to maintain a written plan describing how the security of patients, staff, and facility visitors will be ensured, to conduct proactive risk assessments considering the potential for workplace violence, and to determine a means for identifying individuals on their premises and controlling access to and egress from security-sensitive areas.1