Potential harm to both physician and patient remains a constant challenge for the neurohospitalist. Physicians can be faced with violent or threatening patients where a strategic approach can include assessing for contributing factors, as well as pharmacological and nonpharmacological measures. Inadvertent risks to physicians include exposure to body fluids and needle sticks. Precautions have advanced along with our understanding of transmissible disease. Patients can be subjected to harm. As the systems of delivery and diagnostic and treatment modailities become more complex, the opportunity for medical errors can flourish. Individual errors and system failures can result in serious adverse events or near-misses. Hospital-acquired conditions can be infectious or noninfectious and generally have a deleterious effect on outcomes, cost, and length of stay. Evolving health care policy and hospital practices aim to reduce the potential for harm.
CASE 2-1
A 65-year-old man with bipolar disorder, hypertension, hyperlipidemia, prolonged QT interval, and diabetes mellitus presented to the emergency department with headache and vision loss. He was found to have a subacute ischemic stroke. The night following admission, he became agitated and threatening toward staff. He screamed and repeatedly punched the walls. He lacked decisional capacity, and no family members could be reached. Repeated attempts by staff and the on-call physician were made to calm him, but he remained aggressive.
Workplace violence is a problem in many industries, but hospital workers have the highest rates of nonfatal workplace assault injuries.
Most are violent acts committed by patients toward staff.1,2
50% of healthcare workers will be a victim of work-place violence during their careers.1
Nurses, mental health professionals, and security staff are at greatest risk.2
Neurological, psychiatric, and genetic disorders, and drug abuse can predispose to aggressive behavior(Table 2-1).3,4
Social factors can also contribute.
Identify contributing factors early to mitigate risk.
Predisposing Factors to Violent Behavior
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Environmental elements should be controlled, such as physician and staff attitudes and patient comfort. Offering blankets or refreshments, and relative isolation in a private quiet room can be considered.1,2
Physicians and staff must be vigilant about their surroundings, body language, and exit locations.
Maintain a safe distance and be near an exit in case a situation escalates.
Do not convey a sense of anxiety with body language.
Avoid appearing confrontational.
If a patient becomes agitated, convey concern for the patient’s well-being. Reassure patients that the goal is to help them, and that they are safe.
Whenever a threat is perceived, seek help immediately.
Once a patient has demonstrated violent or threatening behavior, it may be necessary to implement isolation or physical restraint.
Indications for restraint or seclusion include:
Prevent harm to the patient, other patients, or providers
Prevent environmental damage
At the patient’s request1
When restraints are necessary:
At least 5 trained staff members should be present to avoid injury to the patient and others.
Frequently re-evaluate the on-going need for restraints according to hospital policy.
Routinely monitor skin integrity, vital signs, range of motion, and toileting needs.
If nonpharmacological methods fail, medications can be used for chemical restraint (Table 2-2).
It is preferable for the patient to choose the route of administration when possible. Providing patients some control over their care can help de-escalate some situations.
If medication must be administered involuntarily, some agents can be given intramuscularly (IM) and intravenously (IV).
Typical antipsychotics provide rapid sedation, but have several drawbacks.
Extrapyramidal symptoms (EPS) can occur rarely after only 1 dose.
Torsade de pointes can occur from QT interval prolongation. A baseline electrocardiogram is necessary, which can be challenging in a violent patient.
Neuroleptic malignant syndrome (NMS), which presents as autonomic instability, hyperthermia, altered sensorium, and rigidity, occurs in 1% of patients receiving antipsychotics.1
Haloperidol has a sigmoidal dose–effect curve. Doses over 15 mg provide no additional benefit.5
Second-generation antipsychotics are preferred given a lower incidence of EPS.
Risperidone, olanzepine, and ziprasidone are the most commonly used parenteral agents.
Risperidone and olanzapine have a rapidly dissolving oral formulation.
Ziprasidone can prolong the QT interval.
Mortality is increased when these drugs are used in patients with dementia.6
Quetiapine and aripiprazole can be used if the patient is not an immediate threat and is willing to take oral medication.
Benzodiazepines can also be effective.
Lorazepam is widely used because of its variety of formulations. It is the most reliably absorbed IM benzodiazepine.
Midazolam has a rapid onset of action. When administered IV, significant hypotension can occur.1
A trial comparing midazolam, haloperidol, and lorazepam found similar effectiveness, but midazolam had the fastest onset (mean 18 minutes) and shortest time to arousal (mean 81.9 minutes).7
Dexmedetomidine, a continuous IV alpha 2 agonist, can be used for ICU delirium and alcohol withdrawal symptoms.8,9
Common Medications Used for Chemical Restraint
| Medication | Class | Routes | Dose (mg) | Significant Side Effects |
|---|---|---|---|---|
| Haloperidol | Antipsychotic | IM | 2.5–10 | EPS, prolonged QT |
| Risperidone | Atypical antipsychotic | IM, PO | 0.5–1 | EPS |
| Olanzapine | Atypical antipsychotic | IM, PO | 2.5–10 | Mild hypotension, anticholinergic, EPS |
| Zisprasidone | Atypical antipsychotic | IM, PO | 20 | Prolonged QT, EPS |
| Quetiapine | Atypical antipsychotic | PO | 25 | EPS, sedation, prolonged QT |
| Aripiprazole | Atypical antipsychotic | PO, IM | 2–15 | EPS, prolonged QT |
| Lorazepam | Benzodiazepine | IV, IM, PO | 0.5–2 | Confusion, nausea, ataxia, respiratory depression |
| Midazolam | Benzodiazepine | IV, IM | 5 | IV: significant hypotension |
Violent patients are a common challenge. Ensuring the safety of the patient and others is paramount (Figure 2-1).
CASE 2-1 (continued)
The patient above had an underlying psychiatric condition accompanied by an acute ischemic stroke, which resulted in aggression. His prolonged QT interval limited medication options. IV lorazepam was administered without effect. Security was called and he was physically restrained. He subsequently calmed down and was willing to start oral quetiapine, which helped him maintain a calmer demeanor, allowing discontinuation of physical restraints.
An 84-year-old man is admitted for acute ischemic stroke. During the admission fever, leukocytosis, and diarrhea develop. Stool is positive for Clostridium difficile toxin.
Transmission of infections by healthcare workers is not novel. In the mid-19th century, a lack of hand-washing after autopsies led to the spread of puerperal fever. Hand-cleansing with chlorinated lime reduced this risk.10 The HIV epidemic in the 1980s led the Centers for Disease Control and Prevention to define universal precautions (UP), after recognizing that most patients with blood-borne pathogens are asymptomatic.11 Definitions and guidelines have evolved over time.
Standard precautions (SP), including the UP principles, and transmission-based precautions comprise the 2 tiers for preventing nosocomial infection12 transmission.
SP and body substance isolation (BSI) assume that all blood, body fluids, secretions, excretions (except sweat), nonintact skin, and mucous membranes contain transmissible pathogens. They apply to all patient-care in all settings (Table 2-3).11
Types of Precautions, Patient Types, and Requirements of Precaution Type
| Precaution | Patients | Requirements |
|---|---|---|
| Standard | All | Universal precautions and body substance isolation Hand hygiene: after touching bodily substances whether or not gloves are worn and before and after any patient contacts. Use plain soap for routine hand washing. Use an antimicrobial agent or waterless antiseptic for specific circumstances as defined by the infection control program Gloves: when touching any bodily substance, mucous membrane, or nonintact skin. Remove promptly after use, before touching noncontaminated items or another patient. Hand hygiene is required before and after glove use. Mask, eye protection, face shield, gown: when performing activities likely to generate splashes or sprays of bodily substances Equipment, environment, linens: routine care, cleaning, and disinfection of patient-care equipment, surfaces, linens, etc. Occupational health and blood-borne pathogens: when handling needles and other sharp instruments: never recap needles; use a one-handed “scoop” technique or mechanical device for holding the needle sheath. Do not bend, break, or manipulate needles or remove used needles from syringes manually. Dispose in puncture-resistant containers. |
| Airborne | Measles Varicella Zoster Tuberculosis | SP + known or suspected illness transmissible by airborne droplet nuclei (small particle residue) Isolation: negative pressure room, 6–12 air changes hourly. Appropriate discharge or filtration before the air is circulated to other hospital areas. Maintain room door closed. Room sharing only with individuals with the same microorganism Respiratory protection: Fit-tested N95 respirator. Not applicable to persons immune to measles or varicella. |
Droplet | Invasive Haemophilusinfluenzae type b (including meningitis, pneumonia, epiglottitis, and sepsis) Invasive Neisseria meningitidis disease (including meningitis, pneumonia, and sepsis) Bacterial: diphtheria (pharyngeal), mycoplasma pneumonia, pertussis, pneumonic plague Viral: adenovirus, influenza, mumps, parvovirus B19, rubella | SP + known or suspected illness transmissible by droplets (large-particle droplets) generated during coughing, sneezing, talking, or during procedures Isolation: room sharing only with individuals with the same microorganism. When private room not available, maintain at least 3 feet spatial separation. Mask: when working within 3 feet of the patient Transport: for essential purposes only. Mask the patient if possible |
| Contact | GI, respiratory, skin, or wound infection with multidrug-resistant organism Enteric infections including Clostridium difficile, enterohemorrhagic Escherichia coli, Shigella, hepatitis A, or rotavirus for diapered or incontinent patients RSV, parainfluenza virus, or enteroviral infections in children Skin: diphtheria, HSV, impetigo, major (noncontained) abscesses, cellulitis or decubiti, pediculosis, scabies, staphylococcal furunculosis in children, herpes zoster (disseminated or immunocompromised host) Viral/hemorrhagic conjunctivitis Viral hemorrhagic infections (Ebola, Lassa, or Marburg) | SP + known or suspected infection or colonization with pathogen transmitted by direct or indirect contact Isolation: room sharing only with individuals with the same microorganism Gloves and hand hygiene: gloves must be worn when entering the room and changed after contact. Wash hands with soap and water after glove removal. Gown: must be worn if clothing may contact the patient or environment or if incontinence, diarrhea, an ileostomy, colostomy, or wound drainage is present. Transport: for essential purposes only. Mask the patient if possible. Equipment: Dedicate noncritical equipment to a single patient. Adequately clean and disinfect shared equipment. |
Hand hygiene is the most important factor for preventing nosocomial infection.
Wash hands with soap and water or use alcohol-based solutions before and after entering and exiting patient rooms and before/after donning/doffing gloves.12
Needle-stick injuries are a risk for transmitting blood-borne infections. Despite advancements in education, disposal systems, and equipment engineering, needle sticks remain a common cause of occupational exposure to human immunodeficiency virus (HIV), hepatitis B virus (HBV), and hepatitis C virus (HCV). The risk depends upon the pathogen’s prevalence in the patient population, nature of the exposure, and pre- and post-exposure prophylaxis.13 Caution must be taken when handling needles and other sharp instruments (Table 2-3).
Wash the wound immediately with soap and water and report the injury per institutional policy.
Post-exposure prophylaxis (PEP) should be considered and is recommended for HIV. The HIV status of the exposure source should be determined to guide the need for HIV PEP.14 If positive, PEP should be started immediately. The HBV and HCV status of the exposure source should also be ascertained.13
Healthcare workers should be immunized against HBV. PEP with the hepatitis B vaccine and/or immune globulin should be administered after suspected exposure, depending on the individual’s HBV immunity.13
There is no PEP for HCV. Early post-exposure testing is recommended.13
Seroconversion risk after HIV exposure is 3 per 1000 without PEP. The infection risk is 23–62% after HBV exposure and 1.8% after HCV exposure.15
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