Safety in the Psychiatric Emergency Service



Safety in the Psychiatric Emergency Service


Nancy Byatt

Rachel Glick



The psychiatric emergency service (PES) is often a site of risk and uncertainty because of the chaos and acuity inherent in such a setting (1). The potential for violence in a PES is common and presents safety issues for staff, patients, and visitors (2,3,4). Assaults of persons and objects are frequent, severe, and devastating to staff, employees, and patients (2,5). Evidence suggests that violence in emergency departments is prevalent and many institutions are improperly prepared to manage it (6). It is imperative that the PES be appropriately designed to ensure safety, and that staff are adequately trained to prevent, manage, and cope with such incidents (2).


EPIDEMIOLOGY

Violence is a serious hazard in the health care workplace and a growing public health concern (7). It has been estimated that there are thousands of assaults in hospitals in the United States every year. The emergency department (ED) is particularly vulnerable to the many assaults that occur in U.S. hospitals (1,7). Furthermore, violence in the ED is more likely to involve patients requiring medical and psychiatric clearance as well as patients in police custody.

A survey of 7,000 governmental employees revealed that 50% of mental health care workers were likely to be assaulted while working (7). Another survey of 101 therapists found that 74% of therapists had been assaulted at some point in their career and that of 115 psychiatrists 42% had been assaulted at least once (2).

Psychiatrists are commonly victims of assault, with surveys indicating that 50% of psychiatrists have been assaulted during their career. Many assaults have been noted to occur during the beginning of residency. Young physicians and psychiatric residents are at high risk for both physical and sexual assaults by patients. In one survey, more than half of emergency medicine residents reported being physically hit or pushed by patients during residency training. Residents and ED nurses reported in the same survey that fear of assault or injury is one of their primary concerns regarding personal safety (5).

Owen et al. investigated the frequency and types of aggressive behavior in an acute care psychiatric setting. In a 7-month study, 174 patients perpetrated 1,389 incidents, of which staff rated 58% as serious. Of the assault victims, 78% were nursing staff, 4% physicians, and 2% psychologists (2,8). In state hospitals, rates of 11.7 to 16.9 injuries per 100 employees have been reported (9). In the PES, nurses are six times more likely to be assaulted compared to psychiatrists, while psychia- tric technicians, who maintain real-time security and safety, are three times more likely to be assaulted (10).


SEQUELAE

Patients, staff, and visitors all share the risk of experiencing or witnessing violence, and the potentially devastating physical and psychological sequelae that may result. Both patients and staff may be harmed by assaultive behaviors, seclusion and restraints, and the use of forced intramuscular medications. Medical professionals share the same physical and psychological vulnerability to injury as other victims of trauma. Assaults may result in death, permanent or time-limited disability, physical injury, medical leave, industrial accident claims, psychological distress, medical and legal expense, and lost productivity (5). Fear of personal harm can also affect the morale and
performance of PES physicians and nurses. More than 20% of ED nurses reported knowing a peer who left ED nursing secondary to personal victimization. A similar number reported knowledge of colleagues who had left the nursing field solely as a result of violence (3). Violence in the health care setting constitutes a significant threat to daily functioning (7).

In a study of 40 nurses who had been assaulted by a patient, 21% reported suffering life-endangering or multiple injuries, including fractures, lacerations or bruises, and loss of consciousness. Forty-five percent took leave from work as a result of an assault, and 65% required from 1 week to a year for full recovery. At least 30% experienced anger, anxiety, and fear as a result of a violent encounter. Victims also reported symptoms suggestive of posttraumatic stress disorder (PTSD). These findings have been corroborated in a similar study by Mahoney that reports similar rates of injuries, adverse effects on job performance, and psychological effects. Caldwell found that 61% of clinical staff reported symptoms of PTSD with intrusive thoughts or increased emotional anxiety, and 10% received a formal diagnosis of PTSD (2,11).

Psychiatric residents have indicated that they often do not report assaults because of shame, fear, or denial. Residents may be perceived as troublemakers when they request that the department take steps to decrease patient assaults. Violent acts or threats of violence can be the most upsetting part of a psychiatric residency, and trainees often feel unsupported by staff, colleagues, or supervisors (7).

Patients clearly share the same risk of physical and psychological vulnerability secondary to potential trauma as do clinical staff (2,12). An investigative series by the Hartford Courant (13,14,15) reported 142 deaths that occurred nationwide during seclusion and restraint in psychiatric facilities between 1988 and 1998. Of these deaths, 50% were due to asphyxiation, 12% resulted from cardiac arrests in patients with no known cardiac history, 5% were the result of poor technique or poor monitoring, and for 53% the cause of death was unknown. Although the use of seclusion and restraint is a vital component of acute care psychiatric settings that can prevent both injury and agitation, it can have substantial harmful and physiologic effects on both patients and staff (12).


RISK FACTORS

Studies have revealed several risk factors for violence in psychiatric emergency settings. Among them are administrative management practices, presence of psychiatric illness, the phase of illness, and patient characteristics. Violence is also affected by physical plant and architectural design, as well as staff expectations and experience (16).


Administration

Despite the consensus on risk management strategies that reduce the risk of assaults and their impact on staff, health care facility administration may minimize the importance of using such approaches because of fiscal concerns or the complexity of proper training. Owen et al. determined that the risk of violence by patients increased in four domains: the number of patients on the unit, presence of patients with a history of violence, the number of female staff, and the number of staff with little or no psychiatric training (2). PES clinicians are encouraged to work with administration to identify when one or more of these factors are present. Identifying the characteristics of staff victims and addressing their needs remains a serious health concern. Utilizing risk management strategies that mitigate violence, such as increased awareness of patient and staff risk factors, is imperative in creating a safe PES (5).


Patient Risk Factors

Increased knowledge of patient risk factors may lead to increased staff awareness and may enhance assessment of dangerousness. Individual factors associated with violence include acute illness, psychosis, substance abuse, and a history of violence (16).

Untreated mental illness is frequently associated with violent acts (7). Substance use disorders have been associated with both victims and perpetrators of violent acts. Serious violent acts have been associated with the combination of mental illness, substance abuse, and noncom-pliance with treatment (7). Although studies remain inconclusive, a higher prevalence of violent behavior among persons with mental disorders has been demonstrated by several studies (4). The Epidemiological Catchment Area project examined self-reports of violent behaviors obtained
from 10,000 individuals residing in the United States. Patients with mental illness and comorbid substance abuse had a greater probability of violent behavior than patients with schizophrenia, schizoaffective disorder, and other affective disorders. Similar results were found in a smaller study that compared 385 current or former psychiatric patients with 365 who had never received psychiatric treatment. Self-reports of violent behaviors were 2-fold, 1.7-fold, and 3.6-fold more common in patients than nonpatients with respect to hitting someone, fighting, and using a weapon, respectively (17).

In a 3-year, prospective study of 1,136 patients in the United States, Steadman et al. (18) demonstrated the relationship between substance abuse and violence. The presence of substance abuse symptoms significantly increased the rate of violence (4.3%) compared with a community control group. The relationship between substance abuse and medication noncompliance was also examined by Swartz et al. (19), who found an association between violent behavior and the combination of substance abuse and medication noncompliance.

Consideration of medical and psychiatric disorders that are commonly seen in patients presenting with violent behaviors may help predict violence, as well as response to verbal or pharmacologic interventions (4). Specific disorders associated with assault include schizophrenia, bipolar disorder, substance abuse, intoxication or withdrawal, posttraumatic stress disorder, cognitive deficits, personality disorders, and any medical or neurologic disorder that can cause psychiatric symptoms (7). Acute medical causes of agitation and aggression should be considered, such as brain injuries, brain tumors, or metabolic disturbances (4,20).

Psychotic disorders, affective disorders, mood disorders, and anxiety disorders have also been associated with violence. Studies have demonstrated that violence may be associated with persecutory delusions, the acute phase of illness, comorbid substance abuse and withdrawal, and medication noncompliance. Antisocial and borderline personality disorders have been found to be associated with violence due to conduct problems and impulsivity, for both inpatients and outpatients. Although studies have been inconsistent, some association has been found between mood disorders and violence, particularly in manic states with comorbid substance abuse or personality disorders. PTSD has also been associated with anger and hostility, although these findings were inconsistent and generally associated with comorbid substance abuse (4,20).

Patient characteristics that predict clinician assault include history of violence, job loss, poor therapeutic alliance, previous clinician assault, treatment noncompliance, and first presentation to a psychiatric treatment setting. Symptoms that have been noted to predict clinician assault are delusions, hallucinations, pain, violent ideation, and recent threat to assault. Signs that an individual is at high risk of becoming violent include anger, catatonia, bizarre behavior, psychomotor agitation, restlessness, confusion, impatience, excitement, hyperactivity, guardedness, hostility, or impulsivity (7,20).


Clinician Risk Factors

In addition to understanding patient risk factors, increased awareness of the heterogeneous origins of violence is paramount in progressing toward the prevention and management of violence and preservation of patient and clinician safety (21,22). Being alert to both patient and clinician risk factors is crucial in determining precipitants for violence (22).


PSYCHIATRISTS

Certain groups of health care workers are more vulnerable to assault. Psychiatric residents are at high risk for both physical and sexual assaults by patients. This risk is increased in acute care settings such as PESs. Short-tempered residents who may act cantankerous or argumentative, dismiss police officers, or conduct interviews unassisted are particularly vulnerable.

Countertransference reactions such as anxiety, fear, anger, and helplessness can adversely affect assessment and treatment of patients. Defense mechanisms such as projection, denial, fear, or identification may lead physicians to overreact or ignore pertinent historical information or risk factors for violence. Feelings experienced by physicians in response to patients may lead to inappropriate reactions, statements, orders, and clinical decision making, thus increasing the risk of patient violence (7).



NURSING STAFF

Nursing staff are more likely than other staff to experience violence and injuries at some point during their career (2,7). Nurses are victims of up to 90% of assaults that occur during the administration of medication and physical restraints. Research has demonstrated that younger, less experienced, and less formally trained mental health workers and nurses are at higher risk for assault. Nurses who abuse tobacco, caffeine, or alcohol are also more likely to experience violence (7). Women have been noted to have a twofold higher risk of being assaulted than men (5,23), and assaults are more likely when psychiatric units are solely staffed by women at night (7). Data indicate that the staff members who spend the most time with patients are at the greatest risk of experiencing an assault (2).

Staff may play a role in provoking patient violence, which is supported by the finding that staff members are assaulted at higher rates than other patients, and some staff members seem to be attacked repeatedly. Quinsey (24) noted the disparity between staff and patient views on precipitants of violence. Staff commonly note that the violence is unprovoked, whereas patients claim that teasing by other patients or staff triggered the assault. Staff may be unaware of the events that elicit violence.

Other authors have proposed that staff members’ own aggression and anger may lead to the use of projection and projective identification onto the patient, leading to increased risk of violence. Rigid, intolerant, authoritarian, or adversarial staff, especially with the use of inconsistent limit setting, may provoke patient violence. Other research has suggested that patient belief that violence is expected and will be tolerated may lead to an increase in assaults. Such a standard can begin with inadequate management practices and lack of involvement of medical staff (16).


Situational and Structural Factors

Multiple situational and structural risk factors should also be considered as factors that can increase violence (16). Although there is a dearth of research examining situational factors in emergency psychiatry settings, studies have examined the role of such factors in inpatient settings. Violence is influenced by the interaction of a multitude of factors in the immediate environment, including the physical plant and the presence of other staff and patients. Studies point to violence being more complex than simply the manifestation of underlying patient pathology. Provoked by a combination of issues, violence may be heavily influenced by environmental factors (16).

Studies on inpatient psychiatric settings have indicated that the potential for assaultive incidents is greater when a large number of patients are clustered together, often the case in emergency settings. One study found a slightly higher assault rate on coed wards, possibly secondary to the sexual overstimulation that may occur in such settings (16).

Because of a greater recognition of patients’ rights, the use of less restrictive interventions, and the tightening of the commitment criteria for involuntary hospitalization, the severity of illness with which patients present to the ED has dramatically increased. Maintaining a safe and appropriate environment becomes increasingly important as the severity of illness increases in psychiatric acute care settings (16).

Residents have reported that precipitants of assault such as inappropriate facilities, inadequately trained staff, and the presence of high-risk patients can often be anticipated (7). Untrained, physically weak, or elderly security officers can further increase resident vulnerability. In some cases, there may be a tardy response to the use of a panic button. Inadequate facilities may include rooms that contain dangerous objects and lack outward-opening doors, easily accessed panic buttons, and visual and auditory monitoring (7).

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Jun 13, 2016 | Posted by in PSYCHIATRY | Comments Off on Safety in the Psychiatric Emergency Service

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