Violence and Violence and Suicide in the EDSuicide in the ED

Nicholas Cascone, PA-CNicholas Cascone, PA-C

Violence in the EDViolence in the ED 50% of all health care providers will be involved in 50% of all health care providers will be involved in

violence during their careersviolence during their careers ED patients/collaterals are frequently fatigued, hungry, ED patients/collaterals are frequently fatigued, hungry,

frustrated, anxious, higher proportion of substance frustrated, anxious, higher proportion of substance abuseabuse

5% of patients presenting to the ED carry weapons5% of patients presenting to the ED carry weapons Most perpetrators of violence in ED are males with Hx of Most perpetrators of violence in ED are males with Hx of

substance abusesubstance abuse Education, ethnicity, marital status, diagnosis are Education, ethnicity, marital status, diagnosis are notnot reliable reliable

predictorspredictors Factors predisposing ED to violence: long waiting times, Factors predisposing ED to violence: long waiting times,

staff shortages, overcrowding, patient expectations, staff shortages, overcrowding, patient expectations, patient financial problemspatient financial problems

Violence in the EDViolence in the ED

Prodrome of violence:Prodrome of violence: Phase 1: AnxietyPhase 1: Anxiety

Movement with no purpose other than to expend Movement with no purpose other than to expend energyenergy

Pacing, wringing of hands, clenching of fists, Pacing, wringing of hands, clenching of fists, unwillingness to stay in waiting/treatment areaunwillingness to stay in waiting/treatment area

Loud, pressured speechLoud, pressured speech Appropriate response: develop rapport, listen to Appropriate response: develop rapport, listen to

and address concernsand address concerns

Violence in the EDViolence in the ED

Phase 2: DefensivenessPhase 2: Defensiveness Verbal abuse, profanityVerbal abuse, profanity

Directed towards staff or others in the departmentDirected towards staff or others in the department Statements regarding age, weight, heritage, genderStatements regarding age, weight, heritage, gender

Body posturingBody posturing Appropriate response: Appropriate response:

Set simple, clear, enforceable and consistent limitsSet simple, clear, enforceable and consistent limits Offer patient reasonable choicesOffer patient reasonable choices Isolate patient and provide show of force by uniformed Isolate patient and provide show of force by uniformed

security personnelsecurity personnel

Violence in the EDViolence in the ED

Phase 3: Physical AggressionPhase 3: Physical Aggression Total loss of controlTotal loss of control Physical aggression directed towards staff or Physical aggression directed towards staff or

others in the departmentothers in the department Aggressive patients must be confronted and Aggressive patients must be confronted and

controlled physically for the safety of themselves, controlled physically for the safety of themselves, other patients, visitors and staffother patients, visitors and staff

Requires personnel skilled in control techniquesRequires personnel skilled in control techniques Should never be attempted by unskilled personnel or Should never be attempted by unskilled personnel or

single-handedlysingle-handedly

Restraint in the EDRestraint in the ED

Review your organization’s rules for Review your organization’s rules for restraintrestraint

JCAHO policy:JCAHO policy: Only licensed independent practitioner (LIPs) Only licensed independent practitioner (LIPs)

can order restraintcan order restraint Written order must include type of restraint, reason Written order must include type of restraint, reason

for restraint, time limit for restraintfor restraint, time limit for restraint If LIP is not available, restraint may be If LIP is not available, restraint may be

initiated by caregivers but LIP must perform initiated by caregivers but LIP must perform face-to-face evaluation within 1 hourface-to-face evaluation within 1 hour

Restraint in the EDRestraint in the ED

Restrained patients must be evaluated Restrained patients must be evaluated q15min, including examinations for:q15min, including examinations for: InjuryInjury Hydration/nutritionHydration/nutrition Circulation/ROMCirculation/ROM Vital signsVital signs Hygiene/eliminationHygiene/elimination ComfortComfort Psychological statusPsychological status Readiness for discontinuation of restraintReadiness for discontinuation of restraint

Restraint in the EDRestraint in the ED

Reason for restraint must be explained to the Reason for restraint must be explained to the patientpatient

Patient in restraint should never be Patient in restraint should never be abandonedabandoned

No patient who has been restrained should be No patient who has been restrained should be allowed to leave the ED AMAallowed to leave the ED AMA

Patients brought to the ED in restraint should Patients brought to the ED in restraint should remain in restraint until thoroughly assessed remain in restraint until thoroughly assessed for threat of violence and medical conditionfor threat of violence and medical condition

Medical management Medical management of violent behaviorof violent behavior

Used when patients are too violent, even Used when patients are too violent, even under restraint to perform adequate under restraint to perform adequate evaluationevaluation Antipsychotics: haloperidol (HaldolAntipsychotics: haloperidol (Haldol®®) 5 mg IM ) 5 mg IM

q30-45minq30-45min Benzodiazepines: lorazepam (AtivanBenzodiazepines: lorazepam (Ativan®®) 2-4 mg ) 2-4 mg

IM q30minIM q30min More effective when used in combination; More effective when used in combination;

more rapid onset and fewer injections neededmore rapid onset and fewer injections needed

SuicideSuicide

Suicidality is associated with severe Suicidality is associated with severe depression, isolation, loss, stressful life depression, isolation, loss, stressful life eventsevents

Providers’ negative attitudes towards Providers’ negative attitudes towards those who attempt suicide exacerbate those who attempt suicide exacerbate patient riskpatient risk

Risk of suicideRisk of suicide

High riskHigh risk MaleMale Separated/widowed Separated/widowed

divorceddivorced Chaotic/conflictual Chaotic/conflictual

family, FHx of suicidefamily, FHx of suicide UnemployedUnemployed Recent conflict or lossRecent conflict or loss Weak or no religious Weak or no religious

suicide taboosuicide taboo

Low riskLow risk FemaleFemale MarriedMarried

Stable familyStable family

EmployedEmployed Stable relationshipsStable relationships Strong religious taboo Strong religious taboo

against suicideagainst suicide

Risk of suicideRisk of suicide

High risk (cont’d)High risk (cont’d) Acute/chronic illnessAcute/chronic illness Excessive drug/alcohol useExcessive drug/alcohol use Depression/bipolar/Depression/bipolar/

schizophrenia/panicschizophrenia/panic Disruptive behaviorDisruptive behavior Helplessness/Helplessness/

hopelessnesshopelessness Frequent, intense, Frequent, intense,

prolonged suicidal ideationprolonged suicidal ideation

Low risk (cont’d)Low risk (cont’d) Stable healthStable health Little or no drug/alcohol Little or no drug/alcohol

useuse No axis I mental disordersNo axis I mental disorders DirectableDirectable Hopeful, future-orientedHopeful, future-oriented

Infrequent, transient Infrequent, transient ideationideation

Risk of suicideRisk of suicide

High risk (con’td)High risk (con’td) Prior suicide attemptsPrior suicide attempts High-risk, dangerous High-risk, dangerous

attemptsattempts Realistic planRealistic plan Guilt regarding suicide Guilt regarding suicide

ideationideation Lack of concern Lack of concern

regarding attemptsregarding attempts Social isolationSocial isolation

Low risk (cont’d)Low risk (cont’d) No prior attemptsNo prior attempts Attempts with high Attempts with high

likelihood of rescuelikelihood of rescue No planNo plan Embarrassment Embarrassment

regarding ideationregarding ideation Insight regarding affect Insight regarding affect

on otherson others Social integrationSocial integration

Markers for ongoing riskMarkers for ongoing risk

PsychosisPsychosis Hopelessness/helplessnessHopelessness/helplessness ExhaustionExhaustion Lack of anger/remorse/embarassmentLack of anger/remorse/embarassment History of prior attempts, especially high-History of prior attempts, especially high-

risk attemptsrisk attempts Continuing intention to dieContinuing intention to die

Criteria for dischargeCriteria for discharge Medically stableMedically stable Pt agrees to return to ED if suicidal intent recursPt agrees to return to ED if suicidal intent recurs Not intoxicated, delerious, dementedNot intoxicated, delerious, demented Means of self-harm has been removedMeans of self-harm has been removed Treatment of psychiatric diagnoses has been arrangedTreatment of psychiatric diagnoses has been arranged Acute precipitants of suicide have been addressed/resolvedAcute precipitants of suicide have been addressed/resolved Patient and family agrees to follow-through on treatmentPatient and family agrees to follow-through on treatment Patient’s caregivers/family agrees to discharge planPatient’s caregivers/family agrees to discharge plan ““No harm” contract has been establishedNo harm” contract has been established

Document all criteriaDocument all criteria If in doubt, obtain psychiatric consult or hospitalizeIf in doubt, obtain psychiatric consult or hospitalize