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AkiRovasalo
AloJüriloo
AaroToivonen

Encountering a Violent or Threatening Patient

Essentials

  • Quickly assess the situation.
    • Safety: Whose safety is at risk? Does the patient have a weapon?
    • Cooperation: Are you able to create a verbal connection with the threatening person?
    • Treatment: Does the patient have a physical or psychiatric illness or a state of intoxication that requires immediate management?
  • Do the following:
    • Alert!
      • Call for help unnoticed
    • Calm down!
      • Calm down yourself and others.
      • One person is in charge of the situation and takes care of the discussion.
    • Protect!
      • Protect yourself and others under threat.
      • If you cannot do anything (e.g. during shooting) withdraw and escape!
  • Training and preparing for threatening situations should take place in advance. Hopefully nobody reads these instructions for the first time during an acute situation.
  • In a chaotic situation, the immediate safety of all concerned must be the first consideration.
  • If in doubt ask for help. Do not approach a risk situation unaccompanied.
  • If you cannot communicate or negotiate with a threatening person, concentrate on safety.

How to guarantee immediate safety

  • Confidentiality refers to treatment but not to violent conduct of a person.
    • Depending on local legislation, it may be prohibited to inform the police on the person's medical record or even whether the person is a patient. The policy may, however, usually be notified of a person who endangers security.
  • The police must be summoned immediately if the behaviour of the person is such that measures are needed to provide protection to the individual him-/herself, other clients, or family or staff members. Security personnel at the site may, if necessary, restrain and seclude an individual who poses a serious threat to security before the arrival of the police.
  • Do not approach a risk situation unaccompanied. If you are at all unsure, ask a colleague to stay within earshot. A nurse may accompany a doctor if the presence of the nurse is considered justified for medical reasons or on the grounds of safety.
  • There are good experiences from asking a security guard to be present in advance. A difficult patient or a patient known to be threatening does not need to know that the guard is in readiness nearby. Once the appointment has started, the guard may be discreetly asked to move even closer to the appointment room, so that the potentially needed response time is as short as possible. When the treating staff member feels that the situation is secure, an appropriate amount of confidence will, for its part, prevent the situation from escalating towards a bad direction.
  • In a new contact, the first 2-3 seconds are very informative (“micro expressions”).
    • Does the person take eye contact, is he/she upset and glancing around, does he/she seem to have high levels of adrenaline in the blood?
    • Breaking normal eye contact may indicate preparing for violence.
  • If the situation escalates to endanger safety, the following should be considered:
    • does the situation fulfil the criteria for compulsory admission to psychiatric care?
    • are the police needed (threat of violence)?
    • should child welfare authorities be notified?

Verbal intervention

  • Exercise self-control and talk in a calm manner. Do not allow yourself to be provoked by the patient.
  • Emphasise in simple terms that the aim is to work with the person in order to solve his/her problems: ”We want to help you.”
  • Try to convey the wish to work together: ”We want to work with you to find out what is wrong and what we can do for you.”
  • Convey a message of safety: ”There is nothing to worry about. Let us help.”
  • Limits can be set clearly in a friendly manner: ”We cannot help if you behave in such a threatening manner.”
  • If the person threatens indirectly, address the issue straightaway and calmly ask the patient to clarify the statement: “I am not sure whether I understood correctly. Does that include a threat of some sort?”
    • The exact phrasing of a threat (also over the phone) should be memorized and carefully documented.
  • Ask directly whether the person harbours suicidal or violent thoughts.
  • The staff will see the aggression as a sign of the patient's illness (person's fault) whereas the person with violent behaviour feels that the aggression was provoked by external factors, for example by pointless limits or the attitude of the staff.
  • Gestures also convey messages. Do not hold your hands behind your back or in the pockets; it may look threatening. Look at the person at frequent intervals, but do not stare. Nod approvingly.
  • Superiority in the number of persons present, achieved by calling calmly the staff to enter the space, calms down most of threatening situations. Also guards may visit the space pre-emptively without doing anything.

Rapid pharmaceutical intervention

  • An initial diagnostic assessment of the need for treatment should be available before treatment decisions.
    • For example delirium Delirium in the Elderly usually has a specific aetiology. The treatment of alcohol-related and other types of delirium differ significantly.
    • Hypoclycemia, head trauma, organic state of confusion and an intoxication require different kind of treatment than mania or worsening of schizophrenia.
  • Consider forced medication only in cases where it is legally justified. If an aggressive patient refuses medication, the involvement of the police should be considered.
  • The primary choice is oral (or nasal spray) medication, provided that the patient is willing to accept it. In acute situations, orally disintegrating tablets or liquid products should be preferred. If these are not applicable, an injection may be used.
  • Fast pharmacological control may be achieved with the use of an antipsychotic and a benzodiazepine. The effect of the benzodiazepine is primarily sedative. If the patient is not psychotic, it may be warranted to try first with mere lorazepam as the first injectable drug. To a psychotic violent patient, haloperidol and lorazepam may be given, even at the same time.
    • It is useful to become thoroughly familiar with the emergency use of one antipsychotic. The dose may be repeated 2 to 3 times every 1 to 2 hours. If necessary, the dosing interval may be reduced to 30 minutes in order to prevent imminent violence.
      • Haloperidol 5 mg i.m. or i.v. is the conventional antipsychotic drug used to reduce agitation. Its use is reducing due to its QT-prolonging effect. If the dose used exceeds 20 mg/day, the ECG (QTc) should be checked, as soon as the patient is cooperative enough.
      • Olanzapine 10 mg i.m. or an orodispersible tablet 10-20 mg
      • Elderly patients: e.g. risperidone mixture 0.25-0.5 mg. To a patient with a memory disorder, an antipsychotic drug should be given only if lorazepam or a similar tranquillizing drug is not sufficient alone.
      • Droperidol and promethazine are very rarely used in Finland. Inhaled alternatives are being developed. The use of zuclopenthixol acetate is reducing due to the slow start and long duration of its effect.
    • Benzodiazepines may be used in almost all cases, unless the patient is under the influence of alcohol. A benzodiazepine may usually be administered until the patient appears drowsy.
      • Lorazepam 2(-4) mg i.m.;readily absorbed also as a sublingual tablet
      • Diazepam may be administered orally or by slow intravenous injection, but not intramuscularly. A dose of e.g. 10-20 mg of mixture may be administered orally, as required, even every 30-60 minutes.
      • In children, a very small dose of mixture orally, for example, may be sufficient, and the response is usually fast. Use the correct dose in relation to the patient's weight and consult a pediatrician.
      • Breathing and vital functions must be monitored frequently, at 15 minutes' intervals, in the beginning. A potential respiratory depression is treated with flumazenil as necessary.
    • Research evidence on the drugs is poor, since proper trials are difficult to conduct due to the overall setting.
    • If even a second injection is not helpful, a senior physician should be consulted.
  • Benzodiazepines are useful in the emergency treatment of alcohol withdrawal Benzodiazepines for Alcohol Withdrawal Treatment of Alcohol Withdrawal. Even an aggressive patient will usually agree to take the medication because it will quickly ease the patient's discomfort. The most common mistake made in the treatment of alcohol withdrawal delirium is that diazepam is given too slowly.
  • In order to achieve the maximum antiaggressive treatment response, intravenous dexmedetomidine may sometimes be used (under the supervision of an anaesthetist) as an adjuvant therapy after the standard treatment.
  • Monitor the patient's breathing, pulse, body temperature, fluid balance and level of consciousness.

Special issues

  • In some cases, aggression may be caused by an acute physical illness. The possibility of delirium, head injury and intoxication should at least be considered. The blood glucose level must be checked from all aggressive patients.
  • Substance-induced psychoses are unpredictable and dangerous states. Polysubstance abuse (including medications) may also lead to a sudden change in the person's behaviour.
  • If an aggressive patient is confused enough not to be able to express his/her own will, the use of restraints in order to ensure the delivery of acute management is justified. The patient may need to be secluded but kept under constant observation.
  • Use of coersive measures should be propotional to the situation: no under- or overtreatment. Legislation varies in different countries, but usually the principle of least restrictive practice applies regarding both coersive measures and medication.
  • In an unhurried situation, the next-of-kin may be consulted about treatment if the patient is unable to express his/her own will.
  • In addition to deeds carried out when being upset there are also premeditated and planned acts that may be aimed at so-called soft targets, such as health care units.
  • If compulsory hospitalisation is indicated, the assistance of the police may be needed to ensure the patient's safe arrival for treatment or assessment.
  • If you find yourself in a situation for which no guidelines exist and you are not quite sure about the ethical or legal grounds for your actions, make sure that the health and safety of the patient guides your actions. It will then be easy to justify your actions if they need to be explained at a later stage.

Prevention of violence

  • Security matters need to be included in the basic training of all health care professionals.
  • New employees must be made familiar with security matters, including temporary staff (e.g. substitutes).
  • Good experience exists regarding relevant education that takes place close to one's own work place and involves the whole work community.
  • It is not possible to totally eliminate violence. Prevention consists of risk reduction, but some risk will always remain.
  • The best predictor of violence are past aggression and substance use disorder, regardless of the diagnosis.
  • The health authorities must aim to develop policies and approaches to reduce violence in the health sector.
    • The work environment must be designed taking into account different threats.
    • The design of spaces is important (e.g. an escape route from a consulting room).
    • It is the responsibility of each employee to observe the work environment from the viewpoint of security (e.g. whether there are objects that can be used as striking weapons).
  • Do not try to restrain a patient on your own. Keep at arm's length from an agitated patient. Do not enter the patient's personal space, for example when examining the patient, before explaining why it is necessary. Do not walk in front of a threatening person.
  • If you have no professional knowledge about physical restraint techniques it is safest to flee the scene and obtain assistance.
  • No objects that can be used as a weapon (e.g. scissors) should be within reach in the consulting room.
    • The use of metal detectors may be considered in high risk regions.
    • No strings/bands should be worn around the neck.
  • The ways of summoning assistance should be planned beforehand. All emergency departments should be supplied with a personal security system.
    • Personal security systems are not useful if their use is not trained.
  • Temporary measures include previously agreed knocking at the door or a phone call half way through the consultation and the use of code words (a certain word to indicate that the police need to be summoned immediately).
  • A brief note or a reference to earlier violent situation may be included in the patient-specific risk data.
  • Access to care must, however, be decided based on medical grounds.
  • In the management of chronic aggression, consultation of specialist medical services is usually indicated.
  • Research results indicate that minimizing stress related to queueing in emergency services reduces violent incidents.

Debriefing after a violent incident

  • Do not leave a victim of violence alone.
  • After a violent incident, the incident must not be forgotten. The staff should discuss the incident either with their superiors or representatives from the occupational health services. If necessary, the discussions may be kept confidential.
  • The event is recorded in the monitoring system of violent events of the work place.
  • If there is violence within a treatment relationship, which usually is traumatic, one must decide whether the same professional can continue as the person responsible for treating the patient.
  • Whether mistakes were made or not, one should always consider whether lessons could be learnt from the incident.

    References

    • Bak M, Weltens I, Bervoets C ym. The pharmacological management of agitated and aggressive behaviour: A systematic review and meta-analysis. Eur Psychiatry 2019;57:78-100. [PubMed]
    • Hirsch S, Steinert T. The Use of Rapid Tranquilization in Aggressive Behavior. Dtsch Arztebl Int 2019;116(26):445-452. [PubMed] http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6712906/
    • Cookson J. Rapid tranquillisation: The science and advice. BJ Psych Advances (2018), vol. 24, 346-358. DOI: 10.1192/bja.2018.2 http://www.researchgate.net/publication/326997333_Rapid_tranquillisation_The_science_and_advice
    • D'Ettorre G, Pellicani V, Mazzotta M ym. Preventing and managing workplace violence against healthcare workers in Emergency Departments. Acta Biomed 2018;89(4-S):28-36. [PubMed]
    • Ostinelli EG, Brooke-Powney MJ, Li X ym. Haloperidol for psychosis-induced aggression or agitation (rapid tranquillisation). Cochrane Database Syst Rev 2017;7:CD009377. [PubMed]
    • Violence and Aggression. Short-term management in mental health, heath and community settings. NICE Guideline NG10. NICE, London 2015. http://www.nice.org.uk/guidance/ng10
    • Nolan KA, Shope CB, Citrome L, Volavka J. Staff and patient views of the reasons for aggressive incidents: a prospective, incident-based study. Psychiatr Q 2009 Sep;80(3):167-72. [PubMed]
    • Knesper DJ. My favorite tips for engaging the difficult patient on consultation-liaison psychiatry services. Psychiatr Clin North Am 2007 Jun;30(2):245-52. [PubMed]
    • Goedhard LE, Stolker JJ, Heerdink ER, Nijman HL, Olivier B, Egberts TC. Pharmacotherapy for the treatment of aggressive behavior in general adult psychiatry: A systematic review. J Clin Psychiatry 2006 Jul;67(7):1013-24. [PubMed]