CLINICAL SAFETYIN NEUROLOGYJames Brasic, MD, MPH andJerry Ainsworth, MD, PhD

This work is supported by the Department of Psychiatry of Bellevue Hospital Center and the New York University School of Medicine, The Essel Foundation, Family and Friends of Chelsea Coenraads, the National Alliance for Research on Schizophrenia and Depression (NARSAD), the Rett Syndrome Research Foundation (RSRF), and the Tourette Syndrome Association, Inc. Dr. Brasic is a member of the Medical Advisory Board of the Tourette Syndrome Association of Greater Washington in Silver Spring, Maryland. Abdul Kalaff assisted with the preparation of the visual presentation.

ACKNOWLEGMENTS

• Violence directed towards clinicians appears to be increasing.

• Health care workers experience close to two fifths of non-fatal assaults on employees in the United States.

• Clinicians typically deny the existence of the risk of assault by patients.

Violent incidents are underreported due to multiple reasons.

• Staff fear blame for incidents• Reporting takes time• Staff feel that reporting is unimportant

• Individual psychiatric inpatients may perpetrate as many as 7.9 violent incidents per patient.

• On psychiatric units violence is likely to occur in corridors.

• Violent patients are likely to have much longer lengths of stay than nonviolent patients.

• On psychiatric inpatient units violence is likely to be directed at staff members and other patients. • Violent patients are likely to exhibit high levels of aggression and anxiety.

• Abusive language• Bullying• Ethnic slurs• Intimidation• Ridicule• Threatening gestures• Threats of injury• Threats of violence

Examples of Verbal Violence

• Biting• Chasing• Grabbing• Hitting• Kicking• Poking• Pulling hair • Punching• Pushing• Scratching• Slapping• Spitting• Swinging• Throwing

Manifestations of Physical Violence

• Emergency Medical Technicians• Home Health Aides• Neurologists• Nurses• Physicians• Psychiatrists• Social Workers• Protective Services

Clinicians at Risk of Assault

• Emergency medical technicians are at risk of assault.

• Their uniforms may be confused with police uniforms.

• They may encounter their patients in isolated settings without protection.

• Home health aides take care of patients in isolated settings without protection. • They may be misinterpreted by patients as intruders.

• Clinicians must consider the safety of the aide before ordering home care.

• Nurses are frequent victims of patient assault.

• 80% of nurses are assaulted in their careers.

• Assaults are likely to occur at the time of medication administration.

• Evening and night shifts are likely times for assault of nurses by patients.

• Nurses experience violence not only from patients, but also from other nurses, nurse managers, and physicians.

• Nurses are angry when nurse managers and physicians fail to protect them from assault.

• Neurologists are at risk of assault by patients.

• Patients may develop paranoid delusions about their neurologist.

• Patients and family may assault the neurologist for real or imagined morbidity or mortality.

• Patients may attack their neurologist

for denials of requests for disability and

other benefits, and for excuses for

absences from school and work.

• Members of protective services

are at risk of assault.

•Answering calls by teams of at least

two may abort aggression by patients.

• Social workers are at risk of violence.

• Patients who fail to immediately

receive requests for insurance,

housing, food, and other benefits

may assault the social worker.

• Absence of escape routes• Inadequate staff• Malfunctioning equipment• Portable furniture• Portable objects• Unobserved patients• Untrained protective services

Clinical Situations Associated with Violence

• Electrolyte imbalance• Grief• Hypoxia• Insufficient staff• Long hospitalization• Loss

Precipitants of Violence

• Anxiety• Denial of patient request for admission• Disrespect, actual or imagined• Fear• Frustration• Involuntary hospitalization• Hunger• Job loss• Lack of privacy• Long wait• Noise• Pain• Sleep deprivation

Triggers of Violent Episodes

• Clinicians must recognize their intuition that violence is imminent.

• If clinicians feel apprehensive in clinical situations, then they ought to follow their instincts and guard personal safety.

• Experienced clinicians follow their gut reactions that something serious is imminent.

• Flushed facies• Hostility• Impulsivity• Loud outbursts• Name calling• Obscene language• Opening and closing the fist• Pacing• Pointing• Possession of a weapon• Profane language

Signs of Impending Violence

• Pushing furniture• Restlessness• Scars• Slamming objects• Smell of alcohol on breath• Staring eyes• Sudden movements• Tattoos• Tension• Uncooperativeness• Widened eyes

Signs of Impending Violence

• Previous history of violence• Age under 30• Male gender• Abuse and dependence on alcohol and other substances• Alcohol intoxication• Psychotic symptoms

Traits associated with violence

• Acute confusional state• Acute organic psychosis• Alcohol abuse and dependence• Alcohol intoxication• Antisocial personality disorder• Bipolar disorder• Borderline personality disorder• Delirium• Delusional syndromes• Dementia• Fire setting• Grandiosity• Head injury • History of family violence

Conditions associated with violence

• History of physical abuse• History of sexual abuse• History of violence to self or others• Homelessness• Impulsivity• Learning disability• Lower income• Lower socioeconomic status• Male sex• Mental disorders• Mental retardation• Minority status• Paranoid psychosis• Poor social networks• Single

Conditions associated with violence

• Sex offender• Substance abuse and dependence• Schizophrenia• Schizoaffective disorder• Torture of animals• Unemployment• Youth

Conditions associated with violence

Access to guns and other lethal weapons• Agitation• Anger• Delusions, persecutory• Disinhibition due to head trauma• Intoxication with alcohol and other substances• Participation in gangs• Poor impulse control• Recklessness• Risk taking• Verbalization of command auditory hallucinations to perform violence• Verbalization of intent to kill• Verbalization of plan to take revenge• Violence at home

Findings Suggesting Violence

• Do not interview or examine patients in offices without security guards.• Install windows in the doors to examining rooms.• Place notices that violence will not be allowed.• Avoid furniture that can block exit from rooms.• Equip examining rooms, offices, and nursing stations with panic buttons.• Do not interview or examine patients in your home.• Require patients to pass through metal detectors before entering clinical areas.

Strategies to avoid violence

• Closed circuit television monitoring• Panic buttons in all clinical areas• Two-way communication systems

Procedures to prevent violence

• Keep patients in your visual field.

• Do not turn your back on patients.

• Make sure that patients do not invade

your personal space within 4 to 6 feet.

Clinician Behavior to Abort Violence

• Feeling upset• Blaming self• Fear of caring for isolated patients• Irritability• Anger• Headache• Low worker morale• Poor job satisfaction• Poor worker retention• Insecurity• Career change• Lost time from work• Refusal to identify self to patients

Adverse consequences of violence

• Debriefing sessions are helpful immediately after violent episodes.

• Obtain a precise statement of what happened.

•Apply the principles of Critical Incident Stress Management.

• Victims of violence are at risk to develop Post Traumatic Stress disorder.