CLINICAL SAFETY IN NEUROLOGY James Brasic, MD, MPH and Jerry 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.