1. Violence and Suicide in the ED Nicholas Cascone, PA-C

2. Violence in the ED  50% of all health care providers will be involved in violence during their careers  ED patients/collaterals are frequently fatigued, hungry, frustrated, anxious, higher proportion of substance abuse  5% of patients presenting to the ED carry weapons  Most perpetrators of violence in ED are males with Hx of substance abuse  Education, ethnicity, marital status, diagnosis are not reliable predictors  Factors predisposing ED to violence: long waiting times, staff shortages, overcrowding, patient expectations, patient financial problems

3. Violence in the ED  Prodrome of violence:  Phase 1: Anxiety  Movement with no purpose other than to expend energy  Pacing, wringing of hands, clenching of fists, unwillingness to stay in waiting/treatment area  Loud, pressured speech  Appropriate response: develop rapport, listen to and address concerns

4. Violence in the ED  Phase 2: Defensiveness  Verbal abuse, profanity  Directed towards staff or others in the department  Statements regarding age, weight, heritage, gender  Body posturing  Appropriate response:  Set simple, clear, enforceable and consistent limits  Offer patient reasonable choices  Isolate patient and provide show of force by uniformed security personnel

5. Violence in the ED  Phase 3: Physical Aggression  Total loss of control  Physical aggression directed towards staff or others in the department  Aggressive patients must be confronted and controlled physically for the safety of themselves, other patients, visitors and staff  Requires personnel skilled in control techniques  Should never be attempted by unskilled personnel or single-handedly

6. Restraint in the ED  Review your organization’s rules for restraint  JCAHO policy:  Only licensed independent practitioner (LIPs) can order restraint  Written order must include type of restraint, reason for restraint, time limit for restraint  If LIP is not available, restraint may be initiated by caregivers but LIP must perform face-to-face evaluation within 1 hour

7. Restraint in the ED  Restrained patients must be evaluated q15min, including examinations for:  Injury  Hydration/nutrition  Circulation/ROM  Vital signs  Hygiene/elimination  Comfort  Psychological status  Readiness for discontinuation of restraint

8. Restraint in the ED  Reason for restraint must be explained to the patient  Patient in restraint should never be abandoned  No patient who has been restrained should be allowed to leave the ED AMA  Patients brought to the ED in restraint should remain in restraint until thoroughly assessed for threat of violence and medical condition

9. Medical management of violent behavior  Used when patients are too violent, even under restraint to perform adequate evaluation  Antipsychotics: haloperidol (Haldol ® ) 5 mg IM q30-45min  Benzodiazepines: lorazepam (Ativan ® ) 2-4 mg IM q30min  More effective when used in combination; more rapid onset and fewer injections needed

10. Suicide  Suicidality is associated with severe depression, isolation, loss, stressful life events  Providers’ negative attitudes towards those who attempt suicide exacerbate patient risk

11. Risk of suicide  High risk  Male  Separated/widowed divorced  Chaotic/conflictual family, FHx of suicide  Unemployed  Recent conflict or loss  Weak or no religious suicide taboo  Low risk  Female  Married  Stable family  Employed  Stable relationships  Strong religious taboo against suicide

12. Risk of suicide  High risk (cont’d)  Acute/chronic illness  Excessive drug/alcohol use  Depression/bipolar/ schizophrenia/panic  Disruptive behavior  Helplessness/ hopelessness  Frequent, intense, prolonged suicidal ideation  Low risk (cont’d)  Stable health  Little or no drug/alcohol use  No axis I mental disorders  Directable  Hopeful, future-oriented  Infrequent, transient ideation

13. Risk of suicide  High risk (con’td)  Prior suicide attempts  High-risk, dangerous attempts  Realistic plan  Guilt regarding suicide ideation  Lack of concern regarding attempts  Social isolation  Low risk (cont’d)  No prior attempts  Attempts with high likelihood of rescue  No plan  Embarrassment regarding ideation  Insight regarding affect on others  Social integration

14. Markers for ongoing risk  Psychosis  Hopelessness/helplessness  Exhaustion  Lack of anger/remorse/embarassment  History of prior attempts, especially high- risk attempts  Continuing intention to die

15. Criteria for discharge  Medically stable  Pt agrees to return to ED if suicidal intent recurs  Not intoxicated, delerious, demented  Means of self-harm has been removed  Treatment of psychiatric diagnoses has been arranged  Acute precipitants of suicide have been addressed/resolved  Patient and family agrees to follow-through on treatment  Patient’s caregivers/family agrees to discharge plan  “No harm” contract has been established  Document all criteria  If in doubt, obtain psychiatric consult or hospitalize