Violent protocol for patients with repeat aggression?

[spinnerette]

We have flagged quite a few patients who are frequently brought in for violent behaviors by police but we don't have a protocol for these patients.
Most of the time, they strike when you least expect it and multiple staff have been injured.
Do you guys have a protocol for such patients?
Is it possible to flag them and code them automatically or preemptively upon arrival simply based on their hx of repeat aggression towards staff?

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[nitemagi]

I wouldn't touch the legality of this, personally. But I would be mindful of violent behavior not really d/t a mental illness, trying to get away with this bx on a unit without legal consequences. Police should be contacted, and prosecution considered. The laws still exist within a hospital.

 

[gibits]

History of violence and psychomotor agitation are the biggest indicators of violence. I personally have ordered PRNs on repeat patient the instant I hear they clear triage. There is no reason to wait for someone to get hurt before such measures are done.

 

[kugel]

Most states' laws would preclude an automatic or preemptive physical intervention, or any seclusion or restraint, before there is imminent threat. Also, be careful to avoid "chemical restraint." What can be done is increase the level of therapeutic intervention, to have such pt's receive 1:1 staff, or even 2:1 staff. We have used this response. I suppose a hospital might agree to permit extended visiting hours for family of this pt, on the premise that increased interaction with primary support might assist the pt to utilize the resources of the hospital (i.e. Not act out when family is there). The point is, you will need to be able to show that the hospitals' response is designed to provide more effective treatment - not just to deny treatment or to punish.
On the other hand, a medical decision can be made (usually with the medical director along with the treatment team) that there is nothing this hospital can provide for this patient and, thus, there is no cause to keep him in a hospital. We have, at times, involuntarily discharged such patients. If/when the police bring him/her back, we assess if there is any new information. If not, then the pt is discharged again.

 

[gibits]

"Imminent threat" can mean many things to many different people. If someone with a history of violence is posturing aggressively and/or yelling threats is that enough? Or do they have to be punching your techs and RNs before you decide to "chemically restrain" them? Personally I think it is, and my staff thanks me for having their safety in mind rather than have the CYA attitude.

The more worrisome IMO are the acting out patients that just want a shot and are willing to assault your staff to get it. You can (and should) press charges, but it still results in someone getting hurt.

 

[kugel]

"Immiment Threat" is usually pretty well defined by state reg or hospital policy, and the person at the hospital who is responsible for training new nursing staff will have very clear information available. Sometimes attendings have not had any concrete info or training in this area in decades. If something goes wrong and you are in the middle of a dispute about whether restraint/seclusion was justified, what your attending told you (if you can prove it) will not really protect you. If you violated the policy/training of the facility you could be in trouble. Know the policy and/or ask the nurse trainer for the info.

And make sure you understand the proper use of seclusion vs restraint. In most states that I know of, restraint is only permitted for Danger to Self, not Danger to Others. If someone is being aggressive/assaultive, it is generally not permissible to put him/her into restraints, because seclusion (locked room) removes the danger to others and seclusion is seen as "less restrictive" (the pt can still move around). For exceptions, see your institution policy and procedure. One example at our hospital is when attempts to seclude are overtly unsuccessful, e.g. Pt keeps rushing the door before it can be closed. Usually, on the third try I would order restraint. Once secluded, pts will often hit/kick the wall. Although this can lead to an injury, the risk management attorneys I've consulted suggests that a broken toe or broken finger is less of a legal risk than the chance of serious injury or death during the restraint or the risk of mental trauma resulting from the restraint (imagine the trauma to a sexual abuse victim, even the large angry guy, who gets restrained).
I've had staff demand that I restrain a pt in the seclusion room b/c he is hitting the wall with the lateral edge of closed fists (low chance of serious injury) or becasue the pounding on the door is bothering the other patients (a legally unjustifiable reason for restraint).

"Imminent threat" is usually along the lines of A) a direct threat, "I'll break your neck right now" or B) rushing directly at a person or C) aggressive stance/tone/distance. It does not generally need to be waiting until there is an attempt to harm.
However, generally angry talk ("You're an *******!") and/or history of violence in the hospital generally does Not count as "imminent threat."

Know your policy.

 

[michaelrack]

" Or do they have to be punching your techs and RNs before you decide to "chemically restrain" them? .

Leaving the nurses with orders for zyprexa zydis 10 mg prn for agitation and zyprexa 10 IM prn severe agitation usually does the trick, for persons with psychotic/bipolar disorders (or choose your favorite antipsychotic).
In other words, give the nurses the tools they need to work with.
The above wouldn't apply to those violent purely secondary to ASPD.

 

[whopper]

This is from my experience at a state facility with a forensic unit where the practice was above the standard of care and some forensic psych experience.

The norm consists of standard unit protocols (e.g. 15 minutes checks, 1-to-1s of needed...), identifying possible future violence from inappropriate behaviors, using behavioral interventions first, oral meds if those fail, IM meds if they fail, then restraints.

I'm mentioning the following because it's not the norm in dealing with violence on psych units.

There are tests to gauge the risk of future violence. These become useful in attempting to convince courts of increased intervention vs other less violent patients. The HCR-20 or the COVR test are considered above the standard of care and some of the best tests available in risk of future violence.

There are interventions I've seen in a forensic unit that are not typically employed in regular psych units. E.g. wrist-to-waist restraints being put on the patient for a period of several days to even months, psychological behavioral interventions, staff members pressing charges against patients, unit privileges, etc.

In dealing with chronically violent patients, the facility should have top of the line safety measures for staff members. E.g. emergency buttons on necklaces-you press the button, security is there in just a few seconds to minutes, good video surveillance, responsive staff members, well-lit facilities, etc.

A frequent problem I've seen in PESs is police bringing someone due to violence and the person is not mentally ill. In virtually all states, you could only hold someone against their will due to violence if that violence is due to an Axis I mental illness, not antisocial P.D. or other personality disorder traits. I've been in several situations where I've told the police not to bring the person to PES and they ignore me, forcing my hand to discharge someone that I believe will be dangerous in the immediate future but not due to mental illness and that person should've been arrested.

 

[countryboy75]

What we have used at our ER that has proven to be effective is a system within our EMR that shows the patients name highlighted in violet. Once the patient is brought into the ER they are escorted by the hospital police to a psych pod room where they are then searched for weapons. An ER doc then will rapidly assess the patient and address concerns.

If in this time the patient does become violent security is already with the patient and we then have a jsutified reason to prn, seclude or use restraints. Also, we tend to have a nurse/medic team who are well versed in dealing with mentally ill patients and most of the ER is aware of a potentially violent patient being in one of the psych pods. If something does happen then we have all hands on deck to do a quick restraint if needed to maintain safety (longer times in initiating restraints create higher risks)

This is a 100 bed ER, how this would be handled in say a level 3 trauma hospital I don't know.

 

[gibits]

Leaving the nurses with orders for zyprexa zydis 10 mg prn for agitation and zyprexa 10 IM prn severe agitation usually does the trick, for persons with psychotic/bipolar disorders (or choose your favorite antipsychotic).
In other words, give the nurses the tools they need to work with.
The above wouldn't apply to those violent purely secondary to ASPD.

That is my usual course if action and imitate S&R only that proves ineffective. I personally prefer the cocktail of haldol, Ativan and Benadryl. Let the techs and RNs decide if they feel threatened enough to use it.

 

[spinnerette]

That's what I've been finding in literature. It is impossible in the States to automatically physically or chemically restraint a patient who may become violent based on history alone.

Anyone with a written protocol willing to share with me? 😉

 

[countryboy75]

Spinnerette, I sent you a PM

 

[whopper]

Spinerette, are you a student, resident, attending or something else? (Concerned patient, family member, friend, nurse?)

Reason why is most hospitals should already have a solid protocol in place and if you're a student or resident, have people willing to teach you that protocol.

 

[CounselortoMD]

I firmly believe that the best approach to this problem is to do everything humanly possible to screen out these extremely dangerous "patients" in the first place.

If someone was just released a few days ago from 10 years in prison for a violent crime, and now they are suddenly and "inexplicably" acting "agitated"/hostile/threatening in the general hospital ED (perhaps after some delinquent altercation on the street), simply DO NOT allow the referring ED to dump this individual on your psychiatric doorstep--DO NOT fall for their shady pretense of seeking to arrange treatment for this person's so-called "psychotic" episode.

Likewise, if a former patient has previously committed one or more acts of serious interpersonal violence (or threats thereof) within your facility, then they definitely should not be readmitted--under any circumstances. It simply is not fair, ethical, or sensible to place all of the other patients, not to mention the dedicated staff members, at such high risk of being victimized by an aggressive criminal, and possibly suffering from permanent bodily/mental harm as a result.

Of course hospital administration (who only looks at the bottom line) is not always supportive of this unofficial self-preservation safety strategy--especially if there are empty beds and an available source of payment (i.e., Medicaid, Medicare, State funds) for the dangerous patient's "care."

However, the professionals who staff your admissions department are doubtlessly quite savvy about institutional politics, as well as virtually fearless of the "big bosses", due to the outrageous events they handle bravely on a daily basis. These lowly counselors and social workers, who are battling on the front lines of your facility, actually possess significant autonomy to decline/divert/preempt dangerous potential patients such as those mentioned (of course this is done surreptitiously, diplomatically, and--mostly importantly--untraceably). We have our ways, and for good reasons.

I cannot tell you how many times my team of colleagues in the Admissions Department took matters into our own hands, and thus avoided countless probable tragedies caused by these extraordinarily violent criminal offenders who are far-too-often masquerading as psychiatric patients. Really all it takes is the common sense and the backbone to step up and do something proactive about this unfortunate problem.

 

[masterofmonkeys]

Short disclaimer: I hate when psychotic patients are charged with assault after attacking a provider when they are genuinely flagrantly psychotic. I think it lacks a little in the way of compassion for a person whose own brain has revolted against them.

The CYA environment of medicine and EMTALA are the root causes of all this crap. EMTALA is so inflexible that it is literally breaking some PESs. And the legal admissions are just a waste of hospital resources at best, and damaging therapeutically to the patient. Worse, we are raising the risk of injury to caregivers and other patients by admitting these known violent criminals.

I was assaulted by one of these guys a week ago. It was pretty awesome. He's since been back to our ED twice and was admitted the 2nd time. No axis I pathology. Just trying to intimidate his way into narcotic scripts. He threatened three other doctors before me in the space of two months. Then he assaulted myself, a rather large and intimidating guy. And he's threatened another since then. Saying he's at risk of violence is an understatement.

This is the kind of world our current medico-politico-legal landscape has created. Where we fear being sued by a violent criminal more than we care about protecting physicians and patients. Where physicians and hospitals are dinged if a CHF patient goes out skips his diuretics and eats a bag of potato chips after being treated for an exacerbation. Where PCPs are told they are 'underperforming' if their diabetic patients eat cake every day and don't bother to check their FSBGs. It's stupid.