# How to Manage aggressive and violent patients in healthcare set up?

All healthcare workers, especially general practitioners and staff in emergency departments and diagnostic centres staff are likely to encounter aggression and violence. This behaviour may be caused by a medical illness, a psychiatric illness or drug intoxication or withdrawal. These problems can occur in combination. It is important that a diagnosis is made, but in some cases the patient may need sedation before they can be examined. If non-drug management, such as de-escalation techniques, does not work, a benzodiazepine or antipsychotic can be considered. It is essential that sedated patients are monitored for signs of oversedation. Practice design and policies as well as staff training can help to reduce the risk of violence.

What is Aggression patient?

Aggression and violence may be a manifestation of underlying psychiatric disorders. These include drug psychosis, delusional states, mania and personality disorder. Some patients try to use aggression as means of achieving a particular goal, such as being seen earlier or obtaining drugs. Medical illness may result in behaviour disturbance. It can also coexist in patients with mental health, drug and alcohol problems or other conditions.

The Phase of Assault Cycle.

1. Triggering Event

Triggers are perceived by the patient as a serious threat. Triggers may occur well before you meet the patient. e.g. pain, substance abuse, language difficulties, unrealistic expectations, miscommunication, home situation, violation of personal space. Intervention at this point can divert an aggressive incident.

2. Escalation ‘Fight or Flight’ response of the patient.

The things you can see, hear & feel that provide clues that the patient is getting more aggressive are: Rude or vulgar words Aggressive body language Physical & psychological changes.

3. Crisis

 When the aggressive patient becomes physically violent. At this stage the breakaway technique may be of help.

 4. Recovery

The body relaxes & the mind decreases its vigilance. Whilst the confrontation is seen to be over, the crisis can re-ignite at any time. Monitoring of the patient at this point is critical to avoid the re-ignition of the crisis.

5. Post Crisis Depression

The physical and emotional aspects of the crisis often reappear in this phase as fatigue, depression or feelings of guilt. The potential for severe guilt or remorse may result in a suicide attempt..

Managing aggressive person in the Health Facilities

·       If Registered patient: Use the guideline & refer to general flow chart on Management of Aggression in the centre

·       If not Registered patient: Security guards /police should be notified immediately

·       The management of patients with aggression follows the ABCDE algorithm below :

A – Assessment

B – Behaviour stabilization ± Breakaway Technique

C – Choice of medication ± Control & restraint

D – Documentation & Debriefing

E – Event reporting

Mistakes To Avoid

•         Arguing with the aggressive patient

•         Empathic failure

•         Trying to dissuade a fixed belief or delusion

•         Being punitive or threatening

•         Provoking the aggressive patient

•         Humiliating the aggressive patient

•         Traumatizing or re-traumatizing the aggressive patient

•         Inadvertently accepting the aggressive patient’s projection

Measures To Reduce Risk Of Violence

•         A pleasant environment in which there is no overcrowding

•         A predictable ward routine

•         A good range of meaningful activities

•         Well-defined staffing roles

•         Good staffing levels

•         Privacy and dignity without compromising ward observation

What to do?

At centre, the staff should:

·       Assess all patients for possible violent behaviour / history of violence.

·       If the patient is in possession of any weapons,

·       police and /or security guards should be notified as soon as possible.

·       suggest to the patient to voluntarily place the weapon down and move away from it. The weapon should be retrieved once he / she has been taken away from the area.

·        Activate team as per centre emergency department procedure. Place patient in an area where he /she can be easily observed by paramedics.

·       Suggest displaying zero tolerance policy towards abusive and aggressive behaviour at the area.

·       Healthcare provider at registration counters to be familiar with patterns of patients who are potentially aggressive and warn relevant personnel.

·       Alert the security team closest to the clinic and alert additional healthcare providers from nearby clinics.

·       Ensure personal and healthcare providers’ safety.

·       Inform & transfer the patient to the Emergency Department for further management.

Prevention

Prevention Some simple preparatory steps may be helpful in averting trouble or in dealing with difficult situations merely while taking diagnosis as they arise. A sign should make clear that aggression and violence are not tolerated. The diagnostic centre should have a functioning duress system and protocols for responding. Ideally the assessment area should have no dangerous objects easily at hand and should have more than one exit.

The diagnosis is methamphetamine intoxication. A middle-aged man with a long-standing brain injury is often threatening and disruptive while in the waiting room for his regular attendances. His future visits are always scheduled as an early long appointment and it is made clear he must be accompanied by his carer. A 65-year-old man is tremulous, agitated and aggressive. He seems irrational and is experiencing visual hallucinations.