HomeMy WebLinkAboutMINUTES - 02091993 - 2.3 a.1, - ;-1 '
TO: BOARD OF SUPERVISORS
FROM: Mark Finucane, Health Services Director 1 F. ,. Contra
Costa
DATE: February 2, 1993 ^y County
SUBJECT: Report of Task Force on Patient violence
SPECIFIC REQUEST(S)OR RECOMMENDATION(S)&BACKGROUND AND JUSTIFICATION
RECOMMENDATION:
Accept report from the Health Services Director regarding report and recommendations of the Task Force
on Patient Violence.
FINANCIAL IMPACT:
None
BACKGROUND:
In response to several serious incidents of patient violence, a Task Force was established in November 1992
to review work place safety in the following areas:
* Physical plant changes
* Staff training
* Security staffing
* Clinical staffing patterns and assignments
The Task Force has completed its assignment and has submitted the attached report. The report includes
recommendations in each of the above areas as well as a recommendation that the Task Force continue to
meet to work on refining and implementing the basic recommendations.
CONTINUED ON ATTACHMENT: SIGNATURE
RECOMMENDATION OF COUNTY ADMINISTRATOR RECOMMENDATION OF BOARD COMMITTEE
APPROVE OTHER
SIGNATURE(S):
ACTION OF BOARD ON February 9 , 1993 APPROVED AS RECOMMENDED X OTHER
Speaking on this matter was Pat Risser, Contra Costa Network of Mental
Health Clients , 326 Glacier Drive, Martinez 94553.
VOTE OF SUPERVISORS
XX1 HEREBY CERTIFY THAT THIS IS A TRUE
UNANIMOUS (ABSENT - ) AND CORRECT COPY OF AN ACTION TAKEN
AYES: NOES: AND ENTERED ON THE MINUTES OF THE BOARD
ABSENT: ABSTAIN: OF SUPERVISORS ON THE DATE SHOWN.
Contact Person: Mark Finucane,370-5003
CC: Health Services Director
Merrithew Memorial Hospital, ATTESTED February 9 , 1993
Executive Director PHIL BATCHELOR, CLERK OF THE BOARD OF
Mental Health Director SUPERVISORS AND COUNTY ADMINISTRATOR
BY Q -(� DEPUTY
pviolence.bo
errithew
emorial
O�PO4Lad
AND CLINICS
TRANSMITTAL
January 26, 1993
TO: Mark Finucane, Director
Health Services Department
FROM: Barbara McMahon, R.N., D.N.Sc.
Task Force on Patient Violence, Chairperson
RE: Submission of Summary Report
I am pleased to submit to you the Summary Report of the Task Force on Patient Violence.
The task force would like to thank you for the opportunity to present these recommendations
and looks forward to working with you during the implementation phases. The task force
worked extremely hard and were dedicated to making reasonable and practical
recommendations. In evaluating the process, participants felt it had been a very positive
experience offering a forum for discussion and problem solving that had not previously
existed. As a result, the task force is recommending that it continue to meet so that it can
work on refining and implementing the recommendations it has already made.
It is our strong belief that the recommendations can serve as a basis for change and have a
profound impact on improving both safety on the units and as importantly the clinical
treatment and care of patients which is integral to reducing incidents of patient violence.
cc: Pat Roach
Frank Puglisi, Jr.
Task Force Participants
Contra Costa County
coiiK
A-301A (3/87)
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TASK FORCE ON PATIENT VIOLENCE
SUMMARY REPORT
January 1993
INTRODUCTION
The Task Force on Patient Violence was established as a result of several serious incidents of
patient violence on the psychiatric units at Merrithew Memorial Hospital (MMH). The
charge to the task force acknowledged that avoiding patient violence is not just a matter of
security officers. Accordingly, it was assigned the task of reviewing work place safety in
terms of the following:
o Physical plant changes
o Staff training
o Security staffing
o Clinical staffing patterns and assignments
The task force met eight times between November 20 and December 21, 1992. It was
comprised of a diverse group of employees (clerks, nursing staff, mental health treatment
specialists, psychiatrists) representing each of the psychiatric units. In addition, the task
force actively sought input from patient advocate groups and other employees that provide
services on the units (e.g., occupational therapists, housekeepers, lab techs, family nurse
practitioners) by having them come and participate in the meetings of the task force.
This report is intended to briefly summarize the major findings and recommendations of the
task force. A complete set of approved task force minutes, that provide greater detail of task
force discussions and recommendations, are attached for reference.
PATIENT DATA/PROFILES
The task force thought it would be instructive to review available patient data in order to
develop a profile on who the violent patients are and to see whether any trends in the violent
incidents could be identified. Available data however, was very limited due primarily to the
fact that incidents of violence are significantly underreported by staff (this is consistent with
what is found in the literature on this issue). Nevertheless an analysis was done using J-Unit
data (the unit on which the majority of violent incidents have occurred). Findings included:
.o The profile of violent psychiatric patients described in the literature (i.e. patients
with a high risk of behaving violently) include young males (less than 35 year of
age) with a history of violent behavior from lower socioeconomic/educational
groups with a severe (psychotic) mental illness. The patients admitted to J-Unit
are illustrative of this profile and our mission.
o Another finding consistent with what is described in literature research, is that it is
a very small group of patients that account for the majority of violent incidents.
r i
o Almost 29% of the incidents occurred on Monday; 21.4% on Saturday; and
14.3% on Friday and Sunday.
o Day and evening shift accounted for over 90% of the incidents. Peak times for
violence included change of shift and meal times.
o The first few days of hospitalization are the days at greater risk for violent
behavior: within one day of admission 21.4% of the incidents occurred; within
five days 39.3%; and within 10 days 52.6%.
o The incidents of violent and assaultive behavior were clearly under reported.
Minor injuries such as scratching or incidents with a potential for injury later,
such as spitting or muscle strain tend not to be reported. Reasons given for not
reporting these incidents include, "it is part of the job", "it's too time
consuming", and "what will it accomplish?".
The psychiatric patient population of Merrithew is not a homogeneous group. Three levels
of patients are identified within the current patient mix:
o Acute: Patients who are severely and persistently mentally ill with varying
degrees of ability to succeed in an outpatient setting. This population requires
disposition assessments and concrete goals.
o Sub-acute: These are patients who require step-down or rehabilitative level of
care. Chances for successful integration into society is predictably low.
o Long term care: These are patients who are severely compromised and have no
potential for rehabilitation (e.g., Huntington's patients). Primary treatment
objectives are to assist them maintain activities of daily living (e.g., hygiene,
nutritional status, provide some recreation, etc.). These patients place a
disproportionate burden on nursing staff and are particularly vulnerable targets for
acts of patient violence.
This stratification of patients raised several questions:
o What kind of clinical program and strategies are appropriate for these patients?
o Do we have a current clinical program that addresses these needs?
o What kind of staffing is appropriate to meet the needs of these patients?
o Which staff are best prepared to care for each of these levels?
o Is our present staffing capable of handling these patients?
Further adding to the complex nature of the patient population is the fact that the majority of
patients have dual diagnoses (e.g., schizophrenia and substance use/abuse).
RECOMMENDATIONS
The following summarizes the major recommendations of the task force. Please refer to the
task force minutes (attached) for a complete record of all recommendations and relevant
discussion.
1. Physical Plant Changes
Staff of each of the individual psychiatric units made recommendations for physical
plant changes that they felt would result in improved safety of both patients and staff
on the units. Several of the recommendations were common to all the units:
o . Enlarge and enclose the nursing stations
o Install additional video monitoring equipment
o Install security bubble mirrors
o Create appropriate patient security/seclusion areas
o Install panic buttons where appropriate
Other recommendations that were unit specific included:
I-Unit: o Enclose patio area
o Install a handicap bathroom
o Move charts inside nursing station
J-Unit o Add second nursing station that extends into security area
o Install motion sensor lights at front gate
o Add window in activity room to allow for patient
observation
Crisis Unit (E Ward): o Identify appropriate space that is safe for staff to
interview and screen patients
o Add second exit to therapist room
For a complete discussion and list of recommendations refer to the task force minutes.
2. Staff Training
Recommendations regarding training of staff in the management of behavioral
emergencies(MBE) by patients included:
o Increase the amount of training time
o Train staff in teams
o Practice MBE skills through the use of drills
3
o Train staff in the use of verbal techniques as well as in physical "take down"
techniques
o Any hospital staff person working on a psychiatric unit should receive MBE
training (e.g., clinical staff, housekeepers, lab techs, etc.)
Other training and education issues were identified that related to existing staffs'
clinical abilities and backgrounds to handle the type of patients in our system.
Decisions regarding the direction of the clinical program will have a significant
impact on staff training and education needs. This issue is further discussed in the
section on Clinical Staffing Patterns and Assignments.
3. Security Staffing
Public Safety Officer (PSO) Coverage: The task force recommended that PSO
coverage be continued on all shifts on J-Unit and that rounds continue to be made of
I-Unit and the Crisis Unit.
PSO Role in Stat Team Calls: The task force agreed that the PSOs should be the first
line responders in any stat team interventions. Policies and procedures are to be
amended to reflect this change.
Personal Body Alarms: In addition to PSO coverage on the units, the task force
recommended the use of personal body alarms. These will be used to alert other staff _
members on the unit of a staff person's need for assistance. Alarms will be issued to
any hospital staff working on the unit, including clinicians, housekeepers, lab techs,
etc.
Panic Buttons: It was recommended that panic buttons be installed on the units at
strategic locations. Use of the buttons would initiate a call to the hospital operator
that the hospital Stat Team is needed at a certain location.
4. Clinical Staffing Patterns and Assignments
The task force concluded that specific clinical staffing patterns and assignments could
not be discussed until the patient population and their particular needs (i.e. clinical
program) had been defined. The 30-day task force only had time to address the issue
of who our patient population is (see the discussion on Patient Data/Profiles above).
This discussion however, made two things startling clear: 1) that our current staff is
not trained to handle many of our current patients, and more importantly, 2) that
there is a lack of an adequate clinical program and strategy that addresses the
particular needs of our patient population. The consensus of the task force was that
this lack of a meaningful clinical program is a major contributing factor to patient
behavior (i.e., acts of violence) problems on the psychiatric units.
4
i
Defining what is an appropriate clinical program will the first priority of the
Psychiatric Department staff. Specific recommendations of the task force regarding
the development of a relevant clinical program included:
o Increasing the frequency of Riese Hearings
o Offering clinical programs and activities 7 days a week and not just between
the hours of Sam - 5pm
o Strengthening interdisciplinary teams in developing patient care plans
o Incorporating increased physical activity opportunities for patients into the
clinical program
o Developing a three tier program that acknowledges the varying levels of
patients in the system
o Hiring a full time Medical Director
o Having clinical program staff available 7 days a week, not just Monday-Friday
Once the clinical program is defined, the task force recommended that at a minimum
the following issues be addressed with regards to clinical staffing patterns and
assignments:
o Acuity system
o Male/female staffing
o Fitness for duty
CONCLUSION
The above recommendations reflect that the issue of work place safety is indeed far more
complicated than just having public safety officers posted to the units. While the task force
started off by discussing patient violence in the context of needing to increase specific
security measures on the units (e.g., security officer staffing, personal alarm systems, panic
buttons) it ultimately reached the conclusion that a basic clinical strategy, that is pertinent to
the patients in our system, is what is most lacking. In addition, there is a need for clinical
leadership that can direct the development and implementation of an appropriate program.
tfrpt2/26jan93
5
TASK FORCE ON PATIENT VIOLENCE
Participants
Lauren Bergen, Mental Health Treatment Specialist, J-Pych Unit
Henry Clarke, General Manager, Local 1
Curtis Coleman, Senior Clerk, J-Psych Unit
Mike Cornwall, Local 1, President, Mental Health Treatment Specialists
Cesar Court, Supervisor, Mental Health Crisis Service
Peter DelFiorentino, LVN, Mental Health Crisis Service
Bob daRoza, Business Agent, Local 1
David Dornaus, Chief of Security
Anita Duckett, Director of Nursing
Jo Elliff, Family Nurse Practictioner, J-Psych Unit
Pat Finnegan, Mental Health Treatment Speciatlist, J-Psych Unit
Martin Garro, RN, Mental Health Crisis Service
Donna Garro, Charge Nurse, J-Psych Unit
James Goodman, MD, J-Psych Unit
Roberta Harmon, Charge Nurse, I-Psych
Joseph Hartog, MD, Medical Director, Mental Health Services
Cyril Hinds, Psychiatric Technician, J-Psych Unit
William Hoyt, Psychiatric Technician, I-Psych Unit
Kathy Jung, Director Quality Management/Special Projects
Karen Kennedy, Labor Representative, CNA
Linda Kirkhorn, Program Supervisor, Mental Health Crisis Service
Emy Lorenzo, Charge Nurse, J-Psych Unit
Barbara McMahon, Clinical Nurse Specialist, Inpatient Psychiatric Services
Francyne Molina, Clinical Program Supervisor, Mental Health Treatments Specialists I & J
Psych Units
Cecil Patmon, Nurse Manager, J-Psych Unit
Steve Rader, MD, I-Psych Unit
Kathleen Razmek, Psychiatric Technician, I-Psych Unit
Helen Rice, Charge Nurse, I-Psych Unit
Bill Schlant, Business Agent, Local 1
Joyce Schulkins, RN, I-Psych Unit
Sharon Shaw, Nurse Manager, I-Psych Unit and Mental Health Crisis Service
Bruce Simpson, PSO
Becky Starnes, RN, I-Psych Unit
Jan Wasko, Family Nurse Practitioner, I-Psych Unit
Vivian Windham, LVN, J-Psych Unit
Bergen Lauren
Clarke Henry
Coleman Curtis
Cornwall Mike
Court Cesar
DelFiorentino Peter
DeRoza Bob o
Dornaus David
Duckett Anita
Elliff Jo
Finnegan Pat
Garro Martin
Garro Donna
Goodman James
.Harmon Bobbie
Hartog Joe
Hinds Cyril
Hoyt William
Jung Kathy
Kennedy Karen
Kirkhorn Linda
Lorenzo Emy
Mahler Jay
McMahon Barbara
Molina Francine
Patmon Cecil
Rader Steve
Razmek Kathleen
Rice Helen
Schlant Bill
Schulkins Joyce
Shaw Sharon
Simpson Bruce
Starnes Becky
Wasko Jan
Windham Vivian
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TASK FORCE ON PATIENT VIOLENCE
J UNIT PATIENT DATA
December 15. 1992
Issue Discussion
Patient Data Data were collected by cross-referencing
STAT/Support calls and AK30 records with the
census log kept on J Unit. This allowed the
identification of some patients involved in
violent incidents whose medical records were
retrieved and additional data were collected and
analyzed. Twenty-nine patients were identified
as being involved in 56 incidents during the time
period of February 1, 1990 to November 14, 1992.
Incidents of violent/assaultive behavior were
clearly under reported. After the data
collection, staff members recalled incidents not
included in this survey. The problem of under-
reporting of violent incidents has been
frequently described in the research literature.
Unless the assault/violence resulted in an
injury, it is not reported. Minor injuries such
as scratching or incidents with a potential for
injury later, such as spitting or muscle strain
tend not to be reported. Reasons for not
reporting these incidents include, "it is part of
the job," "it's too time consuming," and "what
will it accomplish?"
a. Patient Profile on All patients admitted to J during the data
J Unit collection period were analyzed by age and sex.
Sixty-nine percent of the patients were male with
an average age of 32.4 years. The profile of
violent psychiatric patients described in the
literature (i.e. patients with a high risk of
behaving violently) includes young males (less
than 35 years of age) , with a history of violent
behavior from lower socioeconomic/educational
groups with a severe (psychotic) mental illness.
The patients admitted to J are illustrative of
this profile and our mission. Of the 29 patients
involved in violent incidents, 978 had a history
of violent behavior.
In addition, the research literature identifies a
small group of patients who account for the
majority of incidents on psychiatric units.
Likewise, on J 14 patients accounted for 738 of
the violent incidents reported.
b. Patient Data: Almost 298 of the incidents occurred on Monday,
Violent Incidents with Saturday at 21.48. Friday and Sunday at
by Day of Week 14.38. Hypotheses to explain this included a
t
2
decrease or lull in the treatment program on
weekends with an abrupt increase in activity-
demand for patients on Monday. It was also
proposed that patient requests/needs were delayed
over the weekend with patient frustrations
mounting and reaching a crisis point on Monday,
c. Violent Incidents by Day and evening shift .accounted for over 90% of
Shift & Time of Day incidents. Peak times for violence included
change of shift and meal times. Staffing issues
were discussed in light of this data.
d. Violent Incidents by The first few days of hospitalization are the
Days of days at risk for violent behavior with day one at
Hospitalization 21.4%, within five days at 39.3% and within 10
days .at 52.6%.
Riese hearings which determine whether
antipsychotic medication can be administered are
often delayed. Riese hearings need to be
available on a daily basis as the need arises.
Note: Since violent incidents tend to be under
reported, caution must be used in interpreting
the data. However, better data can be collected
using the variables identified in this project.
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News
News and Views
I.
The Current State of Psychiatry in the Treatment
of Violent Patients
Kenneth Tardiff, MD, MPH ,
• During the past 2 decades psychiatry has made great chiatry's involvement with the problems of violence was
progress in describing patterns of violence by psychiatric often diffuse and sometimes more on the level of philos-
patients and developing standards for the evaluation and ophy than science. Violence was discussed in terms of
treatment of these patients.Studies have found that roughly aggressive drives, as part of human nature, or as the
10%of patients were violent toward other persons just prior product of vague social fomes.'Needless to say,this was
to psychiatric hospitalization.Young male patients and pa- of little practical use to the clinician who was responsible
tients in certain diagnostic groups had higher rates of vio- for treating violent psychiatric patients. f
knce.This report describes the proper evaluation of violent Systematic studies of the characteristics of violent
patients and proposes a model for the short-term potential patients done in the beginning of the 1970s looked at pa-
of violent behavior.Psychiatry has developed guidelines for bents seen at special clinics. The interests of the re-
the acute treatment of violent patients using verbal inter- searchers and the types of patients presenting to these
vention, physical restraint, and emergency medication. dinics were often skewed toward neurophysiologic
Long-term treatment relies on medication for the underly- causes of violent behavior."However,soon the scope of
ing diporder. Beyond their traditional indications, Barba- study of violent psychiatric patients broadened to include
mazepine, propranolol hydrochloride, and lithium carbo- a variety of diagnostic groups as well as clinical settings.b8
sate may be effective in diminishing violence.Some violent Researchers began to study large numbers of patients ad-
patients respond to long-term psychotherapy. miffed to psychiatric hospitals. The first large study
(Arch Gen Psychiatry. 1992;49:493-499) looked at 9365 patients admitted to public hospitals on
Long Island in New York in the mid 1970s.'Ten percent
This report describes the current state of our specialty in of these patients had been physically violent toward other
the diagnosis and treatment of violent patients.The Persons lust before admission to these hospitals. Young
term patients rather than persons points to a basic premise men and some diagnostic groups.had higher rates of vi-
of this report, namely that psychiatrists ashysic.ans olence. M important point made by the study was that
have expertise in the management of violence for a group violence was not uncommon.Subsequent studies of large
of persons defined as patients but not for violence at large Patient populations in a variety of psychiatric hospitals
in society.Violence in society is related to factors such as fo'o'd similar percentages of patients who were physi-
11
economics, culture, criminal behavior, drug dealing, callY violent toward other persons.
mass media, and the availability of weapons. These fac- CHARACTERISTICS OF VIOLENT PATIENTS
tors are not within the usual realm of psychiatric exper-
tise, although such factors must be considered in the What became apparent from these studies was that vi-
treatment of an individual patient. Psychiatric and med- olent patients are not a homogeneous group.There were
ical techniques of assessment,diagnosis,and treatment of many types of patients who were violent,suggesting that
patients with violent behavior parallel the techniques for purposes of treatment psychiatrists and other clin.i-
used for other clinical problems of patients. dans must evaluate the underlying psychopathology,
During the past 2 decades, psychiatry has made great. causing violence in each individual case. A review of the
progress in developing standards for the evaluation and types of violence in relation to diagnosis may be instruc-
treatment of violent patients.There has been exponential tive.
growth in research on the psychopathology of violence A number of studies have found that schizophrenic
and on more specific treatments to St the psychopathol- -patients are overly represented in groups of patients who
ogy manifested by individual patients. Prior to 1970,psy- are violent toward other people just before and/or during
I ps cMatric hospitalization. Studies in the United States
and in other countries,such as Great Britain and Sweden,
From the Department Accepted for publication March 12,1992.nt of Psychiatry,Cornell University Medical link violence to paranoid delusional thinking and haDuci-
,
Center, New York, NY. nations in schizophrenia.o u.1irsr• These patients believe
Reprint requests to the Payne Whitney Clinic New York Hospital, that people are threatening,Wsecuting,or in some other
525 E 68th St, New York, NY 10021 (Dr Tardiff). way trying to harm them. Violence is a reaction to these
Arch Gen Psychiatry—Vol 49, lune 1992 Violent Patients—Tardiff 493
with increased risk of violence, particularly in antisocial violence. Being young increases the risk of vio-
and borderline patients.'-1-"-5-s2 In the case of the lence.3,9A 21=21 However,some studies have found an in-
borderline personality disorder, in addition to frequent crease in violence at the other age extreme.+A6•41 This ap-
l� displays of anger and recurrentphysical violence toward pears to be the consequence of dementia and other
others, the patient with borderline personality disorder organic brain deficits. Perhaps unexpectedly, given racial
manifests a number of other behavioral problems and se- differences in violent crime in society at large, black psy-
vere psychological problems. Violence manifested by ehiatric patients are no more likely than white psychiatric
persons with antisocial personality disorder is just one of patients to manifest violent behavior.9-vx Presumably,
many antisocial behaviors. These patients repeatedly get psychopathology per se is-more important.
into physical fights and manifest a number of other anti-
social behaviors, such as stealing, lying, and reckless EVALUATION OF THE VIOLENT PATIENT
driving. The patient shows no guilt or remorse for Before one decides on treatment,a complete evaluation
violence and other antisocial behavior. These disorders of the patient is essential.When faced with a patient who
should be distinguished from another nonpsychotic epi- speaks of violence and/or has been violent,clinicians may
sodic violence disorder, which has a better prognosis in become fearful or anxious or experience other emotions
regard to treatment. Intermittent explosive disorder is that cause them to veer from the assessment routine fol-
manifested by recurrent outbursts of violence that are lowed for other psychiatric problems-1 Recent writings
grossly out of proportion to any precipitating psychoso- on the evaluation of violent patients should remind clivi-
dal stressor.Following a violent episode there is often re- sans of standard clinical practice.These principles will be
worse. In the intervening period between these violent summarized herein.45-"
episodes,there is little evidence of other behavioral prob- The evaluation of the patient who presents with prob-
lems. leets of violence should include an assessment of the chief '
Episodic nonpsychotic violence usually involves family complaint, history of the present illness, family history,
members,usually a man battering a woman, and less of- personal and developmental history, medical history, i
ben a parent abusing a child. The pattern of violence re- mental status, and results of physical examination, labo-
peats itself in a predictable way.Spouse battering charac- ratory tests,and imaging.In gathering information about
teristica Jy involves a man who has low self-esteem with the patient the clinician should use as many sources of
financial, sexual, or other conflicts that are expressed information as possible. This includes information from
phthan ysically rather an verbally. The female victim feels the patient, the police, relatives, the patient's therapist,
helpless,guilty,ashamed,and afraid to take action to stop and the primary care physician,as well as previous med-
the violence. Arguments escalate in a repetitive fashion, ical and criminal records.
often fueled by alcohol, and culminate in physical vio- The clinician should record the patient's stated reasons
fence toward the woman. for being in the clinical setting at.that time. Even though
Children and adolescents may be violent due to dis- the patient's stated chief complaint may not agree with
ruptive behavioral disorders or mental retardation.10.13-x" other sources of information, the clinician should evalu-
There can be physical violence toward others, cruelty to ate the complaint as stated by the patient. The clinician
animals,stealing,robbery,and other antisocial behaviors. will more fully evaluate the violence later,but it is impor-
This violence and other antisocial behaviors usually are t;ant in the early phase of evaluation to let the patient
not accompanied by guilt or remorse. C3tildren with con- present his or her view of the problem to assess the pa-
duct disorders may grow up to be antisocial violent tient's perspective of what the problem is,to ascertain the
adults."Children and adults with mental retardation are patient's accuracy and reliability,and to avoid confronta-
at greater risk of violence than the general population.10-s' tion in the early phase,which would impede subsequent
Violence in the mentally retarded is associated with evaluation.
hyperarousal, frustration, and anger when the patient is IAll aspects of the patient's present psychiatric illness
unable to achieve goals and cannot verbalize conflicts, should be assessed in the interview, but the focus here is
concerns, and feelings adequately. on the history of violence as a symptom.There should be
It has been noted that a history of violent behavior re- a determination of the time of onset of the first violent
gardless of diagnosis indicates an increased risk of subse- episode and of the occurrence of violence since then.
quent violent behavior.921m-16-5'This emphasizes the need Questions should be asked about the frequency and tar-
to ask patients about past violence in great detail, as will get of violent behavior, with attempts made to identif},
be described further in terms of evaluation of patients. recurring patterns of escalation and violence. Severity of
Other past impulsive behaviors,such as suicide attempts, injury or intended injury should be determined. Assod-
may reflect future increased risk of violence as well as sted symptoms preceding, during, or following the vio-
suicide.'•10-'" Lowcerebrospinal fluid 5-hydroxyin- lent episode should be explored.
doleacetic acid concentration and responses to fenflu- The clinician should inquire about prior evaluations of
ramine challenge in impulsive violent individuals suggest violent behavior,including tests done.A history of treat-
that serotonin may be important in self-control vs impul- ment, including medication and hospitalizations related
sive behaviors."' to violence, as well as to other disorders, should be
There are demographic differences between violent and. obtained. Records of prior evaluations and treatment
nonviolent psychiatric patients. Violent patients are more should be requested. The clinician should inquire about
l likely to be male.1.9.1144.222'•30 However, when long-term other types of impulsive behavior. These include past
chronic inpatients are studied, there is no significant dif- suicidal behavior, reckless driving, destruction of prop-
ference in the rate of violence and gender of the pa- em,fire setting,reci:less spending,and sexual acting out.
tient.to23 In long-term hospitalization, sex role expects- There should be an extensive review of the patient's
tions may not be as important as psychopathology in medical history because, as was pointed out earlier, a
Arch Gen Psychiatry—Vol 49, June 1992 Violent Patients—Tardiff 495
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book.0`0 These guidelines have become minimal stan- Senzodi epines can be used very effectively in emer-
dards across institutions and in the legal arena. These gency situations. Benzodiazepines may be used with the
publications have been supplemented with more details neuroleptic medications for schizophrenics,tnanics, and
' on the use of medication and verbal techniques in recent patients in other psychotic states or they may be used
publications-"`2 alone for the treatment of nonpsychotic patients. For pa-
A decision to attempt to de-escalate aggression by talk-' tients who appear to have some degree of control, they
ing to the patient is made on an individual basis, but it is may be offered as an oral mediation. However, in most
unusual for a psychotic or grossly organic patient to emergency situations intramuscular medication is neces-
respond to verbal interventions. One must turn to re- sary. Lorazepam is preferred since it is reliably and rap-
straint, seclusion, and/or emergency medication. Which idly absorbed from intramuscular injection, unlike diaz-
control is used is based on the clinical needs of the indi- epam or dhlordiazepoxide.'s Diazepam administered
vidual case. For example, if the cause of the violent intravenously is effective,but this is a difficult maneuver
behavior is unknown, restraint may be indicated to with a struggling patient and may lead to respiratory ar-
maintain the patient drug free for purposes of evaluation. rest."" Lorazepam is more appropriate in the long-term
In addition,a violent patient may be preferentially treated treatment of violence than in emergency situations.
in seclusion and restraint because of medical illness or
drug allergies that would preclude the use of certain LONGTERM TREATMENT OF THE VIOLENT PATIENT
medications to control violent behavior. Much progress has been made in formulating the long-
There are contraindications to the use of seclusion and term treatment of violent patients with medication, be-
restraint.They should never be used for punishment,that havioral therapy,and psychotherapy.Medication is used
is, for seeking retribution for an ad when no danger ex- to treat the underlying disorders, for example, schizo-
ists to the patient or others.Seclusion may be contraindi- phrenic, mania, or an organic state. Anticonvulsants,
Bated because of thepatient's clinical or medical condi- "lockers, and lithium have been used to treat violence
tion, for example, if the patient is suicidal or is in in the absence of disorders these medications were
medically unstable condition so that close monitoring and designed to treat.
physical proximity to staff is a necessity.Restraint may beCarbamazepine is effective in managing aggression and
preferable in cases of delirium in which reduced sensory irritability in patients with overt seizures, in schizo-
input may lead to worsening of the dinical state in seclu- phrenic patients with and without EEG abnormalities,
sion. Other situations representing relative'contraindica- and in other types of patients with episodic violence,
tions to seclusion include those in which patients have particularly personality disorders without gross brain
just taken overdoses and require dose monitoring, those damage or mental.retardation.""' Valproic add is used
in which patients present with the symptoms of serious usually after an unsuccessful trial of carbamazepine or in
and uncontrollable self-mutilation, and those in which cases in which'the hematologic status of the patient pre-
seclusion rooms cannot be sufficiently cooled on hot days dudes the use of carbamazepine. Clonazepam can be
for patients receiving drugs, such as neuroleptics, that used for episodic violence on a long-term basis, with rel-
impair thermoregulation. atively few side effects.
Restraint or seclusion is an emergency procedure usu- There have been a number of reports on the effective-
ally initiated by nursing stall,but a physician must see the mess of f�-blockers, particularly propranolol hydrochlo-
patient as soon as possible and write an order to continue ride in the management of aggressive behavior.'11AD. 9 Most
these procedures. Orders are time limited and must,be of the patients who responded to propranolol were those
renewed periodically, depending on the institution's with organic brain disease, often with gross impairment
guidelines. The APA Task Force outlined standards for secondary to trauma, alcoholism, encephalitis, Hunting-
the monitoring and care of a patient in restraint and se- ton's disease, dementia, Wilson's disease, or Korsakoff's
dusion by nursing staff to ensure the patient's safety. psychosis. In addition,some patients with minimal brain .
Emergency medication may be used instead of or in dysfunction or attention-deficit disorder have also been
addition to seclusion or restraint.Neuroleptic medication reported to respond to propranolol.Nearly all the patients
should be used primarily for the treatment of violent pa- in these studies were refractory to other medications, in-
tients who manifest psychotic symptoms. It may be indi- cluding neuroleptics, aruoolytic agents, anticonvulsants,
Bated for patients who are not psychotic but who are vi- and lithium. In a number of cases, concurrent neurolep-
olent, as in the case of patients with organic brain tic medication was used. Other P-blockers, such as
dysfunction whose clinical picture may be worsened with pindolol,nadolol,and metoprolol tartrate have been used
benzodiazepines. successfully to treat aggressive behavior. ''
Much has been written about the use of neuroleptics lithium has-been used to treat a number of different
and the acute treatment of the violent patient."It is im- types of violent patients. In a double-blind trial lithium
portant to distinguish the procedure of rapid "tranquil- was effective in the treatment of aggression in adult men-
ization"using low doses of neuroleptic medication during tally retarded patients.• The administration of lithium
30- to 60-minute intervals with the specific goal of atten- was the same as that for the treatment of bipolar patients.
1 tuating violence, agitation, and excitement from the.pro- There have been other reports of the use of lithium for
cedure of rapid "neuroleptization," which uses high patients with other disorders, including those with or-
doses of neuroleptics for several days in the misguided ganic brain syndrome and head injury;aggressive schizo-
goal of trying to accelerate the decrease of psychotic phrenics; nonpsychotic, aggressive prisoners-and delin-
f symptoms." A range of neuroleptics can be used and quents; and children with conduct disorders and
there is general safety and efficacy wilth rapid tranquiliza- attention defiut.""'Finally, buspirone hydrochloride hay
tion: They have been demonstrated to be effective with been reported to diminish aggression as well as anxiety in
schizophrenia, mania, and other psychotic disorders. developmentally disabled patients.'
Arch Gen Psychiatry—Vol 49, lune 1992 Violent Patients-7ardiff 49;
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latency age children.Am J Psrrhiatry. 1983;140:31.35. 8S. Greendyke RM, Kanter DR.Therapeutic effects of pindolol on
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1
Arch Gen Psychiatry-Vol 49, June 1992 Violent Patients-Tardiff 499
Interview Questions:
1. Do you think safety of patients and staff on I and J wards is a omccm?
2. Were you ever afraid for your safety while you were a patient in I or J Ward?
3. if so, what made you afraid and why?
4. Do you have any ideas on how to improve safety for patients and staff on I and J
NVards?
S. What do you think of the idea of having uniformed security officers as a safety
measure?
6. What do you think of the nursing station being closed off as a means of providing
safety to staff?
7. What do you think of having support groups for patients to talk about the issues of
safety on the ward?
8. What do you think of having trainings for staff around safety issues? What kinds
of trainings do you think staff should receive?
9. How do you feel about nursing staff wearing white uniforms as a safety measure?
10. Do you want to have further input issues, would you like to attend a followup
meeting, do you wish your comments to remain anonymous?
Responses:
Barbara Lvon
I am concerned about the recent incidents where a patient physically assaulted several
staff persons on J -Ward. I am ooneerried about the impact this has had on staff members
as well as patients. When we talk about safety on the wards, however, I hope we are
talking about ensuring the safety of everyone on the wards -- patients as well as staff
Cmembers.
When I was a patient on I-Ward, I didn't always feel safe. In fact, the first night I stayed
on I-Ward someone set fire to my room and a male patient tried to force himself on me.
s However, I feel positive about the treatment I received on I-Ward and over time have
been able to look at these incidents from a proper perspective. I certainly don't blame
anyone for what happened I don't think that all psychiatric wards are unsafe and I don't
think that all men are sexually assaultive in nature.
With regard to the recent attacks on J-Ward , I think we should look at what caused the
patient to become pfiysieally assaultive in the first place and see if there is something we
can learn from this incident. I don't believe that people identified as "mentally ill- are
more prone to violence than anyone else. In fact, my experience is,that patients tend to
be more timid and less violent than most people. So I don't thunk we should address the
issue of safety by assuming that all mental health clients are going to be violent and that
staff members must be protected from them
I do, however, think it is natural for people who have been a victim of violence to
respond with fear and mistrust, at least at first. Out of fear, however, we may look for
quick solutions that may not be beneficial in the long run. In response to the recent
incidents, we must be careful not to put into motion a plan that will create a more
fearful and mistrustful environment on the wards but find ways to ensure safety while
maintaining a caring and healing place.
I think staff members who are feeling fearful as a result of these incidents should be given
a lot of understanding and support. However, I would not support a plan that assurnes
all mental health clients are prone to violence and that this kind of incident is going to
happen everyday and that staff members should be protected from patients. I would,
however, support a plan that would include the following:
1. Provide support to the people who were directly involved in the recent incidents
to help them work through their fears. This would include patients as well as staff
members.
2. In the short-run, provide a security officer on the ward until staff members and
patients have been given an opportunity to work through their fears and can look at the
incidents from a perspective that is not dominated by emotion.
3. Provide ongoing training for staff members on how, to deal with patients who are
angry . There may be ways that staff members can help patients express their anger in
more appropriate ways.
4. Look at the factors that may be contributing to anger and violence on the wards.
How do staff`members and patients relate to each other? What are the attitudes of staff
members toward patients in general? V4'hat are the attitudes of patients toward staff
members? How did these attitudes come about? What causes people to become angry
and frustrated on the wards? (This would include staff members as well as patients. )
How do most people respond when they feel lilat they have little or no control over their
lives, when they must get permission to do things that most of us take for granted, like
having a cigarette when we want to, or going to Bleep when we want to, or getting up
when we want to, or eating when we want to, or wearing our own clothes. How can we
create a freer and more caring and healing environment? How can we create a system
that helps patients while at the same time treats them with dignity and respect.? What
changes need to be made to accomplish this?
If we wish to create a freer and more caring and healing environment, I don't think that
closing off the nurses station, or maintaining security officers around the clock , or
haying staff members wear uniforms, will help us achieve that goal. What it will do is
create a greater distance between staff members and patients which may create more
tension and frustration on the wards. %When there are problems on the wards l think staff
members should talk with patients and get them involved in trying to find ways to solve
the problems. Patients will feel like they have some control over their lives and this alone
could help reduce tension._
MgM,Carley
When I was a patient on I-Ward they brought a new patient on the ward who was
immediately hostile towards me. She came and seemed to single me out as someone she
didn't like the looks of and in her manner she was very threatening and verbally
assaultive. But they irrm iately took her to) AN'ard when that started. They handled the
situation in a safe manner as far as I can see.
To help improve safety on the wards 1 think they should provide some kind of outlet for
people's energy. Other than going out to have a cigarette or watching television, patients
don't have group type therapies where they can talk about what's going on with them.
where people can interact. Energy gets built up and there is no real outlet for it. I
recommend that there be more organized activities and rap sessions for the patients.
Most of the staff are real angels and are very dedicated to helping patients. But there are a
few staff members who have been there for a long time and they don't lilac their jobs,
don't like the patients. Those are the ones that can antagonize patients at the wrong time.
Other staff members know who these staff members are. But the patients don't know at
fist so they have to figure it out' when they get there and they have to find a way to stay
clear of those staff members. You have to realize that when you're in a hospital you are
' 1
a part of a community and there will be different personalities and personality conflicts
that you will have to deal with Unfortunately, some staff members arc blatantly hostile
and disrespectful and dam right mean and inconsiderate toward patients. They tend to
treat them as children and they abuse those children. It would help if the staff had
conflict management training. There may be things they conn learn The last time I was in
the hospital I was treated very inhumanely. Because of my physical size, I requested to
use the bathroom that is ordinarily used for the physically handicapped. But before I
could do that I had to prove to the staff that I could not physically fit in the regular
bathroom stall. It was humiliating. I've never been in a hospital where they had
uniformed security officers on the wards. I've been on locked wards in San Francisco
and seen some pretty major stuff happen and some of the ways they handled people who
were in angry and fearful states worked better than having a uniformed guard. They used
warm sheets, used medications, made sure people had someone to talk to. Staff members
were not disrespectful.
To use uniformed security officers I think would cause more harm than good and would
provoke more violence since people in uniform can sometimes frighten some people.
People can also be threatened by people who wear white coats. To have staff members
return to wearing white uniforms rather than regular street clothes would be a major step
backwards. We all know what effect this has had on people.
To close off the nurses station would not be effective in my opinion. Were the staff
members who were assaulted behind the nurses station at the time of the incident? Are
staff members going to stay behind the nurses station all the time so that they will be
safe? Don't nurses have to move around on the wards? To build a wall that would
separate staff members from patients would be provoking. Kind of like a Berlin Wall. It
would just be another thing to argue about. Another cog in the wheel of conflict.
Having support groups for patients to talk about the issues of safety on the wards is
defuniteh• a good idea. There is such a lack-of group interaction on the units. In fact, one
staff person told me that people don't stay long enough on the wards to get into group
therapy. But I think to have a support group or rap session is something that is really
needed. The community meetings are too structured, not a rap session. I think the
support groups could not only deal with issues of safety but a lot of the issues that come
up while being hospitalized. People need to be able to discuss their feelings and to
problem-solve with support from each other. Patients would be.able to figure out
things that would be helpful because.they need to be safe, too.
I think it would be a good idea if staff members had trainings in conflict management.
They could contact Jill Cooper who is one of the trainers on the conflict resolution panel
which provides free trainings. Her number is 935-4249.
Barbara Ludder
I think the issue of safety on the wards is a real issue. I have been beat up by staff and
patients on J -Ward. They need someone to ensure safety on the wards. I support
having a security officer on duty. I haven't been hospitalized on J -Ward in two years
but it was very violent the last time I was there.
If they put windows up and everything around the nurses station, I think that would just
intimidate the patients more. It would close off die communication. I think it is a gcK-d
idea to have support =,coups because when I was on J-Ward only occasionally we had
someone to talk to. The chaplain and patients' rights advocate talked to us but that's
about it. There were no support groups on the wards, no one to talk with.
S �
t I think- it's a good idea to have trainings for the staff. They should probably receive
mediation training to discuss how to deal with fights so there will not be any more fights
and to get the problems out in the open. They should be trainned in self-defense
because some of the people are very violent and it is not all their fault.
Having staff members wear uniforms will alienate them from the patients too much.
Wearing a badge would be enough
Kathy Fors�lhe _
I think safety is a legitimate oonocrn on the psychiatric wards. Generally the time I was
there I felt safe. I didn't have any scare), incidents to speak of. I got a little scared here"
and there but nothing to be terrified about. Nothing was life threateniug or anything --
Just people acting reallly weird freaked me out for second
I would personally feel more safe with a security guard on duty if there are violent
patients on the ward 1 just realized that since the wards are closed it would be difficult
for the patients-- they would be more vulnerable to incidents of violence. I hope these
recent incidents of assaults on staff members don't have difficult repercussions on the
patients who aren't causing the violence. I hope they don't get grouped into one large
category because one incident has oocur A The majority of people aren't violent. I
hope that they don't associate all mental health clients with being violent.
To close off the nurses station I imagine would be a staff decsion but I like to have
availability of staff, close proximity if needed I prefer it being open from my point of
view.
Support groups would be good Meetings with staff and clients together to discuss
similar issues.. I know that these one or two incidents could result in the whole staff
getting scared but if they get familiar with the patients they will see that the marjority of
patients are safe to be around. So I think staff should have meetings with patients so they
can connect with good people, too.
I think it would be a good idea if staff received training in ways to deal with violence on
the wards. In general I feel they should because if]were a nurse and oould be potentially
assaulted I would definitely .want to know some self -defense because I know when I
lived in Richmond I tooled some self-defense classes and it built up my confidence.
Rather than get jumpy and start putting people in restraints or locked rooms I think staff
members should get some.training in self-defense.
I don't like the idea of staff members wearing uniforms. When 1 was a patient on JAN"ard
staff members wore regular clothes -- people seemed more human by their dress._If it was
necessary for safety on the wards, however, I wouldn't mind if they wore uniforms. I
could take it or leave it.
12 -11-72-
STAT
L -1/-9LSTAT TEAM POLICY PROPOSAL
Responsibilities and Procedures of Public Service Officers (PSOL:
(.. he PSO will respond to all STAT and Support calls.
The PSO will make initial contact with Nurse in charge of init requesting the
Stat team for information about the call, or will recieve that infoanatien
frau the Stat team Captain.
The Stat team Captain will be inczarge of the call.
The PSO will be directed by the Stat team Captain.
If a take down of a violent Patient is necessary, the PSO will make first
contact and effect the take down. If the PSO needs additional help in the
take down, he, she, will request the team to assist.
Once the take dawn is catlete, the PSO will maintain control of the Patient
and the team will apply the restraints and transport the Patient with the .
PSO assisting.
On a support call the team will assume the leadership role with the PSO
acting as back up to assist the team.
PSO team makeup: 2 PSO's per shift, beat .1 and 2 to all STAT and Support
calls. In situations where the responding PSO considers an additional
PSO necessary because of the serious nature of the call, 1 additional
PSO may be pulled frau J to assist.
To maintain a reasonable degree of safety for the PSO's , the Team and
the Patient, it is necessary that the STAT team be maintained with a
staff of 4 persons per shift.
C --raining: All PSO's will attend the NSE training.
All STAT team menbers will attend training given by the PSO on PSO methods.
Content of PSO training will be furnished at a future date.
The STAT Tin policy will remain the same with the addition of the
addition of the above
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