When a hospital patient becomes violent

Rural Hospitals

In this April 25, 2014 photo, a sign points the way to Flint River Hospital which closed its emergency room last year, in Montezuma, Ga. Residents must now drive 20 or 30 miles on slow country roads to the nearest hospital. Alarmed by hospital closures, health officials in Georgia are changing rules to let stressed rural hospitals become expanded emergency rooms that can also handle routine childbirths or outpatient surgery. (AP Photo/David Goldman) (The Associated Press)

Violent incidents against doctors and nurses are a growing problem at Canadian hospitals. The surprise is that the perpetrators are often patients.  That’s according to an editorial in the Canadian Medical Association Journal. As an ER physician, violence is something I have seen throughout my career.

I can remember the first time I witnessed a patient become violent. A middle age man had been brought to a suburban ER where I used to work.  He was on a stretcher in a hallway.  Suddenly, he was off the stretcher, screaming, as he ran toward the nursing station. Like a blur, from the opposite side of the ER, two security guards came running towards the man. They tackled him, pinned him to the floor, and put him back on the stretcher, and put his arms and legs in leather restraints.

There is no such thing as a hospital that is free from a random act of violence. Depending on where the hospital is located, it may be very frequent.  A survey of family doctors found that a third had been the target of aggressive behavior by a patient or a family member of the patient during the preceding month.  Nearly all of them said it had happened at least once in their career. Three quarters of the incidents were considered major (for example, sexual harassment), and nearly 40 per cent were severe incidents such as assault, sexual assault or stalking.

I’m glad that CMAJ published an editorial on the topic of violence because it doesn’t get enough attention.  Still, I found it curious that it singles out physicians as victims of patient violence without talking about other professions.  

The Toronto Star reported data from the Association of Workers’ Compensation Boards of Canada showing that between 2008 and 2013, there were more than 4,000 reported incidents of violence against registered nurses and licensed practical nurses. The Star reported that the figure of 4,000 exceeds the number of incidents reported by police and firefighters put together.  

A few years ago, we did a show on White Coat, Black Art that focused on violence against paramedics.  Unlike other health professions, paramedics are at increased risk because they get little advance warning of impending violence.

The risk factors for violent behaviour are well known. Patients who are violent are often intoxicated with alcohol, drugs or both.  I’ve seen patients who are high act so aggressively that they need as many as six or even eight security personnel and police to restrain them.  There have long been reports of patients who threaten violence against doctors who refuse to prescribe opioid pain relievers.  More recently some patients have carried out the threat.  A significant proportion of violent patients have mental health problems.  Some patients are under stress due to loss of employment divorce and restricted access to their children.  Factors within the health care system include long wait times and doctor shortages.

The push to deal with the problem now comes from reports of high profile cases in which health professionals have been severely beaten. That’s what happened when a patient at a psychiatric unit assaulted a doctor in Penticton, B.C., causing severe facial injures, a broken jaw and other fractures.  There are many more instances in which nurses have been assaulted and ended up with severe injuries.  A survey in Canada found that three quarters did not seek help and nearly two thirds did not report the incident.   

And it’s not just health professionals at risk.  There is also a risk of harm to bystanders – other patients and their family and friends.  There is a sense that more incidents will occur unless hospitals decide to do something about them.

That in my opinion is what turns this from a hospital manner into a public health issue.

The editorial calls for research into violent patients.  I endorse that idea only if it leads to practical ways to prevent it or mitigate the risk.  Violence is yet another reason why we need urgently national and provincial drug strategies to deal with the opioid epidemic.  

A four-day training program called Omega has been shown to increase the confidence of health professionals that they can handle the situation.  Other measures in hospitals include a red flagging system to alert personnel to repeat offenders.  Security cameras can act as a deterrent. Panic buttons and communication with colleagues that a potentially violent patient has arrived also help.  

As the editorial puts it, the big thing that needs to change is a hospital culture that – until recently – behaved as if dealing with violent patient is “just part of the job.”

Dr. Brian Goldman is host of White Coat Black Art, and the house doctor for CBC Radio One.  He works in the ER of a Toronto hospital.

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